Acute Care Advanced Practice Providers' Use of Telehealth During the COVID-19 Pandemic.

Advanced practice registered nurses and physician assistants, collectively termed advanced practice providers (APPs), have been part of telehealth for many years. During the COVID-19 pandemic, APPs experienced the growth in roles, responsibilities, and tools used for telehealth care delivery. This article uses examples from 3 health systems to highlight the ways in which telehealth use was expanded due to the pandemic, how APP roles were altered across the United States during and after the pandemic, and implications for future practice.

Alert to Action: Implementing Artificial Intelligence-Driven Clinical Decision Support Tools for Sepsis.

Background: Sepsis is the leading cause of mortality among hospitalized patients in our health care system and has been the target of major international initiatives such as the Surviving Sepsis Campaign championed by the Society of Critical Care Medicine and Get Ahead of Sepsis led by the Centers for Disease Control and Prevention. Methods: Our institution has strived to improve outcomes for patients by implementing a novel suite of integrated clinical decision support tools driven by a predictive learning algorithm in the electronic health record. The tools focus on sepsis multidisciplinary care using industry-standard heuristics of interface design to enhance usability and interaction. Results: Our novel clinical decision support tools demonstrated a higher level of interaction with a higher alert-to-action ratio compared to the average of all best practice alerts used at Ochsner Health (16.46% vs 8.4% to 12.1%). Conclusion: By using intuitive design strategies that encouraged users to complete best practice alerts and team-wide visualization of clinical decisions via a checklist, our clinical decision support tools for the detection and management of sepsis represent an improvement over legacy tools, and the results of this pilot may have implications beyond sepsis alerting.

A practical approach to establishing a critical care outreach service: An expert panel research design.

BACKGROUND: For over two decades, nurse-led critical care outreach services have improved the recognition, response, and management of deteriorating patients in general hospital wards, yet variation in terms, design, implementation, and evaluation of such services continue. For those establishing a critical care outreach service, these factors make the literature difficult to interpret and translate to the real-world setting. AIM: The aim of this study was to provide a practical approach to establishing a critical care outreach service in the hospital setting. METHOD: An international expert panel of clinicians, managers, and academics with experience in implementing, developing, operationalising, educating, and evaluating critical care outreach services collaborated to synthesise evidence, experience, and clinical judgment to develop a practical approach for those establishing a critical care outreach service. A rapid review of the literature identified publications relevant to the study. A modified Delphi technique was used to achieve expert panel consensus particularly in areas where insufficient published literature or ambiguities existed. FINDINGS: There were 502 publications sourced from the rapid review, of which 104 were relevant and reviewed. Using the modified Delphi technique, the expert panel identified five key components needed to establish a critical care outreach service: (i) approaches to service delivery, (ii) education and training, (iii) organisational engagement, (iv) clinical governance, and (v) monitoring and evaluation. CONCLUSION: An expert panel research design successfully synthesised evidence, experience, and clinical judgement to provide a practical approach for those establishing a critical care outreach service. This method of research will likely be valuable in other areas of practice where terms are used interchangeably, and the literature is diverse and lacking a single approach to practice.

A Survey of Tele-Critical Care State and Needs in 2019 and 2020 Conducted among the Members of the Society of Critical Care Medicine.

The study's objective was to assess facilitators and barriers of Tele-Critical Care (TCC) perceived by SCCM members. By utilizing a survey distributed to SCCM members, a cross-sectional study was developed to analyze survey results from December 2019 and July 2020. SCCM members responded to the survey (n = 15,502) with a 1.9% response rate for the first distribution and a 2.54% response rate for the second survey (n = 9985). Participants (n = 286 and n = 254) were almost equally distributed between non-users, providers, users, and potential users of TCC services. The care delivery models for TCC were similar across most participants. Some consumers of TCC services preferred algorithmic coverage and scheduled rounds, while reactive and on-demand models were less utilized. The surveys revealed that outcome-driven measures were the principal form of TCC performance evaluation. A 1:100 (provider: patients) ratio was reported to be optimal. Factors related to costs, perceived lack of need for services, and workflow challenges were described by those who terminated TCC services. Barriers to implementation revolved around lack of reimbursement and adequate training. Interpersonal communication was identified as an essential TCC provider skill. The second survey introduced after the onset pandemic demonstrated more frequent use of advanced practice providers and focus on performance measures. Priorities for effective TCC deployment include communication, knowledge, optimal operationalization, and outcomes measurement at the organizational level. The potential effect of COVID-19 during the early stages of the pandemic on survey responses was limited and focused on the need to demonstrate TCC value.

Treating Sepsis in Patients with Heart Failure.

Sepsis is a syndrome that is one of the leading causes of morbidity and mortality across the world. Those with pre-existing conditions, such as heart failure, have worse outcomes. This article will discuss the guidelines for the treatment of sepsis and opportunities to enhance the care of patients with heart failure with sepsis.

The Role of Tele-Critical Care in Rescue and Resuscitation.

Tele-critical care (TCC) is a health care delivery model that connects medical information, interprofessional teams, patients, and families through advanced pathways, such as audio-video interfaces, machine learning, risk prediction algorithms, smart alarms, artificial intelligence, and physiologic sensing devices. TCC expands critical care services and expertise beyond the walls of the intensive care unit to logistic centers, emergency departments, general wards, war zones, disaster settings, and pandemics. This article describes the broad use of TCC for rescue and resuscitation and provides case presentations.

Rapid Response System Restructure: Focus on Prevention and Early Intervention.

This article describes the staged restructure of the rapid response program into a dedicated 24/7 proactive rapid response system in a quaternary academic medical center in the southern United States. Rapid response nurses (RRNs) completed clinical leadership training on artificial intelligence, electronic risk stratification alerts, expert nurse rounding, emergency response, teamwork, closed-loop communication, and outcome measurement. The program goal was to reduce preventable deaths and resuscitation events outside the intensive care unit (ICU). Program outcomes between 2017 and 2019 included a 65% decrease in cardiac arrests outside the ICU, a 27% decrease of cardiac arrests inside the ICU, a 4.7% decrease in patients admitted to the ICU from inpatient beds, and a 27% reduction in the risk-adjusted mortality index for patients with expert proactive rounding encounters. Hospital peer group ranking on the Hospital Survey of Patient Safety improved in the areas of events reported, actions promoting patient safety, and continuous improvement suggesting a positive cultural shift. Implementation of a dedicated 24/7 RRN model of care integrating proactive rounding, technology, and ART can improve outcomes for patients and staff.

The Modified Early Warning Score as a Predictive Tool During Unplanned Surgical Intensive Care Unit Admission.

Background: The Modified Early Warning Score (MEWS) has been proposed to warn healthcare providers of potentially serious adverse events. We evaluated this scoring system during unplanned escalation of care in hospitalized surgical patients during a 1-year period. Methods: Following institutional review board approval, all consecutive, unplanned surgical admissions into the surgical intensive care unit (SICU) during 2016 were entered into this study. MEWS and patient demographics during bedside evaluation for SICU admission were extracted from electronic medical records. Logistic regression was used to analyze the association of MEWS with the incidence of future mortality. P values were set at <0.01 for statistical significance. Results: In this series of 263 consecutive patients, the incidence of mortality following unplanned escalation of care was 29.3% (confidence interval [CI] 24.1% to 35.0%), ranging from 22% to 57%, with all positive MEWS values. The association of MEWS with future mortality was not statistically significant (P=0.0107). A misclassification rate of 0.29 (CI 0.24 to 0.35) was observed with this association. Conclusion: MEWS provided no clinical benefit as an early warning system, as mortality was elevated throughout the MEWS scale in this clinical setting. The high misclassification rate indicates MEWS does not provide discriminatory support for patients at risk for mortality.

Nurses' Influence on Patient Wellbeing: Noise Reduction and Sunshine Therapy.

This article describes 2 nurse-driven programs that aimed to improve patient wellbeing and decrease ICU stressors to improve the ICU experience. One program addressed noise reduction and the other describes Sunshine Therapy.

Tele-Critical Care: An Update From the Society of Critical Care Medicine Tele-ICU Committee.

OBJECTIVES: In 2014, the Tele-ICU Committee of the Society of Critical Care Medicine published an article regarding the state of ICU telemedicine, one better defined today as tele-critical care. Given the rapid evolution in the field, the authors now provide an updated review. DATA SOURCES AND STUDY SELECTION: We searched PubMed and OVID for peer-reviewed literature published between 2010 and 2018 related to significant developments in tele-critical care, including its prevalence, function, activity, and technologies. Search terms included electronic ICU, tele-ICU, critical care telemedicine, and ICU telemedicine with appropriate descriptors relevant to each sub-section. Additionally, information from surveys done by the Society of Critical Care Medicine was included given the relevance to the discussion and was referenced accordingly. DATA EXTRACTION AND DATA SYNTHESIS: Tele-critical care continues to evolve in multiple domains, including organizational structure, technologies, expanded-use case scenarios, and novel applications. Insights have been gained in economic impact and human and organizational factors affecting tele-critical care delivery. Legislation and credentialing continue to significantly influence the pace of tele-critical care growth and adoption. CONCLUSIONS: Tele-critical care is an established mechanism to leverage critical care expertise to ICUs and beyond, but systematic research comparing different models, approaches, and technologies is still needed.

Describing advanced practice provider roles within critical care teams with Tele-ICUs: Exemplars from seven US health systems.

Telehealth is an acknowledged strategy to meet patient healthcare needs. In critical care settings, Tele-ICU's are expanding to deliver clinical services across a diverse spectrum of critically ill patients. The expansion of telehealth provides increased opportunities for advanced practice providers including advanced practice nurses and physician assistants; however, limited information on roles and models of care for advanced practice providers in telehealth exist. This article reviews current and evolving roles for advanced practice providers in telehealth in acute and critical care settings across 7 healthcare systems in the United States. The health system exemplars described in this article identify the important role of advanced practice providers in providing patient care oversight and in improving outcomes for acute and critically ill patients. As telehealth continues to expand, additional opportunities will lead to novel roles for advanced practice providers in the field of telehealth to assist with patient care management for subacute, acute, and critically ill patients.

Infections in the Intensive Care Unit: Posttransplant Infections.

Solid organ transplantation has become a well-established standard of care for end-organ failure, and the nurse in the intensive care unit may be exposed to these patients at any stage in the care continuum of pretransplant or posttransplant care. Knowledge of risk factors, timing, and treatments for infections may help to enhance clinical practices and optimize patient safety and clinical outcomes.

Sepsis Update: A New Core Measure of Quality.

This column provides an update on the current literature related to sepsis as a new quality core measure. Sepsis care for adult patients in the acute care setting is outlined. J Contin Educ Nurs. 2016;47(5):204-206.

Using quality improvement principles to improve the care of patients with severe sepsis and septic shock.

BACKGROUND: Sepsis, an inflammatory response to an infection that may lead to severe organ dysfunction and death, is the leading cause of death in medical intensive care units. The Society of Critical Care Medicine has issued guidelines and promoted protocols to improve the management of patients with severe sepsis and septic shock. Generally, the medical community has been slow to adopt these guidelines because of the system challenges associated with protocol implementation. We describe an interdisciplinary team approach to the development and implementation of management protocols for treating patients with severe sepsis and septic shock. METHODS: To determine the effectiveness of the bundled emergency department and critical care order sets developed by the Sepsis Steering Committee, we performed a case review of 1,105 sequential patients admitted to a large academic tertiary referral hospital with a diagnosis of severe sepsis or septic shock between July 2008 and January 2012. RESULTS: Implementation of the protocol led to improved order set use over time, a significant decrease in the median time to antibiotics of 140 (range 1-820) minutes in 2008 to 72 (range 1-1,020) minutes in 2011 (P≤0.001), and a decrease in median length of stay from 8 days (range 1-54) in 2008 to 7 days (range 1-33) in 2011 (P=0.036). CONCLUSION: A multidisciplinary team approach to sepsis management using protocols and early goal-directed therapy is feasible in a large academic medical center to improve the process of care and outcomes.

Rapid response systems update.

Rapid response is a mature concept that is undergoing metamorphosis. The ideal structure and function of these safety teams has not yet been realized but new developments in the field of rapid response systems are evolving.

Crossing the quality chasm: it takes a team to build the bridge.

The paradigm shifts in healthcare delivery now more than ever call for interdisciplinary teamwork to deliver the best patient care. The lessons from the Institute of Medicine's To Err Is Human: Building a Safer Health System report are painful but elucidate the problems with training and working in silos and the consequent inconsistent communication between healthcare providers. We review the literature regarding interprofessional training and describe some strategies and innovations. This article proposes that healthcare professional schools embed interprofessional education into the curriculum to meet the challenges of providing high-quality, efficient, and safe patient care.

Keeping the sickest patients safer: telemedicine and critical care.

Telemedicine in critical care offers opportunities to improve quality and safety by connecting bedside care teams with off-site tele-ICU staff using advanced software and continuous remote monitoring technology. This leads to more proactive care, fewer complications, and timely decisions regarding care.

Nurses' critical role in identifying sepsis and implementing early goal-directed therapy.

Nurses play a critical role in detecting early sepsis-related manifestations and improving adherence to implementation of early goal-directed therapy. Educating staff about sepsis management through translation of best practices is critical to improving sepsis-related outcomes.

Improving sepsis outcomes for acutely ill adults using interdisciplinary order sets.

PURPOSE/OBJECTIVE: The objective of the study was to measure outcomes following implementation of standardized order sets for managing patients with severe sepsis/septic shock. BACKGROUND/RATIONALE: Sepsis is a severe illness, affecting approximately 750 000 people in the United States, with mortality rates of 28% to 50%, and costing $17 billion each year. PROJECT DESCRIPTION: An interdisciplinary team was created to improve early recognition and process of care in patients with severe sepsis/septic shock. Education was rolled out over 6 months, and sepsis "bundle" order sets were implemented. SETTING AND SAMPLE: Adult patients (N = 674) with a diagnosis of severe sepsis or septic shock who were admitted to an emergency department or critical care unit at a 563-bed tertiary care teaching facility from May 2008 through October 2010 were included in data analysis. METHODS: A plan, do, study, act methodology was used. Outcomes following project implementation were measured prospectively including appropriate recognition of patients with a diagnosis of sepsis, hospital site where the order set was initiated, and attainment of treatment goals within 6 hours of onset of severe sepsis/septic shock. FINDINGS: When order set usage was analyzed, the use of order sets was significantly associated with meeting "6-hour goals" successfully (χ1 [n = 662] = 36.16, P < .001); order set usage explained 24% of the variation in meeting goals, R = 0.24, F1,661 = 38.51, P < .0001. CONCLUSIONS: Order sets improved management of septic patients through effective change in delivery systems to support evidence-based medical care. IMPLICATIONS FOR PRACTICE: Administrative support, team collaboration, and standardized order sets can lead to improved process of care.