An innovative programme to track and address burnout in physician trainees.

BACKGROUND: There is a call to action for health care systems to assess and address burnout among physician trainees. To address this need for programmatic change, we developed a novel initiative to (1) proactively assess trainee burnout and identify drivers and (2) provide resources and recommendations for preventing and reducing burnout. APPROACH: This pilot burnout tracking initiative began in 2020. A two-question burnout survey was disseminated to physician trainees at a hospital devoted exclusively to clinical research. The survey assessed burnout level and drivers of burnout. An algorithm was created to recommend action steps based on trainee responses. Participating training programmes completed a 23-question survey annually to provide information about their trainees and feedback. EVALUATION: Seven of 10 (70%) programmes completed the annual survey in the first year, and 12 of the 15 (80%) programmes completed it the second year. Reported average burnout levels and drivers of burnout varied across programmes; all drivers of burnout were cited as key drivers by at least one programme. Most programmes had conversations with their trainees and found these conversations helpful. All responding programmes who administered the trainee survey felt the initiative improved their ability to track and reduce burnout. IMPLICATIONS: An initiative to systematically track burnout levels and offer targeted interventions was feasible and useful. This project can be a model for institution-wide efforts to address trainee burnout and extend to other clinical health care settings and academic medicine faculty.

Interprofessional Care and Teamwork in the ICU.

OBJECTIVES: We describe the importance of interprofessional care in modern critical care medicine. This review highlights the essential roles played by specific members of the interprofessional care team, including patients and family members, and discusses quality improvement initiatives that require interprofessional collaboration for success. DATA SOURCES: Studies were identified through MEDLINE search using a variety of search phrases related to interprofessional care, critical care provider types, and quality improvement initiatives. Additional articles were identified through a review of the reference lists of identified articles. STUDY SELECTION: Original articles, review articles, and systematic reviews were considered. DATA EXTRACTION: Manuscripts were selected for inclusion based on expert opinion of well-designed or key studies and review articles. DATA SYNTHESIS: "Interprofessional care" refers to care provided by a team of healthcare professionals with overlapping expertise and an appreciation for the unique contribution of other team members as partners in achieving a common goal. A robust body of data supports improvement in patient-level outcomes when care is provided by an interprofessional team. Critical care nurses, advanced practice providers, pharmacists, respiratory care practitioners, rehabilitation specialists, dieticians, social workers, case managers, spiritual care providers, intensivists, and nonintensivist physicians each provide unique expertise and perspectives to patient care, and therefore play an important role in a team that must address the diverse needs of patients and families in the ICU. Engaging patients and families as partners in their healthcare is also critical. Many important ICU quality improvement initiatives require an interprofessional approach, including Awakening and Breathing Coordination, Delirium, Early Exercise/Mobility, and Family Empowerment bundle implementation, interprofessional rounding practices, unit-based quality improvement initiatives, Patient and Family Advisory Councils, end-of-life care, coordinated sedation awakening and spontaneous breathing trials, intrahospital transport, and transitions of care. CONCLUSIONS: A robust body of evidence supports an interprofessional approach as a key component in the provision of high-quality critical care to patients of increasing complexity and with increasingly diverse needs.

Preventing Harm in the ICU-Building a Culture of Safety and Engaging Patients and Families.

OBJECTIVE: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. DATA SOURCES: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. STUDY SELECTION: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. DATA EXTRACTION: Our group determined by consensus which resources would best inform this review. DATA SYNTHESIS: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. CONCLUSIONS: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Predicting mortality in the intensive care unit: a comparison of the University Health Consortium expected probability of mortality and the Mortality Prediction Model III.

BACKGROUND: Quality benchmarks are increasingly being used to compare the delivery of healthcare, and may affect reimbursement in the future. The University Health Consortium (UHC) expected probability of mortality (EPM) is one such quality benchmark. Although the UHC EPM is used to compare quality across UHC members, it has not been prospectively validated in the critically ill. We aimed to define the performance characteristics of the UHC EPM in the critically ill and compare its ability to predict mortality with the Mortality Prediction Model III (MPM-III). METHODS: The first 100 consecutive adult patients discharged from the hospital (including deaths) each quarter from January 1, 2009 until September 30, 2011 that had an intensive care unit (ICU) stay were included. We assessed model discrimination, calibration, and overall performance, and compared the two models using Bland-Altman plots. RESULTS: Eight hundred ninety-one patients were included. Both the UHC EPM and the MPM-III had excellent performance (Brier score 0.05 and 0.06, respectively). The area under the curve was good for both models (UHC 0.90, MPM-III 0.87, p = 0.28). Goodness of fit was statistically significant for both models (UHC p = 0.002, MPM-III p = 0.0003), but improved with logit transformation (UHC p = 0.41; MPM-III p = 0.07). The Bland-Altman plot showed good agreement at extremes of mortality, but agreement diverged as mortality approached 50 %. CONCLUSIONS: The UHC EPM exhibited excellent overall performance, calibration, and discrimination, and performed similarly to the MPM-III. Correlation between the two models was poor due to divergence when mortality was maximally uncertain.

An analysis of near misses identified by anesthesia providers in the intensive care unit.

BACKGROUND: Learning from adverse events and near misses may reduce the incidence of preventable errors. Current literature on adverse events and near misses in the ICU focuses on errors reported by nurses and intensivists. ICU near misses identified by anesthesia providers may reveal critical events, causal mechanisms and system weaknesses not identified by other providers, and may differ in character and causality from near misses in other anesthesia locations. METHODS: We analyzed events reported to our anesthesia near miss reporting system from 2009 to 2011. We compared causative mechanisms of ICU near misses with near misses in other anesthesia locations. RESULTS: A total of 1,811 near misses were reported, of which 22 (1.2 %) originated in the ICU. Five causal mechanisms explained over half of ICU near misses. Compared to near misses from other locations, near misses from the ICU were more likely to occur while on call (45 % vs. 19 %, p = 0.001), and were more likely to be associated with airway management (50 % vs. 12 %, p < 0.001). ICU near misses were less likely to be associated with equipment issues (23 % vs. 48 %, p = 0.02). CONCLUSIONS: A limited number of causal mechanisms explained the majority of ICU near misses, providing targets for quality improvement. Errors associated with airway management in the ICU may be underappreciated. Specialist consultants can identify systems weaknesses not identified by critical care providers, and should be engaged in the ICU patient safety movement.

Acquired neuromuscular weakness and early mobilization in the intensive care unit.

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

Is antral follicle count a genetic trait?

OBJECTIVE: The aim of this study was to determine the relationship between maternal age of menopause and antral follicle count. METHODS: This was a cross-sectional study of 124 women aged 25 to 48 years presenting with infertility. Women reported their mother's age of menopause and underwent transvaginal ultrasound to assess antral follicle count. Participant age, age greater than 37 years, and maternal age of menopause, as well as interactions among these, were incorporated into a multiple linear regression model to predict antral follicle count. Three different ages of maternal menopause were inputted into this model to illustrate the relationship between maternal age of menopause and rate of decline in antral follicle count. RESULTS: Women with a lower maternal age of menopause have lower antral follicle counts but also a slower decline until the age of 37 years. CONCLUSIONS: Maternal age of menopause predicts antral follicle count and its decline, indicating a genetic component to this trait.

Perioperative glycemic control: an evidence-based review.

Hyperglycemia in perioperative patients has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to reduce morbidity and mortality among the critically ill, decrease infection rates and improve survival after cardiac surgery, and improve outcomes in acute neurologic injury and acute myocardial infarction. However, recent evidence of severe hypoglycemia and adverse events associated with IIT brings its safety and efficacy into question. In this article, we summarize the mechanisms and rationale of hyperglycemia and IIT, review the evidence behind the use of IIT in the perioperative period, and discuss the implications of including glycemic control in national quality benchmarks. We conclude that while avoidance of hyperglycemia is clearly beneficial, the appropriate glucose target and specific subpopulations who might benefit from IIT have yet to be identified. Given the potential for harm, inclusion of glucose targets in national quality benchmarks is premature.

Strategies for success: A PDSA analysis of three QI initiatives in critical care.

BACKGROUND: Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness. LESSONS LEARNED: A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality. CONCLUSIONS: The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.

Medication errors associated with code situations in U.S. hospitals: direct and collateral damage.

A retrospective analysis of 842 medication errors related to code situations revealed that "collateral damage" errors accounted for 74% of all code-related errors, whereas 21% involved patients directly experiencing codes.