Intensive Care Unit Clinicians Research Articles

Impact of the Neonatal Resuscitation Video Review program for neonatal staff: a qualitative analysis.

Neonatal resuscitation video review (NRVR) involves recording and reviewing resuscitations for education and quality assurance. Though NRVR has been shown to improve teamwork and skill retention, it is not widely used. We evaluated clinicians' experiences of NRVR to understand how NRVR impacts learning and can be improved. Neonatal Intensive Care Unit (NICU) clinicians with previous NRVR experience were recruited for individual semi-structured interviews. Using a social constructivist viewpoint, five researchers used thematic analysis to analyze participant responses. Twenty-two clinicians (11 nurses, 11 doctors) were interviewed. All participants expressed positive attitudes towards NRVR. Four themes were identified: (1) Learning from reality-exposure to real-life resuscitations was highly clinically relevant. (2) Immersive self-regulation-watching videos aided recall and reflection. (3) Complexities in learner psychological safety-all participants acknowledged viewing NRVR videos could be confronting. Some expressed fear of judgment from colleagues, though the educational benefit of NRVR superseded this. (4) Accessing and learning from diverse vantage points-NRVR promoted group discussion, which prompted participant learning from colleagues' viewpoints. Neonatal clinicians reported NRVR to be an effective and safe method for learning and refining skills required during neonatal resuscitation, such as situational awareness and communication. Neonatal resuscitation video review is not known to be widely used in neonatal resuscitation teaching, and published research in this area is limited. Our study examined clinician attitudes towards an established neonatal resuscitation video review program. We found strong support for teaching using neonatal resuscitation video review among neonatal doctors and nurses, with key benefits including increased situational awareness and increased clinical exposure to resuscitations, while maintaining psychological safety for participants. The results of this study add evidence to support the addition of video review to neonatal resuscitation training.

Reducing administrative burden by implementing a core set of quality indicators in the ICU: a multicentre longitudinal intervention study

BackgroundThe number of quality indicators for which clinicians need to record data is increasing. For many indicators, there are concerns about their efficacy. This study aimed to determine whether working...

"It's all about setting the stage." The nurse facilitator trial: perceived outcomes and implementation issues. A qualitative study among ICU clinicians and nurse facilitators.

For the first time in France, a randomised controlled trial was conducted to evaluate the impact of a nurse facilitator on family psychological symptoms. We sought to explore the implementation of the intervention, how it was experienced by clinicians, as well as the barriers and facilitators to implementing the change. We conducted qualitative semi-structured interviews with intensive care unit (ICU) clinicians and facilitators involved in the trial. Interview questions focused on participants' perceptions of the intervention and its outcomes, including the effect of the intervention on patients, families and the health care team, and barriers and facilitators to its implementation. Interviews were conducted by two social science researchers, audio recorded, transcribed, and analyzed using thematic content analysis. Twenty-three clinicians were interviewed from the five participating ICUs. Three themes emerged, capturing clinicians' perspectives on implementing the intervention: (1) improved communication and enhanced care for families and the ICU team, albeit with some associated risks; (2) active listening and support, both for families and ICU clinicians but with certain limitations; (3) barriers to implementation including lack of organizational readiness, exclusion of under-represented groups, and facilitator challenges including role ambiguity and the need for role support. Participants believed the facilitator intervention potentially improved families' experience. However, they also highlighted emotional difficulties and tensions with some members of the participating teams, due to competing territories and ambiguous role definitions. Facilitators' failure to affect decision-making suggests their role in enhancing goal-concordant care was inadequate within the setting.

Looking to "Level the Field": A Qualitative Study of How Clinicians Operationalize Social Determinants in Critical Care.

Current critical care practice does not integrate social determinants of health (SDOH) in systematic or standardized ways. Routine assessment of SDOH in the intensive care unit (ICU) may improve clinical decision-making, patient- and family-centered outcomes, and clinician well-being. Given the appropriateness and feasibility of SDOH assessment in the ICU is unknown, we aimed to understand how ICU clinicians think about and use SDOH. We conducted semi-structured interviews with clinicians focused on barriers to and facilitators of assessing SDOH during critical illness and perceptions on screening for SDOH in the ICU. We used chart-stimulated recall to assist clinicians in reflecting on how SDOH applied to and was used in patients' care. After deidentifying interviews, we analyzed transcripts guided by a thematic analysis approach using a combination of inductive and deductive coding, the latter framed within the Centers for Disease Control SDOH Healthy People framework. We completed interviews with 30 clinicians, in a variety of professional roles. The majority of clinicians self-identified as men (17, 56.7%) of White race (25, 83.3%). Clinicians contextualize their use of SDOH within three frames of reference: 1) their own identity and experiences; 2) their relationships and communication with patients and caregivers; and 3) immediate structures of care around ICU patients including clinician advocacy, care transitions, and readmission. Clinicians identified that discussing SDOH could allow them to recognize bias faced by their patients, elucidate drivers of critical illness, and navigate communication with patients caregivers. Clinicians worried about ICU-specific factors impeding the discussion of SDOH including time contraints and acuity, high stakes and emotions, and negative anticipatory emotions. Clinicians gather SDOH during critical illness both to understand their patients' stories and provide individualized care, which may lead to better clinician satisfaction and patient- and family-centered care outcomes. Educational and operational efforts to increase SDOH assessment and use in critical care should also gather and integrate the perspectives of patients and caregivers regarding the collection and use of SDOH in the ICU.

“I'm completely off base here on what this child is capable of”: A qualitative analysis of how medical ableism manifests in PICU clinicians' care of children with severe neurological impairment

BackgroundChildren with severe neurological impairment (SNI) are at heightened risk of experiencing medical ableism from clinicians in the pediatric intensive care unit (PICU), where barriers such as time scarcity and heavy workloads limit clinicians’ ability to provide personalized care. ObjectiveTo examine medical ableism and strategies to support PICU clinicians in understanding the lives of children with SNI and their families. MethodsThis US-based, single-center, qualitative study included PICU clinicians identified by the parents/caregivers of a child with SNI. Semi-structured 1:1 60-min interviews about the challenges of caring for children with SNI were conducted virtually. Coded data were extracted, thematically analyzed, and further conceptualized using the Dual Process Theory (DPT) bias reduction framework. ResultsNineteen PICU clinicians participated. Three major themes emerged: 1) assumptions and misconceptions about children with SNI and their families, 2) barriers to providing personalized care, and 3) clinician-suggested strategies to honor the lives of children with SNI. These themes aligned with the DPT framework. As outlined in the DPT, system 1 “fast thinking” errors occur when quick observations inform decisions (e.g., snap judgments about a child's capabilities). Second, barriers (e.g., insufficient time for meaningful interactions) may prevent clinicians from providing unbiased care. Third, system 2 “slow thinking,” where complex decision-making occurs, and can be enhanced through personalization strategies (e.g., viewing visuals of the child at baseline health). ConclusionsIncreasing clinician awareness of their potential implicit biases and utilizing bias reduction strategies to mitigate medical ableism in care are critical areas for future research.

STOPTHEBURN: A Randomized Controlled Trial of Death Cafés for Burnout Prevention in ICU Employees.

Effective interventions to prevent burnout among intensive care unit (ICU) clinicians are urgently needed. Death Cafés, group discussions about death, build a sense of community and create a space for reflection on distressing events. To assess whether participation in regular Death Cafés can prevent burnout in ICU clinicians (physicians, nurses, pharmacists, therapists). A randomized clinical trial was conducted from July 2020-December 2022 in ten ICUs in Louisiana. Subjects were randomized to attend four psychotherapist-facilitated, virtual Death Cafés or to a control arm. The primary outcome was burnout defined by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS) at 6 months. Depression and anxiety scores were measured as well as qualitative data on stressors, coping, and Death Café experience. Among 340 clinicians screened and consented (171 physicians; 169 non-physicians), 251 participated (mean age 31.06.8 years, 63% female, 72% white, 37% nurses, 27% residents, 25% interns, 11% other). Burnout prevalence was 19% at baseline. Of 136 participants who completed 6-month follow-up, no significant differences were found between intervention and control for the primary outcome (18% versus 25%, unadjusted OR 0.64 [95% CI 0.26-1.57], p=0.33). There were no differences in anxiety or depression. Notably, the study was limited by an inability to achieve target enrollment and high attrition rate (46%). Virtual Death Cafés were unable to reduce burnout, although the study was underpowered to detect differences between groups. Clinical trial registered with Clinicaltrials.gov (NCT04347811).

Human-AI Teaming in Critical Care: A Comparative Analysis of Data Scientists' and Clinicians' Perspectives on AI Augmentation and Automation.

Artificial intelligence (AI) holds immense potential for enhancing clinical and administrative health care tasks. However, slow adoption and implementation challenges highlight the need to consider how humans can effectively collaborate with AI within broader socio-technical systems in health care. In the example of intensive care units (ICUs), we compare data scientists' and clinicians' assessments of the optimal utilization of human and AI capabilities by determining suitable levels of human-AI teaming for safely and meaningfully augmenting or automating 6 core tasks. The goal is to provide actionable recommendations for policy makers and health care practitioners regarding AI design and implementation. In this multimethod study, we combine a systematic task analysis across 6 ICUs with an international Delphi survey involving 19 health data scientists from the industry and academia and 61 ICU clinicians (25 physicians and 36 nurses) to define and assess optimal levels of human-AI teaming (level 1=no performance benefits; level 2=AI augments human performance; level 3=humans augment AI performance; level 4=AI performs without human input). Stakeholder groups also considered ethical and social implications. Both stakeholder groups chose level 2 and 3 human-AI teaming for 4 out of 6 core tasks in the ICU. For one task (monitoring), level 4 was the preferred design choice. For the task of patient interactions, both data scientists and clinicians agreed that AI should not be used regardless of technological feasibility due to the importance of the physician-patient and nurse-patient relationship and ethical concerns. Human-AI design choices rely on interpretability, predictability, and control over AI systems. If these conditions are not met and AI performs below human-level reliability, a reduction to level 1 or shifting accountability away from human end users is advised. If AI performs at or beyond human-level reliability and these conditions are not met, shifting to level 4 automation should be considered to ensure safe and efficient human-AI teaming. By considering the sociotechnical system and determining appropriate levels of human-AI teaming, our study showcases the potential for improving the safety and effectiveness of AI usage in ICUs and broader health care settings. Regulatory measures should prioritize interpretability, predictability, and control if clinicians hold full accountability. Ethical and social implications must be carefully evaluated to ensure effective collaboration between humans and AI, particularly considering the most recent advancements in generative AI.

Mechanical ventilation management and airway pressure release ventilation practice in acute respiratory distress syndrome: A cross‐sectional survey of intensive care unit clinicians in mainland China

Mechanical ventilation management and airway pressure release ventilation practice in acute respiratory distress syndrome: A cross‐sectional survey of intensive care unit clinicians in mainland China

Palliative Care in the Intensive Care Unit: The Standard of Care

Intensive care unit–based palliative care has evolved over the past 30 years due to the efforts of clinicians, researchers, and advocates for patient-centered care. Although all critically ill patients inherently have palliative care needs, the path was not linear but rather filled with the challenges of blending the intensive care unit goals of aggressive treatment and cure with the palliative care goals of symptom management and quality of life. Today, palliative care is considered an essential component of high-quality critical care and a core competency of all critical care nurses, advanced practice nurses, and other intensive care unit clinicians. This article provides an overview of the current state of intensive care unit–based palliative care, examines how the barriers to such care have shifted, reviews primary and specialist palliative care, addresses the impact of COVID-19, and presents resources to help nurses and intensive care unit teams achieve optimal outcomes.

“How to navigate this new area”: Intensive care clinicians’ perceptions of voluntary assisted dying in the intensive care unit: A multisite exploratory study

BackgroundThere is growing momentum worldwide for assisted dying. In Australia, voluntary assisted dying may occur in any setting, including an intensive care unit (ICU). As the subject of much debate worldwide, exploring ICU clinicians’ perceptions of assisted dying is essential. AimThe aim of this study was to explore clinicians’ perceptions of and preparedness for voluntary assisted dying in the ICU. MethodAn exploratory qualitative descriptive design using individual interviews was used. Medical, nursing, and allied health clinicians from three ICUs were recruited. Interviews were conducted between Nov 2022 and Jan 2023, with a hypothetical scenario about voluntary assisted dying used to prompt discussion. Interviews were recorded, professionally transcribed, and analysed using inductive content analysis. FindingsICU registered nurses (n = 20), physicians (n = 2), and allied health clinicians (n = 4) participated with interviews lasting 18–45 min (mean: 28 min). Analysis revealed four themes: (i) purpose of ICU reflected that ICU care was not all about saving lives, yet recognising dying and changing priorities was challenging; (ii) dying in the ICU is complex due to difficulties in talking about dying, accepting death as the outcome and evaluating care efficacy; (iii) voluntary assisted dying is a lot of grey because of perceived clinical and ethicolegal challenges; and finally, (iv) respecting choice was about respecting patients' values, beliefs, and autonomy, as well as clinicians’ beliefs and right to exercise autonomy through conscientious objection. ConclusionDying and death are inevitable, and views and perspectives about assisted dying will continue to evolve. Respecting patient choice is at the core of assisted dying, but respecting clinicians’ perspectives and choice is equally important. With voluntary assisted dying now legal in all Australian states, ensuring ICU team and individual clinician preparedness through access to education, resources, and specialist support services is key to raising awareness and easing uncertainty about deaths through voluntary assisted dying.

ICU Staffing in the United States

BackgroundThe last national estimates of US intensive care unit (ICU) physician staffing are 25 years old and lack information about interprofessional teams. Research QuestionHow are US adult ICUs currently staffed? Study Design and MethodsWe conducted a cross-sectional survey (05/04/2022-02/02/2023) of adult ICU clinicians (targeting nurse/physician leadership) contacted using 2020 American Hospital Association (AHA) database information and, secondarily, through professional organizations. The survey included questions about interprofessional ICU staffing availability and roles at steady-state (pre-COVID-19). We linked survey data to hospital data in the AHA database to create weighted national estimates by extrapolating ICU staffing data to non-respondent hospitals based on hospital characteristics. ResultsThe cohort consisted of 596 adult ICUs (response rates—AHA contacts: 2.1%; professional organizations: unknown) with geographic diversity and size variability (median [interquartile range]: 20 [12,25] beds); most cared for mixed populations (414 [69.5%]), yet medical (55 [9.2%]), surgical (70 [11.7%]), and specialty (57 [9.6%]) ICUs were well represented. 554 (93.0%) had intensivists available, with intensivists covering all patients in 75.6% of these and onsite 24 hours/day in half (53.3% weekdays; 51.8% weekends). Of all ICUs, 69.8% had physicians-in-training and 77.7% nurse practitioners/physician assistants. For mechanically ventilated patients, nurse:patient ratios were 1:2 in 89.6%. Clinical pharmacists were available in 92.6%, and respiratory therapists in 98.8%. We estimated 85.1% (95% confidence interval: 85.7%, 84.5%) of hospitals nationally had ICUs with intensivists, 51.6% (50.6%, 52.5%) with physicians-in-training, 72.1% (71.3%, 72.9%) with nurse practitioners/physician assistants, 98.5% (98.4%, 98.7%) with respiratory therapists, and 86.9% (86.4%, 87.4%) with clinical pharmacists. For mechanically ventilated patients, 86.4% (85.8%, 87.0%) used 1:2 nurses:patients. InterpretationIntensivist presence in adult US ICUs has greatly increased over 25 years. Intensivists, respiratory therapists, and clinical pharmacists are commonly available, and each nurse usually provides care for two mechanically ventilated patients. However, team composition and workload vary.

Antimicrobial therapeutic drug monitoring in critically ill adult patients – An international perspective on access, utilisation, and barriers

BackgroundTherapeutic drug monitoring (TDM) is an effective method for individualising antimicrobial therapy in critically ill patients. The 2021 ADMIN-intensive care unit survey studied a wide range of intensive care unit clinicians worldwide to gain their perspectives on antimicrobial TDM. This article reports the responses from this survey relating to TDM access, utilisation, and barriers. MethodsAn online survey consisted of multiple-choice questions and 5-point Likert scales. The survey examined respondent's access to minimum inhibitory concentration (MIC) results, drug assays, and dosing software, as well as barriers to TDM. ResultsThe survey included 538 clinicians from 409 hospitals in 45 countries, with 71% physicians and 29% pharmacists. Despite most respondents having access to assays, 21% and 26% of respondents lacked access to vancomycin and aminoglycosides, respectively. In lower-income countries, almost 40% reported no access. Delayed drug assay turnaround time was the most significant barrier to TDM, particularly in lower-income countries. Routine access to MIC results was unavailable for 41% of respondents, with 25% of lower-income country respondents having no access to MIC or susceptibility reports. ConclusionsThis global survey indicated that consistent TDM usage is hindered by assay access in some sites and the timeliness of assay results in others. Addressing barriers to TDM, particularly in low-income countries, should be a priority to ensure equitable access to affordable TDM.

The current state of intensive care unit discharge practices - Results of an international survey study.

Increasing pressure on limited intensive care capacities often requires a subjective assessment of a patient's discharge readiness in the absence of established Admission, Discharge, and Transfer (ADT) guidelines. To avoid suboptimal care transitions, it is important to define clear guidelines for the admission and discharge of intensive care patients and to optimize transfer processes between the intensive care unit (ICU) and lower care levels. To achieve these goals, structured insights into usual ICU discharge and transfer practices are essential. This study aimed to generate these insights by focusing on involved stakeholders, established processes, discharge criteria and tools, relevant performance metrics, and current barriers to a timely and safe discharge. In 2022, a structured, web-based, anonymous cross-sectional survey was conducted, aimed at practicing ICU physicians, nurses, and bed coordinators. The survey consisted of 29 questions (open, closed, multiple choice, and scales) that were divided into thematic blocks. The study was supported by several national and international societies for intensive care medicine and nursing. A total of 219 participants from 40 countries (105 from Germany) participated in the survey. An overload of acute care resources with ~90% capacity utilization in the ICU and the general ward (GW) leads to not only premature but also delayed patient transfers due to a lack of available ward and intermediate care (IMC) beds. After multidisciplinary rounds within the intensive care team, the ICU clinician on duty usually makes the final transfer decision, while one-third of the panel coordinates discharge decisions across departmental boundaries. By the end of the COVID-19 pandemic, half of the hospitals had implemented ADT policies. Among these hospitals, nearly one-third of the hospitals had specific transfer criteria established, consisting primarily of vital signs and laboratory data, patient status and autonomy, and organization-specific criteria. Liaison nurses were less common but were ranked right after the required IMC capacities to bridge the care gap between the ICU and normal wards. In this study, 80% of the participants suggested that transfer planning would be easier if there was good transparency regarding the capacity utilization of lower care levels, a standardized transfer process, and improved interdisciplinary communication. To improve care transitions, transfer processes should be managed proactively across departments, and efforts should be made to identify and address care gaps.

Centralized Multipatient Dashboards' Impact on Intensive Care Unit Clinician Performance and Satisfaction: A Systematic Review.

Intensive care unit (ICU) clinicians encounter frequent challenges with managing vast amounts of fragmented data while caring for multiple critically ill patients simultaneously. This may lead to increased provider cognitive load that may jeopardize patient safety. This systematic review assesses the impact of centralized multipatient dashboards on ICU clinician performance, perceptions regarding the use of these tools, and patient outcomes. A literature search was conducted on February 9, 2023, using the EBSCO CINAHL, Cochrane Central Register of Controlled Trials, Embase, IEEE Xplore, MEDLINE, Scopus, and Web of Science Core Collection databases. Eligible studies that included ICU clinicians as participants and tested the effect of dashboards designed for use by multiple users to manage multiple patients on user performance and/or satisfaction compared with the standard practice. We narratively synthesized eligible studies following the SWiM (Synthesis Without Meta-analysis) guidelines. Studies were grouped based on dashboard type and outcomes assessed. The search yielded a total of 2,407 studies. Five studies met inclusion criteria and were included. Among these, three studies evaluated interactive displays in the ICU, one study assessed two dashboards in the pediatric ICU (PICU), and one study examined centralized monitor in the PICU. Most studies reported several positive outcomes, including reductions in data gathering time before rounds, a decrease in misrepresentations during multidisciplinary rounds, improved daily documentation compliance, faster decision-making, and user satisfaction. One study did not report any significant association. The multipatient dashboards were associated with improved ICU clinician performance and were positively perceived in most of the included studies. The risk of bias was high, and the certainty of evidence was very low, due to inconsistencies, imprecision, indirectness in the outcome measure, and methodological limitations. Designing and evaluating multipatient tools using robust research methodologies is an important focus for future research.

A common data model for the standardization of intensive care unit medication features.

Common data models provide a standard means of describing data for artificial intelligence (AI) applications, but this process has never been undertaken for medications used in the intensive care unit (ICU). We sought to develop a common data model (CDM) for ICU medications to standardize the medication features needed to support future ICU AI efforts. A 9-member, multi-professional team of ICU clinicians and AI experts conducted a 5-round modified Delphi process employing conference calls, web-based communication, and electronic surveys to define the most important medication features for AI efforts. Candidate ICU medication features were generated through group discussion and then independently scored by each team member based on relevance to ICU clinical decision-making and feasibility for collection and coding. A key consideration was to ensure the final ontology both distinguished unique medications and met Findable, Accessible, Interoperable, and Reusable (FAIR) guiding principles. Using a list of 889 ICU medications, the team initially generated 106 different medication features, and 71 were ranked as being core features for the CDM. Through this process, 106 medication features were assigned to 2 key feature domains: drug product-related (n = 43) and clinical practice-related (n = 63). Each feature included a standardized definition and suggested response values housed in the electronic data library. This CDM for ICU medications is available online. The CDM for ICU medications represents an important first step for the research community focused on exploring how AI can improve patient outcomes and will require ongoing engagement and refinement.

Impact of COVID-19-related restricted family presence policies on Canadian pediatric intensive care unit clinicians: a qualitative study

PurposePediatric intensive care units (PICUs) worldwide restricted family presence in response to the COVID-19 pandemic. We aimed to explore the experiences and impact of restricted family presence policies on Canadian PICU clinicians.MethodsWe conducted a qualitative study that followed an interpretive phenomenological design. Participants were PICU clinicians providing direct patient care in Canada during periods of COVID-19-related restricted family presence. We purposively sampled for maximum variation among survey participants who consented to be contacted for further research on the same topic. In-depth interviews were conducted remotely via telephone or video-call, audio-recorded, and transcribed. Interviews were inductively coded and underwent thematic analysis. Proposed themes were member-checked by interviewees.ResultsSixteen PICU clinicians completed interviews. Interviewees practiced across Canada, represented a range of disciplines (eight nurses, two physicians, two respiratory therapists, two child life specialists, two social workers) and years in profession (0–34 years). We identified four themes representing the most meaningful aspects of restricted family presence for participants: 1) balancing infection control and family presence; 2) feeling disempowered by hospital and policy-making hierarchies; 3) empathizing with family trauma; and 4) navigating threats to the therapeutic relationship.ConclusionPediatric intensive care unit clinicians were impacted by restricted family presence policies during the COVID-19 pandemic. These policies contributed to feelings of disempowerment and challenged clinicians’ perceived ability to provide the best family-centred care possible. Frontline expertise should be incorporated into the design and implementation of policies to best support family-centred care in any context and minimize risks of moral distress for PICU clinicians.

Factors Influencing Integration and Usability of Model-Informed Precision Dosing Software in the Intensive Care Unit.

Antimicrobial dosing in critically ill patients is challenging and model-informed precision dosing (MIPD) software may be used to optimize dosing in these patients. However, few intensive care units (ICU) currently adopt MIPD software use. To determine the usability of MIPD software perceived by ICU clinicians and identify implementation barriers and enablers of software in the ICU. Clinicians (pharmacists and medical staff) who participated in a wider multicenter study using MIPD software were invited to participate in this mixed-method study. Participants scored the industry validated Post-study System Usability Questionnaire (PSSUQ, assessing software usability) and Technology Acceptance Model 2 (TAM2, assessing factors impacting software acceptance) survey. Semistructured interviews were used to explore survey responses. The framework approach was used to identify factors influencing software usability and integration into the ICU from the survey and interview data. Seven of the eight eligible clinicians agreed to participate in the study. The PSSUQ usability scores ranked poorer than the reference norms (2.95 vs. 2.62). The TAM2 survey favorably ranked acceptance in all domains, except image. Qualitatively, key enablers to workflow integration included clear and accessible data entry, visual representation of recommendations, involvement of specialist clinicians, and local governance of software use. Barriers included rigid data entry systems and nonconformity of recommendations to local practices. Participants scored the MIPD software below the threshold that implies good usability. Factors such as availability of software support by specialist clinicians was important to participants while rigid data entry was found to be a deterrent.

What every intensivist should know about: Trust in the ICU

Trust is an essential element in the relationship between patients and intensive care unit (ICU) clinicians. Without a foundation of trust, communication is difficult, conflict is more likely, and even clinical outcomes can be affected. The ICU is a particularly challenging environment for trust to flourish. Illness occurs suddenly, emotions can be charged, the environment is impersonal, and there is rarely a prior relationship between patients and their caregivers. Therefore, intensivists must have some understanding of the factors that impact patient and family trust, as well as the actions they can take to improve it.

Integrating Social Determinants of Health in Critical Care

BackgroundSocial determinants of health (SDOH) mediate outcomes of critical illness. Increasingly, professional organizations recommend screening for social risks. Yet, how clinicians should identify and then incorporate SDOH into acute care practice is poorly defined. Research QuestionHow do medical intensive care unit (ICU) clinicians currently operationalize SDOH within patient care, given that SDOH are known to mediate outcomes of critical illness? Study Design and MethodsUsing ethnographic methods, we observed clinical work rounds in three urban ICUs within a single academic health system to capture use of SDOH during clinical care. Adults admitted to the medical ICU with respiratory failure were prospectively sequentially enrolled. Observers wrote field notes and narrative excerpts from rounding observations. We also reviewed electronic medical record (EMR) documentation for up to 90 days following ICU admission. We then qualitatively coded and triangulated data using a constructivist grounded theory approach and the Centers for Disease Control Healthy People SDOH framework. ResultsSixty-six patients were enrolled and over 200 observation hours of clinical work rounds were included in the analysis. ICU clinicians infrequently integrated social structures of patients’ lives into their discussions. Social structures were most frequently invoked when related to: 1) etiologies of acute respiratory failure, 2) decisions on life sustaining therapies, and 3) transitions of care. There was no systematic way in which data about common SDOH were collected (e.g., food and housing insecurity) and some SDOH were rarely or never discussed (e.g., access to education, discrimination, incarceration). InterpretationClinicians do not incorporate many areas of known SDOH into ICU rounds. Improvements in integration of SDOH should leverage the multidisciplinary team, identifying who is best suited to collect information of SDOH during different timepoints in critical illness. Next steps include clinician, patient-, and caregiver-focused assessments of feasibility and acceptability of an ICU-based SDOH assessment.

More isn't always better: Technology in the intensive care unit.

Clinical care in modern intensive care units (ICUs) combines multidisciplinary expertise and a complex array of technologies. These technologies have clearly advanced the ability of clinicians to do more for patients, yet so much equipment also presents the possibility for cognitive overload. The aim of this study was to investigate clinicians' experiences with and perceptions of technology in ICUs. We analyzed qualitative data from 30 interviews with ICU clinicians and frontline managers within four ICUs. Our interviews identified three main challenges associated with technology in the ICU: (a) too many technologies and too much data; (b) inconsistent and inaccurate technologies; and (c) not enough integration among technologies, alignment with clinical workflows, and support for clinician identities. To address these challenges, interviewees highlighted mitigation strategies to address both social and technical systems and to achieve joint optimization. When new technologies are added to the ICU, they have potential both to improve and to disrupt patient care. To successfully implement technologies in the ICU, clinicians' perspectives are crucial. Understanding clinicians' perspectives can help limit the disruptive effects of new technologies, so clinicians can focus their time and attention on providing care to patients. As technology and data continue to play an increasingly important role in ICU care, everyone involved in the design, development, approval, implementation, and use of technology should work together to apply a sociotechnical systems approach to reduce possible negative effects on clinical care for critically ill patients.