Intensive Care Unit Team Research Articles

Enhancing Patient Safety in the Trauma/Surgical Intensive Care Unit

Preventable deaths due to errors in trauma patients with otherwise survivable injuries account for up to 10% of fatalities in Level I trauma centers, 50% of these errors occur in the intensive care unit (ICU). The root cause of 67% of the Joint Commission sentinel events is communication errors. The objective is (1) to study how critical information degrades and how it is lost over 24 hours and (2) to determine whether a structured checklist for ICU handoffs prevents information loss. Prospective cohort study of trauma and surgical ICU teams observed with and without use of the checklist. An observational period (control group) was followed by a didactic session on the science and use of a checklist (study group), which was used for patient management and handoffs. Information was tracked for a 24-hour period and all handoffs. Comparisons use chi or Fisher's exact test and a p value <0.05 was defined as significant. Three hundred and thirty-two patient ICU days were observed (119 control, 213 study) and 689 patient care items (303 control, 386 study) were followed. Seventy-five (10.9%) items were lost over 24 hours; 61 of 303 (20.1%) without checklist and 14 of 386 (3.6%) with checklist (p < 0.0001). Critical laboratory values and test results were the most frequent lost items (36.1% control vs. 4.5% study p < 0.0001). Six of 75 (8.1%) items were correctly ordered but not carried out by ICU nursing staff--all caught and corrected with checklist use. Critical information is degraded over 24 hours in the ICU. A structured checklist significantly reduces patient errors due to lost information and communication lapses between trauma ICU team members at handoffs of care.

The Practice of and Documentation on Withholding and Withdrawing Life Support: A Retrospective Study in Two Dutch Intensive Care Units

We determined how often life support was withheld or withdrawn in patients who died in the intensive care unit (ICU) or early after ICU discharge and evaluated documentation on decisions regarding these changes in life support orders. This was a retrospective study in a university hospital and a general teaching hospital. Charts of patients who died during ICU stay or within 7 days after ICU discharge in 2005 were reviewed. Of 2578 admitted patients, 356 patients (14%) died either in the ICU or within 7 days after ICU discharge. For 9 patients data were missing, leaving 347 patients for analysis. Seventy-seven patients (22%) died with full life support, 85 (25%) died while treatment was being withheld, and 185 (53%) patients died while treatment was being withdrawn. One or more changes in life support orders were noted in 266 patients (77%). Only 8% of the patients were recorded to be incapacitated at the time of the change. Patients' preferences regarding life support were documented in less than one-quarter of cases. In approximately one third of cases, it was not documented which member(s) of the ICU team were involved in an end-of-life decision. In the documented cases, end-of-life decisions were made along with the patient (7%) or with the patient's representatives (59%). ICU nonsurvivors and patients who die shortly after ICU discharge predominantly die with orders to withhold or withdraw life support. Documentation on the decisions to forgo full life support is poor.

The Use of Wireless E-Mail to Improve Healthcare Team Communication

ObjectiveTo assess the impact of using wireless e-mail for clinical communication in an intensive care unit (ICU). DesignThe authors implemented push wireless e-mail over a GSM cellular network in a 26-bed ICU during a 6-month study period. Daytime ICU staff (intensivists, nurses, respiratory therapists, pharmacists, clerical staff, and ICU leadership) used handheld devices (BlackBerry, Research in Motion, Waterloo, ON) without dedicated training. The authors recorded e-mail volume and used standard methods to develop a self-administered survey of ICU staff to measure wireless e-mail impact. MeasurementsThe survey assessed perceived impact of wireless e-mail on communication, team relationships, staff satisfaction and patient care. Answers were recorded on a 7-point Likert scale; favorable responses were categorized as Likert responses 5, 6, and 7. ResultsStaff sent 5.2 (1.9) and received 8.9 (2.1) messages (mean [SD]) per day during 5 months of the 6-month study period; usage decreased after study completion. Most (106/125 [85%]) staff completed the questionnaire. The majority reported that wireless e-mail improved speed (92%) and reliability (92%) of communication, improved coordination of ICU team members (88%), reduced staff frustration (75%), and resulted in faster (90%) and safer (75%) patient care; Likert responses were significantly different from neutral (p < 0.001 for all). Staff infrequently (18%) reported negative effects on communication. There were no reports of radiofrequency interference with medical devices. ConclusionsInterdisciplinary ICU staff perceived wireless e-mail to improve communication, team relationships, staff satisfaction, and patient care. Further research should address the impact of wireless e-mail on efficiency and timeliness of staff workflow and clinical outcomes.

Limitations and practicalities of CAM-ICU implementation, a delirium scoring system, in a Dutch intensive care unit

Delirium is a frequently missed diagnosis in the intensive care unit (ICU). Implementation of the Confusion Assessment Method for the ICU (CAM-ICU) may improve recognition of delirium. However, the ICU team may be reluctant to adopt daily assessment by a screening tool. This report focusses on the obstacles and barriers encountered with respect to organisational context and prevailing opinions and attitudes when implementing the CAM-ICU in daily practice in a Dutch ICU. A structured implementation process was set up comprising four phases: (1) assessing the current situation to understand behaviour towards delirium; (2) the identification of barriers to the implementation of the CAM-ICU; (3) preparation of the ICU team for a change in attitude; and (4) evaluation of the effects of implementation. Phase 1 demonstrated that there was no delirium protocol available; it was left to the attending physicians when and how to diagnose delirium in each individual patient. In addition, nurses acted on delirium in a non-structured way; nurses thought implementation of the CAM-ICU would be very time-consuming and would not add to their ability in recognising delirium. In Phase 2, several barriers to implementation were addressed. Firstly, all nurses had to be convinced that delirium is an important problem and, secondly, logistics had to be put in place, for example, picture cards at every bedside, communication between daily nurses and a delirium working group had to be improved. In Phase 3, 10 nurses were educated to perform the CAM-ICU through several training sessions which included videos to illustrate different delirium states; these trained nurses educated all other nurses. A check box in the daily records was introduced to denote whether the CAM-ICU had been performed. In Phase 4, after a training period and 2 months of actual routine bedside CAM-ICU performance, evaluation demonstrated that frequency of assessments on un-sedated patients had increased from 38% to 95% per nursing shift. A short survey amongst the ICU nurses also showed that awareness of delirium and appreciation of the clinical problem had markedly increased. Implementation of the CAM-ICU in daily critical care is feasible. A structural training programme is probably helpful for success of implementation.

Developing a team performance framework for the intensive care unit*

There is a growing literature on the relationship between teamwork and patient outcomes in intensive care, providing new insights into the skills required for effective team performance. The purpose of this review is to consolidate the most robust findings from this research into an intensive care unit (ICU) team performance framework. Studies investigating teamwork within the ICU using PubMed, Science Direct, and Web of Knowledge databases. Studies investigating the relationship between aspects of teamwork and ICU outcomes, or studies testing factors that are found to influence team working in the ICU. Teamwork behaviors associated with patient or staff-related outcomes in the ICU were identified. Teamwork behaviors were grouped according to the team process categories of "team communication," "team leadership," "team coordination," and "team decision making." A prototype framework explaining the team performance in the ICU was developed using these categories. The purpose of the framework is to consolidate the existing ICU teamwork literature and to guide the development and testing of interventions for improving teamwork. Effective teamwork is shown as crucial for providing optimal patient care in the ICU. In particular, team leadership seems vital for guiding the way in which ICU team members interact and coordinate with others.

Role of Clinical Ethicists in Making Decisions About Levels of Care in the Intensive Care Unit

Role of Clinical Ethicists in Making Decisions About Levels of Care in the Intensive Care Unit

Daily interruption of sedative infusions in an adult medical–surgical intensive care unit: randomized controlled trial

This article is a report of a study conducted to determine if a nursing-implemented protocol of daily interruption of sedative infusions vs. sedation as directed by the intensive care unit team would decrease duration of mechanical ventilation. Continuous rather than intermittent infusion of sedative and analgesic agents leads to greater stability in sedation level, but has been correlated with prolongation of mechanical ventilation and hospitalization of critical care patients. Daily interruption of sedative infusions in mechanically ventilated patients has reduced the duration of mechanical ventilation and length of stay in intensive care. A randomized controlled trial was carried out from November 2004 to March 2006 with 97 patients receiving mechanical ventilation and continuous infusion of sedative drugs in an intensive care unit in Greece. The primary outcome measure was the duration of mechanical ventilation. Secondary outcomes were length of intensive care unit stay, length of hospital stay, overall mortality, total doses of sedative and analgesic medicines and Ramsay scores and duration of cessation of sedative infusions per day. The median duration of mechanical ventilation was 8.7 days vs. 7.7 days (P = 0.7). Length of intensive care unit stay (median: 14 vs. 12, P = 0.5) and in the hospital (median: 31 vs. 21, P = 0.1) was similar between the intervention and control groups. The absence of statistically significant differences in these variables remained when patients with brain injury were examined separately. The nursing-implemented protocol of daily interruption of sedative infusions was neither beneficial nor harmful compared with usual practice, which has as its primary target the earliest possible awakening of patients.

Patient Safety and Collaboration of the Intensive Care Unit Team

Patient Safety and Collaboration of the Intensive Care Unit Team

Ineffective participation: reactions to absentee and incompetent nurse leadership in an intensive care unit

The aim of the present study was to analyse reactions to ineffective leader participation in an intensive care unit (ICU). Critical examination of leadership failures helps identify nurse manager behaviours to avoid. An online survey collected data from 51 interacting healthcare providers who work in an intensive care unit. Participants reported dissatisfaction with nurse leaders who were perceived as absent or ill prepared. Participants categorized intensive care unit productivity and morale as moderate to low. Multiple regression suggested the best predictor of perceived unit productivity was supervisor communication; the best predictor of employee morale was perceived leader mentoring. Intensive care unit nurses reported wanting active participation from their leaders and expressed dissatisfaction when supervisors were perceived as absent or incompetent. Ineffective leader participation significantly correlated with lower employee perceptions of productivity and morale. Senior managers should recruit and develop supervisors with effective participation skills. Organizations primarily concerned about productivity should focus on developing the communication skills of nurse leaders. Units mainly concerned with employee morale should emphasize mentorship and role modelling. Formal assessment of nurse leaders by all intensive care unit team members should also be used to proactively identify opportunities for improvement.

Pay for performance in the intensive care unit—Opportunity or threat?*

Ongoing evidence of poor-quality healthcare has stimulated the development of provider reimbursement schemes linked to the delivery of high-quality care. Our objective was to describe these programs and their potential implementation in intensive care units (ICUs). MEDLINE (2000-May, 2008) and personal files. We selected empirical studies, narrative and systematic reviews, and commentaries addressing pay-for-performance programs. Using a narrative review format, we discuss the definition of pay-for-performance, describe current implementations, suggest challenges of applying these programs to the ICU setting, and discuss alternative quality improvement programs. The ICU will likely become a target for pay-for-performance plans, considering the high cost of care, development of ICU quality-of-care measures, and interest from healthcare regulators and funders. Existing plans applied outside the ICU have varied in the amount of financial incentive and targeted provider and quality measures. Evaluations are sparse. Implementation challenges specific to the ICU include selecting evidence-based and feasible quality of care measures, motivating the entire interdisciplinary team, integrating multifaceted behavior change strategies, and developing informatics infrastructure for timely audit and feedback. Other incentive-based alternatives to improve ICU quality of care include a "centers of excellence" approach (referral of patients to centers with excellent outcomes), public reporting of ICU outcomes, and payments to hospitals for participating in quality improvement programs. Participation in pay-for-performance programs is a potential opportunity for intensivists and ICU teams to improve outcomes for their patients in partnership with regulatory agencies and healthcare funders. Because many aspects of optimal design of these programs in ICUs are unknown, robust evaluations of their effect on healthcare quality should be integrated into any implementations.

Therapeutic hypothermia and controlled normothermia in the intensive care unit: Practical considerations, side effects, and cooling methods*

Hypothermia is being used with increasing frequency to prevent or mitigate various types of neurologic injury. In addition, symptomatic fever control is becoming an increasingly accepted goal of therapy in patients with neurocritical illness. However, effectively controlling fever and inducing hypothermia poses special challenges to the intensive care unit team and others involved in the care of critically ill patients. To discuss practical aspects and pitfalls of therapeutic temperature management in critically ill patients, and to review the currently available cooling methods. Review article. None. Cooling can be divided into three distinct phases: induction, maintenance, and rewarming. Each has its own risks and management problems. A number of cooling devices that have reached the market in recent years enable reliable maintenance and slow and controlled rewarming. In the induction phase, rapid cooling rates can be achieved by combining cold fluid infusion (1500-3000 mL 4 degrees C saline or Ringer's lactate) with an invasive or surface cooling device. Rapid induction decreases the risks and consequences of short-term side effects, such as shivering and metabolic disorders. Cardiovascular effects include bradycardia and a rise in blood pressure. Hypothermia's effect on myocardial contractility is variable (depending on heart rate and filling pressure); in most patients myocardial contractility will increase, although mild diastolic dysfunction can develop in some patients. A risk of clinically significant arrhythmias occurs only if core temperature decreases below 30 degrees C. The most important long-term side effects of hypothermia are infections (usually of the respiratory tract or wounds) and bedsores. Temperature management and hypothermia induction are gaining importance in critical care medicine. Intensive care unit physicians, critical care nurses, and others (emergency physicians, neurologists, and cardiologists) should be familiar with the physiologic effects, current indications, techniques, complications and practical issues of temperature management, and induced hypothermia. In experienced hands the technique is safe and highly effective.

Interprofessional intensive care unit team interactions and medical crises: A qualitative study

Research has suggested that interprofessional collaboration could improve patient outcomes in the intensive care unit (ICU). Maintaining optimal interprofessional interactions in a setting where unpredictable medical crises occur periodically is however challenging. Our study aimed to investigate the perceptions of ICU health care professionals regarding how acute medical crises affect their team interactions. We conducted 25 semi-structured interviews of ICU nurses, staff physicians, and respiratory therapists. All interviews were audio-taped and transcribed, and the analysis was undertaken using an inductive thematic approach. Our data indicated that the nature of interprofessional interactions changed as teams passed through three key temporal periods around medical crises. During the “pre-crisis period”, interactions were based on the mutual respect of each other's expertise. During the “crisis period”, hierarchical interactions were expected and a certain lack of civility was tolerated. During the “post-crisis period”, divergent perceptions emerged amongst health professionals. Post-crisis team dispersion left the nurses with questions and emotions not expressed by other team members. Nurses believed that systematic interprofessional feedback sessions held immediately after a crisis could address some of their needs. Further research is needed to establish the possible benefits of strategies addressing ICU health care professionals' specific needs for interprofessional feedback after a medical crisis.

Family Presence at the Bedside

“In Our Unit” highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming “In Our Unit,” send it to Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, ccn@aacn.org. The ICU team has embraced families and welcomed them at the bedside. We now have open visitation, so our families are integrated into the care of their loved ones. At Southern Ohio Medical Center in Portsmouth, Ohio, the intensive care unit (ICU) patient satisfaction team made a proactive choice to offer family presence during invasive procedures and cardiopulmonary resuscitation. In September 2007, a resuscitation team was formed consisting of 8 members, all registered nurses (RNs). In order to gain a better understanding of staff perceptions regarding family presence at the bedside, the project Family Presence During Resuscitation and Invasive Procedures was put together; the first phase of the project included a basic 5-item survey with answers measured on a 4 to 1 Likert scale. This survey was given to all ICU RNs, respiratory therapists, ICU physicians, pastoral care, unit clerks, nurse technicians, and security personnel. The survey questions were as follows: 1. Should family presence be permissible during simple procedures such as intravenous insertions? 2. Should family presence be permissible during phlebotomy? 3. Should family presence be permissible during all procedures, including central catheter insertions? 4. Should family presence not be permissible during any procedures? 5. Should family presence be permissible during resuscitation? The survey identified a common theme among staff members, namely, that education of the family is vital; however, almost half (47%) of staff members were opposed to family presence during resuscitation and procedures. During phase 2 of the project, a second survey was given to RNs, ICU physicians, and pastoral care representatives. Results from this survey indicated that a formal policy or protocol and a family facilitator would significantly improve the family presence process in our ICU. Phase 3 of the project consisted of compiling the data of both surveys, which were then presented to the ICU staff during the annual ICU education retreat. A PowerPoint presentation with the data results was shown as well as a video recorded by the resuscitation team. The video presented various scenarios the staff might encounter, including family members who were violent or angry, excessively emotional, drugor alcohol-altered, or arguing with one another. The staff members were then given helpful tips on how to use appropriate techniques to resolve the difficult situations shown in the video. It was reinforced many times that the safety of the patient and staff members is the priority in every situation. In Our Unit

Implementation of pharmacy services in a telemedicine intensive care unit

The implementation of a remote intensive care unit (ICU) pharmacy service in a 13-hospital health system is discussed. Significant challenges for small hospitals are timely, consistent delivery of critical care and being able to have highly experienced critical care physicians, nurses, and pharmacists available onsite within the ICU during all hours of the day. To remedy these problems, Aurora Health Care turned to telemedicine. All 246 ICU beds in the health system are connected to a remote, office-based ICU monitoring facility powered by the eICU, a telemedicine technology. The remote ICU is located in an independent facility. The staff consists of 5.2 full-time equivalent (FTE) pharmacists and 2.2 FTE pharmacy technicians and they monitor ICU patients at all of the hospitals in the system. Each remote ICU pharmacist was educated about expectations and is familiar with the different site processes and practices. All hospitals in the system were required to implement order-scanning technology to allow the remote ICU pharmacy staff to efficiently process orders. Computerized physician order entry, which results in orders being received directly by the pharmacy information system for verification, was also implemented within the system. The remote ICU pharmacists make recommendations for problems to either the hospital-based staff or the remote ICU team. Appropriate antimicrobial coverage and formulary support were the most common recommendations. Cost reduction is an important element of the remote ICU pharmacy service, but the primary motivation for implementation was to improve the quality of patient care. Implementation of a remote ICU pharmacy service in a 13-hospital health system resulted in the provision of consistent pharmaceutical care while minimizing costs.

Intensive Care Unit Outbreak of Extended-Spectrum β-Lactamase–Producing Klebsiella Pneumoniae Controlled by Cohorting Patients and Reinforcing Infection Control Measures

To describe an outbreak of extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae in the intensive care units (ICUs) of a hospital and the impact of routine and reinforced infection control measures on interrupting nosocomial transmission. Outbreak report. A 31-bed intensive care department (composed of 4 ICUs) in a university hospital in Belgium. After routine infection control measures (based on biweekly surveillance cultures and contact precautions) failed to interrupt a 2-month outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures were implemented. The frequency of surveillance cultures was increased to daily sampling. Colonized patients were moved to a dedicated 6-bed ICU, where they received cohorted care with the support of additional nurses. Two beds were closed to new admissions in the intensive care department. Meetings between the ICU and infection control teams were held every day. Postdischarge disinfection of rooms was enforced. Broad-spectrum antibiotic use was discouraged. Compared with a baseline rate of 0.44 cases per 1,000 patient-days for nosocomial transmission, the incidence peaked at 11.57 cases per 1,000 patient-days (October and November 2005; rate ratio for peak vs baseline, 25.46). The outbreak involved 30 patients, of whom 9 developed an infection. Bacterial genotyping disclosed that the outbreak was polyclonal, with 1 predominant genotype. Reinforced infection control measures lasted for 50 days. After the implementation of these measures, the incidence fell to 0.08 cases per 1,000 patient-days (rate ratio for after the outbreak vs during the outbreak, 0.11). These data indicate that, in an intensive care department in which routine screening and contact precautions failed to prevent and interrupt an outbreak of ESBL-producing K. pneumoniae, reinforced infection control measures controlled the outbreak without major disruption of medical care.

Detecting myocardial infarction in critical illness using screening troponin measurements and ECG recordings

IntroductionTo use screening cardiac troponin (cTn) measurements and electrocardiograms (ECGs) to determine the incidence of elevated cTn and of myocardial infarction (MI) in patients admitted to the intensive care unit (ICU), and to assess whether these findings influence prognosis. This is a prospective screening study.Materials and methodsWe enrolled consecutive patients admitted to a general medical-surgical ICU over two months. All patients underwent systematic screening with cTn measurements and ECGs on ICU admission, then daily for the first week in ICU, alternate days for up to one month and weekly thereafter until ICU death or discharge, for a maximum of two months. Patients without these investigations ordered during routine clinical care underwent screening for study purposes but these results were unavailable to the ICU team. After the study, all ECGs were interpreted independently in duplicate for ischaemic changes meeting ESC/ACC criteria supporting a diagnosis of MI. Patients were classified as having MI (elevated cTn and ECG evidence supporting diagnosis of MI), elevated cTn only (no ECG evidence supporting diagnosis of MI), or no cTn elevation.ResultsOne hundred and three patients were admitted to the ICU on 112 occasions. Overall, 37 patients (35.9 per cent) had an MI, 15 patients (14.6 per cent) had an elevated cTn only and 51 patients (49.5 per cent) had no cTn elevation. Patients with MI had longer duration of mechanical ventilation (p < 0.0001), longer ICU stay (p = 0.001), higher ICU mortality (p < 0.0001) and higher hospital mortality (p < 0.0001) compared with those with no cTn elevation. Patients with elevated cTn had higher hospital mortality (p = 0.001) than patients without cTn elevation. Elevated cTn was associated with increased hospital mortality (odds ratio 27.3, 95 per cent CI 1.7 – 449.4), after adjusting for APACHE II score, MI and advanced life support. The ICU team diagnosed 18 patients (17.5 per cent) as having MI on clinical grounds; four of these patients did not have MI by adjudication. Thus, screening detected an additional 23 MIs not diagnosed in practice, reflecting 62.2 per cent of MIs ultimately diagnosed. Patients with MI diagnosed by the ICU team had similar outcomes to patients with MI detected by screening alone.ConclusionSystematic screening detected elevated cTn measurements and MI in more patients than were found in routine practice. Elevated cTn was an independent predictor of hospital mortality. Further research is needed to evaluate whether screening and subsequent treatment of these patients reduces mortality.

Pediatric critical care nurses?? perceptions, knowledge, and attitudes regarding organ donation after cardiac death*

Donation after cardiac death (DCD) is being implemented nationwide in the United States to increase the number of organ donors. Pediatric critical care nurses (PCRNs) are key facilitators in the organ donation process. This study assesses their perception, level of knowledge, and understanding of DCD and the effect of an educational intervention. Anonymous questionnaire administered before and after an educational intervention. Children's hospital with 39 pediatric and cardiac/transplant intensive care unit beds. PCRNs in these intensive care units. DCD education. Response to the initial questionnaire was 93 of 123 (76%): 63% of PCRNs supported organ donation, 69% felt it gives meaning and worth to death, and 76% felt that it contributes positively to the donating family's grieving process. Ninety-five percent agreed that DCD patients have a right to pain medications, and 92% supported such medications even if they hasten death. However, 11% feared that the DCD donor feels pain and suffering. Fourteen percent felt that a 5-min observation period after asystole is insufficient to pronounce death, and 8% feared legal repercussions. PCRNs scored lower on questions assessing their knowledge (p < .01), their comfort answering family questions (p < .05), and their comfort in calling the organ procurement agency about DCD donors compared with similar questions about brain-dead donors. One month after 104 PCRNs attended the educational intervention, 64 (62%) completed a follow-up survey. Correct identification of the DCD process improved from 20% to 79%. Confidence with knowledge, comfort answering family questions, and comfort in calling the organ procurement agency about DCD donors improved by 41%, 25%, and 18%, respectively. PCRNs are generally supportive of organ donation but have a self-perceived and objectively identified knowledge deficit regarding DCD, resulting in their being unprepared to identify potential DCD donors or handle family questions. A simple educational intervention can improve PCRNs' knowledge of the DCD process and their confidence and comfort with this process. As DCD policies are implemented, specific interventions should target these key members of the intensive care unit team.

Noninvasive ventilation in acute respiratory failure

Noninvasive ventilation has assumed an important role in the management of respiratory failure in critical care units, but it must be used selectively depending on the patient's diagnosis and clinical characteristics. We review the strong evidence supporting the use of noninvasive ventilation for acute respiratory failure to prevent intubation in patients with chronic obstructive pulmonary disease exacerbations or acute cardiogenic pulmonary edema, and in immunocompromised patients, as well as to facilitate extubation in patients with chronic obstructive pulmonary disease who require initial intubation. Weaker evidence supports consideration of noninvasive ventilation for chronic obstructive pulmonary disease patients with postoperative or postextubation respiratory failure; patients with acute respiratory failure due to asthma exacerbations, pneumonia, acute lung injury, or acute respiratory distress syndrome; during bronchoscopy; or as a means of preoxygenation before intubation in critically ill patients with severe hypoxemia. Noninvasive ventilation has assumed an important role in managing patients with acute respiratory failure. Patients should be monitored closely for signs of noninvasive ventilation failure and promptly intubated before a crisis develops. The application of noninvasive ventilation by a trained and experienced intensive care unit team, with careful patient selection, should optimize patient outcomes.

Facilitating clinician adherence to guidelines in the intensive care unit: A multicenter, qualitative study*

To determine perceived facilitators and barriers to guideline implementation and clinician adherence to guidelines in the intensive care unit (ICU). Multicenter qualitative study in three university-affiliated ICUs in Canada. We conducted individual semistructured interviews of 44 ICU clinicians (12 intensivists, two physician directors, 12 nurses, three nurse educators, three nurse managers, nine respiratory therapists, and three respiratory therapist educators). We elicited attitudes and perceptions regarding the facilitators and barriers to adherence to guidelines in the ICU. We transcribed all interviews and analyzed data in duplicate using grounded theory to identify themes and develop a model to describe clinicians' views. The presence of a culture within the ICU that enabled guideline implementation and clinician adherence to guidelines was considered essential. Central to this culture was an ICU team that believed guidelines would reduce practice variation, help implement research findings at the bedside, and result in a more rapid implementation of best practice. Effective leadership and positive interprofessional team dynamics were deemed requisites for this culture. Important strategies identified by the participants to overcome potential barriers to clinician adherence to guidelines were: the presence of effective leaders to promote adoption of the guideline and its adherence, education tailored to the learning preferences of different professional groups, and repeated educational interventions, reminders, and audit and feedback. Participants suggested that the use of strategies to select and prioritize guidelines, simple guideline formats, and electronic media to implement guidelines may further contribute to successful guideline programs. Complex ICU practices and unique interprofessional team dynamics influence clinician adherence to guidelines. Initiatives that employ an approach addressing these issues may optimize guideline uptake and adherence. The optimal approach and its effectiveness may be guideline-dependent and requires further study.

Implementation of early goal-directed therapy for severe sepsis and septic shock: A decision analysis

Early goal-directed therapy (EGDT) reduced mortality from septic shock in a single-center trial. However, implementation of EGDT faces several barriers, including perceived costs and logistic difficulties. We conducted a decision analysis to explore the potential costs and consequences of EGDT implementation. Estimates of effectiveness and resource use were based on data from the original trial and published sources. Implementation costs and lifetime projections were modeled from published sources and tested in sensitivity analyses. We generated incremental cost-effectiveness ratios from the hospital (short-term) and U.S. societal (lifetime) perspectives, excluding nonhealthcare costs, and applying a 3% annual discount. Simulation of an average U.S. emergency department. Total of 1,000 simulation cohorts (n = 263 for each cohort) of adult patients with severe sepsis/septic shock. EGDT under three alternative implementation strategies: emergency department-based, mobile intensive care unit team, and intensive care unit-based (after emergency department transfer). For an average emergency department, we estimated 91 cases per yr, start-up costs from $12,973 (intensive care unit-based) to $26,952 (emergency department-based), and annual outlay of $100,113. EGDT reduced length of stay such that net hospital costs fell approximately 22.9% ($8,413-$8,978). EGDT implementation had a 99.4% to 99.8% probability of being dominant (saved lives and costs) from the hospital perspective, and cost from $2,749 (intensive care unit-based) to $7019 (emergency department-based) per quality-adjusted life-yr with 96.7% to 97.7% probability of being <$20,000 per quality-adjusted life-yr from the societal perspective. The intensive care unit-based strategy was the least expensive, because of lower start-up costs, but also least effective, because of implementation delay, and all three strategies had similar cost-effectiveness ratios. Sensitivity analyses showed these estimates to be particularly sensitive to EGDT's effect on mortality and intensive care unit length of stay, but insensitive to other variables. EGDT has important start-up costs, and modest delivery costs, but assuming LOS and mortality are reduced, EGDT can be cost-saving to the hospital and associated with favorable lifetime cost-effectiveness projections.