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Poor EHR design adds further challenges, especially in the areas of order entry and information visualization, with a net effect of increased rates of incidents, accidents, and ...mortality in ICU settings.
The purpose of this study was to propose a novel, mixed-methods framework to understand EHR-related information overload by identifying and characterizing areas of suboptimal usability and clinician frustration within a vendor-based, provider-facing EHR interface.
A mixed-methods, live observational usability study was conducted at a single, large, tertiary academic medical center in the Southeastern US utilizing a commercial, vendor based EHR. Physicians were asked to complete usability patient cases, provide responses to three surveys, and participant in a semi-structured interview.
Of the 25 enrolled ICU physician participants, there were 5(20%) attending physicians, 9 (36%) fellows, and 11 (44%) residents; 52% of participants were females. On average, residents were the quickest in completing the tasks while attending physician took the longest to complete the same task. Poor usability, complex interface screens, and difficulty to navigate the EHR significantly correlated with high frustration levels. Significant association were found between the occurrence of error messages and temporal demand such that more error messages resulted in longer completion time (p = .03).
Physicians remain frustrated with the EHR due to difficulty in finding patient information. EHR usability remains a critical challenge in healthcare, with implications for medical errors, patient safety, and clinician burnout. There is a need for scientific findings on current information needs and ways to improve EHR-related information overload.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Treatment decisions commonly have to be made in intensive care units (ICUs). These decisions are difficult for surrogate decision makers and often lead to decisional conflict, psychological distress, ...and treatments misaligned with patient preferences.
To determine whether a decision aid about prolonged mechanical ventilation improved prognostic concordance between surrogate decision makers and clinicians compared with a usual care control.
Multicenter, parallel, randomized, clinical trial. (ClinicalTrials.gov: NCT01751061).
13 medical and surgical ICUs at 5 hospitals.
Adult patients receiving prolonged mechanical ventilation and their surrogates, ICU physicians, and ICU nurses.
A Web-based decision aid provided personalized prognostic estimates, explained treatment options, and interactively clarified patient values to inform a family meeting. The control group received information according to usual care practices followed by a family meeting.
The primary outcome was improved concordance on 1-year survival estimates, measured with the clinician-surrogate concordance scale (range, 0 to 100 percentage points; higher scores indicate more discordance). Secondary and additional outcomes assessed the experiences of surrogates (psychological distress, decisional conflict, and quality of communication) and patients (length of stay and 6-month mortality). Outcomes assessors were blinded to group allocation.
The study enrolled 277 patients, 416 surrogates, and 427 clinicians. Concordance improvement did not differ between intervention and control groups (mean difference in score change from baseline, -1.7 percentage points 95% CI, -8.3 to 4.8 percentage points; P = 0.60). Surrogates' postintervention estimates of patients' 1-year prognoses did not differ between intervention and control groups (median, 86.0% interquartile range {IQR}, 50.0% vs. 92.5% IQR, 47.0%; P = 0.23) and were substantially more optimistic than results of a validated prediction model (median, 56.0% IQR, 43.0%) and physician estimates (median, 50.0% IQR, 55.5%). Eighty-two intervention surrogates (43%) favored a treatment option that was more aggressive than their report of patient preferences. Although intervention surrogates had greater reduction in decisional conflict than control surrogates (mean difference in change from baseline, 0.4 points CI, 0.0 to 0.7 points; P = 0.041), other surrogate and patient outcomes did not differ.
Contamination among clinicians could have biased results toward the null hypothesis.
A decision aid about prolonged mechanical ventilation did not improve prognostic concordance between clinicians and surrogates, reduce psychological distress among surrogates, or alter clinical outcomes. Decision support in acute care settings may require greater individualized attention for both the cognitive and affective challenges of decision making.
National Institutes of Health.
OBJECTIVE:To demonstrate the feasibility of a placebo-controlled trial of antipsychotics for delirium in the intensive care unit and to test the hypothesis that antipsychotics would improve days ...alive without delirium or coma.
DESIGN:Randomized, double-blind, placebo-controlled trial.
SETTING:Six tertiary care medical centers in the US.
PATIENTS:One hundred one mechanically ventilated medical and surgical intensive care unit patients.
INTERVENTION:Patients were randomly assigned to receive haloperidol or ziprasidone or placebo every 6 hrs for up to 14 days. Twice each day, frequency of study drug administration was adjusted according to delirium status, level of sedation, and side effects.
MEASUREMENTS AND MAIN OUTCOMES:The primary end point was the number of days patients were alive without delirium or coma. During the 21-day study period, patients in the haloperidol group spent a similar number days alive without delirium or coma (median interquartile range, 14.0 6.0–18.0 days) as did patients in the ziprasidone (15.0 9.1–18.0 days) and placebo groups (12.5 1.2–17.2 days; p = 0.66). No differences were found in secondary clinical outcomes, including ventilator-free days (p = .25), hospital length of stay (p = .68), and mortality (p = .81). Ten (29%) patients in the haloperidol group reported symptoms consistent with akathisia, compared with six (20%) patients in the ziprasidone group and seven (19%) patients in the placebo group (p = .60), and a global measure of extrapyramidal symptoms was similar between treatment groups (p = .46).
CONCLUSIONS:A randomized, placebo-controlled trial of antipsychotics for delirium in mechanically ventilated intensive care unit patients is feasible. Treatment with antipsychotics in this limited pilot trial did not improve the number of days alive without delirium or coma, nor did it increase adverse outcomes. Thus, a large trial is needed to determine whether use of antipsychotics for intensive care unit delirium is appropriate.
TRIAL REGISTRATION:ClinicalTrials.gov, number NCT00096863.
Many survivors of critical illness and their family members experience significant psychological distress after patient discharge.
To compare the effects of a coping skills training (CST) program ...with an education program on patient and family psychological distress.
In this five-center clinical trial, adult patients who received mechanical ventilation for more than 48 hours and one family member of each patient were randomized to six weekly CST telephone sessions plus access to a study website or a critical illness education program.
The primary outcome was the patient Hospital Anxiety and Depression Scale (HADS) score at 3 months. Secondary outcomes included 3- and 6-month HADS subscales and the Impact of Events Scale-Revised. Among the 175 patients randomized to CST (n = 86) or education (n = 89), there was no significant difference between CST and education in either 3-month HADS scores (difference, 1.3; 95% confidence interval CI, -0.9 to 3.4; P = 0.24) or secondary patient and family outcomes. In prespecified analyses, among patients with high baseline distress (n = 60), CST recipients had greater improvement in 6-month HADS score (difference, -4.6; 95% CI, -8.6 to -0.6; P = 0.02) than the education group. Among patients ventilated longer than 7 days (n = 47), education recipients had greater improvement in 3-month HADS score (difference, -4.0; 95% CI, -8.1 to -0.05; P = 0.047) than the CST group.
CST did not improve psychological distress symptoms compared with an education program. However, CST improved symptoms of distress at 6 months among patients with high baseline distress, whereas the education program improved distress at 3 months among those ventilated for more than 7 days. Future efforts to address psychological distress among critical illness survivors should target high-risk populations. Clinical trial registered with www.clinicaltrials.gov (NCT01983254).
Purpose
To identify specific components of ICU clinician supportive care and communication that are associated with increased post-traumatic stress disorder (PTSD) symptoms for surrogate decision ...makers of patients with chronic critical illness (CCI).
Methods
We conducted a secondary analysis of data from a randomized controlled trial of palliative care-led meetings to provide information and support for CCI surrogates. The primary outcome for this secondary analysis was PTSD symptoms at 90 days, measured by the Impact of Event Scale-Revised (IES-R). Caregiver perceptions of clinician support and communication were assessed using a version of the After-Death Bereaved Family Member Interview (ADBFMI) instrument modified for use in non-bereaved in addition to bereaved caregivers. The association between ADBFMI items and IES-R score was analyzed using multiple linear regression.
Results
Ninety-day follow up was complete for 306 surrogates corresponding to 224 patients. Seventy-one percent of surrogates were female, and the mean age was 51 years. Of the domains, negative perception of the patient’s physical comfort and emotional support was associated with the greatest increase in surrogate PTSD symptoms (beta coefficient 1.74, 95% CI 0.82–2.65). The three specific preselected items associated with increased surrogate PTSD symptoms were surrogate perception that clinicians did not listen to concerns (beta coefficient 10.7, 95% CI 3.6–17.9), failure of the physician to explain how the patient’s pain would be treated (beta coefficient 12.1, 95% CI 4.9–19.3), and lack of sufficient religious contact (beta coefficient 11.7, 95% CI 2–21.3).
Conclusion
Modifiable deficits in ICU clinician support and communication were associated with increased PTSD symptoms among CCI surrogates.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Family caregivers of patients with acute cardiorespiratory failure are at high risk for distress, which is typically defined as the presence of psychological symptoms such as anxiety, depression, or ...posttraumatic stress. Interventions to reduce caregiver distress and increase wellness have been largely ineffective to date. An incomplete understanding of caregiver wellness and distress may hinder efforts at developing effective support interventions.
To allow family caregivers to define their experiences of wellness and distress 6 months after patient intensive care unit (ICU) admission and to identify moderators that influence wellness and distress.
Primary family caregivers of adult patients admitted to the medical ICU with acute cardiorespiratory failure were invited to participate in a semistructured interview 6 months after ICU admission as part of a larger prospective cohort study. Interview guides were used to assess caregiver perceptions of their own well-being, record caregiver descriptions of their experiences of family caregiving, and identify key stress events and moderators that influenced well-being during and after the ICU admission. This study was guided by the Chronic Traumatic Stress Framework conceptual model, and data were analyzed using the five-step framework approach.
Among 21 interviewees, the mean age was 58 years, 67% were female, and 76% were White. Nearly half of patients (47%) had died before the caregiver interview. At the time of the interview, 9 caregivers endorsed an overall sense of distress, 10 endorsed a sense of wellness, and 2 endorsed a mix of both. Caregivers defined their experiences of wellness and distress as multidimensional and composed of four main elements:
) positive versus negative physical and psychological outcomes,
) high versus low capacity for self-care,
) thriving versus struggling in the caregiving role, and
) a sense of normalcy versus ongoing life disruption. Postdischarge support from family, friends, and the community at large played a key role in moderating caregiver outcomes.
Caregiver wellness and distress are multidimensional and extend beyond the absence or presence of psychological outcomes. Future intervention research should incorporate novel outcome measures that include elements of self-efficacy, preparedness, and adaptation and optimize postdischarge support for family caregivers.
Growing numbers of critically ill patients receive prolonged mechanical ventilation. Little is known about the patterns of care as patients transition from acute care hospitals to postacute care ...facilities or about the associated resource utilization.
To describe 1-year trajectories of care and resource utilization for patients receiving prolonged mechanical ventilation.
1-year prospective cohort study.
5 intensive care units at Duke University Medical Center, Durham, North Carolina.
126 patients receiving prolonged mechanical ventilation (defined as ventilation for >or=4 days with tracheostomy placement or ventilation for >or=21 days without tracheostomy), as well as their 126 surrogates and 54 intensive care unit physicians, enrolled consecutively over 1 year.
Patients and surrogates were interviewed in the hospital, as well as 3 and 12 months after discharge, to determine patient survival, functional status, and facility type and duration of postdischarge care. Physicians were interviewed in the hospital to elicit prognoses. Institutional billing records were used to assign costs for acute care, outpatient care, and interfacility transportation. Medicare claims data were used to assign costs for postacute care.
103 (82%) hospital survivors had 457 separate transitions in postdischarge care location (median, 4 transitions interquartile range, 3 to 5 transitions), including 68 patients (67%) who were readmitted at least once. Patients spent an average of 74% (95% CI, 68% to 80%) of all days alive in a hospital or postacute care facility or receiving home health care. At 1 year, 11 patients (9%) had a good outcome (alive with no functional dependency), 33 (26%) had a fair outcome (alive with moderate dependency), and 82 (65%) had a poor outcome (either alive with complete functional dependency 4 patients; 21% or dead 56 patients; 44%). Patients with poor outcomes were older, had more comorbid conditions, and were more frequently discharged to a postacute care facility than patients with either fair or good outcomes (P < 0.05 for all). The mean cost per patient was $306,135 (SD, $285,467), and total cohort cost was $38.1 million, for an estimated $3.5 million per independently functioning survivor at 1 year.
The results of this single-center study may not be applicable to other centers.
Patients receiving prolonged mechanical ventilation have multiple transitions of care, resulting in substantial health care costs and persistent, profound disability. The optimism of surrogate decision makers should be balanced by discussions of these outcomes when considering a course of prolonged life support.
None.
CONTEXT Studies suggest that many survivors of critical illness experience long-term cognitive impairment but have not included premorbid measures of cognitive functioning and have not evaluated risk ...for dementia associated with critical illness. OBJECTIVES To determine whether decline in cognitive function was greater among older individuals who experienced acute care or critical illness hospitalizations relative to those not hospitalized and to determine whether the risk for incident dementia differed by these exposures. DESIGN, SETTING, AND PARTICIPANTS Analysis of data from a prospective cohort study from 1994 through 2007 comprising 2929 individuals 65 years old and older without dementia at baseline residing in the community in the Seattle area and belonging to the Group Health Cooperative. Participants with 2 or more study visits were included, and those who had a hospitalization for a diagnosis of primary brain injury were censored at the time of hospitalization. Individuals were screened with the Cognitive Abilities Screening Instrument (CASI) (score range, 0-100) every 2 years at follow-up visits, and those with a score less than 86 underwent a clinical examination for dementia. MAIN OUTCOME MEASURES Score on the CASI at follow-up study visits and incident dementia diagnosed in study participants, adjusted for baseline cognitive scores, age, and other risk factors. RESULTS During a mean (SD) follow-up of 6.1 (3.2) years, 1601 participants had no hospitalization, 1287 had 1 or more noncritical illness hospitalizations, and 41 had 1 or more critical illness hospitalizations. The CASI score was assessed more than 45 days after discharge for 94.3% of participants. Adjusted CASI scores averaged 1.01 points lower for visits following acute care illness hospitalization compared with follow-up visits not following any hospitalization (95% confidence interval CI, −1.33 to −0.70; P < .001) and 2.14 points lower on average for visits following critical illness hospitalization (95% CI, −4.24 to −0.03; P = .047). There were 146 cases of dementia among those not hospitalized, 228 cases of dementia among those with 1 or more noncritical illness hospitalizations, and 5 cases of dementia among those with 1 or more critical illness hospitalizations. The adjusted hazard ratio for incident dementia was 1.4 following a noncritical illness hospitalization (95% CI, 1.1 to 1.7; P = .001) and 2.3 following a critical illness hospitalization (95% CI, 0.9 to 5.7; P = .09). CONCLUSIONS Among a cohort of older adults without dementia at baseline, those who experienced acute care hospitalization and critical illness hospitalization had a greater likelihood of cognitive decline compared with those who had no hospitalization. Noncritical illness hospitalization was significantly associated with the development of dementia.
Patients requiring prolonged mechanical ventilation consume a disproportionate amount of healthcare resources and clinician time. Measurement and knowledge of their outcomes will guide efforts to ...improve their care.
The number of patients requiring prolonged mechanical ventilation after acute illness is increasing. Their long-term outcome is poor and has not improved significantly over the past 20 years. The symptom burden for patients is considerable, and family members often suffer from significant physical and emotional strain. Long-term survivors report lasting physical limitations, but their emotional health is generally good. Care for many patients requiring prolonged mechanical ventilation is shifting to post-intensive care unit settings. While this trend has resulted in cost savings for hospitals and payers, it has not had a major impact on patient outcomes.
The long-term outcomes of patients requiring prolonged mechanical ventilation are poor for the majority of patients, especially the elderly. Continued research is needed to identify the highest-risk patients, and to improve outcomes during hospitalization and in the immediate postdischarge period.
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