We conducted a retrospective, observational study of patient outcomes in two intensive care units in the same hospital. The surgical ICU (SICU) implemented telemedicine and electronic medical ...records, while the medical ICU (MICU) did not. Medical charts were reviewed for a one-year period before telemedicine and a one-year period afterwards. In the SICU, records were obtained for 246 patients before and 1499 patients after implementation; in the MICU, records were obtained for 220 patients and 285 patients in the same periods. The outcomes of interest were ICU length of stay and mortality, and hospital length of stay and mortality. Outcome variables were severity-adjusted using APACHE scoring. A bootstrap method, with 1000 replicates, was used to assess stability of the findings. The adjusted ICU length of stay, ICU mortality, and hospital mortality for the SICU patients all decreased significantly after the implementation of telemedicine. There was no change in adjusted outcome variables in the MICU patients. Implementation of telemedicine and electronic records in the surgical ICU was associated with a profound reduction in severity-adjusted ICU length of stay, ICU mortality, and hospital mortality. However, it is not possible to conclude definitively that the observed associations seen in the SICU were due to the intervention.
Medical cyber-physical systems (MCPS) are life-critical, context-aware, networked systems of medical devices. These systems are increasingly used in hospitals to provide high-quality continuous care ...for patients. The need to design complex MCPS that are both safe and effective has presented numerous challenges, including achieving high assurance in system software, intoperability, context-aware intelligence, autonomy, security and privacy, and device certifiability. In this paper, we discuss these challenges in developing MCPS, some of our work in addressing them, and several open research issues.
Preadmission testing (PAT) before surgical procedures ensures patient safety and decreases last minute case cancellations.
PAT before surgery improves efficiency for the health system; however, the ...process is often inconvenient for the patient. We sought to determine the impact of telemedicine on the presurgical assessment.
We performed a retrospective review comparing patients who participated in telemedicine-based PAT to patients who had a routine, on-site PAT. Our outcomes aligned with National Quality Forum recommended domains for telehealth measures: access (time spent in evaluation), experience (patient satisfaction), and effectiveness (case cancellation rate).
There were 7,803 people evaluated; 361 with telemedicine and 7,442 without telemedicine. Compared with those not using telemedicine, the telemedicine group spent less time in the PAT by 24 min (95% confidence interval, 21.4-26.5), and had no case cancellations (0% vs. 1.1%; 95% confidence interval for the difference, 0.028-1.25%). Patient experience showed high rates of satisfaction with telemedicine.
We found that using telemedicine for PAT had benefits in terms of access, patient experience, and effectiveness, the three domains recommended for use in telehealth quality measures by the National Quality Forum. The improvements in evaluation times are beneficial for both patients and providers.
PAT utilizing telemedicine reduced overall patient time in the PAT and improved patient satisfaction without increasing the operative case cancellation rate.
This project aimed to create and implement a safe and efficient role-based process to rapidly extricate traumatically injured persons transported to the emergency department via police transport or ...private vehicle.
A simulation exercise was conducted with an interdisciplinary team of ED personnel, Philadelphia Police Department, and University of Pennsylvania police officers to identify the necessary steps to rapidly extricate traumatically injured individuals.
The simulation exercise identified several new processes needed to complete rapid extrications of traumatically injured individuals from private and police vehicles. These included a safe drop-off location, ED personnel role identification, proper personal protective equipment donning, 2 rapid extrication techniques, and a hard stop for weapon check by security before entering the emergency department.
Through simulation, the ED interdisciplinary team was able to develop a role-based safe and efficient rapid extrication process. Educating new ED personnel, security, and Pennsylvania police continues to facilitate ongoing safe rapid extrication practices in the emergency department.
Coronavirus Disease 2019 (COVID-19) has caused over 1 200 000 deaths worldwide as of November 2020. However, little is known about the clinical outcomes among hospitalized patients with active ...COVID-19 after in-hospital cardiac arrest (IHCA).
We aimed to characterize outcomes from IHCA in patients with COVID-19 and to identify patient- and hospital-level variables associated with 30-day survival.
We conducted a multicentre retrospective cohort study across 11 academic medical centres in the U.S. Adult patients who received cardiopulmonary resuscitation and/or defibrillation for IHCA between March 1, 2020 and May 31, 2020 who had a documented positive test for Severe Acute Respiratory Syndrome Coronavirus 2 were included. The primary outcome was 30-day survival after IHCA.
There were 260 IHCAs among COVID-19 patients during the study period. The median age was 69 years (interquartile range 60–77), 71.5% were male, 49.6% were White, 16.9% were Black, and 16.2% were Hispanic. The most common presenting rhythms were pulseless electrical activity (45.0%) and asystole (44.6%). ROSC occurred in 58 patients (22.3%), 31 (11.9%) survived to hospital discharge, and 32 (12.3%) survived to 30 days. Rates of ROSC and 30-day survival in the two hospitals with the highest volume of IHCA over the study period compared to the remaining hospitals were considerably lower (10.8% vs. 64.3% and 5.9% vs. 35.7% respectively, p < 0.001 for both).
We found rates of ROSC and 30-day survival of 22.3% and 12.3% respectively. There were large variations in centre-level outcomes, which may explain the poor survival in prior studies.
Debriefing is used in clinical settings to support interprofessional staff, improve processes, and identify educational needs. Nurses who lead debriefing sessions are empowered to improve processes.
...Nurse leaders identified the need for debriefing outside the critical care areas due to the rising acuity levels.
Two nurse leaders developed a debriefing initiative in one urban teaching hospital following rapid responses, codes, and stressful situations. Nurses developed a Debriefing Facilitation Guide to collect qualitative aspects of clinical emergencies to improve processes, education, and team dynamics.
Following each debriefing session, we deductively purposively coded the qualitative data into 3 a priori themes: the American Heart Association's team dynamics, process improvement, and educational opportunities. We identified opportunities for improvement for these themes during our first 54 debriefing sessions.
Following each debriefing session, the debriefing nurse leader intervened on all educational and process improvement opportunities identified and facilitated positive team dynamics.
Intensive care unit telemedicine is an innovative approach to providing critical care services for a broad geographic area, but its success may depend on acceptance by bedside providers.
To determine ...critical care nurses' attitudes toward and perceptions about the use of telemedicine in critical care.
A total of 179 nurses in 3 critical care units in 2 university-affiliated academic hospitals that use telemedicine intensivists and nurses were surveyed via the Internet about their practice and perceptions of telemedicine.
Among the 93 respondents (response rate, 52%), 72 worked at least 1 night shift and therefore had experience with the telemedicine unit. Reported contact with the telemedicine unit was relatively infrequent: 31% reported being called by the unit 3 or more times in the preceding 6 months. A total of 44% reported regularly incorporating interventions suggested by the telemedicine staff. A majority (72%) thought that telemedicine increases patients' survival, but fewer thought that telemedicine prevents medical errors (47%) or improves the satisfaction of patients' families (42%). Some respondents thought that telemedicine interrupted work flow (9%), was intrusive (11%), or resulted in a feeling of being spied upon (13%). Most nurses thought that personally knowing the telemedicine physician was important (79%), and nurses were more likely to contact the telemedicine unit if they knew the physician on call (61%).
Practicing bedside nurses with experience in telemedicine generally support its use, but concerns about privacy issues and the desire to personally know the telemedicine physician may hinder broader application of the technology.
The tele-intensive care unit (ICU) provides a remote monitoring system that adds an additional layer of support for critically ill patients. However, to optimize contributions, the bedside team must ...incorporate this resource into the patient's plan of care. Using the American Association of Critical-Care Nurses' Healthy Work Environment Standards as a platform, we can create and nurture a new partnership model. Strategies that embrace the standards of skilled communication, true collaboration, and effective decision making become mutual goals for improving patient safety and outcomes. Joint communication guidelines facilitate timely and meaningful communication. Trust and the desire to cooperate encourage provider engagement to strengthen collaboration. The use of tele-ICU technology can assist in the interpretation and transformation of data to affect decision making at all levels to influence patient care. Through the lens of the healthy work environment, the tele-ICU/ICU partnership provides enhanced opportunities for improved patient care and team satisfaction.
The goal of this work was to provide a review of the implementation of data science-driven applications focused on structural or outcome-related nurse-sensitive indicators in the literature in 2021. ...By conducting this review, we aim to inform readers of trends in the nursing indicators being addressed, the patient populations and settings of focus, and lessons and challenges identified during the implementation of these tools.
We conducted a rigorous descriptive review of the literature to identify relevant research published in 2021. We extracted data on model development, implementation-related strategies and measures, lessons learned, and challenges and stakeholder involvement. We also assessed whether reports of data science application implementations currently follow the guidelines of the Developmental and Exploratory Clinical Investigations of DEcision support systems driven by AI (DECIDE-AI) framework.
Of 4,943 articles found in PubMed (NLM) and CINAHL (EBSCOhost), 11 were included in the final review and data extraction. Systems leveraging data science were developed for adult patient populations and were primarily deployed in hospital settings. The clinical domains targeted included mortality/deterioration, utilization/resource allocation, and hospital-acquired infections/COVID-19. The composition of development teams and types of stakeholders involved varied. Research teams more frequently reported on implementation methods than implementation results. Most studies provided lessons learned that could help inform future implementations of data science systems in health care.
In 2021, very few studies report on the implementation of data science-driven applications focused on structural- or outcome-related nurse-sensitive indicators. This gap in the sharing of implementation strategies needs to be addressed in order for these systems to be successfully adopted in health care settings.
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