Little is known about strategies to implement new critical care practices in response to COVID-19. Moreover, the association between differing implementation climates and COVID-19 clinical outcomes ...has not been examined. The purpose of this study was to evaluate the relationship between implementation determinants and COVID-19 mortality rates.
We used mixed methods guided by the Consolidated Framework for Implementation Research (CFIR). Semi-structured qualitative interviews were conducted with critical care leaders and analyzed to rate the influence of CFIR constructs on the implementation of new care practices. Qualitative and quantitative comparisons of CFIR construct ratings were performed between hospital groups with low- versus high-mortality rates.
We found associations between various implementation factors and clinical outcomes of critically ill COVID-19 patients. Three CFIR constructs (implementation climate, leadership engagement, and engaging staff) had both qualitative and statistically significant quantitative correlations with mortality outcomes. An implementation climate governed by a trial-and-error approach was correlated with high COVID-19 mortality, while leadership engagement and engaging staff were correlated with low mortality. Another three constructs (needs of patient; organizational incentives and rewards; and engaging implementation leaders) were qualitatively different across mortality outcome groups, but these differences were not statistically significant.
Improving clinical outcomes during future public health emergencies will require reducing identified barriers associated with high mortality and harnessing salient facilitators associated with low mortality. Our findings suggest that collaborative and engaged leadership styles that promote the integration of new yet evidence-based critical care practices best support COVID-19 patients and contribute to lower mortality.
To describe the impact of coronavirus disease 2019 on family engagement among ICUs participating in a multicenter collaborative promoting implementation of family-centered care projects and to report ...sites' experiences with the collaborative itself prior to its cancelation due to the pandemic in March 2020.
Cross-sectional survey.
Twenty-seven academic and community ICUs in the United States and South Korea.
Site leaders.
Prior to March 2020, all sites had participated in 6 months of webinars, monthly calls, and listserv communication to facilitate projects and to collect preimplementation family satisfaction and clinician perception data.
Planned projects included ICU orientation initiatives (12, 44.4%), structured family care conferences (6, 22.2%), and ICU diaries (5, 18.5%). After cancelation of the collaborative, 22 site leaders (81.5%) were surveyed by phone from June 2020 to July 2020. Twenty (90.1%) reported having stopped their site project; projects that continued were 1) a standardized palliative extubation protocol and 2) daily written clinical summaries for families. Sites described significant variability in visitor restriction policies and uncertainty regarding future policy changes. Four sites (18.2%) reported that their hospital did not provide personal protective equipment to visitors. Regarding video conferencing with families, 11 sites (52.4%) reported clinicians' using their own personal devices. Two-hundred twelve family surveys and 346 clinician surveys collected prior to cancelation highlighted a broad need for family support. When leaders were asked on a scale from 0 to 10 how helpful collaborative activities had been prior to cancelation, mean response was 8.0 (sd 2.5).
While the collaborative model can help promote ICU family engagement initiatives, coronavirus disease 2019 has impeded implementation of these initiatives even among motivated units. ICUs need adequate personal protective equipment for visitors and video conferencing capabilities on hospital devices while strict visitor restrictions continue to evolve.
Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle ...performance and patient-centered outcomes in critical care.
Prospective, multicenter, cohort study from a national quality improvement collaborative.
68 academic, community, and federal ICUs collected data during a 20-month period.
15,226 adults with at least one ICU day.
We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders.
Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio AOR, 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).
ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.
To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify ...program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda.
Review of the published medical literature, governmental documents, and opinions of experts from the Society of Critical Care Medicine ICU Telemedicine Committee.
Formal ICU telemedicine programs now support 11% of nonfederal hospital critically ill adult patients. There is increasingly robust evidence of association with lower ICU (0.79; 95% CI, 0.65-0.96) and hospital mortality (0.83; 95% CI, 0.73-0.94) and shorter ICU (-0.62 d; 95% CI, -1.21 to -0.04 d) and hospital (-1.26 d; 95% CI, -2.49 to -0.03 d) length of stay. Physicians in training report experiences with telemedicine intensivists that are positive and increased patient safety. Early studies suggest that implementation of ICU telemedicine programs has been associated with lower numbers of malpractice claims and costs. The requirements for Medicare reimbursement and states with legislation addressing providing professional services by telemedicine are detailed.
The inclusion of an ICU telemedicine program as a major part of their critical care delivery paradigm has been implemented for 11% of critically ill U.S. adults as a solution for the problem of access to adult critical care services. Implementation of an ICU telemedicine program is one practical way to increase access and reduce mortality as well as length of stay. ICU telemedicine research including comparative effectiveness studies is urgently needed.
Sepsis is a leading cause of global mortality in children, yet definitions for pediatric sepsis are outdated and lack global applicability and validity. In adults, the Sepsis-3 Definition Taskforce ...queried databases from high-income countries to develop and validate the criteria. The merit of this definition has been widely acknowledged; however, important considerations about less-resourced and more diverse settings pose challenges to its use globally. To improve applicability and relevance globally, the Pediatric Sepsis Definition Taskforce sought to develop a conceptual framework and rationale of the critical aspects and context-specific factors that must be considered for the optimal operationalization of future pediatric sepsis definitions. It is important to address challenges in developing a set of pediatric sepsis criteria which capture manifestations of illnesses with vastly different etiologies and underlying mechanisms. Ideal criteria need to be unambiguous, and capable of adapting to the different contexts in which children with suspected infections are present around the globe. Additionally, criteria need to facilitate early recognition and timely escalation of treatment to prevent progression and limit life-threatening organ dysfunction. To address these challenges, locally adaptable solutions are required, which permit individualized care based on available resources and the pretest probability of sepsis. This should facilitate affordable diagnostics which support risk stratification and prediction of likely treatment responses, and solutions for locally relevant outcome measures. For this purpose, global collaborative databases need to be established, using minimum variable datasets from routinely collected data. In summary, a "Think globally, act locally" approach is required.
Awareness of patient-centered and family-centered care research can assist clinicians to promote patient and family engagement in the intensive care unit. Project Dispatch (Disseminating ...Patient-Centered Outcomes Research to Healthcare Professionals) was developed to disseminate patient- and family-centered care research and encourage its application in clinical practice. The 3-year project involved the development of an interactive website platform, online educational programming, social media channels, a podcast and webcast series, and electronic and print media. The project's webpages received more than 5200 page views with over 4000 unique visitors from 36 countries. The podcast series has download numbers ranging from 35 596 for "Family Presence in the ICU" to 25 843 for "Improving Patient and Family satisfaction in the ICU" and 22 148 for "Family Satisfaction in the ICU." The project therefore successfully developed resources for critical care health care professionals to promote the patient- and family-centric perspective.
Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death.
To describe structures, processes, and variability of end-of-life care delivered in ICUs in ...the United States.
This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019.
Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU.
Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units 22.2%) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units 39.7%) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units 38.1%) achieved high rates across all favorable end-of-life events.
In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.
The ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; ...E, early mobility and exercise; and F, family engagement and empowerment) improves intensive care unit patient-centered outcomes and promotes interprofessional teamwork and collaboration. The Society of Critical Care Medicine recently completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, multicenter, national quality improvement initiative that formalized dissemination and implementation strategies to promote effective adoption of the ABCDEF bundle. The purpose of this article is to describe 8 of the most frequently asked questions during the Collaborative and to provide practical advice from leading experts to other institutions implementing the ABCDEF bundle.
We collected data on a national sample of existing community-based tobacco cessation programs for youths to understand their prevalence and overall characteristics.
We employed a 2-stage sampling ...design with US counties as the first-stage probability sampling units. We then used snowball sampling in selected counties to identify administrators of tobacco cessation programs for youths. We collected data on cessation programs when programs were identified.
We profiled 591 programs in 408 counties. Programs were more numerous in urban counties; fewer programs were found in low-income counties. State-level measures of smoking prevalence and tobacco control expenditures were not associated with program availability. Most programs were multisession, school-based group programs serving 50 or fewer youths per year. Program content included cognitive-behavioral components found in adult programs along with content specific to adolescence. The median annual budget was 2000 dollars. Few programs (9%) reported only mandatory enrollment, 35% reported mixed mandatory and voluntary enrollment, and 56% reported only voluntary enrollment.
There is considerable homogeneity among community-based tobacco cessation programs for youths. Programs are least prevalent in the types of communities for which national data show increases in youths' smoking prevalence.
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