Browsing by Subject "Critical Care"
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Item Chronic critical illness: the limbo between life and death(2015-02-06) Ruggiero, RosechelleItem End of life care in the ICU(2016-05-13) Finklea, David JrItem Extracorporeal life support for respiratory failure(2019-11-08) Mohanka, ManishItem Families in the ICU(2020-10-16) DeLisle, SylvainItem Improving Adherence to an Integrated Spontaneous Awakening and Spontaneous Breathing Trial Protocol(2023-05-01T05:00:00.000Z) Seal, Brayden Christopher; Reed, W. Gary; Bartolome, Sonja; Kershaw, Corey D.BACKGROUND: Integration of nursing-driven spontaneous awakening trial (SAT) and respiratory therapy-driven spontaneous breathing trial (SBT) protocols for patients on mechanical ventilation in the intensive care unit (ICU) is associated with fewer ventilator days, shorter ICU stays, and reduced hospital length-of-stay. However, institutional adherence is often suboptimal due to the complexity and multidisciplinary nature of these integrated protocols. This project aims to describe baseline compliance with our institution's SAT/SBT protocol, identify factors influencing compliance, and increase adherence to the existing SAT/SBT protocol in the ICU to a goal of greater than 95% compliance by August 2023. LOCAL PROBLEM: Data from a retrospective chart review indicated a SAT screen rate of 63.8% and a SBT screen rate of 85%. Therefore, the SAT/SBT protocol adherence at our institution is sub-optimal. METHODS: Initially, we determined baseline adherence rates through a retrospective chart review of SAT and SBT documentation. Specifically, we identified the rates of correctly performed SAT and SBT screenings for all eligible patients and the subsequent rates of correct SAT and SBT performance for patients who passed the appropriate screening. We then sought to identify factors influencing adherence to the SBT/SAT protocol by employing an ethnographic approach, including: (a) process mapping of the integrated SAT/SBT protocol, (b) literature-driven surveys using the Likert scale to assess potential barriers to protocol adherence, (d) informal interviews with nurses and respiratory therapists, and (e) direct observation in the medical ICU. Individual factors identified were organized using the Systems Engineering Initiative for Patient Safety (SEIPS) sociotechnical framework. The SEIPS model allowed for further design of targeted interventions to improve protocol adherence. RESULTS: Factors influencing adherence were identified from survey responses by 63 nurses and 26 respiratory therapists, 30 hours of direct observation, and tabulated comments from surveys and informal interviews. Prominent factors influencing compliance included knowledge of the protocol, protocol variation across intensive care units, accessibility of the protocol, ease of documentation in the electronic medical record (EMR), and the exclusion of nurses and respiratory therapists in physician-led ICU rounds. CONCLUSION: Data from a retrospective chart review and ethnographic investigation of SAT/SBT protocols indicated sub-optimal adherence. Further investigation into the specific factors influencing adherence allowed us to propose specific interventions to improve performance. Such future interventions will include: (a) EMR redesign using feedback obtained in our investigation to improve accessibility and allow reliable surveillance of protocol adherence, (b) enhanced, standardized multidisciplinary ICU rounds, (c) protocol education sessions, (d) continuous monitoring of protocol metrics with intermittent feedback provided to staff, and (e) a Quality Assurance and Performance Improvement Workgroup dedicated to regular engagement of key stakeholders for process improvement.Item Lessons learned at UCSD about COVID-19 in the ICU(2021-05-28) Malhotra, AtulItem Metabolism and nutrition in sepsis: a need for precision medicine(2021-06-04) Huen, SarahItem Responding to requests for futile or potentially inappropriate treatment(2017-03-14) White, Douglas B.Managing requests for potentially inappropriate treatment is deceptively complex and exposes unanswered questions about the boundaries of good medical practice in patients with advanced illness. This talk will summarize the recent guidelines from five major United States and European critical care societies on how to respond to such requests and how to proceed in the face of intractable conflict.Item Selected topics in intensive care(1983-06-09) Chappell, T. R.Item Update in critical care: an old dog presents new tricks(2005-03-24) Yarbrough, W. C.Item The Validity of Hourly Neurologic Assessments in the Intensive Care Unit for Patients with Traumatic Brain Injury(2017-01-17) Kabangu, Jean-Luc; Bedros, Nicole; Williams, Brian; Aoun, Salah; Geoffrion, Tracy; Provenzale, Natalie; Baker, Stacy; Minshall, ChristianLEARNING OBJECTIVES: Traumatic brain injury (TBI) is a leading cause of disability and mortality worldwide. The standard of care at many trauma centersis to admit patients with TBI to the Intensive Care Unit (ICU) for hourly neurologic assessments. There is a proven discrepancy between documented GCS (Glasgow Coma Scale score) and the presence of significant organic intracranial injuries and their clinical impact. Additionally, unnecessary ICU stay incurs significant financial costs to and resource utilization, and may adversely affect patient outcomes. There is no consensus regarding the optimal duration or frequency of hourly neurologic assessments. METHODOLOGY: As a feasibility study we retrospectively reviewed data from the trauma registry at our urban, level I trauma center over a 2-month period, Data points included head injury type, admission GCS, lowest GCS within 24 hours of admission, lowest GCS during hospitalization, ICU length of stay, total length of stay; and unplanned surgical, medical, or diagnostic intervention prompted by a decline in GCS. RESULTS: Twenty-two patients were admitted to the ICU based on the radiographic and clinical diagnoses of traumatic brain injury. Eighty-two percent of patients did not experience a decline in GCS within the first 24 hours of admission. Among them, 17% experienced a decline after 24 hours for non-neurological reasons. Of the 18% that did experience a decline within 24 hours, none prompted an unplanned intervention in their previously management plan. CONCLUSIONS: All patients with TBI may not require hourly neurologic assessments in the ICU. The majority of patients in our review did not experience a decline in GCS. Additionally, those that did decline did not trigger a significant change in clinical management. Further data is required to elucidate certain patient or injury criteria to separate patients that truly require hourly neurologic assessments from those that can be monitored in a lower acuity setting.