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Journal ArticleDOI

Improving communication in the ICU using daily goals.

01 Jun 2003-Journal of Critical Care (Elsevier)-Vol. 18, Iss: 2, pp 71-75
TL;DR: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS.
About: This article is published in Journal of Critical Care.The article was published on 2003-06-01. It has received 638 citations till now. The article focuses on the topics: Acute care & Health care.
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Journal ArticleDOI
TL;DR: An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.
Abstract: A b s t r ac t A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P≤0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval (CI), 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. Conclusions An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

3,844 citations

Journal ArticleDOI
TL;DR: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in the authors' surgical ICU.
Abstract: Objective To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). Design Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. Setting The Johns Hopkins Hospital. Patients All patients with a central venous catheter in the ICU. Intervention To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. Measurement The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. Main results Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. Conclusions Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.

901 citations

Journal ArticleDOI
TL;DR: Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening, and failure to carry out intended treatment correctly was the leading category.
Abstract: Objective: Critically ill patients require high-intensity care and may be at especially high risk of iatrogenic injury because they are severely ill. We sought to study the incidence and nature of adverse events and serious errors in the critical care setting. Design: We conducted a prospective 1-year observational study. Incidents were collected with use of a multifaceted approach including direct continuous observation. Two physicians independently assessed incident type, severity, and preventability as well as systems-related and individual performance failures. Setting: Academic, tertiary-care urban hospital. Patients Medical intensive care unit and coronary care unit patients. Interventions: None. Measurements and Main Results: The primary outcomes of interest were the incidence and rates of adverse events and serious errors per 1000 patient-days. A total of 391 patients with 420 unit admissions were studied during 1490 patient-days. We found 120 adverse events in 79 patients (20.2%), including 66 (55%) nonpreventable and 54 (45%) preventable adverse events as well as 223 serious errors. The rates per 1000 patient-days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively. Among adverse events, 13% (16/120) were life-threatening or fatal; and among serious errors, 11% (24/223) were potentially life-threatening. Most serious medical errors occurred during the ordering or execution of treatments, especially medications (61%; 170/277). Performance level failures were most commonly slips and lapses (53%; 148/ 277), rather than rule-based or knowledge-based mistakes. Conclusions: Adverse events and serious errors involving critically ill patients were common and often potentially life-threatening. Although many types of errors were identified, failure to carry out intended treatment correctly was the leading category. Copyright © 2005 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins.

886 citations


Additional excerpts

  • ...Significant 19 (35) 30 (46) 49 (41) 57 (43) 44 (49) 101 (45) Severe 28 (52) 27 (41) 55 (46) 57 (43) 41 (46) 98 (44) Life-threatening 5 (9) 9 (14) 14 (12) 19 (14) 5 (6) 24 (11) Fatal 2 (4) 0 (0) 2 (2) NA NA NA Total 54 66 120 133 90 223...

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Journal ArticleDOI
TL;DR: Interprofessional checklist briefings reduced the number of communication failures and promoted proactive and collaborative team communication in general surgery at a Canadian academic tertiary care hospital.
Abstract: Objective To assess whether structured team briefings improve operating room communication. Design, Setting, and Participants This 13-month prospective study used a preintervention/postintervention design. All staff and trainees in the division of general surgery at a Canadian academic tertiary care hospital were invited to participate. Participants included 11 general surgeons, 24 surgical trainees, 41 operating room nurses, 28 anesthesiologists, and 24 anesthesia trainees. Intervention Surgeons, nurses, and anesthesiologists gathered before 302 patient procedures for a short team briefing structured by a checklist. Main Outcome Measure The primary outcome measure was the number of communication failures (late, inaccurate, unresolved, or exclusive communication) per procedure. Communication failures and their consequences were documented by 1 of 4 trained observers using a validated observational scale. Secondary outcomes were the number of checklist briefings that demonstrated “utility” (an effect on the knowledge or actions of the team) and participants' perceptions of the briefing experience. Results One hundred seventy-two procedures were observed (86 preintervention, 86 postintervention). The mean (SD) number of communication failures per procedure declined from 3.95 (3.20) before the intervention to 1.31 (1.53) after the intervention ( P Conclusions Interprofessional checklist briefings reduced the number of communication failures and promoted proactive and collaborative team communication.

571 citations


Cites result from "Improving communication in the ICU ..."

  • ...within clinical teams.(9-13) Many studies of...

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  • ...Consistent with other studies in the OR, intensive care unit, and emergency department settings, we found that a routine team checklist briefing was feasible and had positive perceived effects on team communication and teamwork.(9-11,13) What distinguishes our study is the objec-...

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Journal ArticleDOI
TL;DR: This narrative is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to the implementation of checklists.

565 citations


Cites background or methods from "Improving communication in the ICU ..."

  • ...[34] Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T,...

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  • ...Their formwas based on that of Pronovost et al who showed a 50% decrease in ICU length of stay after the introduction of their checklist of daily goals along with an 85% improvement in clinicians understanding of the daily care goals for each patient [34]....

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References
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Journal ArticleDOI
TL;DR: The specialty of obstetrics and gynaecology will benefit from several related groups already working within the Cochrane Collaboration, and it is hoped that the ‘wooden spoon’ can be discarded from the authors' ranks for good.
Abstract: Summary In the current era of patients seeking better information, managers seeking cost-effective treatments, clinicians struggling to keep up with the expanding medical literature, and professional groups requiring continuing medical education, there is a clear need for up-to-date and relevant systematic reviews of the effectiveness of treatment within our specialty. Such reviews will play an increasing role in the education of health professionals and lay people, in the evolution of the health service and in the direction of future research. The Cochrane Collaboration provides the infrastructure for the development and dissemination of these reviews. The specialty of obstetrics and gynaecology will benefit from several related groups already working within the Cochrane Collaboration (Pregnancy and Childbirth, Subfertility, Menstrual Disorders and Incontinence). Other groups are in the process of, or likely to, register in the near future (Fertility Control, Gynaecological Cancer). However, the need and demand for a large number of systematic reviews exceeds the current capacity of those who have committed themselves to prepare and maintain such reviews, and substantial challenges remain. However, there is every reason to believe that a concerted effort over many years will be worth while. Earlier in this commentary, obstetrics and gynaecology was referred to as the specialty most deserving of the ‘wooden spoon’ for its lack of evidence-based practice. With the development of various gynaecological groups within the Collaboration, we hope that the ‘wooden spoon’ can be discarded from our ranks for good.

2,561 citations

01 Jan 2001
TL;DR: This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety and identify practices with the strongest supporting evidence that decrease the risks associated with hospitalization, critical care, or surgery.
Abstract: Objectives Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety Search strategy and selection criteria Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation This process resulted in the identification of 79 practices for review The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice Pertinent studies were identified using various bibliographic databases (eg, MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts Data collection and analysis Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature" For most practices, the project team required that the primary outcome consist of a clinical endpoint (ie, some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality This criterion was relaxed for some practices drawn from the non-health care literature The evidence supporting each practice was summarized using a prospectively determined format The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries A separate ranking was developed for research priorities Main results Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery Many patient safety practices drawn primarily from nonmedical fields (eg, use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections Conclusions An evidence-based approach can help identify practices that are likely to improve patient safety Such practices target a diverse array of safety problems Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care

1,556 citations

Journal ArticleDOI
18 Mar 2000-BMJ
TL;DR: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital and barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance.
Abstract: OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN:: Cross sectional surveys. SETTING:: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS:: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES:: Perceptions of error, stress, and teamwork. RESULTS:: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.

1,510 citations

Journal ArticleDOI
TL;DR: A significant number of dangerous human errors occur in the ICU, and applying human factor engineering concepts to the study of the weak points of a specific ICU may help to reduce the number of errors.
Abstract: Objectives The purpose of this study was to investigate the nature and causes of human errors in the intensive care unit (ICU), adopting approaches proposed by human factors engineering. The basic assumption was that errors occur and follow a pattern that can be uncovered.Design Concurrent incident

894 citations

Journal ArticleDOI
TL;DR: There was a perfect rank order correlation between unit-level organizational collaboration and patient outcomes across the three units, and medical ICU nurses' reports of collaboration were associated positively with patient outcomes.
Abstract: Objective:To investigate the association of collaboration between intensive care unit (ICU) physicians and nurses and patient outcome.Design:Prospective, descriptive, correlational study using self-report instruments.Settings:A community teaching hospital medical ICU, a university teaching hospital

652 citations