Franco, Pablo Moreno

Introduction/objective Improving graduate medical trainee involvement with patient safety and incident reporting is an important task in teaching hospitals that has been recognised across the country and led to numerous efforts to address barriers to incident reporting. A variety of studies have started to define the reasons why trainees are not optimally involved and interventions that may be helpful. The present study aims to add to this literature by primarily addressing barriers that can be considered ‘non-technical’ such as fears surrounding potential professional repercussions after submitting a report, perceptions that reporting incidents is not useful, and concerns about anonymity. Methods Barriers to incident reporting were previously analysed at our institution. A video was produced to directly target the barriers discovered. A 2-hour educational session was delivered which included the video intervention. The educational session was part of the standard patient safety curriculum at our institution. Paper surveys were used to capture changes in perceived barriers to incident reporting. Baseline and postintervention surveys were analysed for changes using t-tests and a p value of <0.05 to determine significance. Survey development included literature review, patient safety expert discussion and cognitive interviews. Results Perceived knowledge about the reporting process significantly improved after the intervention (t=−4.49; p<0.05). Attitudes about reporting also significantly improved with reduction in fear of negative consequences and anonymity. Perceptions of reporting being a futile activity were also diminished after the intervention. Conclusions This study demonstrates that targeting non-technical barriers to incident reporting with a video intervention is an effective way to improve perceived knowledge and attitude about incident reporting.

ABSTRACT Background and purpose: Daily chest radiographs (CXRs) have long been a routine part of care. However, evidence as well as changing technology has promoted on-demand CXRs as beneficial to patient care. We found that a substantial number of routine daily CXRs were being ordered, with some of the orders staying active even after extubation. Methods: Within a 19-bed adult medical ICU, we prospectively utilized 3 intervention phases from October 1, 2014, to February 28, 2018, to reduce routine CXRs. Nurse Practitioners (NP) initiated this quality improvement (QI) project, aiming to reduce the number of unnecessary of CXRs. Interventions included staff survey, routine CXR order removal, duplicate alerts, visual reminders, and an electronic clinical decision support tool. Monthly education of appropriate CXRs and bedside ultrasound were facilitated by NPs. The outcome measures of interest include: the number of CXRs per patient-day, the number of routine and on-demand CXRs, mortality rate, ICU length of stay, and ventilator days, radiation and cost. Conclusions: Total number of CXRs per patient-day decreased by 36.1%. The proportion of routine CXRs decreased from 55.37% to 13.18%; on-demand orders increased, from 44.63% to 86.82%; and calculated radiation-exposure per census decreased, from 0.011 to 0.008 mSv. In addition, charges to patients for CXRs decreased by $7,750/month. ICU mortality and ventilator days per census remained stable. Implications for practice: By an orchestrated process that included creating awareness and desire to change CXR ordering practices, we were able to decrease routine CXRs and increase on-demand utilization while maintaining counterbalance measures.

Background: Portopulmonary hypertension (POPH) is defined as pulmonary arterial hypertension (PAH) in the context of portal hypertension. Severe POPH has been considered an absolute contraindication of orthotopic liver transplantation (OLT).Objective: Since there are no definitive guidelines for the immediate preoperative, intraoperative, and postoperative evaluation and treatment of POPH patients, we have used published literature along with our experience to review current knowledge in this area.Summary: Moderate-to-severe POPH has important consequences in the perioperative management of candidates for OLT. Adequate right ventricular function is critical to survive the hemodynamic burden of OLT. Immediate preoperative assessment of hemodynamics; careful intraoperative monitoring and management of volume status, pressure changes, and ventricular function; and postoperative transitions of PAH-specific therapy are key components to successful OLT. We emphasize the advantages of the echocardiogram during all of these phases and stress the importance of a team approach to plan care and respond to the multiple challenges of OLT in POPH.

The Surviving Sepsis Campaign guidelines are designed to decrease mortality through consistent application of a 7-element bundle. This study evaluated the impact of improvement in bundle adherence using a time-series analysis of compliance with the bundle elements before and after interventions intended to improve the process, while also looking at hospital mortality. This article describes interventions used to improve bundle compliance and hospital mortality in patients admitted through the emergency department with sepsis, severe sepsis, or septic shock. Quality improvement methodology was used to develop high-impact interventions that led to dramatically improved adherence to the Surviving Sepsis Campaign guidelines bundle. Improved performance was associated with a significant decrease in the in-hospital mortality of severe sepsis patients presenting to the emergency department.

Abstract Rationale The management of severe and refractory hypoxemia in critically ill adult patients is practice based. Variability across individual practitioners and institutions is not well documented. Objectives To conduct a nationwide survey of critical care physicians in the United States regarding accepted definitions and management strategies for severe and refractory hypoxemia. Methods A web-based survey was distributed to a stratified random sample of adult intensivists listed in the American Medical Association Physician Masterfile. The survey was generated by using a mixed-methods approach. Measurements and Main Results: In the survey, 4,865 e-mails were sent and 791 (16.3%) were opened. Among those who opened the e-mail message, 50% (n = 396) responded, representing 8.1% of total surveys sent. Seventy-two percent stated that their institutions lacked a protocol for identification and management of severe or refractory hypoxemia in the setting of acute respiratory failure. While the majority of respondents used low-Vt ventilation (81%), high positive end-expiratory pressure (86%), recruitment maneuvers (89%), and either bolus or infusion neuromuscular blockade (94%), there was marked variability in the use of specific rescue strategies as tier 1 or 2 interventions: prone position (27.8% vs. 47.8%, respectively), extracorporeal membrane oxygenation (2.3% vs. 51.2%, respectively), airway pressure release ventilation (49% vs. 34.5%, respectively), inhaled vasodilators (30.1% vs. 40%, respectively), and high-frequency oscillatory ventilation (7.8% vs. 40%, respectively). The variability was partly explained by providers’ expertise with particular rescue strategies (77.7%), advance directives (70.1%), the training of allied health staff (62.3%), and institutional availability (53.8%). Conclusions U.S. adult critical care physicians predominantly employ lung-protective ventilation for severe hypoxemia. A wide variation in other rescue strategies is noted, which is partly explained by user expertise and availability. Less than 30% institutions have formal protocols for management of refractory hypoxemia.