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Perspectives on strained intensive care unit capacity: A survey of critical care professionals.

ABSTRACT: BACKGROUND:Strained intensive care unit (ICU) capacity represents a supply-demand mismatch in ICU care. Limited data have explored health care worker (HCW) perceptions of strain. METHODS:Cross-sectional survey of HCW across 16 Alberta ICUs. A web-based questionnaire captured data on demographics, strain definition, and sources, impact and strategies for management. RESULTS:658 HCW responded (33%; 95%CI, 32-36%), of which 452 were nurses (69%), 128 allied health (19%), 45 physicians (7%) and 33 administrators (5%). Participants (agreed/strongly agreed: 94%) reported that strain was best defined as "a time-varying imbalance between the supply of available beds, staff and/or resources and the demand to provide high-quality care for patients who may become or who are critically ill"; while some recommended defining "high-quality care", integrating "safety", and families in the definition. Participants reported significant contributors to strain were: "inability to discharge ICU patients due to lack of available ward beds" (97%); "increases in the volume" (89%); and "acuity and complexity of patients requiring ICU support" (88%). Strain was perceived to "increase stress levels in health care providers" (98%); and "burnout in health care providers" (96%). The highest ranked strategies were: "have more consistent and better goals-of-care conversations with patients/families outside of ICU" (95%); and "increase non-acute care beds" (92%). INTERPRETATION:Strain is perceived as common. HCW believe precipitants represent a mix of patient-related and operational factors. Strain is thought to have negative implications for quality of care, HCW well-being and workplace environment. Most indicated strategies "outside" of ICU settings were priorities for managing strain.

SUBMITTER: Opgenorth D

PROVIDER: S-EPMC6104911 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Admission to the intensive care unit (ICU) outside daytime hours has been shown to be variably associated with increased morbidity and mortality. We aimed to describe the characteristics and outcomes of patients admitted to the ICU afterhours (22:00-06:59 h) in a large Canadian health region. We further hypothesized that the association between afterhours admission and mortality would be modified by indicators of strained ICU capacity. METHODS:This is a population-based cohort study of 12,265 adults admitted to nine ICUs in Alberta from June 2012 to December 2014. We used a path-analysis modeling strategy and mixed-effects multivariate regression analysis to evaluate direct and integrated associations (mediated through Acute Physiology and Chronic Health Evaluation (APACHE) II score) between afterhours admission (22:00-06:59 h) and ICU mortality. Further analysis examined the effects of strained ICU capacity and varied definitions of afterhours and weekend admissions. ICU occupancy ? 90% or clustering of admissions (??0.15, defined as number of admissions 2 h before or after the index admission, divided by the number of ICU beds) were used as indicators of strained capacity. RESULTS:Of 12,265 admissions, 34.7% (n?=?4251) occurred afterhours. The proportion of afterhours admissions varied amongst ICUs (range 26.7-37.8%). Patients admitted afterhours were younger (median (IQR) 58 (44-70) vs 60 (47-70) years, p?<?0.0001), more likely to have a medical diagnosis (75.9% vs 72.1%, p?<?0.0001), and had higher APACHE II scores (20.9 (8.6) vs 19.9 (8.3), p?<?0.0001). Crude ICU mortality was greater for those admitted afterhours (15.9% vs 14.1%, p?=?0.007), but following multivariate adjustment there was no direct or integrated effect on ICU mortality (odds ratio (OR) 1.024; 95% confidence interval (CI) 0.923-1.135, p?=?0.658). Furthermore, direct and integrated analysis showed no association of afterhours admission and hospital mortality (p?=?0.90) or hospital length of stay (LOS) (p?=?0.27), although ICU LOS was shorter (p?=?0.049). Early-morning admission (00:00-06:59 h) with ICU occupancy ? 90% was associated with short-term (??7 days) and all-cause ICU mortality. CONCLUSIONS:One-third of critically ill patients are admitted to the ICU afterhours. Afterhours ICU admission was not associated with greater mortality risk in most circumstances but was sensitive to strained ICU capacity.

Project description:PurposeTo systematically review and evaluate the effectiveness of interventions in order to improve the safety and efficiency of patient handover between intensive care unit (ICU) and general ward healthcare professionals at ICU discharge.MethodsPubMed, CINAHL, PsycINFO, EMBASE, Web of Science, and the Cochrane Library were searched for intervention studies with the aim to improve clinical handover between ICU and general ward healthcare professionals that had been published up to and including June 2013. The methods for article inclusion and data analysis were pre-specified and aligned with recommendations outlined in the PRISMA guideline. Two reviewers independently extracted data (study purpose, setting, population, method of sampling, sample size, intervention characteristics, outcome, and implementation activities) and assessed the quality of the included studies.ResultsFrom the 6,591 citations initially extracted from the six databases, we included 11 studies in this review. Of these, six (55 %) reported statistically significant effects. Effective interventions included liaison nurses to improve communication and coordination of care and forms to facilitate timely, complete and accurate handover information. Effective interventions resulted in improved continuity of care (e.g., reduced discharge delay) and in reduced adverse events. Inconsistent effects were observed for use of care, namely, reduction of length of stay versus increase of readmissions to higher care. No statistically significant effects were found in the reduction of mortality. The overall methodological quality of the 11 studies reviewed was relatively low, with an average score of 4.5 out of 11 points.ConclusionsThis review shows that liaison nurses and handover forms are promising interventions to improve the quality of patient handover between the ICU and general ward. More robust evidence is needed on the effectiveness of interventions aiming to improve ICU handover and supportive implementation strategies.

Project description:Strained intensive care unit (ICU) capacity represents a fundamental supply-demand mismatch in ICU resources. Strain is likely to be influenced by a range of factors; however, there has been no systematic evaluation of the spectrum of measures that may indicate strain on ICU capacity.We performed a systematic review to identify indicators of strained capacity. A comprehensive peer-reviewed search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection was performed along with selected grey literature sources. We included studies published in English after 1990. We included studies that: (1) focused on ICU settings; (2) included description of a quality or performance measure; and (3) described strained capacity. Retrieved studies were screened, selected and extracted in duplicate. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Analysis was descriptive.Of 5297 studies identified in our search; 51 fulfilled eligibility. Most were cohort studies (n = 39; 76.5%), five (9.8%) were case-control, three (5.8%) were cross-sectional, two (3.9%) were modeling studies, one (2%) was a correlational study, and one (2%) was a quality improvement project. Most observational studies were high quality. Sixteen measures designed to indicate strain were identified 110 times, and classified as structure (n = 4, 25%), process (n = 7, 44%) and outcome (n = 5, 31%) indicators, respectively. The most commonly identified indicators of strain were ICU acuity (n = 21; 19.1% [process]), ICU readmission (n = 18; 16.4% [outcome]), after-hours discharge (n = 15; 13.6% [process]) and ICU census (n = 13; 11.8% [structure]). There was substantial heterogeneity in the operational definitions used to define strain indicators across studies.We identified and characterized 16 indicators of strained ICU capacity across the spectrum of healthcare quality domains. Future work should aim to evaluate their implementation into practice and assess their value for evaluating strategies to mitigate strain.This systematic review was registered at PROSPERO (March 27, 2015; CRD42015017931 ).

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Perspectives on strained intensive care unit capacity: A survey of critical care professionals.

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