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Hospitalist and Intensivist Experiences of the "Open" Intensive Care Unit Environment: a Qualitative Exploration.

ABSTRACT: BACKGROUND:Most U.S. academic medical centers employ "closed" intensive care units (ICUs), where critically ill patients are admitted under the supervision of intensivists managing dedicated ICU teams. Some centers utilize a unique "open" ICU structure, where primary services longitudinally follow patients who become critically ill into the ICU with intensivist comanagement. The impact of open ICUs on patient care and education of trainees has not been well-characterized. OBJECTIVE:The objective of this study is to characterize affordances and barriers to education and patient care, from the perspectives of hospitalists and intensivists teaching in the ICU. DESIGN:We conducted semi-structured interviews with hospitalist and intensivist faculty at a large academic medical center with an open ICU structure. We coded deidentified interview transcripts to inductively analyze the data for themes and subthemes. PARTICIPANTS:We recruited hospitalist and intensivist faculty members who attend on teaching services in the open ICU system. APPROACH:Given the complexity of multiple teachers and learners in the ICU environment, we selected shared mental models as our primary theoretical lens through which we analyzed and interpreted our data. KEY RESULTS:We identified three main themes regarding education in the open ICU system: (1) communication challenges, (2) educational barriers and affordances, and (3) structural barriers and affordances. Hospitalists and intensivists agreed on some barriers and facilitators to education, such as continuity of care, yet they disagreed on others. Specifically, hospitalists and intensivists had a shared mental model regarding barriers to patient care and education in the open ICU structure, but had divergent opinions regarding the affordances of the structure, such as continuity and availability of ICU expertise. CONCLUSIONS:The open ICU environment presents facilitators and barriers to trainee education and patient care. Our findings can be leveraged to improve communication, education, and patient care on both hospitalist and ICU teams.

SUBMITTER: Santhosh L

PROVIDER: S-EPMC7253146 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Hospitalist and Intensivist Experiences of the "Open" Intensive Care Unit Environment: a Qualitative Exploration.

Santhosh Lekshmi L Sewell Justin J

Journal of general internal medicine 20200527 8

<h4>Background</h4>Most U.S. academic medical centers employ "closed" intensive care units (ICUs), where critically ill patients are admitted under the supervision of intensivists managing dedicated ICU teams. Some centers utilize a unique "open" ICU structure, where primary services longitudinally follow patients who become critically ill into the ICU with intensivist comanagement. The impact of open ICUs on patient care and education of trainees has not been well-characterized.<h4>Objective</h ...[more]

PMID: 32462568

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Project description:BackgroundDeath of a child in the pediatric intensive care unit is a rare event that can occur after failed cardiopulmonary resuscitation efforts, after a brain death diagnosis, or after a decision to limit therapeutic efforts. Nevertheless, even in the case of children with terminal and progressive illnesses, death is a crisis that comes as a surprise to parents and is perceived as unexpected. In the final stage of a child's life, health care staff play a key role in sharing feelings and experiences with the family and in supporting them throughout the process in order to facilitate the grieving process.ObjectiveThe aim of this study is to explore the experiences of parents whose children have died in a pediatric intensive care unit.MethodsTo address the study aims, a qualitative phenomenological study based on the van Manen proposal will be carried out. The study will be conducted in the pediatric intensive care unit of a tertiary care hospital. The study population will be parents or guardians (older than 18 years) of children who have died in the unit at least 6 months prior to potential participation in the study. Purposive sampling will be used to ensure sample diversity in relation to experiential variables. Families will be initially contacted by letter sent alongside the standard letter of condolences from the hospital, and then recruited in a subsequent telephone call. The sample size will be determined by data saturation. In-depth interviews will be conducted individually or in pairs. Parents will decide when, how, and where to conduct the interviews, which will be transcribed verbatim and examined using thematic discourse analysis.ResultsThis study was awarded a grant in December 2020 and was approved by the Medical and Health Research Ethics Committee on December 21, 2020. Data collection started in April 2021, and the results are expected to be published in 2023.ConclusionsThis project is intended to maintain, strengthen, and build on a particular line of research on end-of-life care with a focus on effective coping, spiritual well-being, and the adaptive grieving process. The results will contribute to establishing action guidelines that are both based on the discourses of parents who have experienced the death of a child and geared toward high-quality end-of-life care through dignified death and adaptive grief management.International registered report identifier (irrid)DERR1-10.2196/43756.

Project description:Critically ill intensive care unit (ICU) patients commonly develop severe muscle wasting and impaired muscle function, leading to delayed recovery, with subsequent increased morbidity and financial costs, and decrease quality of life of survivors. Acute Quadriplegic Myopathy (AQM) is one of the most common neuromuscular disorders associated with ICU-acquired muscle weakness. Although there are no available treatments for the ICU-acquired muscle weakness, it has been demonstrated that early mobilization can improve its prognosis and functional outcomes. This study aims at improving our understanding of the effects of passive mechanical loading on skeletal muscle structure and function by using a unique experimental rat ICU model allowing analyses of the temporal sequence of changes in mechanically ventilated and pharmacologically paralyzed animals at durations varying from 6 h to 14 days. Results show that passive mechanical loading alleviated the muscle wasting and the loss of force-generation associated with the ICU intervention, resulting in a doubling of the functional capacity of the loaded vs. unloaded muscles after a 2-week ICU intervention. We demonstrated that the improved maintenance of muscle structure and function is likely a consequence of a reduced oxidative stress, and a reduced loss of the molecular motor protein myosin. A complex temporal gene expression pattern, delineated by microarray analysis, was observed with loading-induced changes in transcript levels of sarcomeric proteins, muscle developmental processes, stress response, ECM/cell adhesion proteins and metabolism. Thus, the results from this study show that passive mechanical loading alleviates the severe negative consequences on muscle structure and function associated with mechanical silencing in ICU patients, strongly supporting early and intense physical therapy in immobilized ICU patients. This study aims to unravel the effects of passive mechanical loading on skeletal muscle structure and function in an experimental rat ICU model at duration varying between 6h and 14 days. A total of 23 experimental female Sprague-Dawley rats were included in this study. The experimental rats were anaesthetized, treated with the neuromuscular blocking agent (NMBA) M-NM-1-cobrotoxin, mechanically ventilated and monitored for durations varying from 6h to 4 days (n=13), from 5 to 8 days (n=4), and from 9 to 14 days (n=6). The left leg of the animal was activated for 6 hours at the shortest duration and 12 hours per day at durations 12 hours and longer throughout the experiment, using a mechanical lever arm that produced a continuous passive maximal ankle joint flexions-extensions at a speed of 13.3 cycles per minute. Muscle biopsies were obtained from gastrocnemius muscle (proximal part) immediately after euthanasia, were quickly frozen in liquid propane cooled by liquid nitrogen, and stored at -80M-BM-0C. RNA was extracted.

Dataset Information

Hospitalist and Intensivist Experiences of the "Open" Intensive Care Unit Environment: a Qualitative Exploration.

Publications

Hospitalist and Intensivist Experiences of the "Open" Intensive Care Unit Environment: a Qualitative Exploration.

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