Background: To efficiently capture evaluation and management (E&M) and procedural billing in our surgical intensive care unit (SICU), we have developed an electronic billing system that links to the electronic medical record (EMR). In this system, only notes electronically signed and coded by an attending generate billing charges. We hypothesized that capture of missed billing during nighttime and weekends might be sufficient to subsidize 24/7 in-house attending coverage. Methods: A retrospective chart EMR review was performed of the EMRs for all SICU patients during a 2-month period. Note type, date, time, attending signature, and coding were analyzed. Notes without attending signature, diagnosis, or current procedural terminology (CPT) code were considered incomplete and identified as "missed billing." Results: Four hundred and forty-three patients had 465 admissions generating 2,896 notes. Overall, 76% of notes were signed and coded by an attending and billed. Incomplete (not billed) notes represented an overall missed billing opportunity of $159,138 for the 2-month time period (∼$954,000 annually). Unbilled E&M encounters during weekdays totaled $54,758, whereas unbilled E&M and procedures from weeknights and weekends totaled $88,408 ($44,566 and $43,842, respectively). Missed billing after-hours thus represents ∼$530K annually, extrapolating to ∼$220K in collections from our payer mix. Surprisingly, missed E&M and procedural billing during weekdays totaled $70,730 (∼$425K billing, ∼$170K collections annually), and typically represented patients seen, but transferred from the SICU before attending documentation was completed. Conclusions: Capture of nighttime and weekend ICU collections alone may be insufficient to add faculty or incentivize in-house coverage, but could certainly complement other in-house derived revenues to such ends. In addition, missed daytime billing in busy modern ICUs can be substantial, and use of an EMR to identify missed billing opportunities can help create solutions to recover these revenues.

Critical illness can be iatrogenic, arising from the lifesaving measures undertaken during admission to critical care. Early mobilization (EM) of patients receiving intensive care unit (ICU)-level care may reduce the possible iatrogenic effects of critical care following cardiac surgery. While evidence supports the safety and efficacy of physiotherapy in the medical-surgical ICU, few studies have included critically ill patients with complicated, prolonged post-operative recoveries despite the worldwide frequency of cardiac surgery. This has resulted in a lack of clinical practice guidelines or systematic reviews to help guide critical care physiotherapy practice in post-operative cardiac surgery. In-bed cycling is a modality to initiate EM. However, its safety and feasibility have yet to be established in the critically ill cardiac surgery population. There is also a paucity of qualitative research investigating clinicians’ attitudes and beliefs about in-bed cycling as an acceptable rehabilitation modality. Purposes: (1) To describe current physiotherapy practice for critically ill adult patients requiring prolonged admissions to ICU post cardiac surgery in Ontario via an electronic, self-administered survey; (2) To investigate the feasibility of in-bed cycling in a pilot study in a sample of critically ill cardiac surgery patients in Hamilton, Ontario; (3) To explore primary frontline clinicians’ experiences and impressions of their involvement with in-bed cycling in the cardiac surgical ICU via an interpretive description qualitative interview study. With adequate physiotherapy staffing, in-bed cycling was found to be safe and feasible with few adverse events occurring during cycling. With an 80% response rate, our survey results suggest that Ontario critical care physiotherapists provide a variety of interventions ranging from chest physiotherapy to functional mobility. Clinicians supported the use of in-bed cycling. Concerns included how to identify appropriate patients and timing of the intervention. This thesis built upon the current critical care research by increasing the presence of the cardiac surgery population in the rehabilitation literature. / Thesis / Doctor of Rehabilitation (RhD) / Early exercise can help patients rehabilitate after a critical illness. No current research exists examining the role of in-bed cycling with patients who become critically ill after heart surgery (so called “off-track”). The thesis goals were: (1) to conduct a survey of Ontario ICU physiotherapists to understand their role treating off-track patients with a complicated post-operative recovery; (2) to determine if cycling is safe and feasible with sick patients after heart surgery in the intensive care unit (ICU); and (3) to interview staff in the Hamilton heart surgery ICU to understand their experiences with in-bed cycling. Ontario physiotherapists provide a multitude of interventions in the heart surgery ICU. Cycling was found to be safe and feasible with adequate physiotherapy staffing. Intensive care unit staff supported in-bed cycling but were concerned about choosing the right patients and how best to time its introduction. With limited evidence around physiotherapy in the heart surgery ICU, larger studies are needed.

Objectives: The quality of securement directly impacts the functionality, duration of patency and likelihood of a complication for a given peripheral intravenous catheter. The objective of the study was to determine which method of peripheral intravenous catheter securement, StatLock or Tegabear dressing was more effective by comparing duration of catheter patency and complication rates. Study Design & Method: A quasi-experimental study using the Model for Improvement was conducted in a neonatal intensive care unit of a tertiary care hospital. Infants requiring insertion of a peripheral intravenous catheter for parenteral nutrition or administration of medications were eligible to participate. The study was conducted over a 4-month period and was divided into two phases, with each phase lasting two months. Results: A total of 363 peripheral intravenous catheters were inserted in 175 infants. There were 211 catheters secured with StatLock and 108 secured with Tegabear dressing. There were 42 catheters which were unable to use StatLock or Tegabear dressing and were secured with a combination of transparent dressing/ tape. There were two peripheral intravenous catheters inserted where the method of securement was not indicated. The groups were similar with regards to all demographic variables except postmenstrual age, where the Tegabear group consisted of a larger proportion of older infants (p=<0.001). There was no significant difference in the mean duration of catheter patency between the StatLock and Tegabear group (46.04 hours versus 45.33 hours respectively), p=0.84. Complication rates and reasons for catheter removal did not significantly differ between the two groups (p=0.78 and p=0.93 respectively). The proportion of catheters that used an arm board was significantly greater with the Tegabear dressing (23.8%) compared to 10.5% with StatLock (p=0.002). Twenty one percent (n=23/108) of the catheters secured with the Tegabear dressing required reinforcement with tape or transparent dressing whereas no catheters in the StatLock group needed to be reinforced (p<0.001). Conclusion: Catheter dwell time and complication rates did not differ significantly between StatLock and Tegabear dressing. However, when evaluating a new product, it is important to consider that there is often a learning curve that must be overcome. A larger study with a more rigorous design such as a randomized controlled trial is needed to validate or dispute the study findings. In the meantime, nurses must exercise individual and independent judgment when selecting a securement method most appropriate for their patient. / Thesis / Master of Science in Nursing (MSN)

Background: Patients with severe COVID-19 evolve to acute respiratory distress syndrome (ARDS) and require management in Intensive Care Units (ICU) where they are exposed to immobilization, immunosuppression, malnutrition, nosocomial infections; may develop ICU Acquired Weakness (ICUAW), which increases with the stay and use of mechanical ventilation (MV).There is evidence of the use of different modalities in rehabilitation to mitigate these effects. Goal: To determine the efficacy of a Multimodal Rehabilitation Program (MRP) in reducing the number of days of mechanical ventilation and stay in patients hospitalized for COVID-19 in ICU, as well as to describe its clinical and hospital characteristics. Material and Methods: An quasi-experimental study was designed, with sequential sampling and without blinding. A control and intervention group was formed, with 32 participants each. A Multimodal Rehabilitation Program (MRP) based on four therapeutic modalities was applied and the intervention was quantified through the use of proposed indicators. Results: The variation in days of ICU stay and days of MV were similar in both groups. The Multimodal Rehabilitation Index (iMR) ranged from 0.1 to 2.7 (mean = 1.2, SD = 0.7) and had significance for cut-off points ≤ 0.81 and ≤ 0.94 in mortality (p = 0.02) and Ventilator-free days at 28 days (VFDs-28) (p = 0.01). Conclusions: No statistically significant difference was found in favor of the intervention in terms of days of stay in the ICU and days of MV. Explanatorily, it was reported that iMR was related to (VFDs-28) and mortality in patients with severe COVID-19.

No description available.

Teamwork is essential for ensuring the quality and safety of healthcare delivery in the intensive care unit (ICU). Complex procedures are conducted with a diverse team of clinicians with unique roles and responsibilities. Information about care plans and goals must also be developed, communicated, and coordinated across multiple disciplines and transferred effectively between shifts and personnel. The intricacies of routine care are compounded during emergency events, which require ICU teams to adapt to rapidly changing patient conditions while facing intense time pressure and conditional stress. Realities such as these emphasize the need for teamwork skills in the ICU. The measurement of teamwork serves a number of different purposes, including routine assessment, directing feedback, and evaluating the impact of improvement initiatives. Yet no behavioral marker system exists in critical care for quantifying teamwork across multiple task types. This study contributes to the state of science and practice in critical care by taking a (1) theory-driven, (2) context-driven, and (3) psychometrically-driven approach to the development of a teamwork measure. The development of the marker system for the current study considered the state of science and practice surrounding teamwork in critical care, the application of behavioral marker systems across the healthcare community, and interviews with front line clinicians. The ICU behavioral marker system covers four core teamwork dimensions especially relevant to critical care teams: Communication, Leadership, Backup and Supportive Behavior, and Team Decision Making, with each dimension subsuming other relevant subdimensions. This study provided an initial assessment of the reliability and validity of the marker system by focusing on a subset of teamwork competencies relevant to subset of team tasks. Two raters scored the performance of 50 teams along six subdimensions during rounds (n=25) and handoffs (n=25). In addition to calculating traditional forms of reliability evidence [intraclass correlations (ICCs) and percent agreement], this study modeled the systematic variance in ratings associated with raters, instances of teamwork, subdimensions, and tasks by applying generalizability (G) theory. G theory was also employed to provide evidence that the marker system adequately distinguishes teamwork competencies targeted for measurement. The marker system differentiated teamwork subdimensions when the data for rounds and handoffs were combined and when the data were examined separately by task (G coefficient greater than 0.80). Additionally, variance associated with instances of teamwork, subdimensions, and their interaction constituted the greatest proportion of variance in scores while variance associated with rater and task effects were minimal. That said, there remained a large percentage of residual error across analyses. Single measures ICCs were fair to good when the data for rounds and handoffs were combined depending on the competency assessed (0.52 to 0.74). The ICCs ranged from fair to good when only examining handoffs (0.47 to 0.69) and fair to excellent when only considering rounds (0.53 to 0.79). Average measures ICCs were always greater than single measures for each analysis, ranging from good to excellent (overall: 0.69 to 0.85, handoffs: 0.64 to 0.81, rounds: 0.70 to 0.89). In general, the percent of overall agreement was substandard, ranging from 0.44 to 0.80 across each task analysis. The percentage of scores within a single point, however, was nearly perfect, ranging from 0.80 to 1.00 for rounds and handoffs, handoffs, and rounds. The confluence of evidence supported the expectation that the marker system differentiates among teamwork subdmensions. Yet different reliability indices suggested varying levels of confidence in rater consistency depending on the teamwork competency that was measured. Because this study applied a psychometric approach, areas for future development and testing to redress these issues were identified. There also is a need to assess the viability of this tool in other research contexts to evaluate its generalizability in places with different norms and organizational policies as well as for different tasks that emphasize different teamwork skills. Further, it is important to increase the number of users able to make assessments through low-cost, easily accessible rater training and guidance materials. Particular emphasis should be given to areas where rater reliability was less than ideal. This would allow future researchers to evaluate team performance, provide developmental feedback, and determine the impact of future teamwork improvement initiatives.

In this dissertation I explore the cultures of death and dying in medical institutions, hospices and funeral work. I argue that not only are there competing cultures of death and dying in American society, but within these institutions that produce tension and conflict, sometimes among the workers, other times between the workers and those they serve, and other times between the institution and outside organizations. Medical institutions, by medicalizing death and dying, constructed a "death as enemy" orientation in which doctors fight death with the use of medical technology, practice detached concern from their patients, and marginalize religion and spirituality. On the other hand, a "suffering as enemy" orientation has also emerged, primarily in the form of palliative medicine, in which needless suffering is considered worse than death, therefore life-saving technology is removed, doctors empathize with patients and families, and spirituality is incorporated. Hospice started as a social movement to change how dying patients were treated at the end of life, addressing patients' physical, spiritual and emotional pain. However, the bureaucratization of hospice, particularly the Medicare Hospice Benefit, has led to a compromise of the social movement's ideals and these competing orientations shape how hospice workers, particularly nurses and social workers, express frustrations with their work. Funeral directors assert their jurisdictional claims of the right to handle the corpse and assuage the grief of the bereaved, through embalming, informal grief counseling and the funeral performance, but funeral directors encounter resistance from large funeral corporations and the funeral societies. Large corporations centralize embalming, turning the corpse from a craft to a product, recruit other professionals to practice grief counseling, and sell standardized funeral packages. Funeral societies challenge the necessity of embalming, funeral directors' expertise in grief counseling, and focusing on the value of simple, dignified and affordable funerals. I conclude this dissertation by showing how orientations toward death and dying vary in American society and these institutions because of tension between experts who espouse a particular orientation and activists who resist the claims of the experts.

No description available.

Diarrhea is common during critical illness; however, the etiology, definitions, incidence and risk factors for diarrhea and its impact on patient important outcomes require further investigation. There are many possible etiologies of diarrhea, including iatrogenic causes such as laxative medications, often administered as part of bowel protocols, as well as Clostriodiodes difficile associated diarrhea (CDAD). This thesis includes 6 chapters that address the knowledge gaps in the literature regarding the epidemiology of diarrhea in the intensive care unit (ICU), the impact of bowel protocols on diarrhea, and CDAD in critically ill adults. Chapter 1 provides an introduction to gaps in the literature that are addressed by the studies included in this thesis. Chapter 2 outlines the methodology used to inform the protocol for the Diarrhea, Incidence, Consequences and Epidemiology in the Intensive Care Unit (DICE-ICU) Study. Chapter 3 reports on the findings of DICE-ICU including the incidence, risk factors, definitions, and outcomes of patients who develop diarrhea in the ICU. Chapter 4 provides a content analysis of bowel protocols used in multiple ICUs. Chapter 5 summarizes a nested cohort study addressing the incidence, prevalence, timing, treatments, and outcomes of CDAD in critically ill patients enrolled in the PROSPECT Trial. Chapter 6 summarizes the work and discusses the strengths and limitations, implications and conclusions presented in this PhD thesis. / Thesis / Doctor of Philosophy (PhD)

No description available.