Background: Based on survey data from both Canada and abroad, most people would prefer to be cared for and to die in their own homes. Although 70% of elderly patients state a preference for comfort care over high technology life prolonging treatment in an inpatient setting, 54% are still admitted to intensive care units (ICUs). Understanding their wishes regarding end-of-life care, and being able to engage in evidence informed end-of-life discussions has never been so important, in order to empower patients, and to optimize scarce resource management. For the purpose of this thesis, “very old” patients will be defined as those eighty years of age and older. All three manuscripts will be based on data from the Realistic 80 study, a prospective cohort trial of 1671 critically ill very old patients admitted to 22 Canadian ICUs. Objectives: Manuscript 1: To describe the hospital outcomes of the entire cohort of Realistic 80 patients, including their ICU mortality and length of stay, their hospital mortality and length of stay, and their ultimate dispositions. Manuscript 2: To derive a clinical prediction rule for hospital mortality in the medical patient cohort. Manuscript 3: To derive a clinical prediction rule for hospital mortality in the emergency surgical patient cohort. Data Source: A prospective, multicenter cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Methods: Clinical decision rule methodology was used to analyze the data set and to create two separate clinical prediction tools, one for critically ill elderly medical patients, and one for critically ill surgical emergency patients. A third manuscript describing general clinical outcomes was also produced. Results of Manuscript 1: A total of 1671 patients were included in this section of the “Realities, Expectations and Attitudes to Life Support Technologies in Intensive Care for Octogenarians: The Realistic 80 Study (a prospective cohort of nearly 2000 critically ill Canadian patients over eighty years old enrolled from 22 ICUs across Canada) that will provide the data for this thesis. The Realistic 80 cohort had a mean age of 84.5, a baseline Apache II score of 22.4, a baseline SOFA score of 5.3, an overall ICU mortality of 21.8%, and an overall hospital mortality of 35%. The cohort had a median ICU length of stay of 3.7 days, and an overall median hospital length of stay of 16.6 days. Only 46.4% of the survivors were able to return home to live. Results of Manuscript 2: Age, renal function, level of consciousness, and serum pH were the important predictors of hospital mortality in critically ill elderly medical patients. Our clinical prediction tool is very good, particularly at the all-important extremes of prognosis, and ready for external validation. Results of Manuscript 3: Renal function and serum pH were the important predictors of hospital mortality in critically ill elderly surgical patients. Our model’s performance is very good, and will serve to inform clinical practice once validated. Conclusions: Very old medical patients have longer ICU stays and higher mortality than their surgical counterparts. Premorbid health status and severity of illness are associated with mortality. Our medical patient clinical prediction tool is very good and ready for external validation. Our surgical emergency clinical prediction tool shows promise, but will require the incorporation of more patients and a repeat derivation phase prior to external validation or clinical implementation.

Magister Scientiae (Physiotherapy) - MSc(Physio) / The professional status of physiotherapists in Sudan is reported to be low even though the profession was established in Khartoum, Sudan in 1969. Intensive care units are operating in Khartoum, Sudan. Physiotherapists have been reported to be integral to the management of intensive care patients. Globally, the role of ICU physiotherapists in the management of ICU patients have been explored and described; however, this information is lacking for Khartoum, where the profession is still in its infancy. Therefore, this study aimed to explore and describe the physiotherapists’ perceptions of their role in the management of intensive care patients in Khartoum, Sudan. / 2022

Thesis (M.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / Nurses are subjected to occupational stress factors that can result in the syndrome of burnout. This study compared levels of burnout in nurses in a medical-surgical ICU setting to those in non-ICU medical-surgical settings. A randomized sample of 40 nurses of an urban hospital in Taiwan, twenty nurses in an ICU and 20 in five non-ICU settings (general medical-surgical wards), who returned the questionnaire used to measure burnout, were included in the study. The instrument utilized was the Staff Burnout Scale for Health Professionals. The study found no significant difference in levels of burnout in the two groups. Both groups in this study experienced a higher level of burnout than was reported in other studies in United States literature. In particular, two general medical-surgical wards which had high patient/nurse ratios, had very high levels of burnout. The study also found that all nurses with lower educational levels and ICU nurses with more years of work experience had more burnout. / 2031-01-01

The overuse of antibiotics is a large problem in healthcare today, accelerating the development of microbial resistance to antibiotics. Antibiotic stewardship campaigns have been implemented to help clinicians curb their use. Procalcitonin is a serum peptide and marker of inflammation secreted in response to microbial toxins. For this reason it is more specific to bacterial infections than other markers of general inflammation , like Creactive protein. The population of patients with sepsis in the Intensive Care Unit is one in which extended durations of antibiotics are used. The FDA has approved use of procalcitonin to guide de-escalation of antibiotic therapy in critically ill patients with sepsis to avoid both antibiotic overuse and antibiotic related side effects. Review of current literature shows that procalcitonin is efficacious in reducing duration of antibiotic therapy in patients with sepsis in the ICU setting. This result, however, is not being observed in clinical practice. This discrepancy is due to the inappropriate use of procalcitonin that does not align with use outlined in randomized control trials. We propose a study to determine how procalcitonin is being used in clinical practice in four Boston area hospital Intensive Care Units. Through chart review, we will identify patients in the Intensive Care Unit with sepsis from 2013-2018 recording patient demographic information and patient characteristics. We will determine whether they had PCT measured during their stay, and if they did, whether or not discontinuation of antibiotics was in accordance with FDA’s proposed algorithm. We will aim to compare whether discontinuing antibiotic therapy in accordance with the FDA’s procalcitonin deescalation algorithm is associated with reduced duration of antibiotic therapy or incidence of Clostridium Difficile infection. In conducting this study, we hope to identify patterns of procalcitonin use in clinical practice and provide further evidence that using the algorithm to guide therapy can serve as an effective tool in reducing exposure to unnecessary antibiotics and the complications from their use.

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.