Download Report

sccm.org/criticalconnections • facebook.com/SCCM1 • twitter.com/SCCM
Volume 14, Number 1
February/March 2015
Critical Connections
The Complete News Source for Critical Care Professionals
Thank you for your membership in
the Society of Critical Care Medicine.
Learn more about the benefits of
membership at www.sccm.org or
call +1 847 827-6888.
In This Issue…
Team Science
Learn about useful methods and tools
that can be used to assess effective
collaboration in healthcare settings. . . 6
Examine the efficacy of team-based
training and the nuances of instituting
team training programs . . . . . . . . . . . 14
Explore the role of simulation
in promoting multidisciplinary
teamwork. . . . . . . . . . . . . . . . . . . . . . 16
Clinical Spotlight
Using Teamwork to Improve Patient Outcomes
A team includes two or more people interacting interdependently toward a common goal. In
the intensive care unit (ICU), the common goal is
improved patient outcomes, often thought of as
survival or discharge from the ICU. Additional goals
such as liberation from mechanical ventilation and
patient safety (prevention of adverse events) should
not be overlooked, though. Teams may be formed
across medical specialties or disciplines, and in the
ICU often include physicians, nurses, pharmacists,
respiratory therapists, dieticians, physical therapists,
social workers, and others. Each of these caregivers has a specific role in patient care, and each can
contribute positively to patient outcomes. In light of
the benefits of multiprofessional critical care teams
to patients and their families, team-based care is
expressly included in the Society of Critical Care
Medicine’s (SCCM) envisioned future statement
and guiding principles for the organization and
members.1
“Using Teamwork to Improve
Patient Outcomes” p 7
SCCM Stalwart Inger Margareta Grenvik Passes
The Society of Critical Care Medicine (SCCM) lost a member
of its family earlier this year. Inger Margareta Grenvik, beloved
wife of founding Society member and past president, Ake
Grenvik, MD, PhD, MCCM, passed away on January 21 at the
age of 83.
“The Society has lost a giant,” said Society President Craig M.
Coopersmith, MD, FCCM. “Inger was an important member
of our SCCM family from the very beginnings of the organization.” Her contributions, he added, “will never be forgotten.”
Inger was born in Stockholm, Sweden, on Sept. 14, 1931.
After completing a then traditional all-girls school, she received an
associate degree in medical technology at the Karolinska Institute.
Inger and Ake married on May 31, 1952. Lifelong partners, Inger
provided unconditional support as Ake revolutionized the field
of critical care medicine through his prolific clinical research and
integral role in founding the Society.
“Inger Grenvik was a truly special contributor to SCCM and
its mission,” said Patrick M. Kochanek, MD, MCCM, Ake N.
Grenvik Professor of Critical Care Medicine at the University
“SCCM Stalwart Inger Margareta
Grenvik Passes” p5
Registration Now Open for the
Adult Multiprofessional Critical
Care Board Review Course
August 11-15, 2015
Fairmont Chicago, Millennium Park
Chicago, Illinois, USA
Visit www.sccm.org/adultboardreview for details.
Figure 1.
individual or team. The focus should be on continuous
improvement, which may require interventions at multiple levels.
So far we have considered the assessment knowledge,
skills and attitudes of teams and individual members. The
relevant outcome measures for overall team performance can
be considered using the input-process-output framework2
(Figure 1).
Measurable inputs influencing team performance
include: attributes of team members, including their
knowledge, skills and attitudes relevant to teamwork
and communication; the task at hand; environmental resources (e.g., availability of checklists, scheduled
team briefings); and the organizational culture in which
the team functions (e.g., valuing democracy in teams).
Observable behaviors, as measured by teamwork measurement tools, and compliance with established protocols
are process measures. Output measures include: patient
outcomes (complications, length of hospital stay, 30-day
mortality); use of time and resources; and impact on staff
(staff morale, staff retention). Mazzocco et al24 developed
the Behavioral Marker Risk Index, a simple instrument
to measure teamwork in operating room teams, and
found an association between index scores and the rate
of adverse patient events, suggesting a clear link between
teamwork process measures and patient outcomes.
Input-Process-Output Framework for Measuring Team Performance2
Input
Process
Output
Individual attributes
Teamwork behaviors
Patient outcomes
Team composition
Compliance with
protocols
Resource utilization
The task
Staff satisfaction
Environmental resources
Organizational culture
Conclusion
The purpose of assessing teamwork and communication
is to improve team performance. Effective teamwork and
communication depend on the knowledge, skills and attitudes of individual team members, their ability to form
teams, and an enabling environment and organizational
culture. Instruments to measure teamwork can:
1) help individuals and workgroups acquire the skills and
behaviors of effective teams, and 2) demonstrate improvement following interventions. The aim of improving team
performance is to produce better outcomes for patients,
and assessment of the quality and safety of patient care is
the ultimate yardstick against which to measure and drive
improvement in teamwork and communication.
References and disclosures are available at
www.sccm.org/criticalconnections.
Jennifer Weller, MD, MBBS, MClinEd, FANZCA, is an
associate professor of medical education at the University of
Auckland, New Zealand, and a consultant anesthesiologist at
Auckland City Hospital.
“Using Teamwork to Improve Patient Outcomes” continued from p1
Teamwork can be described in many ways, but researchers have utilized an input, process/mediator and output
framework to describe ICU team performance. In this
framework, team and task characteristics are components
of the inputs, transition and action processes are components of the process/mediator, and patient or team outcomes are components of the outputs.2 Examples of transition processes include multidisciplinary patient care rounds
and use of daily goals checklists. Patient care rounds are
an important team activity where the patient’s plan of
care is discussed formally and tasks prioritized. Initiation
of patient care rounds has been associated with positive
patient outcomes. For example, implementation of daily
multidisciplinary rounds by the nursing staff, a physician,
and a respiratory therapist to review a checklist of ventilator bundle goals for each patient decreased the incidence
of ventilator-associated pneumonia (VAP) from 1.5 per
month to 0.5 per month in a study of surgical trauma ICU
patients.3 Similar findings of a reduced VAP incidence
with the institution of multidisciplinary patient care rounds
were also observed in an open trauma ICU.4 Daily patient
care rounds led by an intensivist have been associated with
decreases in hospital length of stay (LOS), hospital costs
and postoperative complications.5 Additionally, nurses’
reports of collaboration with physicians on the decision to
transfer patients out of the ICU were positively associated
with patient mortality.6
Completion of a daily patient-centered goals form
during multiprofessional rounds was associated with an
increase in the understanding of daily goals (>85% of
nurses and medical residents) and decreased the average
patient ICU LOS by about one day.7 Although the study
could not establish a causal relationship between the use
of the goals form and a decrease in ICU LOS, the authors
attributed the benefit to clarifying tasks, care plans and
communication plans among caregivers.
In the Keystone ICU project, clinicians in 108 adult
ICUs in Michigan adopted evidence-based procedures to
Critical Connections
decrease catheter-related bloodstream infections, including use of a checklist to ensure protocol adherence. The
observed 66% reduction in the incidence of catheterrelated bloodstream infection is well-known to ICU clinicians. It is easily overlooked, though, that in addition to the
study procedures, the ICUs also implemented the use of
daily goals sheets to improve clinician communication, and
implemented a unit-based safety program to improve safety
culture, which may also have positively impacted the study
results.8
The benefit of checklists has also been demonstrated in
pediatric ICUs. In one study, implementation of a rounding checklist in a pediatric ICU was associated with fewer
accidental extubations.9 Many institutions have adopted
checklists for patient care with positive results, but ensuring
compliance with checklist completion may be challenging
and overuse of checklists should be avoided.10
Interestingly, although interventions to improve teamwork and perceptions of caregiver teamwork have been
associated with reductions in intermediate endpoints (i.e.,
patient LOS), an association with patient mortality has not
been consistently demonstrated. Additionally, ICUs with
higher levels of teamwork do not reliably perform better
when compared with ICUs with lower levels of teamwork.11 These inconsistent findings regarding the influence of teamwork on patient mortality are likely due to
confounding or lack of adequate study power and should
be addressed in future studies. Improvements in the quality
of teamwork have been associated with a broad variety of
positive patient outcomes, and efforts to improve teamwork
within an ICU should be investigated and implemented as
much as possible.
While improved team interactions have been associated
with positive patient outcomes, poor team interactions have
been associated with ICU adverse events. In an observational single-center study, communication events between
nurses and physicians comprised only 2% of observed
activities in the ICU, but were associated with 37% of
www.sccm.org
errors.12 A similar finding was observed in a multicenter
study where poor teamwork contributed to 32% of patient
safety incidents.13 About half of all ICU adverse events
are adverse drug events (ADEs).14 Patients experiencing
two or more ADEs have a threefold increase in the risk of
ICU death15 and half of all ADEs occur at the prescription stage.16 Medication errors may be prevented by the
inclusion of a pharmacist as an ICU team member. In
one study from the United States where pharmacists were
present at the time of medication prescription (either during patient care rounds or for consultation in the ICU),
a 66% reduction in the number of preventable ADEs
was observed.17 Similarly, in a Dutch study, ICU hospital
pharmacist review of admission orders was associated with
a 75% reduction in preventable ADEs.18 Furthermore, the
presence of clinical pharmacists in ICUs has been associated with a shorter time to liberation from mechanical
ventilation,19 lower mortality rates, and shorter ICU LOS
in patients with infections.20
In conclusion, the complexity of the care of critically ill
patients requires a coordinated team effort. Practitioners in
the ICU should seek opportunities to improve teamwork
in their own institutions. Team efforts such as multidisciplinary patient care rounds and a checklist with patient
care goals may improve patient outcomes and avoid
adverse events.
References and disclosures are available at
www.sccm.org/criticalconnections.
Seth Bauer, PharmD, FCCM, is a medical ICU clinical
specialist and member of the Medical ICU Quality Committee
at the Cleveland Clinic.
February/March 2015
|
7