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OBJECTIVES: To understand frontline ICU clinician's perceptions of end-of-life care delivery in the ICU. DESIGN: Qualitative observational cross-sectional study. SETTING: Seven ICUs across three hospitals in an integrated academic health system. SUBJECTS: ICU clinicians (physicians [critical care, palliative care], advanced practice providers, nurses, social workers, chaplains). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 27 semi-structured interviews were conducted, recorded, and transcribed. The research team reviewed all transcripts inductively to develop a codebook. Thematic analysis was conducted through coding, category formulation, and sorting for data reduction to identify central themes. Deductive reasoning facilitated data category formulation and thematic structuring anchored on the Systems Engineering Initiative for Patient Safety model identified that work systems (people, environment, tools, tasks) lead to processes and outcomes. Four themes were barriers or facilitators to end-of-life care. First, work system barriers delayed end-of-life care communication among clinicians as well as between clinicians and families. For example, over-reliance on palliative care people in handling end-of-life discussions prevented timely end-of-life care discussions with families. Second, clinician-level variability existed in end-of-life communication tasks. For example, end-of-life care discussions varied greatly in process and outcomes depending on the clinician leading the conversation. Third, clinician-family-patient priorities or treatment goals were misaligned. Conversely, regular discussion and joint decisions facilitated higher familial confidence in end-of-life care delivery process. These detailed discussions between care teams aligned priorities and led to fewer situations where patients/families received conflicting information. Fourth, clinician moral distress occurred from providing nonbeneficial care. Interviewees reported standardized end-of-life care discussion process incorporated by the people in the work system including patient, family, and clinicians were foundational to delivering end-of-life care that reduced both patient and family suffering, as well as clinician moral distress. CONCLUSIONS: Standardized work system communication tasks may improve end-of life discussion processes between clinicians and families.

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BACKGROUND AND PURPOSE: Patients with acute ischemic stroke (AIS) eligible for thrombolysis benefit when thrombolysis is administered quickly, and mobile stroke units (MSU) can facilitate timely thrombolysis. We sought to compare time metrics and clinical outcomes of AIS patients receiving thrombolysis in an MSU compared with patients arriving via local emergency medical services (EMS). METHODS: We performed a retrospective, non-randomized, cohort study comparing MSU-arriving to EMS-arriving AIS patients from January 20, 2017 through November 30, 2020. The primary outcome was rate of return to baseline functional status as measured by the modified Rankin Score (mRS) 90 days after thrombolysis. Secondary outcomes included evaluation and treatment intervals from last known well, treatment rate in the first hour of symptoms, hospital length of stay, and mortality. Chi square and Student's t-test were used to compare groups. RESULTS: Of 1752 total patients with prehospital suspected stroke, 975 (55.7%) were transported via MSU, of whom 431 (44.2%) were diagnosed with stroke, including 368 (85.4%) with AIS, and 69 AIS patients (18.8%) received thrombolysis. Of 777 (44.3%) EMS-arriving patients, 373 (48%) were diagnosed with stroke, including 305 (81.8%) with AIS, and 74 (24.3%) received thrombolysis. Though not statistically significant, point estimates of the proportion of AIS patients treated with thrombolysis returning to baseline functional status were more commonly observed for MSU than for EMS transports when the baseline mRS was 0-2 (45.8% vs 33.3%), 0-3 (41.9% vs 33.3%), and 4-5 (71.4% vs 20.0%). MSU patients were more likely to receive thrombolysis in the first 60 minutes of symptom onset (31.9% vs 12.2%, p = 0.006). Overall mortality rates regardless of baseline mRS were similar between groups. CONCLUSIONS: AIS patients received thrombolysis faster in the MSU compared with EMS and more frequently within 60 minutes of stroke onset. Point estimates for 90-day clinical outcomes of AIS patients treated with thrombolysis favored MSU without a statistically significant difference.

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INTRODUCTION/BACKGROUND: Point-of-care testing (POCT) platforms support patient-centered approaches to health care delivery and may improve patient care. We evaluated implementation of a POCT platform at a large, acute care hospital in the Midwestern United States. METHODS: We used lactate testing as part of a sepsis bundle protocol to evaluate compliance and mortality outcomes. Respiratory team members were surveyed to assess perception of efficiency, ease of use, timely patient care, and overall engagement with the POCT system. Annualized cost per test of a benchtop analyzer and a POCT platform were compared across 3 years for each platform. RESULTS: Lactate testing volume increased from 61% to 91%, which was associated with improved sepsis bundle protocol compliance. Employees reported high levels of engagement, improvements in efficiency and time savings, and better patient care with POCT. Average cost per test was $10.02 for the benchtop system and $6.21 for the POCT platform. POCT saved our institution $88,476 annually in labor costs. DISCUSSION: Combined with a robust training program emphasizing the use of lactate testing in the context of the overall clinical picture, POCT enabled adherence to the sepsis bundle protocol and may have contributed to lower mortality. Additionally, the COVID-19 pandemic has provided us with unanticipated benefits of using POCT; it has enhanced our ability to deal with stringent infectious disease protocols, saving time and minimizing patient and staff exposure. CONCLUSIONS: Implementation of a POCT platform was associated with improved compliance to our sepsis protocol, reduced sepsis mortality, high employee engagement, and cost savings.

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The hemodynamic monitoring landscape is rapidly evolving from pressure-based and static parameters to more blood flow-based and dynamic parameters. Consensus guidelines for cardiac surgery state that the pulmonary artery catheter is neither required nor helpful in most patients. In the meantime, critical care has been searching for the alternatives to the pulmonary artery catheter and protocols for use. Best available evidence for any protocol developed suggests the inclusion of stroke volume optimization to determine fluid responsiveness. Additional strategies to using stroke volume to optimize hemodynamics, including case studies, are discussed.

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BACKGROUND: In our large community hospital, we observed that traditional oxygen masks were sometimes set at an inappropriately low flow. We hoped to eliminate this safety concern through adoption of an open-design oxygen mask. We also hoped that more immediate flow changes would lead to a decrease in medical gas consumption. Finally, by standardizing to one mask, goals were to reduce the cost of oxygen delivery. METHODS: We conducted a retrospective analysis, 12 months before and 12 months after implementation of the open-design oxygen mask. Unusual occurrence reports related to supplemental oxygen delivery were reviewed. Oxygen device use and bulk oxygen consumption were recorded. The total number of patient days was obtained from the electronic medical record. RESULTS: There were no unusual occurrence reports or concerns involving an oxygen device in those areas that converted to the open-design oxygen mask. In fiscal year 2014, bulk oxygen use was 13,036,686 cubic feet, and there were 74,734 patient days. In fiscal year 2016, bulk oxygen use was 12,072,610 cubic feet and there were 99,428 patient days. The reduction in oxygen consumption was $3,670 despite the increase in patient days. In fiscal year 2014, 3,848 oxygen devices were used for a cost of $3,411, and in fiscal year 2016, 5,512 devices were used for a cost of $12,963. The net savings from open-design oxygen mask conversion was $23,487 annual and corrected for increased patient population. Oxygen consumption and supply cost per patient day resulted in $1.19 per patient day pre-implementation and $0.95 after implementation of the open-design oxygen mask (P = .003). CONCLUSIONS: The open-design oxygen mask may be a safe and less costly alternative to traditional oxygen delivery devices.

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Multidisciplinary care refers to a practice in which physicians from multiple specialties attend to the same patient population. There are many advantages to the model, including reduced time to treatment, coordinated treatment plans, increased patient and physician satisfaction, and increased enrollment onto clinical trials. At Central Dupage Hospital, multidisciplinary clinics have been instituted in lung and gynecologic cancer. We describe the structure and operation of each clinic and highlight their considerable success in improving patient care.