RESUMEN

OBJECTIVES: The complex care needs and high mortality of critically ill patients in intensive care unit (ICU) warrants a team approach. While studies have affirmed the integral role of palliative care teams in ICU, little is known about the ICU healthcare professional's perception on how this integration affects the care of the critically ill.This study examines their perception of how integration of palliative care into ICU practice affects interprofessional collaborative practices and relationships in the delivery of care. METHODS: A qualitative study was conducted in 13 focus group discussions with 54 ICU healthcare professionals recruited through purposive sampling. Data were analysed using a qualitative descriptive approach reflecting uninterpreted participants' description of their experiences in its most unbiased manner. RESULTS: ICU clinicians perceived that palliative care integration into the ICU enhanced care of patients and team dynamics in three areas: (1) bridging care, (2) cultural shift and (3) empowering, advocating and enhancing job satisfaction. Enhanced collaborative efforts between disciplines led to improved mutual understanding, shared-decision making and alignment of care goals. There was a shift in perception of dying as a passive process, to an active process of care where various healthcare professionals could work together to optimise symptom control and support grieving families. Team members felt empowered to advocate for patients, improving their sense of job fulfilment. CONCLUSIONS: Palliative care integration enhanced perception of collaborative practices in caring for the dying. Future studies could use empirical methods to measure collaboration and patient outcomes to further understand team dynamics.

RESUMEN

Patients who suffer from dyspnea while dying from COVID-19 are treated with opioids and benzodiazepines. In some instances, patients may experience refractory dyspnea at the end of life. Palliative sedation can be prescribed to alleviate such patients' suffering. We describe two patients being treated for severe COVID-19 pneumonia in a tertiary hospital. Both developed intractable dyspneic crises despite high-dose opioids and benzodiazepines. This led to their requirement of palliative sedation in the general ward using subcutaneous phenobarbitone (phenobarbital). We outline clinical considerations for the use of palliative sedation in COVID-19 related dyspnea. In particular, we discuss the evidence for, benefits and limitations of using phenobarbitone for palliative sedation in COVID-19 patients.

Asunto(s)

RESUMEN

OBJECTIVES: We conducted a pilot quality improvement (QI) project with the aim of improving accessibility of palliative care to critically ill neurosurgical patients. METHODS: The QI project was conducted in the neurosurgical intensive care unit (NS-ICU). Prior to the QI project, referral rates to palliative care were low. The ICU-Palliative Care collaborative comprising of the palliative and intensive care team led the QI project from 2013 to 2015. The interventions included engaging key stake-holders, establishing formal screening and referral criteria, standardizing workflows and having combined meetings with interdisciplinary teams in ICU to discuss patients' care plans. The Palliative care team would review patients for symptom optimization, attend joint family conferences with the ICU team and support patients and families post-ICU care. We also collected data in the post-QI period from 2016 to 2018 to review the sustainability of the interventions. RESULTS: Interventions from our QI project and the ICU-Palliative Care collaborative resulted in a significant increase in the number of referrals from 9 in 2012 to 44 in 2014 and 47 the year later. The collaboration was beneficial in facilitating transfers out of ICU with more deaths outside ICU on comfort-directed care (96%) than patients not referred (75.7%, p < 0.05). Significantly more patients had a Do-Not-Resuscitation (DNR) order upon transfer out of ICU (89.7%) compared to patients not referred (74.2.%, p < 0.001), and had fewer investigations in the last 48 hours of life (p < 0.001). Per-day ICU cost was decreased for referred patients (p < 0.05). CONCLUSIONS: Multi-faceted QI interventions increased referral rates to palliative care. Referred patients had fewer investigations at the end-of-life and per-day ICU costs.

Asunto(s)

Asunto(s)

RESUMEN

PURPOSE: The purpose of this paper is to outline considerations and steps taken to introduce electronic reporting and verification from systems design and multidisciplinary collaborations to gap analysis and devising solutions. It also evaluates carefully placed forcing functions' impact on verification rates. DESIGN/METHODOLOGY/APPROACH: A multidisciplinary workgroup was formed to stop print and establish electronic reporting. The electronic verification's success was assessed by weekly activity analysis. FINDINGS: Introducing a verification forcing function markedly improved verification activity. Thereafter, non-verified results stabilized at 7 percent up to 75 weeks post-implementation. PRACTICAL IMPLICATIONS: This paper illustrates how results reporting and verification could be implemented in a tertiary hospital using a mixed electronic and paper record. Factors that were critical to success include stakeholder engagement and applying systems design that focussed on patient safety as a key priority. The electronic reporting system was augmented by strategically inserted forcing functions, clear clinical-responsibility lines and ancillary alert systems. ORIGINALITY/VALUE: The systems design method's value in managing non-critical but abnormal results appears to have been under-appreciated. This paper describes how systems design could be used to improve health information delivery and management.

Asunto(s)