Background Bedside nurse turnover in the United States is 15.9%, representing a national challenge that has been attributed to poor work environments. Healthy work environments are associated with improved nurse satisfaction and retention as well as positive patient outcomes; unhealthy work environments have the opposite effects. Objectives To implement the American Association of Critical-Care Nurses (AACN) healthy work environment (HWE) framework in an intensive care unit and to evaluate staff satisfaction, turnover, and tenure 2 years later. Methods A pre-post study design was used to evaluate implementation of the HWE framework in an intensive care unit in a large academic medical facility. Interventions for each of the 6 HWE standards were performed. The AACN HWE assessment survey was used to measure skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership in 2017 and in 2019. Results Nurse cohorts (n = 165 in 2017; n = 176 in 2019) had a mean age of 31 (median, 27; range, 23-63) years, were predominantly female (76%), and had a mean of 5 (median, 3) years of intensive care unit nursing experience. Statistically significant improvements were found in all standards except the skilled communication and overall measures. Registered nurse turnover remained stable and tenure increased by 79 days in this 2-year period. Conclusions Findings from this study suggest that interventions addressing the HWE standards are associated with improved staff satisfaction, turnover, and average tenure, further demonstrating the value of the HWE framework in improving retention.

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Background Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient’s baseline physiological condition, workflow processes, and provider practice patterns. Local Problem Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes. Methods This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates. Results In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts. Conclusions The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.

Introduction: As patients, hospitals and scientific communities are struck by rapidly evolving effects of the COVID-19 pandemic, new approaches to achieving high quality care and communication in the context of “restricted visitation” are emerging. The evidence for optimal communication strategies in the context of restrictive visitation is lacking in the literature. Methods: We used a rapid-cycle quality improvement approach to design and evaluate high quality, effective communication with families in the context of visitor restrictions in two cardiothoracic ICUs in an academic health system. The effectiveness of video chat, assessment of loved-ones’ awareness, understanding and inclusion in the plan of care, and the engagement of the healthcare team in communication of decisions were each defined using validated response scales. To evaluate the effectiveness of communication using video chat, six questions were included from two subscales using a visual analogue scale. To evaluate the inclusion in healthcare decisions, three items were included using Likert scales and binary or open-ended narratives. Results: Overall, 92 adult patients contributed complete data for analysis. Communication with the ICU team met expectations (Always-95.3%), with expected frequency (Always - 91.9%), and duration (Always - 97.7%), and quality, including having questions answered (Always - 96.5%) and seeing (visualizing) members of the healthcare team when requested (Always - 82.6%). Patient and families reported high levels of “presence” on a validated scale reflecting the quality, sensitivity and responsiveness of the providers to critical conversations. In 96.3% of cases, patients and family reported feeling “that I had the impression that I was actively participating” and that “the other person reacted to my presence.” Conclusion: The COVID-19 pandemic introduced opportunities for rapid innovation due to the need for fully restrictive visitation. This case demonstrates that teamwork, collaboration and creative engagement of people and resources across clinical, administrative and academic partners can efficiently improve patient-provider communication in rapid-cycle timeframes.

Background: The Society of Thoracic Surgeons (STS) defines early extubation after cardiac operations as endotracheal extubation and separation from mechanical ventilation in less than 6 hours of surgery, which is associated with improved postoperative outcomes. Objectives: 1. To improve rates of early extubation in post-operative cardiac surgery patients. 2. To evaluate implementation of a multidisciplinary fast-track extubation (FTE) protocol on the duration of mechanical ventilation after adult cardiac surgery as compared to historical unmatched-controls. Methods: After IRB approval, prospective data were collected on 101 consecutive patients identified by the operating surgeon as appropriate for early extubation based on standard protocols (Control Cohort). Our multidisciplinary stakeholder group evaluated barriers to early extubation and developed a sustainable FTE protocol. Post-implementation data was collected for 3 months (FTE Cohort). A structural framework to alter culture and behavior was utilized for long-term adoption of our protocol. Results: The study included 312 patients (Control Cohort N=101 / FTE Cohort N=211). Patient and procedural demographics were similar between the groups. Extubation occurred within 6 hours in 48% (N=48) in the control cohort versus 73% (N=153) in the FTE cohort (p <0.001) (Figure 1). Following implementation of the FTE protocol, patients with more complex surgeries, not meeting original inclusion criteria, were also safely extubated using the protocol. Conclusion: Our FTE protocol safely improved the rate of early extubation after routine and complex cardiac surgery. A behavioral change framework was instrumental in establishing and maintaining staff engagement.