Impact of Nurse-Led Remote Screening and Prompting for Evidence-Based Practices in the ICU*

Abstract

Objective Evidence-based practices are not consistently applied in the intensive care unit (ICU). We sought to determine if nurse-led remote screening and prompting for evidence-based practices using an electronic health record could impact ICU care delivery and outcomes in an academic medical center. Design Single-center, before-after evaluation of a quality improvement project. Setting Urban, academic medical center in the mid-Atlantic United States with 8 subspecialty ICUs and 156 ICU beds. Patients Adult patients admitted to the ICU between January 1, 2011 and August 31, 2012. Intervention Beginning on July 25, 2011, trained ICU nurses screened all ICU patients for selected evidence-based practices on a daily basis. The screening was conducted from a remote office, facilitated by the electronic health record. Selected practices included compliance with a ventilator care bundle, assessment of appropriateness of indwelling venous and urinary catheters, and concordance between sedation orders and documented level of sedation. When gaps were observed they were communicated to the point-of-care bedside nurse via telephone, page or facsimile. Measurements and Main Results 14,823 unique patients were admitted during the study period. We excluded 1,546 patients during a 2-month run-in period from July 1, 2011 to August 31, 2011, resulting in 4,339 patients in the 6-month pre-intervention period and 8,938 patients in the 12-month post-intervention period. Compared to patients admitted in the pre-intervention period, patients admitted in the post-intervention period were more likely to receive sedation interruption (incidence rate ratio: 1.57, 95% CI: 1.45 – 1.71) and a spontaneous breathing trial (incidence rate ratio: 1.24, 95% CI: 1.20 – 1.29). Hospital acquired infection rates were not different between the two periods. Adjusting for patient characteristics and illness severity, patients in the post-intervention period experienced shorter duration of mechanical ventilation (adjusted reduction: 0.61 days, 95% CI: 0.27 – 0.96, p <0.001), shorter ICU length of stay (adjusted reduction: 0.22 days, 95% CI: 0.04 – 0.41, p=0.02), and shorter hospital length of stay (adjusted reduction: 0.55 days, 95% CI: 0.15 – 0.93, p=0.006). In-hospital mortality was unchanged (adjusted odds ratio: 0.96, 95% CI 0.84 – 1.09, p=0.54). The results were robust to tests for concurrent temporal trends and coincident interventions. Conclusions A program by which nurses screened ICU patients for best-practices from a remote location was associated with improvements in the quality of care and reductions in duration of mechanical ventilation and length of stay, but had no impact on mortality.

ICU Telemedicine and Critical Care Mortality

“…For hospitals with reduced mortality, ICU telemedicine may promote evidence-based practice via prompting and checklists, 23,24 facilitate early recognition and treatment of physiological deterioration, 25 and improve care coordination between interprofessional care providers. 26 For hospitals in which telemedicine did not affect mortality, the technology may be underutilized, with infrequent contact between the ICU telemedicine “hub” unit and the target ICUs 27 or skepticism among the ICU staff that the technology is useful.…”

Development and Implementation of Sepsis Alert Systems

“…57 Likewise, investigation into the most appropriate clinician recipient (attending physicians, fellows, residents, and/or nurse practitioners/physician assistants) for alert delivery is limited. 58, 59 As multidisciplinary response teams have been demonstrated to improve the process of care and mortality in septic shock, 60 an appropriate trigger for multidisciplinary team activation needs to be determined for each individual setting. In the medical ICU of the Mayo Clinic, the electronic sepsis alert is currently send to a single team member who, if appropriate, activates a multidisciplinary response team (currently “shock response team” consisting of physicians, nurses, respiratory therapists, pharmacists and laboratory technicians) in charge of rapid execution of time-sensitive interventions.…”

The Evolving Application of Implementation Science in Critical Care*

“…In this issue of Critical Care Medicine , Kahn et al (9) intriguingly merge these two recent lines of critical care implementation research by extending the paradigm of ICU telemedicine to focus solely on screening for omissions of evidence-based care and by building on the idea of an external prompting mechanism that relies on dedicated prompting personnel. At a single academic medical center, they employed a pre/postimplementation design to determine whether remote screening for selected practices— including ventilator bundle compliance, concordance between sedation orders and level of sedation, and the appropriateness of indwelling catheters—and prompting providers if gaps were observed improved adherence to these practices.…”

“…The work by Kahn et al (9) is an important step in the maturation of implementation science interventions from the impersonal and distant to the more direct. They take advantage of telemedicine technology and couple this technology with newer implementation strategies focused on near real-time, point-of-care interventions, such as prompting.…”

“…This merger of technology and strategy may help achieve an efficient balance between the advantages of bedside prompting (real-time direct intervention) and the advantages of telemedicine (centralization and scalability). Studies such as this one by Kahn et al (9) will help us learn more about which implementation methods most effectively translate evidence-based therapy into clinical practice.…”