Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail.
Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data.
It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM.
Netherlands Trial Register (NTR): NTR1976
Diabetes care in our inner‐city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence‐based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes.
To assess the effect of the CRM intervention on adherence to evidence‐based diabetes care standards, work processes, standardised clinical communication and patient outcomes.
Time‐series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619).
The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention.
The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement.
The aviation domain provides a better analogy for the "temporary" teams that are found in acute medical specialities than industrial or military teamwork research based on established teams. Crew resource management (CRM) training, which emphasises portable skills (for whatever crew a pilot is rostered to on a given flight), has been recognised to have potential application in medicine, especially for teams in the operating theatre, intensive care unit, and emergency room. Drawing on research from aviation psychology that produced the behavioural marker system NOTECHS for rating European pilots' non-technical skills for teamwork on the flightdeck, this paper outlines the Anaesthetists Non-Technical Skills behavioural rating system for anaesthetists working in operating theatre teams. This taxonomy was used as the design basis for a training course, Crisis Avoidance Resource Management for Anaesthetists used to develop these skills, based in an operating theatre simulator. Further developments of this training programme for teams in emergency medicine are outlined.
The aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork. Its conceptualization of teamwork, development of training programs, and design of assessment tools are highly relevant to the intensive care unit (ICU). Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. However, there are substantial differences in the nature of work and structure of teams in the ICU in comparison with those in aviation. While intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs, interventions must be tailored to the highly specific demands of the ICU.
Parent-healthcare provider (HCP) communication is an important component of pediatric asthma management. Given the high prevalence of complementary and alternative medicine (CAM) and over-the-counter (OTC) medication use among this population, it is important to examine parental nondisclosure of these asthma management strategies.
One-time interview and one-year retrospective medical record review with 228 parents of 5–12 year old children with asthma enrolled from 6 pediatric primary care practices examining parental nondisclosure of CAM and OTC medication use, reasons for nondisclosure, medical record documentation of CAM usage, and association between parent-HCP relationship and nondisclosure.
Seventy-one percent of parents reported using CAM and/or OTC medication for children’s asthma management and 54% of those parents did not disclose usage. Seventy-five percent “did not think” to discuss it. Better parent-HCP relationship led to decreased nondisclosure.
HCPs can play an important role in creating an environment where parents feel comfortable sharing information about their children’s asthma management strategies in order to arrive at a shared asthma management plan for the child leading to improved asthma health outcomes.
Objective: To identify barriers to accessing sexual health care among the Bangladeshi community of east London and to develop a model of community participation in service development.
Methods: Qualitative study using one to one interviews with sexual health service users plus focus groups in community settings.
Results: 58 people participated in the study, 12 in individual interviews and the remainder in six focus groups. All were of Bangladeshi origin. Four main themes were reported as impacting on access to services; confidentiality concerns, relevance of services to the community, problems with discussing sexual issues, and problems with previous experiences of health promotion. Community values regarding sex outside of marriage were an important underlying factor in participants' responses. Existing sexual health services were seen as culturally insensitive by patients and community groups.
Conclusions: Community based health initiatives among hard to reach ethnic minority groups should use existing networks of statutory and non-statutory groups to benefit from local expertise and relationships. Steering groups composed of members of the local communities served by the clinic can usefully inform service development.
To identify the distinctive contributions of high-reliability theory (HRT) and normal accident theory (NAT) as frameworks for examining five patient safety practices.
Data Sources/Study Setting
We reviewed and drew examples from studies of organization theory and health services research.
After highlighting key differences between HRT and NAT, we applied the frames to five popular safety practices: double-checking medications, crew resource management (CRM), computerized physician order entry (CPOE), incident reporting, and root cause analysis (RCA).
HRT highlights how double checking, which is designed to prevent errors, can undermine mindfulness of risk. NAT emphasizes that social redundancy can diffuse and reduce responsibility for locating mistakes. CRM promotes high reliability organizations by fostering deference to expertise, rather than rank. However, HRT also suggests that effective CRM depends on fundamental changes in organizational culture. NAT directs attention to an underinvestigated feature of CPOE: it tightens the coupling of the medication ordering process, and tight coupling increases the chances of a rapid and hard-to-contain spread of infrequent, but harmful errors.
Each frame can make a valuable contribution to improving patient safety. By applying the HRT and NAT frames, health care researchers and administrators can identify health care settings in which new and existing patient safety interventions are likely to be effective. Furthermore, they can learn how to improve patient safety, not only from analyzing mishaps, but also by studying the organizational consequences of implementing safety measures.
Double-check; crew resource management; computerized physician order entry; incident reporting; root cause analysis
To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew.
Cross sectional surveys.
Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world.
1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers).
Main outcome measures:
Perceptions of error, stress, and teamwork.
Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes.
Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
Species conservation is difficult. Threats to species are typically high and immediate. Effective solutions for counteracting these threats, however, require synthesis of high quality evidence, appropriately targeted activities, typically costly implementation, and rapid re-evaluation and adaptation. Conservation management can be ineffective if there is insufficient understanding of the complex ecological, political, socio-cultural, and economic factors that underlie conservation threats. When information about these factors is incomplete, conservation managers may be unaware of the most urgent threats or unable to envision all consequences of potential management strategies. Conservation research aims to address the gap between what is known and what knowledge is needed for effective conservation. Such research, however, generally addresses a subset of the factors that underlie conservation threats, producing a limited, simplistic, and often biased view of complex, real world situations. A combination of approaches is required to provide the complete picture necessary to engage in effective conservation. Orangutan conservation (Pongo spp.) offers an example: standard conservation assessments employ survey methods that focus on ecological variables, but do not usually address the socio-cultural factors that underlie threats. Here, we evaluate a complementary survey method based on interviews of nearly 7,000 people in 687 villages in Kalimantan, Indonesia. We address areas of potential methodological weakness in such surveys, including sampling and questionnaire design, respondent biases, statistical analyses, and sensitivity of resultant inferences. We show that interview-based surveys can provide cost-effective and statistically robust methods to better understand poorly known populations of species that are relatively easily identified by local people. Such surveys provide reasonably reliable estimates of relative presence and relative encounter rates of such species, as well as quantifying the main factors that threaten them. We recommend more extensive use of carefully designed and implemented interview surveys, in conjunction with more traditional field methods.
Sexuality is a key aspect of women’s physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well-positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women’s health more broadly, warrant up-to-date information regarding ob/gyns’ sexual history-taking routine.
To determine obstetrician/gynecologists’ practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.
A population-based sample of 1154 practicing U.S. obstetrician/gynecologists (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.
Main Outcome Measures
Self-reported frequency measures of ob/gyns’ communication practices with patients including whether or not ob/gyns discuss patients’ sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients’ sexual practices. Multivariable analysis was used to correlate physicians’ personal and practice characteristics with these communication practices.
Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients’ sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients’ sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.
The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients’ sexuality are not routinely discussed.
Female Sexuality; Patient-Physician Communication; Sexual History-Taking; Female Sexual Health
Dr. Judith Kazimirski of Nova Scotia becomes the CMA's 126th president during the association's annual meeting in Sydney, NS, this month. She says her priority for the next year is to help the CMA play a lead role as the debate intensifies about the future of health and health care in Canada. "The time is right for a very public debate about what people want their system to be, what problems they're having, and how reform is moving ahead," she says, "and physicians have a critical leadership role to play."
Critical care leaders frequently must face challenging situations requiring specific leadership and management skills for which they are, not uncommonly, poorly prepared. Such a fictitious scenario was discussed at a Canadian interdisciplinary critical care leadership meeting, whereby increasing intensive care unit (ICU) staff turnover had led to problems with staff recruitment. Participants discussed and proposed solutions to the scenario in a structured format. The results of the discussion are presented. In situations such as this, the ICU leader should first define the core problem, its complexity, its duration and its potential for reversibility. These factors often reside within workload and staff support issues. Some examples of core problems discussed that are frequently associated with poor retention and recruitment are a lack of a positive team culture, a lack of a favorable ICU image, a lack of good working relationships between staff and disciplines, and a lack of specific supportive resources. Several tools or individuals (typically outside the ICU environment) are available to help determine the core problem. Once the core problem is identified, specific solutions can be developed. Such solutions often require originality and flexibility, and must be planned, with specific short-term, medium-term and long-term goals. The ICU leader will need to develop an implementation strategy for these solutions, in which partners who can assist are identified from within the ICU and from outside the ICU. It is important that the leader communicates to all stakeholders frequently as the process moves forward.
To evaluate the effectiveness of training and institutionalizing teamwork behaviors, drawn from aviation crew resource management (CRM) programs, on emergency department (ED) staff organized into caregiver teams.
Nine teaching and community hospital EDs.
A prospective multicenter evaluation using a quasi-experimental, untreated control group design with one pretest and two posttests of the Emergency Team Coordination CourseTM (ETCC). The experimental group, comprised of 684 physicians, nurses, and technicians, received the ETCC and implemented formal teamwork structures and processes. Assessments occurred prior to training, and at intervals of four and eight months after training. Three outcome constructs were evaluated: team behavior, ED performance, and attitudes and opinions. Trained observers rated ED staff team behaviors and made observations of clinical errors, a measure of ED performance. Staff and patients in the EDs completed surveys measuring attitudes and opinions.
Hospital EDs were the units of analysis for the seven outcome measures. Prior to aggregating data at the hospital level, scale properties of surveys and event-related observations were evaluated at the respondent or case level.
A statistically significant improvement in quality of team behaviors was shown between the experimental and control groups following training (p = .012). Subjective workload was not affected by the intervention (p = .668). The clinical error rate significantly decreased from 30.9 percent to 4.4 percent in the experimental group (p = .039). In the experimental group, the ED staffs' attitudes toward teamwork increased (p = .047) and staff assessments of institutional support showed a significant increase (p = .040).
Our findings point to the effectiveness of formal teamwork training for improving team behaviors, reducing errors, and improving staff attitudes among the ETCC-trained hospitals.
Teams; teamwork; MedTeams; teamwork training; medical error
This Commentary addresses issues related to exposures to teratogens and makes the case for increased research into the safety of medications during pregnancy for mothers and fetuses. Not only are medications commonly used during pregnancy, but evidence points to an increasing prevalence and number of drug exposures experienced by the embryo or fetus, particularly during the critical first trimester of pregnancy. Although the first trimester represents a particularly vulnerable period of organogenesis, exposures during other gestational time periods may also be associated with deleterious outcomes. In addition to the changing (and in many cases unknown) risks to a developing fetus, other challenges to studying medication exposures and their effects during pregnancy include the dramatic changes in physiology that occur in pregnant women and the ethical dilemmas posed by including this vulnerable population in randomized controlled trials of safety and efficacy. However, without adequate knowledge of the pharmacokinetics, pharmacodynamics, efficacy, and safety of medication use in pregnancy, women may be under-dosed to minimize exposure or not treated at all, resulting in inadequate treatment and potential harm to the mother and her baby. The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) is undertaking studies on medications and teratogenic exposures during pregnancy, including alcohol, maternal diabetes, oral hypoglycemic agents, and antiviral medications, through several of its research networks. Although this is a start, there is a critical need for further research on medications used during pregnancy, especially their effects on both the mother and her developing child.
medication; exposure; pregnancy; teratogen; research
Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given to issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed.
Perinatal conditions make the largest contribution to the burden of disease in low-income countries. Although postneonatal mortality rates have declined, stillbirth and early neonatal mortality rates remain high in many countries in Africa and Asia, and there is a concentration of mortality around the time of birth. Our article begins by considering differences in the interpretation of ‘intervention’ to improve perinatal survival. We identify three types of intervention: a single action, a collection of actions delivered in a package and a broader social or system approach. We use this classification to summarise the findings of recent systematic reviews and meta-analyses. After describing the growing evidence base for the effectiveness of community-based perinatal care, we discuss current concerns about integration: of women’s and children’s health programmes, of community-based and institutional care, and of formal and informal sector human resources. We end with some thoughts on the complexity of choices confronting women and their families in low-income countries, particularly in view of the growth in non-government and private sector healthcare.
Although we have recently witnessed substantial progress in management and outcome of patients with chronic heart failure, acute heart failure (AHF) management and outcome have not changed over almost a generation. Vasodilators are one of the cornerstones of AHF management; however, to a large extent, none of those currently used has been examined by large, placebo-controlled, non-hemodynamic monitored, prospective randomized studies powered to assess the effects on outcomes, in addition to symptoms. In this article, we will discuss the role of vasodilators in AHF trying to point out which are the potentially best indications to their administration and which are the pitfalls which may be associated with their use. Unfortunately, most of this discussion is only partially evidence based due to lack of appropriate clinical trials. In general, we believe that vasodilators should be administered early to AHF patients with normal or high blood pressure (BP) at presentation. They should not be administered to patients with low BP since they may cause hypotension and hypoperfusion of vital organs, leading to renal and/or myocardial damage which may further worsen patients’ outcome. It is not clear whether vasodilators have a role in either patients with borderline BP at presentation (i.e., low-normal) or beyond the first 1–2 days from presentation. Given the limitations of the currently available clinical trial data, we cannot recommend any specific agent as first line therapy, although nitrates in different formulations are still the most widely used in clinical practice.
Acute heart failure; Vasodilators; Nitrates
Antenatal, delivery and postnatal care services are amongst the recommended interventions aimed at preventing maternal and newborn deaths worldwide. West Java is one of the provinces of Java Island in Indonesia with a high proportion of home deliveries, a low attendance of four antenatal services and a low postnatal care uptake. This paper aims to explore community members' perspectives on antenatal and postnatal care services, including reasons for using or not using these services, the services received during antenatal and postnatal care, and cultural practices during antenatal and postnatal periods in Garut, Sukabumi and Ciamis districts of West Java province.
A qualitative study was conducted from March to July 2009 in six villages in three districts of West Java province. Twenty focus group discussions (FGDs) and 165 in-depth interviews were carried out involving a total of 295 respondents. The guidelines for FGDs and in-depth interviews included the topics of community experiences with antenatal and postnatal care services, reasons for not attending the services, and cultural practices during antenatal and postnatal periods.
Our study found that the main reason women attended antenatal and postnatal care services was to ensure the safe health of both mother and infant. Financial difficulty emerged as the major issue among women who did not fulfil the minimum requirements of four antenatal care services or two postnatal care services within the first month after delivery. This was related to the cost of health services, transportation costs, or both. In remote areas, the limited availability of health services was also a problem, especially if the village midwife frequently travelled out of the village. The distances from health facilities, in addition to poor road conditions were major concerns, particularly for those living in remote areas. Lack of community awareness about the importance of these services was also found, as some community members perceived health services to be necessary only if obstetric complications occurred. The services of traditional birth attendants for antenatal, delivery, and postnatal care were widely used, and their roles in maternal and child care were considered vital by some community members.
It is important that public health strategies take into account the availability, affordability and accessibility of health services. Poverty alleviation strategies will help financially deprived communities to use antenatal and postnatal health services. This study also demonstrated the importance of health promotion programs for increasing community awareness about the necessity of antenatal and postnatal services.
Patients with lymphadenopathy are commonly referred to general surgeons for diagnostic lymph node biopsy. We were concerned at potential long waits for this service in our hospital and thus wanted to compare the efficiency of written and telephone referral with a view to identifying the optimum care pathway for these patients.
PATIENTS AND METHODS
Sixty patients were included in a 2-year retrospective review (excluding referrals associated with breast lumps which were managed separately). Hospital Episode Statistics data were used to analyse notes for the source and method of referral, waiting time to biopsy, clinic attendance and diagnosis.
Of referrals, 33% were from haematology and 28% from general practice. Overall, 47% of patients were referred by letter; of these, 64% were seen in clinic before biopsy. Personal referral between clinicians, by direct discussion, e-mail or fax led to a mean wait of 4 days, compared to 51 days when patients were referred by letter. Clinic attendance had no significant bearing on diagnostic accuracy or complication rate. Neoplasia accounted for 43% of diagnoses and infection (including four cases of tuberculosis) for 10%. Of biopsies, 33% showed benign changes, 8% were unrecorded and 5% were incorrect.
In this study, 43% of biopsies revealed malignancy and we advise that lymph node biopsy requests should be managed on a fast-track pathway, expedited by direct personal request. Following this study, we have implemented a fast-track pathway for such patients.
Lymphadenopathy; Health services administration; Clinical pathways
Medical students may fear that their training leeches away the caring attitudes which attracted them to medicine. Some research suggests they are right. The medical school has a duty to support and encourage their values, but the reverse may happen. Students are taught about legal consent but not ethical consent. They may see or participate in concealment of medical mistakes and learn to practise deceit. The use of unconscious females for gynaecology teaching may encourage the wrong attitudes to patients. Trainee GPs may learn that the doctors' rights are more important than those of the patient. Measuring patients' views should be included in research protocols.
The Presidential Address of the European Association of Developmental Psychology this year concerned how genes and environments interplay to shape loneliness and other developmental psychological relevant outcomes. This is a very welcome. However, when developmental psychology now is ready to integrate recent genetic and neuroscience knowledge and methods, I think it would be very wise to not uncritical go through the mistakes that have be done in other disciplines and instead learn from their hard lessons. I discuss some problems (genes versus environments, identifying gene for a phenotype, environments cause of developmental outcomes, and gene X environment interaction and epigenetics) and some suggestions for solutions which can be used to avoid throwing in the bathwater with the baby.
It is generally accepted that crew rowing requires perfect synchronization between the movements of the rowers. However, a long-standing and somewhat counterintuitive idea is that out-of-phase crew rowing might have benefits over in-phase (i.e., synchronous) rowing. In synchronous rowing, 5 to 6% of the power produced by the rower(s) is lost to velocity fluctuations of the shell within each rowing cycle. Theoretically, a possible way for crews to increase average boat velocity is to reduce these fluctuations by rowing in antiphase coordination, a strategy in which rowers perfectly alternate their movements. On the other hand, the framework of coordination dynamics explicates that antiphase coordination is less stable than in-phase coordination, which may impede performance gains. Therefore, we compared antiphase to in-phase crew rowing performance in an ergometer experiment. Nine pairs of rowers performed a two-minute maximum effort in-phase and antiphase trial at 36 strokes min−1 on two coupled free-floating ergometers that allowed for power losses to velocity fluctuations. Rower and ergometer kinetics and kinematics were measured during the trials. All nine pairs easily acquired antiphase rowing during the warm-up, while one pair’s coordination briefly switched to in-phase during the maximum effort trial. Although antiphase interpersonal coordination was indeed less accurate and more variable, power production was not negatively affected. Importantly, in antiphase rowing the decreased power loss to velocity fluctuations resulted in more useful power being transferred to the ergometer flywheels. These results imply that antiphase rowing may indeed improve performance, even without any experience with antiphase technique. Furthermore, it demonstrates that although perfectly synchronous coordination may be the most stable, it is not necessarily equated with the most efficient or optimal performance.
Our quality improvement program began in 2004 to improve cardiac surgery outcomes. Early tracheal extubation in the cardiovascular intensive unit was utilized as a multidisciplinary driver for the quality improvement program. Continuous improvement in the rate of early extubation to drive multidisciplinary quality improvement in cardiac critical care correlated with decreased mortality, morbidity, and improved operational efficiency. Supportive educational efforts included, but were not limited to, principles of change, trust, competing values, crew resource management, evidence based medicine, and quality improvement.
cardiac surgery; quality improvement; mechanical ventilation; fast track
Delirium prevalence in the intensive care unit (ICU) is high. Numerous psychotropic agents are used to manage delirium in the ICU with limited data regarding their efficacy or harms.
This is a randomized controlled trial of 428 patients aged 18 and older suffering from delirium and admitted to the ICU of Wishard Memorial Hospital in Indianapolis. Subjects assigned to the intervention group will receive a multicomponent pharmacological management protocol for delirium (PMD) and those assigned to the control group will receive no change in their usual ICU care. The primary outcomes of the trial are (1) delirium severity as measured by the Delirium Rating Scale revised-98 (DRS-R-98) and (2) delirium duration as determined by the Confusion Assessment Method for the ICU (CAM-ICU). The PMD protocol targets the three neurotransmitter systems thought to be compromised in delirious patients: dopamine, acetylcholine, and gamma-aminobutyric acid. The PMD protocol will target the reduction of anticholinergic medications and benzodiazepines, and introduce a low-dose of haloperidol at 0.5-1 mg for 7 days. The protocol will be delivered by a combination of computer (artificial intelligence) and pharmacist (human intelligence) decision support system to increase adherence to the PMD protocol.
The proposed study will evaluate the content and the delivery process of a multicomponent pharmacological management program for delirium in the ICU.
Backstage communication has been shown to play a vital role in a bona fide group’s teamwork. Hospice interdisciplinary teams are considered bona fide groups, and hospice interdisciplinary team meetings constitute backstage communication because they occur away from patients and families. Video recordings of interdisciplinary team meetings were systematically coded for backstage communication mess ages and the extent to which different interdisciplinary team members participated in backstage communication was explored. Results revealed that predominant backstage communication messages included offering of impressions and formal reporting. The sharing of backstage messages in interdisciplinary team meetings enable hospice staff to manage emotions in the safety of the backstage as well as prepare for frontstage professionalism.
Bona fide groups; hospice; backstage communication