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In the fall of 1997 George D. Lundberg and John E. Wennberg wrote an editorial in JAMA calling for comprehensive quality improvement programs to become the driver of the American health care system. The suggestion came during the Second European Forum on Quality Improvement in Health Care held in Paris, France, in April 1997 and was based on comments made by Donald Berwick. The concept was to focus on an organized response to problem identification and proposed solutions to improve patient care and protect the health of the public. Critical care medicine represents a large segment of health care and is undergoing dramatic changes during our managed care revolution. General ICU severity of illness models have been developed, tested, and shown to provide a useful estimate of hospital mortality for populations of critically ill patients. These systems have captured the imagination of clinical researchers and have become an integral component of a large number of publications as well as a part of many ICU databases. These risk adjustment severity models are remarkably robust for heterogeneous patient populations but the models have not been shown to validate well in new settings. We feel that by focusing on the episode of critical illness rather than each individual ICU admission and by going beyond the traditional acute hospital discharge to determine whether the patient lives or dies, we can better evaluate critical care system performance and cost-effectiveness. The incentives for high quality/low cost should favor integrated comprehensive critical care delivery systems. Programs that score well should be identified as high quality and be honored as medallion level 1 ICUs. We challenge national and international critical care societies to evaluate and then debate the described definitions and recommendations as a call to action. [ABSTRACT FROM AUTHOR]

This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises. [ABSTRACT FROM AUTHOR]

A growing body of literature suggests that face-to-face interaction among clinicians in hospitals affects patient outcomes. How can face-to-face interaction among clinicians be influenced positively to improve patient outcomes in hospitals? So far, most strategies for improving face-to-face interaction in hospitals have focused on changing organizational culture. In contrast, this paper proposes a theoretical model that shows how spatial program and structure can help face-to-face interaction fulfill its purposes in hospitals by controlling the interfaces among different communities of clinicians. [ABSTRACT FROM AUTHOR]

BACKGROUND: Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation. AIMS: The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks. FINDINGS: Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation. CONCLUSION: The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break. [ABSTRACT FROM AUTHOR]

Background: COVID-19 significantly impacted care delivery to seriously ill patients, especially around including family and caregivers in patient care. Aim: Based on routinely collected bereaved family reports, actionable practices were identified to maintain and improve care in the last month of life, with potential application to all seriously ill patients. Design: The Veterans Health Administration's Bereaved Family Survey is used nationally to gather routine feedback from families and caregivers of recent in-patient decedents; the survey includes multiple structured items as well as space for open narrative responses. The responses were analyzed using qualitative content analysis with dual review. Setting/participants: Between February 2020 and March 2021, there were 5372 responses to the free response questions of which 1000 (18.6%) responses were randomly selected. The 445 (44.5%) responses from 377 unique individuals included actionable practices. Results: Bereaved family members and caregivers identified four opportunities with a total of 32 actionable practices. Opportunity 1: Facilitate the use of video communication, included four actionable practices. Opportunity 2: Provide timely and accurate responses to family concerns, included 17 actionable practices. Opportunity 3: Accommodate family/caregiver visitation, included eight actionable practices. Opportunity 4: Offer physical presence to the patient when family/caregivers are unable to visit, included three actionable practices. Conclusion: The findings from this quality improvement project are applicable during a pandemic, but also translate to improving the care of seriously ill patients in other circumstances, such as when family members or caregivers are geographically distant from a loved one during the last weeks of life. [ABSTRACT FROM AUTHOR]

Policy PointsThe predominantly fee‐for‐service reimbursement architecture of the US health care system contributes to waste and excess spending.While the past decade of payment reforms has galvanized the adoption of alternative payment models and generated moderate savings, uptake of truly population‐based payment systems continues to lag, and interventions to date have had limited impact on care quality, outcomes, and health equity.To realize the promise of payment reforms as instruments for delivery system transformation, future policies for health care financing must focus on accelerating the diffusion of value‐based payment, leveraging payments to redress inequities, and incentivizing partnerships with cross‐sector entities to invest in the upstream drivers of health. [ABSTRACT FROM AUTHOR]

For centuries, hospitals have served as the cornerstone of the United States healthcare system. Just like the majority of the general population, the respiratory care profession was born inside the hospital walls, just over 6 decades ago. While the knowledge, skills, and attributes of the respiratory therapist are critically necessary in acute care settings, the profession must move itself to a stronger position across the entire continuum of care of patients with acute and chronic cardiopulmonary diseases within the next several years to stay ahead of the curve of healthcare reform. In this paper, based on the 28th annual Philip Kittredge Memorial Lecture, I will examine the necessary strategies and values that the profession of respiratory care will need to successfully embrace to "think outside the box" and move the profession beyond the hospital walls for patient- and outcomes-focused, sustainable impact in the future healthcare delivery system. [ABSTRACT FROM AUTHOR]

Because of the severity of illness, the intensive care unit (ICU) is a setting where death is common. Approximately 20% of all deaths in the United States occur in ICUs. Although optimal palliative care of out-patients may prevent many ICU admissions, the ICU will always remain an important setting for end-of-life care because of the severity of illness of patients in the ICU. This review provides an overview of the principles and practice of integrating palliative and critical care, with a focus on 4 specific areas: the role of palliative care in the ICU; symptom assessment and management; communication with patients and family members; and interdisciplinary communication and collaboration. This review also describes the development and evaluation of a new intervention for hospitals and individual ICUs: Integrating Palliative and Critical Care (IPACC). The goal of the IPACC intervention and this paper is to teach ICU clinicians basic palliative care skills and the language of palliative care, and to encourage all ICU clinicians to prioritize palliative care as one of the important things that we do in the ICU. [ABSTRACT FROM AUTHOR]

Historically, African Americans have not been well represented in hospice care. African Americans make up approximately 12 percent of the general population, but according to the National Hospice and Palliative Care Organization, in the year 2002, African Americans constituted only 8 percent of the more than 600,000 Americans who died while receiving hospice care. As diversity increases in the United States, cultural misunderstandings and differences emerge around end-of-life care. This paper will focus on African Americans' underuse of hospice services. First, the author considers the increased need for communication and cross-cultural understanding. Second, the author discusses African American challenges and concerns that may result from cultural differences, values, spirituality, beliefs, and trust. Third, the hospice experiences of two African American families are presented. Finally, the author raises the question: What is needed to support and assist the African American community in utilizing hospice interventions? [ABSTRACT FROM AUTHOR]

Older adults with complex medical needs can age in place even when experiencing unplanned acute episodes. Such episodes may be an inevitable consequence of chronic disease, frailty, and disability. Because these episodes affect cost, patient risk, and care experience, acute care in the home can enhance value and support successful aging. This article describes models that balance proactive engagement with on-demand responses, and details lessons learned from a preliminary collaboration, along with next steps for advocates to promote lower costs and better care for older adults [ABSTRACT FROM AUTHOR]

Purpose: A review of the implementation and development of telepharmacy services that ensure access to a critical care-trained pharmacist across a healthcare system. Summary: Teleintensive care unit (tele-ICU) services use audio, video, and electronic databases to assist bedside caregivers. Telepharmacy, as defined by the American Society of Health-System Pharmacists, is a method in which a pharmacist uses telecommunication technology to oversee aspects of pharmacy operations or provide patient care services. Telepharmacists can ensure accurate and timely order verification, recommend interventions to improve patient care, provide drug information to clinicians, assist in standardization of care, and promote medication safety. This tele-ICU pharmacy team is one of the only entirely clinical-based tele-ICU pharmacy models among the tele-ICU programs across the United States. The use of technology for customized alert generation and intervention proposal with medication orders and chart notation are unique. In a 34-month period from September 2015 to July 2018, more than 110 000 alerts were generated and 13 000 interventions were performed by telepharmacists. Conclusions: Tele-ICU pharmacists employ limited resources to provide critical care pharmacy expertise to multiple sites within a healthcare system during nontraditional hours with documented clinical and financial benefits. Further study is needed to determine the impact of tele-ICU pharmacists on ICU and hospital length of stay, morbidity, and mortality. [ABSTRACT FROM AUTHOR]

Aim: This study examined the extent, range, and nature of registered nurse (RN) and practical nurse (PN) collaboration in acute care hospitals and identified research gaps in the existing literature. Background: Optimal patient care requires collaboration between RNs and PNs. A lack of unity and unresolved tension among different types of nurses influences collaboration and has significant implications on practice and the organizations where nurses work. Methods: Using Arksey and O'Malley's (2005) framework, a scoping review was undertaken to answer the research question: what is known from the existing literature about the structures, processes, and outcomes of RN‐PN collaboration in hospitals? Results: Twenty‐nine studies were included with the majority coming from North America. Donabedian's model assisted with the identification of three themes: scope of practice, interpersonal skills, and nurse and patient‐related outcomes. Conclusion: The findings demonstrate there is a paucity of research specific to RN‐PN collaboration. Nurse administrators/managers play an important role in addressing the interpersonal skills of nurses and providing an ongoing education on collaboration in the practice setting. Additional studies should focus on the development of nursing collaborative practice models of patient care, the examination of interventions to improve RN‐PN collaborative practice, and the assessment of outcomes relating to collaboration among nurses. [ABSTRACT FROM AUTHOR]

Purpose: Children with hypoplastic left heart syndrome (HLHS) experience numerous vulnerabilities during transitions from hospital to home during their first year of life. This paper examines the parents' responses to the situations they experience during the initial interstage transition as described through illness blogs. Design and methods: A qualitative descriptive design through inductive theme development using thematic analysis was performed for this study. Text data were used from publically available blogs written by parents of HLHS children on their feelings and experiences during transitions between hospital‐ and home‐care during the interstage period. Results: Six blogs were analyzed. Overall, the lack of difference in normalcy for these parents and their families was apparent. Major themes included: thoughts and feelings when discharged from the hospital, difficulties with hospital readmissions, protecting their child from infection, and developing a support system. Conclusions: Parents looked forward to going home and learned all they could about properly caring for their child before going home. They were disappointed and frustrated when returning to the hospital for either emergency or scheduled admissions and were not prepared to see their child in the intensive care unit environment again. Many parents isolated themselves and avoided the hospital as much as possible to avoid their child developing an infection. All parents had support systems through family and/or friends and found an unexpected sense of support through their blog families. [ABSTRACT FROM AUTHOR]

Objective: To determine between-hospital variation in interventions provided to patients with do not resuscitate (DNR) orders.Data Sources/setting: United States Agency of Healthcare Research and Quality, Healthcare Cost and Utilization Project, California State Inpatient Database.Study Design: Retrospective cohort study including hospitalized patients aged 40 and older with potential indications for invasive treatments: in-hospital cardiac arrest (indication for CPR), acute respiratory failure (mechanical ventilation), acute renal failure (hemodialysis), septic shock (central venous catheterization), and palliative care. Hierarchical logistic regression to determine associations of hospital "early" DNR rates (DNR order placed within 24 hours of admission) with utilization of invasive interventions.Data Collection/extraction Methods: California State Inpatient Database, year 2011.Principal Findings: Patients with DNR orders at high-DNR-rate hospitals were less likely to receive invasive mechanical ventilation for acute respiratory failure or hemodialysis for acute renal failure, but more likely to receive palliative care than DNR patients at low-DNR-rate hospitals. Patients without DNR orders experienced similar rates of invasive interventions regardless of hospital DNR rates.Conclusions: Hospitals vary widely in the scope of invasive or organ-supporting treatments provided to patients with DNR orders. [ABSTRACT FROM AUTHOR]

Objectives: To test whether a care management program could replicate its success in an earlier trial and determine likely explanations for why it did not.Data Sources/setting: Medicare claims and nurse contact data for Medicare fee-for-service beneficiaries with chronic illnesses enrolled in the trial in eastern Pennsylvania (N = 483).Study Design: A randomized trial with half of enrollees receiving intensive care management services and half receiving usual care. We developed and tested hypotheses for why impacts declined.Data Extraction: All outcomes and covariates were derived from claims and the nurse contact data.Principal Findings: From 2010 to 2014, the program did not reduce hospitalizations or generate Medicare savings to offset program fees that averaged $260 per beneficiary per month. These estimates are statistically different (p < .05) from the large reductions in hospitalizations and spending in the first trial (2002-2010). The treatment-control differences in the second trial disappeared because the control group's risk-adjusted hospitalization rate improved, not because the treatment group's outcomes worsened.Conclusion: Even if demonstrated in a randomized trial, successful results from one test may not replicate in other settings or time periods. Assessing whether gaps in care that the original program filled exist in other settings can help identify where earlier success is likely to replicate. [ABSTRACT FROM AUTHOR]

Aim: To examine how Australia, Singapore and the United States of America (USA) match to the World Stroke Organization Global Stroke Services health system monitoring indicators (HSI). Design: Descriptive comparative study Participants: The health systems of Australia, Singapore, the USA. Outcome measures: Published data available from each country were mapped to the 10 health system monitoring indicators proposed by the World Stroke Organization. Results: Most health system monitoring indicators were at least partially met in each country. Thrombolytic agents were available for use in acute stroke. Stroke guidelines and stroke registry data were available in all three countries. Stroke incidence, prevalence, and mortality rates were available but at non-uniform times post-stroke. The International Classification of Disease 9 or 10 coding systems are used in all three countries. Standardized clinical audits are routine in Australia and the USA, but not in Singapore. The use of the modified Rankin Scale is collected sub-acutely but not at one year post-stroke in all three countries. Conclusions: The three developed countries are performing well against the World Stroke Organization health system monitoring indicators for acute and sub-acute stroke care. However, improvements in stroke risk assessment and at oneyear post-stroke outcome measurement are needed. [ABSTRACT FROM AUTHOR]

Background: Central line-associated bloodstream infections (CLABSI) represent a serious patient safety issue. To prevent these infections, bundled interventions are increasingly recommended. We examine the extent of adoption of Central Line (CL) Bundle elements throughout US intensive care units (ICU) and determine their effectiveness in preventing CLABSIs. Methodology/Principal Findings: In this cross-sectional study, National Healthcare Safety Network (NHSN) hospitals provided the following: ICU-specific NHSN-reported rates of CLABSI/1,000 central line days; policies and compliance rates regarding bundle components; and other setting characteristics. In 250 hospitals the mean CLABSI rate was 2.1 per 1000 central line days and 49% reported having a written CL Bundle policy. However, of those that monitored compliance, only 38% reported very high compliance with the CL Bundle. Only when an ICU had a policy, monitored compliance, and had ≥95% compliance did CLABSI rates decrease. Complying with any one of three CL Bundle elements resulted in decreased CLABSI rates (β = -1.029, p = 0.015). If an ICU without good bundle compliance achieved high compliance with any one bundle element, we estimated that its CLABSI rate would decrease by 38%. Conclusions/Significance: In NHSN hospitals across the US, the CL Bundle is associated with lower infection rates only when compliance is high. Hospitals must target improving bundle implementation and compliance as opposed to simply instituting policies. [ABSTRACT FROM AUTHOR]

Background The Therapeutic Intervention Scoring System is widely used in both Western Europe and the United States to assess the level of patients' need for nursing care. Poland currently has 3 types of intensive care according to a territorial division of the country and the scope of medical treatment offered: poviat, voivodeship, and clinical. Objective To determine the need for nursing care for patients in the 3 types of intensive care units in southeastern Poland. Methods The investigation was conducted at 6 intensive care units in southeastern Poland in 2005 and 2006. Two units were randomly selected from each type of intensive care unit. A total of 155 patients from the units were categorized according to scores on the Therapeutic Intervention Scoring System 28. Results Among the 3 types of units, patients varied significantly with respect to age, length of hospitalization, and scores on the Therapeutic Intervention Scoring System 28. Nevertheless, demand for nursing care during night and day shifts was similar in all 3 types. On the basis of the patients' scores, all 3 types of units provided appropriate staffing levels necessary to meet the demands for nursing care. Most patients required category III level of care. Conclusion Need or demand for nursing care in intensive care units in Poland varies according to the type of intensive care unit and can be determined on the basis of scores on the Therapeutic Intervention Scoring System 28. [ABSTRACT FROM AUTHOR]

The author reflects on the evolution of critical care outreach in the U.S. He cites that logistic regression and death parameters hinder the success of intensive medical care. He states that critical care management facilitates medical intervention. Moreover, he stresses the need for critical care medicine development.

With the increasing corporate and governmental rationalisation of medical care, the mandate of efficiency has caused many to fear that concern for the individual patient will be replaced with impersonal, rule-governed allocation of medical resources. Largely ignored is the role of moral principles in medical decision-making. This analysis comes from an ethnographic study conducted from 1999–2001 in three US Intensive Care Units, two of which were using the computerised decision-support tool, APACHE III (Acute Physiological and Chronic Health Evaluation III), which notably predicts the probability that a patient will die. It was found that the use of APACHE presents a paradox regarding concern for the individual patient. To maintain jurisdiction over the care of patients, physicians share the data with the payers and regulators of care to prove they are using resources effectively and efficiently, yet they use the system in conjunction with moral principles to justify treating each patient as unique. Thus, concern for the individual patient is not lessened with the use of this system. However, physicians do not share the data with patients or surrogate decision-makers because they fear they will be viewed as more interested in profits than patients. [ABSTRACT FROM AUTHOR]

Investigates what is known and not known about medical expenditures at the end of life in the United States. Types of studies of medical care expenditures at the end of life; Costs incurred in hospital special or intensive-care units; Spending on patients who die compared to patients who survive; Increase in the use of the hospital as a place to die; Ways to curb the rising medical care costs.

In the United States, shortages of qualified health-care professionals have created a major threat to the availability and quality, of critical care services for seriously ill patients. An unprecedented, and largely unrecognized, shortage of physician intensivists in the near future will deny standard critical care services for large populations of patients with serious illnesses. If the current trend persists, shortages of these specialists, combined with the current shortages of critical care nurses, pharmacists, and respiratory therapists, will become severe by 2007 and will worsen through 2030. Numerous studies demonstrate that critical care services directed by physicians who are formally trained in critical care medicine reduce mortality in the ICU and reduce health-care costs. While people of all ages, from low-birth-weight newborns to senior citizens, benefit from treatment in the ICU, older Americans receive a disproportionate share of ICU services. The demand for ICU services, therefore, will continue to grow as the baby boom generation ages. To address the shortage, the critical care professional societies recommend that steps be taken to improve the efficiency of critical care providers, to increase the number of critical care providers, and to address the demand for critical care services. [ABSTRACT FROM AUTHOR]

The article offers an analysis on the continuous expansion of palliative care in the hospitals and the development of hospice care in the U.S. It states that the rapid expansion of the two fields is traced to the constructive responses on the results of the trial in 1995 that tested the ability of advance care planning to the care for seriously ill patients. It also notes that such advances in medicine implies the acceptability of advance care planning by the public.