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Objectives: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU).Design and Setting: Prospective cohort study in a university surgical ICU.Patients: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time.Measurements and Results: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year.Conclusions: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU. [ABSTRACT FROM AUTHOR]

This document introduces and explains common implementation concepts and frameworks relevant to healthcare epidemiology and infection prevention and control and can serve as a stand-alone guide or be paired with the "SHEA/IDSA/APIC Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2022 Updates," which contain technical implementation guidance for specific healthcare-associated infections. This Compendium article focuses on broad behavioral and socio-adaptive concepts and suggests ways that infection prevention and control teams, healthcare epidemiologists, infection preventionists, and specialty groups may utilize them to deliver high-quality care. Implementation concepts, frameworks, and models can help bridge the "knowing-doing" gap, a term used to describe why practices in healthcare may diverge from those recommended according to evidence. It aims to guide the reader to think about implementation and to find resources suited for a specific setting and circumstances by describing strategies for implementation, including determinants and measurement, as well as the conceptual models and frameworks: 4Es, Behavior Change Wheel, CUSP, European and Mixed Methods, Getting to Outcomes, Model for Improvement, RE-AIM, REP, and Theoretical Domains.

Introduction: Podcasts have become popular among medical trainees. However, it is unclear how well learners retain information from podcasts compared to traditional educational modalities, and whether multitasking affects the learner's ability to pay attention and learn. This study attempted to examine the effectiveness of podcast learning by using electroencephalography (EEG) to measure learner attention, in addition to test performance, task load, and preferences., Methods: The study used a repeated measures design with three conditions: podcast listening on a treadmill, podcast listening seated, and textbook reading seated. Participants were anesthesiology residents and medical students at a large United States academic medical center. Three topics were chosen: allergic response, liver physiology, and statistics. Each participant studied all three topics that were randomly assigned to one of three learning conditions - in random order. Participants completed a knowledge test at baseline, after each condition, and at four-week follow-up, and reported preferred learning modality and task load under each modality. Activation levels in alerting, orienting, and executive attentional networks were examined using EEG.  Results: Sixty-one participants (11 anesthesiology residents and 50 medical students) were included in the study. Of the 61, six were excluded from the EEG analyses due to corrupted recordings. EEG results showed that mean attention network activation scores did not differ between the study conditions. Trainees preferred podcast learning over reading for all three topics. When compared to textbook reading, podcast learning (seated or on a treadmill) produced significantly better learning gain, and equivalent retention for two of the three topics., Conclusions: Our study is the first to use neurocognitive data, self-reported satisfaction, and knowledge test performance to demonstrate that podcasts are at least equivalent to textbooks for maintaining attention, immediate learning, and retention - even while exercising., Competing Interests: Jed Wolpaw is the founder and host of the Anesthesia and Critical Care Reviews and Commentary (ACCRAC) podcast but receives no financial compensation for the work which is provided free of charge to listeners. Sahin Ozsoy is the owner of BioSoftPro and Chief Engineer at NeuroField Inc. Beyond that, to the author's knowledge, no conflict of interest, financial or other, exists related to this work., (Copyright © 2022, Wolpaw et al.)

Background: Formative events during training help shape professional identity and may impact well-being. This study sought to identify formative experiences during anesthesia residency and measure their perceived impact on well-being., Methods: A 24-item survey exploring the frequency and perceived impact of formative events was developed through a rigorous process involving a literature search, consultation with medical education experts, resident focus groups, graduate interviews, and pilot testing. All 80 anesthesiology residents at Johns Hopkins University were invited to participate. We measured the frequency of event exposure and perceived impact on well-being., Results: Seventy-six residents (95%) completed the survey. Event exposure rate ranged from 56.6% to 100%. Events with greatest relative impact (RI) overall included leaving work earlier than expected (RIoverall = 85.8), a patient expresses genuine gratitude (RIoverall = 80.2), identifying a faculty role model (RIoverall = 75.7), and having a patient die under my care (RIoverall = 75.6). There was no statistically significant difference on RI for positive versus negative events. The perceived impact of events on well-being varied by gender., Conclusions: This work provides clarity for residency program leaders and educators about the commonly experienced formative events that have the greatest perceived impact on resident well-being. These results may inform curricular planning and can suggest times when trainees may need attention or support. Future research should evaluate the direct impact of formative events on well-being and the success of related interventions., Competing Interests: Conflicts of interest: None, (© 2019 Society for Education in Anesthesia.)

Background: A Surgical Unit-based Safety Programme (SUSP) has been shown to improve perioperative prevention practices and to reduce surgical site infections (SSI). It is critical to understand the factors influencing the successful implementation of the SUSP approach in low- and middle-income settings. We undertook a qualitative study to assess viability, and understand facilitators and barriers to implementing the SUSP approach in 5 African hospitals., Methods: Qualitative study based on interviews with individuals from all hospitals participating in a WHO-coordinated before-after SUSP study. The SUSP intervention consisted of a multimodal strategy including multiple SSI prevention measures combined with an adaptive approach aimed at improving teamwork and safety culture., Results: Thirteen interviews (5 head surgeons, 3 surgeons, 5 nurses) were conducted with staff from five hospital sites. Identified facilitators included influential individuals (intrinsic motivation of local SUSP teams, boundary spanners, multidisciplinary engagement, active leadership support), peer-to-peer learning (hospital networking and positive deviance, benchmarking), implementation fitness (enabling infrastructures, momentum from previous projects), and timely feedback of infection rates and process indicators. Barriers (organisational 'constipators', workload, mistrust, turnover) and local solutions to these were also identified., Conclusions: Participating hospitals benefitted from the SUSP programme structures (e.g. surveillance, hospital networks, formation of multidisciplinary teams) and adaptive tools (e.g. learning from defects, executive rounds guide) to change perceptions around patient safety and improve behaviours to prevent SSI. The combination of technical and adaptive elements represents a promising approach to facilitate the introduction of evidence-based best practices and to improve safety culture through local team engagement in resource-limited settings., Competing Interests: Competing interestsThe authors report no competing interests.

Background: Evidence-based guidelines from the World Health Organization (WHO) have recommended a high (80%) fraction of inspired oxygen (FiO 2 ) to reduce surgical site infection in adult surgical patients undergoing general anaesthesia with tracheal intubation. However, there is ongoing debate over the safety of high FiO 2 . We performed a systematic review to define the relative risk of clinically relevant adverse events (AE) associated with high FiO 2 ., Methods: We reviewed potentially relevant articles from the WHO review supporting the recommendation, including an updated (July 2018) search of EMBASE and PubMed for randomised and non-randomised controlled studies reporting AE in surgical patients receiving 80% FiO 2 compared with 30-35% FiO 2 . We assessed study quality and performed meta-analyses of risk ratios (RR) comparing 80% FiO 2 against 30-35% for major complications, mortality, and intensive care admission., Results: We included 17 moderate-good quality trials and two non-randomised studies with serious-critical risk of bias. No evidence of harm with high FiO 2 was found for major AE in the meta-analysis of randomised trials: atelectasis RR 0.91 [95% confidence interval (CI) 0.59-1.42); cardiovascular events RR 0.90 (95% CI 0.32-2.54); intensive care admission RR 0.93 (95% CI 0.7-1.12); and death during the trial RR 0.49 (95% CI 0.17-1.37). One non-randomised study reported that high FiO 2 was associated with major respiratory AE [RR 1.99 (95% CI 1.72-2.31)]., Conclusions: No definite signal of harm with 80% FiO 2 in adult surgical patients undergoing general anaesthesia was demonstrated and there is little evidence on safety-related issues to discourage its use in this population., (Copyright © 2018 World Health Organization. Published by Elsevier Ltd.. All rights reserved.)

Background: Surgical site infections (SSIs) portend high patient morbidity and mortality. Although evidence-based clinical interventions can reduce SSIs, they are not reliably delivered in practice, and data are limited on the best approach to improve adherence., Objective: To summarize implementation strategies aimed at improving adherence to evidence-based interventions that reduce SSIs., Design: Systematic reviewMethods:We searched PubMed, Embase, CINAHL, the Cochrane Library, the WHO Regional databases, AFROLIB, and Africa-Wide for studies published between January 1990 and December 2015. The Effective Practice and Organization Care (EPOC) criteria were used to identify an acceptable-quality study design. We used structured forms to extract data on implementation strategies and grouped them into an implementation model called the "Four Es" framework (ie, engage, educate, execute, and evaluate)., Results: In total, 125 studies met our inclusion criteria, but only 8 studies met the EPOC criteria, which limited our ability to identify best practices. Most studies used multifaceted strategies to improve adherence with evidence-based interventions. Engagement strategies included multidisciplinary work and strong leadership involvement. Education strategies included various approaches to introduce evidence-based practices to clinicians and patients. Execution strategies standardized the interventions into simple tasks to facilitate uptake. Evaluation strategies assessed adherence with evidence-based interventions and patient outcomes, providing feedback of performance to providers., Conclusions: Multifaceted implementation strategies represent the most common approach to facilitating the adoption of evidence-based practices. We believe that this summary of implementation strategies complements existing clinical guidelines and may accelerate efforts to reduce SSIs.

BACKGROUND Measuring processes of care performance rates is an invaluable tool for quality improvement; however, collecting daily process measure data is time-consuming and burdensome. OBJECTIVE To evaluate the accuracy of sampling strategies to estimate monthly compliance rates with ventilator-associated pneumonia prevention measures. SETTING AND PARTICIPANTS A total of 37 intensive care units affiliated with 29 hospitals participating in a 2-state 35-month ventilator-associated pneumonia prevention collaborative. Analysis was limited to 325 unit-months with complete data entry rates. METHODS We calculated unit-month level actual and sample monthly compliance rates for 6 ventilator-associated pneumonia prevention measures, using 4 sampling strategies: sample 1 day per month, sample 1 day per week, sample 7 consecutive days per month, and sample 7 consecutive days per month plus additional consecutive days as necessary to obtain at least 30 ventilator-days for that month whenever possible. We compared sample versus actual rates using paired t test and χ2 test. RESULTS Mean sampling accuracy ranged 84%-97% for 1 day per month, 91%-98% for 1 day per week, 92%-98% for 7 consecutive days per month, and 96%-99% for 7 consecutive days with at least 30 days per month if possible. The most accurate sampling strategy was to sample 7 consecutive days with at least 30 ventilator-days per month if possible. With this strategy, sample rates were within 10% of actual rates in 88%-99% of unit-months and within 5% of actual rates in 74%-97% of unit-months. CONCLUSION Sampling process measures intermittently rather than continually can yield accurate estimates of process measure performance rates. Infect Control Hosp Epidemiol 2016;37:1037-1043.

Background: Ventilator-associated pneumonia (VAP) is among the most common type of health care-associated infection in the intensive care unit and is associated with significant morbidity and mortality. Existing VAP prevention intervention bundles vary widely on the interventions included and in the approaches used to develop these bundles. The objective of this study was to develop a new VAP prevention bundle using a systematic approach that elicits clinician perceptions on which interventions are most important and feasible to implement., Methods: We identified potential interventions to include through a review of current guidelines and literature. We implemented a 2-step modified Delphi method to gain consensus on the final list of interventions. An interdisciplinary group of clinical experts participated in the Delphi process, which was guided by a technical expert panel., Results: We identified 65 possible interventions. Through the Delphi method, we narrowed that list to 19 interventions that included 5 process and 14 structural measures., Conclusions: We described a structured approach for developing a new VAP prevention bundle. Obtaining clinician input on what interventions to include increases the likelihood that providers will adhere to the bundle., (Copyright © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.)

Immunization for influenza and pneumococcal pneumonia were incorporated into The Joint Commission "global immunization" core measure January 1, 2012. The authors' hospital chose to adhere strictly to guidelines to avoid overvaccination. An immunization order set was created to aid appropriate ordering practices. In spite of this effort, compliance rates remained below the goal. The objective was to improve compliance with inpatient vaccination core measures to >96%. An educational slide set was created and distributed by the Housestaff Patient Safety and Quality Council (HPSQC). A competition was established among departments. Finally, the HPSQC partnered with quality improvement staff to improve communication and optimize concurrent review processes. The average compliance prior to the HPSQC vaccination initiative was 78% for pneumococcal pneumonia and 84% for influenza; average compliance in the months following the intervention was 96% and 97.5%, respectively. This project yielded significant improvement in compliance with vaccination core measures., (© The Author(s) 2014.)

Ventilator-associated pneumonia (VAP) is common, lethal, and expensive. Little is known about optimal strategies to evaluate process measures for VAP prevention. The authors conducted a prospective study of different sampling strategies for evaluating head of bed (HOB) elevation and oral care. There was no significant difference between morning and evening shift HOB elevation compliance rates (P = .47). If oral care was performed at least once during a 12-hour shift, there was an 87% probability that it also was performed at least twice. If oral care was performed at least twice during a 12-hour shift, then there was a 93% probability that chlorhexidine oral care was performed at least once. The results of this study suggest that sampling HOB elevation twice as compared with once daily is unlikely to change the estimate of performance, oral care need not be frequently sampled, and high oral care compliance may predict chlorhexidine oral care compliance., (© 2013 by the American College of Medical Quality.)

Objective: Diagnosing ventilator-associated pneumonia (VAP) is difficult, and misdiagnosis can lead to unnecessary and prolonged antibiotic treatment. We sought to quantify and characterize unjustified antimicrobial use for VAP and identify risk factors for continuation of antibiotics in patients without VAP after 3 days., Methods: Patients suspected of having VAP were identified in 6 adult intensive care units (ICUs) over 1 year. A multidisciplinary adjudication committee determined whether the ICU team's VAP diagnosis and therapy were justified, using clinical, microbiologic, and radiographic data at diagnosis and on day 3. Outcomes included the proportion of VAP events misdiagnosed as and treated for VAP on days 1 and 3 and risk factors for the continuation of antibiotics in patients without VAP after day 3., Results: Two hundred thirty-one events were identified as possible VAP by the ICUs. On day 1, 135 (58.4%) of them were determined to not have VAP by the committee. Antibiotics were continued for 120 (76%) of 158 events without VAP on day 3. After adjusting for acute physiology and chronic health evaluation II score and requiring vasopressors on day 1, sputum culture collection on day 3 was significantly associated with antibiotic continuation in patients without VAP. Patients without VAP or other infection received 1,183 excess days of antibiotics during the study., Conclusions: Overdiagnosis and treatment of VAP was common in this study and led to 1,183 excess days of antibiotics in patients with no indication for antibiotics. Clinical differences between non-VAP patients who had antibiotics continued or discontinued were minimal, suggesting that clinician preferences and behaviors contribute to unnecessary prescribing.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Background: Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital., Methods: Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline., Results: Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000)., Discussion: The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.

By making the clinical decision making process explicit, conscious, and science based, we may avoid confusing opinion with evidence. EBM may help sharpen our critical appraisal skills and thus improve the way we practice, teach, and conduct research. Nevertheless, EBM will need to supplement rather than substitute for other approaches to patient care and teaching. EBM may better incorporate patients' values into clinical decision making, and this may be especially important in anesthesiology, where we are in need of valid evidence about important clinical issues such as preoperative testing and postoperative analgesia. By incorporating valid scientific evidence and patients' values into clinical decision making, we may improve patient outcomes. Outside of internal medicine, the literature suggesting that the practice of EBM improves outcomes is sparse, though increasing. Future studies to critically evaluate the practice of EBM in anesthesiology and critical care would be helpful.