Publications

CONTEXT: Dyspnea is an uncomfortable and distressing sensation experienced by hospitalized patients.

OBJECTIVES: There is no large-scale study of the prevalence and intensity of patient-reported dyspnea at the time of admission to the hospital.

METHODS: Between March 2014 and September 2016, we conducted a prospective cohort study among all consecutive hospitalized patients at a single tertiary care center in Boston, MA. During the first 12 hours of admission to medical-surgical and obstetric units, nurses at our institution routinely collect a patient's 1) current level of dyspnea on a 0-10 scale with 10 anchored at "unbearable," 2) worst dyspnea in the past 24 hours before arrival at the hospital on the same 0-10 scale, and 3) activities that were associated with dyspnea before admission. The prevalence of dyspnea was identified, and tests of difference were performed across patient characteristics.

RESULTS: We analyzed 67,362 patients, 12% of whom were obstetric patients. Fifty percent of patients were admitted to a medical-surgical unit after treatment in the emergency department. Among all noncritically ill inpatients, 16% of patients experienced dyspnea in the 24 hours before the admission. Twenty-three percent of patients admitted through the emergency department reported any dyspnea in the past 24 hours. Eleven percent experienced some current dyspnea when interviewed within 12 hours of admission with 4% of patients experiencing dyspnea that was rated 4 or greater. Dyspnea of 4 or more was present in 43% of patients admitted with respiratory diagnoses and 25% of patients with cardiovascular diagnoses. After multivariable adjustment for severity of illness and patient comorbidities, patients admitted on the weekend or during the overnight nursing shift were more likely to report dyspnea on admission.

CONCLUSION: Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.

A nurse project consultant role empowered 3 critical care nurses to expand their scope of practice beyond the bedside and engage within complex health care delivery systems to reduce harms in the intensive care unit. As members of an interdisciplinary team, the nurse project consultants contributed their clinical expertise and systems knowledge to develop innovations that optimize care provided in the intensive care unit. This article discusses the formal development of and institutional support for the nurse project consultant role. The nurse project consultants' responsibilities within a group of quality improvement initiatives are described and their challenges and lessons learned discussed. The nurse project consultant role is a new model of engaging critical care nurses as leaders in health care redesign.

BACKGROUND: Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center.

METHODS: Lean-inspired methodology and information provided by frontline staff regarding inefficiencies and barriers to optimal team functioning were used in designing a toolkit for standardization of rounds in the ICUs. Staff perceptions about communication were measured, and direct observations of rounds were conducted before and after implementation of the intervention.

RESULTS: After implementation of the intervention, nurse participation during presentation of patient data increased from 17/47 (36.2%) to 56/78 (71.8%) (p < 0.0002) in the surgical ICUs and from 8/23 (34.8%) to 107/107 (100%) (p <0.0001) in the medical ICUs. Nurse participation during generation of the daily plan increased in the surgical ICUs from 24/47 (51.1%) to 63/78 (80.8%) (p = 0.0005) and from 7/23 (30.4%) to 106/107 (99.1%) (p < 0.0001) in the medical ICUs. Miscommunications and errors were corrected in nearly half of the rounding episodes observed.

CONCLUSION: This study demonstrated that the implementation of a simple toolkit that can be incorporated into existing work flow and rounding culture in several different types of ICUs can result in improvements in engagement of nursing staff and in overall communication.

OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes.

DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline).

SETTING: Administrative claims data collected from medical centers across the United States (Vizient).

PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day.

INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit.

MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation.

CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.

RATIONALE: Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown.

OBJECTIVES: We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States.

METHODS: We analyzed all adult admissions, using a retrospective cohort study from 162 hospitals in 44 states, discharged between January 1, 2009, and September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose during this time. Admissions were identified using the Clinical Database/Resource Manager of Vizient, the successor to the University Health System Consortium.

RESULTS: Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined on the basis of previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence interval [CI], 51.8-53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI, 43-46 per 10,000) to 59 per 10,000 ICU admissions (95% CI, 57-61 per 10,000; P < 0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI, 7.0-7.6%) but increased to 10% in 2015 (95% CI, 8.8-10.8%).

CONCLUSIONS: The number of deaths of ICU patients with opioid overdoses increased substantially in the 7 years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

IMPORTANCE: A physician's prior experience caring for a patient may be associated with patient outcomes and care patterns during and after hospitalization.

OBJECTIVE: To examine differences in the use of health care resources and outcomes among hospitalized patients cared for by hospitalists, their own primary care physicians (PCPs), or other generalists.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective study analyzed admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from January 1 through December 31, 2013. Patients had at least 1 previous encounter with an outpatient clinician within the 365 days before admission, and diagnoses were restricted to the 20 most common diagnosis related groups. Data were collected from Medicare Parts A and B claims data, and outcomes were analyzed from January 1, 2013, through January 31, 2014.

EXPOSURES: Physician types included hospitalists, PCPs (ie, the physicians who provided a plurality of ambulatory visits in the year preceding admission), or generalists (not the patients' PCPs).

MAIN OUTCOMES AND MEASURES: Number of in-hospital specialist consultations, length of stay, discharge site, all-cause 7- and 30-day readmission rates, and 30-day mortality.

RESULTS: A total of 560 651 admissions were analyzed (41.9% men and 59.1% women; mean [SD] age, 80 [8] years). Patients' physicians were hospitalists in 59.7% of admissions; PCPs, in 14.2%; and other generalists, in 26.1%. Primary care physicians used consultations 3% more (relative risk, 1.03; 95% CI, 1.02-1.05) and other generalists used consultations 6% more (relative risk, 1.06; 95% CI, 1.05-1.07) than hospitalists. Lengths of stay were 12% longer among patients cared for by PCPs (adjusted incidence rate ratio, 1.12; 95% CI, 1.11-1.13) and 6% longer among those cared for by other generalists (adjusted incidence rate ratio, 1.06; 95% CI, 1.05-1.07) compared with patients cared for by hospitalists. However, PCPs were more likely to discharge patients home (adjusted odds ratio [AOR], 1.14; 95% CI, 1.11-1.17), whereas other generalists were less likely to do so (AOR, 0.94; 95% CI, 0.92-0.96). Relative to hospitalists, patients cared for by PCPs had similar readmission rates at 7 days (AOR, 0.98; 95% CI, 0.96-1.01) and 30 days (AOR, 1.02; 95% CI, 0.99-1.04), whereas other generalists' readmission rates were greater than hospitalists' rates at 7 (AOR, 1.05; 95% CI, 1.02-1.07) and 30 (AOR, 1.04; 95% CI, 1.03-1.06) days. Patients cared for by PCPs had lower 30-day mortality than patients of hospitalists (AOR, 0.94; 95% CI, 0.91-0.97), whereas the mortality rate of patients of other generalists was higher (AOR, 1.09; 95% CI, 1.07-1.12).

CONCLUSIONS AND RELEVANCE: A PCP's prior experience with a patient may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home but also were less likely to die within 30 days compared with those cared for by hospitalists or other generalists.