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BackgroundThe end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL.AimTo assess whether the 3WP is associated with improved ratings of EOL care.Program descriptionIn the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families.Setting2-hospital academic healthcare system.ParticipantsDying patients in the ICU and their families.Program evaluationA modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS-derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care).ResultsOf 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups.DiscussionThe 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience.

Patient- and family-centered end-of-life care can be difficult to achieve in light of visitation restrictions and infection-prevention measures. We evaluated how the 3 Wishes Program evolved to allow continued provision of compassionate end-of-life care for critically ill patients during the coronavirus disease 2019 pandemic.DesignThis is a prospective observational study where data were collected 1 year prior to the coronavirus disease 2019 pandemic and 1 year after (from March 1, 2019, to March 31, 2021). The number of deceased patients whose care involved the 3 Wishes Program, their characteristics, and wishes were compared between prepandemic and pandemic periods.SettingSix adult ICUs of a two-hospital health system in Los Angeles.PatientsDeceased patients whose care involved the 3 Wishes Program.InterventionsThe 3 Wishes Program is a palliative care intervention in which individualized wishes are implemented for dying patients and their families.Measurements and main resultsDuring the study period, the end-of-life care for 523 patients involved the 3 Wishes Program; more patients received the 3 Wishes Program as part of their end-of-life care during the pandemic period than during the prepandemic study period (24.8 vs 17.6 patients/mo; p = 0.044). Patients who died during the pandemic compared with prepandemic were less likely to have family at the bedside and more likely to have postmortem wishes fulfilled for their families. Compared with the 736 wishes implemented during the prepandemic period, the 969 wishes completed during the pandemic were more likely to involve keepsakes. Wishes were most commonly implemented by bedside nurses, although the 3 Wishes Program project manager (not involved in the patient's clinical care) was more likely to assist remotely during the pandemic (24.8% vs 12.1%; p < 0.001).ConclusionsBedside innovations, programmatic adaptations, and institutional support made it possible for healthcare workers to continue the 3 Wishes Program and provide compassionate end-of-life care in the ICU during this pandemic.

BackgroundThe 3 Wishes Project (3WP) is an end-of-life program that honors the dignity of dying patients by fostering meaningful connections among patients, families, and clinicians. Since 2013, it has become embedded in the culture of end-of-life care in over 20 ICUs across North America. The purpose of the current study is to describe the variation in implementation of 3WP across sites, in order to ascertain which factors facilitated multicenter implementation, which factors remain consistent across sites, and which may be adapted to suit local needs.MethodsUsing the methodology of qualitative description, we collected interview and focus group data from 85 clinicians who participated in the successful initiation and sustainment of 3WP in 9 ICUs. We describe the transition between different models of 3WP implementation, from core clinical program to the incorporation of various research activities. We describe various sources of financial and in-kind resources accessed to support the program.ResultsBeyond sharing a common goal of improving end-of-life care, sites varied considerably in organizational context, staff complement, and resources. Despite these differences, the program was successfully implemented at each site and eventually evolved from a clinical or research intervention to a general approach to end-of-life care. Key to this success was flexibility and the empowerment of frontline staff to tailor the program to address identified needs with available resources. This adaptability was fueled by cross-pollination of ideas within and outside of each site, resulting in the establishment of a network of like-minded individuals with a shared purpose.ConclusionsThe successful initiation and sustainment of 3WP relied on local adaptations to suit organizational needs and resources. The semi-structured nature of the program facilitated these adaptations, encouraged creative and important ways of relating within local clinical cultures, and reinforced the main tenet of the program: meaningful human connection at the end of life. Local adaptations also encouraged a team approach to care, supplementing the typical patient-clinician dyad by explicitly empowering the healthcare team to collectively recognize and respond to the needs of dying patients, families, and each other.Trial registrationNCT04147169 , retrospectively registered with clinicaltrials.gov on October 31, 2019.

Background: The end-of-life (EOL) experience in the intensive care unit (ICU) is emotionally challenging, and there are opportunities for improvement. The 3 Wishes Program (3WP) promotes the dignity of dying patients and their families by eliciting and implementing wishes at the EOL. Aim: To assess whether the 3WP is associated with improved ratings of EOL care. Program Description: In the 3WP, clinicians elicit and fulfill simple wishes for dying patients and their families. Setting: 2-hospital academic healthcare system. Participants: Dying patients in the ICU and their families. Program Evaluation: A modified Bereaved Family Survey (BFS), a validated tool for measuring EOL care quality, was completed by families of ICU decedents approximately 3 months after death. We compared patients whose care involved the 3WP to those who did not using three BFS–derived measures: Respectful Care and Communication (5 questions), Emotional and Spiritual Support (3 questions), and the BFS-Performance Measure (BFS-PM, a single-item global measure of care). Results: Of 314 completed surveys, 117 were for patients whose care included the 3WP. Bereaved families of 3WP patients rated the Emotional and Spiritual Support factor significantly higher (7.5 vs. 6.0, p = 0.003, adjusted p = 0.001) than those who did not receive the 3WP. The Respectful Care and Communication factor and BFS-PM were no different between groups. Discussion: The 3WP is a low-cost intervention that may be a feasible strategy for improving the EOL experience. [ABSTRACT FROM AUTHOR]

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Canadian Journal of Anaesthesia / Journal Canadien d'Anesthésie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Although many performance-based measures assess patients' physical function in intensive care unit (ICU) survivors, to our knowledge, there are no patient-reported ICU rehabilitation-specific measures assessing function. We developed the Patient-Reported Functional Scale-ICU (PRFS-ICU), which measures patients' perceptions of their ability to perform 6 activities (rolling, sitting edge of bed, sit-to-stand and bed-to-chair transfers, ambulation, and stair climbing). Each item is scored from 0 (unable) to 10 (able to perform at pre-ICU level) to a maximum of 60. Objectives: Estimate the feasibility, reliability, responsiveness, and validity of the PRFS-ICU. Methods: This was a substudy of TryCYCLE, a single-center, prospective cohort examining the safety and feasibility of early in-bed cycling with mechanically ventilated patients (NCT01885442). To determine feasibility, we calculated the number of patients with at least 1 PRFS-ICU assessment during their hospital stay. To assess reliability, 2 raters blinded to each other's assessments administered the PRFS-ICU within 24-hours of each other. We calculated the intraclass correlation coefficient (ICC; 95% confidence interval [CI]), standard error of measurement (SEM, 95% CI), and minimal detectable change (MDC90). To assess validity, we estimated convergent validity of the PRFS-ICU with the Functional Status Score for ICU (FSS-ICU), Medical Research Council Sum Score (MRC-SS), Physical Function Test for ICU (PFIT-s), Katz Index of Independence in Activities of Daily Living (Katz ADLs), and a pooled index using Pearson's correlation coefficient (r, 95% CI). Results: Feasibility: 20 patients completed a PRFS-ICU assessment. Reliability and responsiveness: 16 patients contributed data. The ICC, SEM, and MDC90 were 0.91 (0.76, 0.97), 4.75 (3.51, 7.35), and 11.04 points, respectively. Validity: 19 patients contributed data and correlations were (r [95% CI]): FSS-ICU (0.40 [-0.14, 0.76]), MRC-SS (0.51 [0.02, 0.80]), PFIT-s (0.43 [-0.13, 0.78]), Katz ADLs (0.53 [0.10, 0.79]), and pooled index (0.48 [-0.14, 0.82]). Conclusions: Our pilot work suggests the PRFS-ICU may be a useful tool to assess and monitor patients' perceptions of function over time. [ABSTRACT FROM AUTHOR]

Background: Survivors of critical illness may experience physical-function deficits after intensive care unit (ICU) discharge. In-ICU cycle ergometry may facilitate early mobilization and decrease functional impairment.Objective: We conducted a systematic review and meta-analysis to understand the effect of in-ICU leg-cycle ergometry on patient-important and clinically relevant outcomes.Data Sources: We searched eight electronic databases from inception until July 2019.Data Extraction: We included randomized controlled trials (RCTs) and nonrandomized studies of critically ill adults admitted to the ICU for ≥24 hours, comparing cycling interventions to control arms that did not receive cycling. Main outcomes included physical function, mechanical ventilation (MV) duration, length of stay (LOS), quality of life (QoL), mortality, and safety. We conducted independent duplicate-citation screening, data abstraction, and risk-of-bias assessments. We pooled RCTs using a random-effects model and calculated the risk ratio (RR), mean difference (MD), or standardized MD with 95% confidence intervals (CIs). We assessed certainty of outcomes using the Grading of Recommendations Assessment, Development, and Evaluation approach.Results: Of 6,531 citations, we included 12 RCTs and 2 nonrandomized studies (n = 926). Between the cycling and control groups, there were no differences in physical function at hospital discharge (3 RCTs; n = 225; standardized MD, 0.07 [95% CI, -0.38 to 0.53]; very low certainty), MV duration (9 RCTs; n = 676; MD, 0.01 [-1.04 to 1.07] days; moderate certainty), ICU LOS (10 RCTs; n = 511; MD, 0.23 [-1.44 to 1.89] days; moderate certainty), hospital LOS (7 RCTs; n = 393, MD -0.07 [-3.87 to 3.73] days; moderate certainty), QoL at 6 months after hospital discharge (2 RCTs; n = 103; MD, 9.13 [13.80 to 32.05] points higher; very low certainty), or hospital mortality (7 RCTs; n = 710; RR 1.09 [0.82 to 1.46]; moderate-certainty). The adverse event rate in cycling sessions was 0.16% across studies (10 studies; 5 of 3,117 sessions; very low certainty).Conclusions: Cycling initiated in the ICU is probably safe; however, we did not find any differences in physical function, MV duration, LOS, QoL, or mortality compared with those not receiving cycling. Rigorously designed RCTs are needed to improve precision and further investigate the effect of cycling on patient-important outcomes. [ABSTRACT FROM AUTHOR]

Background: End-of-life (EOL) care is an important aspect of practice in the intensive care unit (ICU), where approximately one of every five patients may die. Objective: The objective of this study was to describe clinicians' experiences with the 3 Wishes Project (3WP) and understand the influence of the project on care in the ICU. Design: The 3WP is a palliative care intervention in which clinicians elicit and implement final wishes for patients dying in the ICU; it had been implemented for seven months at the time of this study. This mixed-methods study includes quantitative data from clinician surveys and qualitative data from clinician focus groups. Setting: A 24-bed medical ICU in a tertiary academic center. Subjects: Perspectives of 97 clinicians working in the ICU during the study period were obtained by self-administered surveys. Five focus groups with 25 nurses and 5 physicians were held, digitally recorded, transcribed, and analyzed. Measurements and Results: During the 7-month period, 67 decedents and their families participated in the 3WP. The overarching concept identified through analysis of the survey and focus group data is that the 3WP improves EOL care in the ICU, which was supported by three main themes: (1) The 3WP facilitates meaningful EOL care; (2) The 3WP has a positive impact on nurses and physicians; and (3) clinicians observe a positive influence of the 3WP on families. Conclusions: This patient-centered and family-partnered intervention facilitates meaningful EOL care, favorably impacting the ICU team and positively influencing family members. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The objectives of this study are to describe organizational and safety culture in Canadian intensive care units (ICUs), to correlate culture with the number of beds and physician management model in each ICU, and to correlate organizational culture and safety culture. Materials and Methods: In this cross-sectional study, surveys of organizational and safety culture were administered to 2374 clinical staff in 23 Canadian tertiary care and community ICUs. For the 1285 completed surveys, scores were calculated for each of 34 domains. Average domain scores for each ICU were correlated with number of ICU beds and with intensivist vs nonintensivist management model. Domain scores for organizational culture were correlated with domain scores for safety culture. Results: Culture domain scores were generally favorable in all ICUs. There were moderately strong positive correlations between number of ICU beds and perceived effectiveness at recruiting/retaining physicians (r = 0.58; P < .01), relative technical quality of care (r = 0.66; P < .01), and medical director budgeting authority (r = 0.46; P = .03), and moderately strong negative correlations with frequency of events reported (r = −0.46; P = .03), and teamwork across hospital units (r = −0.51; P = .01). There were similar patterns for relationships with intensivist management. For most pairs of domains, there were weak correlations between organizational and safety culture. Conclusion: Differences in perceptions between staff in larger and smaller ICUs highlight the importance of teamwork across units in larger ICUs. [Copyright &y& Elsevier]

Abstract: A qualitative research design can provide unique contributions to research in the intensive care unit. Qualitative research includes the entire process of research: the methodology (conceptualization of the research question, choosing the appropriate qualitative strategy, designing the protocol), methods (conducting the research using qualitative methods within the chosen qualitative strategy, analysis of the data, verification of the findings), and writing the narrative. The researcher is the instrument and the data are the participants'' words and experiences that are collected and coded to present experiences, discover themes, or build theories. A number of strategies are available to conduct qualitative research and include grounded theory, phenomenology, case study, and ethnography. Qualitative methods can be used to understand complex phenomena that do not lend themselves to quantitative methods of formal hypothesis testing. Qualitative research may be used to gain insights about organizational and cultural issues within the intensive care unit and to improve our understanding of social interaction and processes of health care delivery. In this article, we outline the rationale for, and approaches to, using qualitative research to inform critical care issues. We provide an overview of qualitative methods available and how they can be used alone or in concert with quantitative methods. To illustrate how our understanding of social phenomena such as patient safety and behavior change has been enhanced we use recent qualitative studies in acute care medicine. [Copyright &y& Elsevier]

Objective: To determine how frequently life support is withheld or withdrawn from adult critically ill patients, and how physicians and patients families agree on the decision regarding the limitation of life support. Design: Prospective multi-centre cohort study. Setting: Six adult medical-surgical Spanish intensive care units (ICUs). Patients and participants: Three thousand four hundred ninety-eight consecutive patients admitted to six ICUs were enrolled. Measurements and results: Data collected included age, sex, SAPS II score on admission and within 24 h of the decision to limit treatment, length of ICU stay, outcome at ICU discharge, cause and mode of death, time to death after the decision to withhold or withdraw life support, consultation and agreement with patient's family regarding withholding or withdrawal, and the modalities of therapies withdrawn or withheld. Two hundred twenty-six (6.6%) of 3,498 patients had therapy withheld or withdrawn and 221 of them died in the ICU. Age, SAPS II and length of ICU stay were significantly higher in patients dying patients who had therapy withheld or withdrawn than in patients dying despite active treatment. The proposal to withhold or withdraw life support was initiated by physicians in 210 (92.9%) of 226 patients and by the family in the remaining cases. The patient's family was not involved in the decision to withhold or withdraw life support therapy in 64 (28.3%) of 226 cases. Only 21 (9%) patients had expressed their wish to decline life-prolonging therapy prior to ICU admission. Conclusions: The withholding and withdrawing of treatment was frequent in critically ill patients and was initiated primarily by physicians. [ABSTRACT FROM AUTHOR]

Abstract: Background: We assessed multidisciplinary team members'' perspectives of patient safety climate in a 15-bed, closed medical-surgical intensive care unit through a self-administered questionnaire. Methods: We invited all clinicians and nonclinicians to complete a short demographic section and a modified Safety Climate Survey (SCS) in which higher scores represent a better safety climate. We used multivariable regression to examine factors associated with higher safety climate scores. In an open-ended question, we asked all respondents for suggestions to improve patient safety, analyzing text in triplicate, independently. Results: Our response rate was 93.2% (136/146). Respondents were nurses (49.4%), physicians (16.1%), other clinicians (30.3%), and nonclinical staff (11.8%). The mean (SD) SCS score was 4.0 (0.6) of a maximum of 5. We found no independent predictors of safety climate scores. Qualitative data revealed 3 major safety themes needing solutions: appropriate staffing, medication safety, and improving the bedside care of obese patients. Conclusions: Although our baseline safety climate score was encouraging, room for improvement exists. Future research will analyze the responsiveness of the SCS scale to change, following our recently instituted initiatives such as a new graduate integration program, an improved medication dispensing system, newly installed lifting devices, and the critical care response team. [Copyright &y& Elsevier]

Objective: To evaluate the impact of direct discharge home (DDH) from ICUs compared with ward transfer on safety outcomes of readmissions, emergency department (ED) visits, and mortality. Data Sources: We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature from inception until March 28, 2022. Study Selection: Randomized and nonrandomized studies of DDH patients compared with ward transfer were eligible. Data Extraction: We screened and extracted studies independently and in duplicate. We assessed risk of bias using the Newcastle-Ottawa Scale for observational studies. A random-effects meta-analysis model and heterogeneity assessment was performed using pooled data (inverse variance) for propensity-matched and unadjusted cohorts. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. Data Synthesis: Of 10,228 citations identified, we included six studies. Of these, three high-quality studies, which enrolled 49,376 patients in propensity-matched cohorts, could be pooled using meta-analysis. For DDH from ICU, compared with ward transfers, there was no difference in the risk of ED visits at 30-day (22.4% vs 22.7%; relative risk [RR], 0.99; 95% CI, 0.95–1.02; p = 0.39; low certainty); hospital readmissions at 30-day (9.8% vs 9.6%; RR, 1.02; 95% CI, 0.91–1.15; p = 0.71; very low-to-low certainty); or 90-day mortality (2.8% vs 2.6%; RR, 1.06; 95% CI, 0.95–1.18; p = 0.29; very low-to-low certainty). There were no important differences in the unmatched cohorts or across subgroup analyses. CONCLUSIONS: Very low-to-low certainty evidence from observational studies suggests that DDH from ICU may have no difference in safety outcomes compared with ward transfer of selected ICU patients. In the future, this research question could be further examined by randomized control trials to provide higher certainty data. [ABSTRACT FROM AUTHOR]

Objectives: Cost utility analyses compare the costs and health outcome of interventions, with a denominator of quality-adjusted life year, a generic health utility measure combining both quality and quantity of life. Cost utility analyses are difficult to compare when methods are not standardized. It is unclear how cost utility analyses are measured/reported in critical care and what methodologic challenges cost utility analyses pose in this setting. This may lead to differences precluding cost utility analyses comparisons. Therefore, we performed a systematic review of cost utility analyses conducted in critical care. Our objectives were to understand: 1) methodologic characteristics, 2) how health-related quality-of-life was measured/reported, and 3) what costs were reported/measured.Design: Systematic review.Data Sources: We systematically searched for cost utility analyses in critical care in MEDLINE, Embase, American College of Physicians Journal Club, CENTRAL, Evidence-Based Medicine Reviews' selected subset of archived versions of UK National Health Service Economic Evaluation Database, Database of Abstracts of Reviews of Effects, and American Economic Association electronic databases from inception to April 30, 2020.Setting: Adult ICUs.Patients: Adult critically ill patients.Interventions: None.Measurements and Main Results: Of 8,926 citations, 80 cost utility analyse studies were eligible. The time horizon most commonly reported was lifetime (59%). For health utility reporting, health-related quality-of-life was infrequently measured (29% reported), with only 5% of studies reporting baseline health-related quality-of-life. Indirect utility measures (generic, preference-based health utility measurement tools) were reported in 85% of studies (majority Euro-quality-of-life-5 Domains, 52%). Methods of estimating health-related quality-of-life were seldom used when the patient was incapacitated: imputation (19%), assigning fixed utilities for incapacitation (19%), and surrogates reporting on behalf of incapacitated patients (5%). For cost utility reporting transparency, separate incremental costs and quality-adjusted life years were both reported in only 76% of studies. Disaggregated quality-adjusted life years (reporting separate health utility and life years) were described in only 34% of studies.Conclusions: We identified deficiencies which warrant recommendations (standardized measurement/reporting of resource use/unit costs/health-related quality-of-life/methodological preferences) for improved design, conduct, and reporting of future cost utility analyses in critical care. [ABSTRACT FROM AUTHOR]

Background: In-hospital cardiac arrest (IHCA) is common and associated with high mortality. Frailty is increasingly recognized as a predictor of worse prognosis among critically ill patients, but its association with outcomes and resource utilization following IHCA is unknown.Methods: We performed a retrospective analysis (2013-2016) of a prospectively collected registry from two hospitals of consecutive hospitalized adult patients with IHCA occurring on the hospital wards. We defined frailty using the Clinical Frailty Scale (CFS) score ≥5. CFS scores were based on validated medical review criteria. The primary outcome is hospital mortality. Secondary outcomes include return of spontaneous circulation (ROSC), discharge to long-term care, and hospital costs. We used multivariable logistic regression to adjust for known confounders.Results: We included 477 patients, and 124 (26.0%) had frailty. Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 2.91 [95% confidence interval [CI]: 2.37-3.48) and discharge to long-term care (aOR 1.94 [95% CI: 1.57-2.32]). Compared with patients without frailty, patients with frailty had decreased odds of ROSC following IHCA (aOR 0.63 [95% CI: 0.41-0.93]). No difference in mean total costs was demonstrated between patients with and without frailty ($50,799 vs. $45,849). Frail patients did have higher cost-per-survivor ($947,546 vs. $161,550).Conclusions: Frail individuals who experience an IHCA are more likely to die in hospital or be discharged to long-term care, and less likely to achieve ROSC in comparison with individuals who are not frail. The hospital costs per-survivor of IHCA are increased when frailty is present. [ABSTRACT FROM AUTHOR]

The article presents the cross-sectional surveys which investigate the relationship between organizational culture and family satisfaction in critical care in Canada. Data from the Organization and Management of Intensive Care Units survey and the Hospital Survey on Patient Safety Culture are examined. According to the surveys, improving organizational culture will positively affect family satisfaction.

The article attempts to determine the safety and feasibility of a randomized trial to determine whether adults managed with both protocolized sedation (PS) and daily sedative interruption (DI) have a shorter duration of mechanical ventilation (MV) than patients managed with PS alone. The study confirms the safety and acceptability of the sedation protocol and DI.