In a large health system in the United States, investigators examined whether mortality, receipt of mechanical ventilation, and patient acuity changed over time among adult patients with COVID-19–related critical illness admitted to intensive care units.

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Rationale: Prone positioning reduces mortality in patients with severe acute respiratory distress syndrome (ARDS), a feature of severe COVID-19. Despite this, most patients with ARDS do not receive this life-saving therapy. Objectives: To identify determinants of prone positioning utilization, to develop specific implementation strategies, and to incorporate strategies into an overarching response to the COVID-19 crisis. Methods: We used an implementation mapping approach guided by implementation science frameworks. We conducted semi-structured interviews with 30 ICU clinicians who staffed 12 ICUs within the Penn Medicine health system and the University of Michigan Medical Center. We performed thematic analysis utilizing the Consolidated Framework for Implementation Research (CFIR). We then conducted three focus groups with a task force of ICU leaders to develop an implementation menu, using the Expert Recommendations for Implementing Change (ERIC) framework. The implementation strategies were adapted as part of the Penn Medicine COVID-19 pandemic response. Results: We identified five broad themes of determinants of prone positioning: knowledge, resources, alternative therapies, team culture, and patient factors, which collectively spanned all five CFIR domains. The task force developed five specific implementation strategies: educational outreach, learning collaborative, clinical protocol, prone positioning team, and automated alerting, elements of which were rapidly implemented at Penn Medicine.

Untreated pain and pain management with opioids are independent precipitating factors for delirium. This retrospective study evaluated the relationships among pain severity, its management with opioids, and the onset of delirium in older adult patients admitted to the surgical intensive care unit (SICU). Consecutive patients aged 65 or greater admitted to the SICU over a 5-month period were examined ( n = 172). When assessed using a multivariable general estimating equation model, opioids (chi-square [χ2], 12.34, p = .0004), but not pain (χ2, 3.31, p = .0688) were significant in predicting next-day delirium status. Controlling for pain, patients exposed to opioids were 2.5 times more likely to develop delirium than patients not exposed (95% Confidence Interval: 1.44–4.36). Our data shows that opioid administration predicted the onset of next-day delirium. In an effort to prevent delirium, future research should focus on opioid-sparing pain management approaches to mitigate pain and delirium.

Objective: To assess the effectiveness of standardizing operating room (OR) to intensive care unit (ICU) handoffs in a mixed surgical population. Summary of Background Data: Standardizing OR to ICU handoffs improves information transfer after cardiac surgery, but there is limited evidence in other surgical contexts. Methods: This prospective interventional cohort study (NCT02267174) was conducted in 2 surgical ICUs in 2 affiliated hospitals. From 2014 to 2016, we developed, implemented, and assessed the effectiveness of a new standardized handoff protocol requiring bedside clinician communication using an information template. The primary study outcome was number of information omissions out of 13 possible topics, recorded by trained observers. Data were analyzed using descriptive statistics, bivariate analyses, and multivariable regression. Results: We observed 165 patient transfers (68 pre-, 97 postintervention). Before standardization, observed handoffs had a mean 4.7 ± 2.9 information omissions each. After standardization, information omissions decreased 21.3% to 3.7 ± 1.9 (P = 0.023). In a pre-specified subanalysis, information omissions for new ICU patients decreased 36.2% from 4.7 ± 3.1 to 3.0 ± 1.6 (P = 0.008, interaction term P = 0.008). The decrement in information omissions was linearly associated with the number of protocol steps followed (P < 0.001). After controlling for patient stability, the intervention was still associated with reduced omissions. Handoff duration increased after standardization from 4.1 ± 3.3 to 8.0 ± 3.9 minutes (P < 0.001). ICU mortality and length of stay did not change postimplementation. Conclusion: Standardizing OR to ICU handoffs significantly improved information exchange in 2 mixed surgical ICUs, with a concomitant increase in handoff duration. Additional research is needed to identify barriers to and facilitators of handoff protocol adherence.

Critical care clinicians experienced high rates of burnout and depression early in the coronavirus disease 2019 (COVID-19) pandemic. [1][2][3] We sought to longitudinally evaluate burnout, depression, and professional fulfillment -as measures of overall clinician wellnessamong critical care healthcare professionals at seven hospitals within our hospital network. We hypothesized that well-being and depression would initially worsen over time but would improve with the arrival of the vaccine, and that burnout rates would be higher among nonphysicians with less professional time dedicated to non-clinical activities such as education and research, which may allow time for renewal. MethodsWe administered a questionnaire quarterly to attending physicians, advanced practice providers (APPs; including nurse practitioners and physician assistants), respiratory therapists (RTs), and clinical pharmacists who staffed ICUs of seven hospitals at Penn Medicine. Nurses did not participate due to concurrent research studies and leadership concern about survey fatigue. As detailed elsewhere, our integrated, academic medical center leveraged the health system Critical Care Alliance to create the COVID-19 Task Force, which served to develop and disseminate standardized clinical protocols, educate critical care clinicians, and monitor and optimize outcomes. 4,5 We invited participants by email in July/

Measureable patient outcomes are achievable in the early stages of PAD guideline initiatives and can inform future systems-level organizational change. Pain, agitation, and delirium assessment tools form the foundation for clinical implementation and evaluation. High-acuity surgical critical care patients can achieve more time at goal RASS, decreased ventilator days, and less exposure to continuous opioid infusions, all while maintaining stable analgesia.

The complexity and growth of healthcare systems provide nurse leaders an opportunity to recognize and facilitate professional development for experienced frontline clinicians and to create formal structures that give expert direct care nurses a stronger voice. The purpose of this article is to describe how one health system developed and implemented an innovative Distinguished Nurse Clinician Academy. This elite academy demonstrates the longitudinal impact of a health systems' Magnet® culture.