The Allocation of Intensivists’ Rounding Time under Conditions of Intensive Care Unit Capacity Strain

Brown, Sydney E. S.; Rey, Michael M.; Pardo, Dustin; Weinreb, Scott; Ratcliffe, Sarah J.; Gabler, Nicole B.; Halpern, Scott D.

doi:10.1164/rccm.201406-1127le

Cited by 29 publications

(15 citation statements)

References 15 publications

(26 reference statements)

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“…and have been used in prior studies [7–9]. These 3 measures included ICU census, the proportion of new admissions, and the acuity of other patients in the ICU [8].…”

Section: Methodsmentioning

confidence: 99%

“…Conceivably, when ICUs are strained, clinicians may have insufficient time or cognitive reserve to have in-depth discussions with families and other physicians regarding end-of-life decisions [9]. Decision-making related to the use of life-sustaining therapy is time-consuming, and competing demands on clinicians’ time has been cited as a barrier to end-of-life care delivery [10].…”

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confidence: 99%

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Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

et al. 2016

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Purpose The effect of capacity strain in an ICU on the timing of end-of-life decision making is unknown. We sought to determine how changes in strain impact timing of new DNR orders and of death. Methods Retrospective cohort study of 9,891 patients dying in the hospital following an ICU stay ≥ 72 hours in Project IMPACT, 2001–2008. We examined the effect of ICU capacity strain (measured by standardized census, proportion of new admissions, and average patient acuity) on time to initiation of DNR orders and time to death for all ICU decedents using fixed-effects linear regression. Results Increases in strain were associated with shorter time to DNR for patients with limitations in therapy (predicted time to DNR 6.11 days for highest versus 7.70 days for lowest quintile of acuity, p=0.02; 6.50 days for highest versus 7.77 days for lowest quintile of admissions, p<0.001), and shorter time to death (predicted time to death 7.64 days for highest versus 9.05 days for lowest quintile of admissions, p<0.001; 8.28 days for highest versus 9.06 days for lowest quintile of census, only in closed ICUs, p=0.006). Time to DNR order significantly mediated relationships between acuity and admissions and time to death, explaining the entire effect of acuity, and 65% of the effect of admissions. There was no association between strain and time to death for decedents without a limitation in therapy. Conclusions Strains in ICU capacity are associated with end-of-life decision making, with shorter times to placement of DNR orders and death for patients admitted during high-strain days.

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“…and have been used in prior studies [7–9]. These 3 measures included ICU census, the proportion of new admissions, and the acuity of other patients in the ICU [8].…”

Section: Methodsmentioning

confidence: 99%

mentioning

confidence: 99%

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

et al. 2016

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“…(9) Increasing ICU strain also influences physician workflow, with studies showing that strain is associated with increased time spent on direct patient care and trainee education, (10) reduced documentation time, (10) and decreased time spent on newly admitted patients. (11) These studies collectively demonstrate that ICU resources (including clinicians' time) are allocated differently under conditions of strain.…”

Section: What Are the Implications Of Intensive Care Unit Capacity Stmentioning

confidence: 88%

The implications of intensive care unit capacity strain for the care of critically ill patients

Kohn¹,

Halpern²,

Kerlin³

2016

Revista Brasileira De Terapia Intensiva

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“…Increasing strain may exert detrimental effects on processes of care. For example, the time physicians allocate to individual ICU patients is inversely associated with the strain that day (6). …”

Section: Introductionmentioning

confidence: 99%

Intensive care unit capacity strain and adherence to prophylaxis guidelines

Weissman

Gabler

Brown

et al. 2015

Journal of Critical Care

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Purpose To examine the relationship between different measures of capacity strain and adherence to prophylaxis guidelines in the intensive care unit (ICU). Materials and Methods We conducted a retrospective cohort study within the Project IMPACT database. We used multivariable logistic regression to examine relationships between ICU capacity strain and appropriate usage of venous thromboembolism prophylaxis (VTEP) and stress ulcer prophylaxis (SUP). Results Of 776,905 patient-days eligible for VTEP, appropriate therapy was provided on 68%. Strain as measured by proportion of new admissions (OR 0.91, 95% CI 0.90 – 0.91) and census (OR 0.97, 95% CI 0.97 – 0.98) was associated with decreased odds of receiving VTEP. With increasing strain as measured by new admissions, the degradation of VTEP utilization was more severe in ICUs with closed (OR 0.85, 95% CI 0.83 – 0.88) than open (OR 0.91, 95% CI 0.91 – 0.92) staffing models (interaction p-value < 0.001). Of 185,425 patient-days eligible for SUP, 48% received appropriate therapy. Administration of SUP was not significantly influenced by any measure of strain. Conclusions Rising capacity strain in the ICU reduces the odds that patients will receive appropriate VTEP but not SUP. The variability among different types of ICUs in the extent to which strain degraded VTEP use suggests opportunities for systems improvement.

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The Allocation of Intensivists’ Rounding Time under Conditions of Intensive Care Unit Capacity Strain

Cited by 29 publications

References 15 publications

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

Effect of ICU strain on timing of limitations in life-sustaining therapy and on death

The implications of intensive care unit capacity strain for the care of critically ill patients

Intensive care unit capacity strain and adherence to prophylaxis guidelines

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