title: Diffusion of Evidence-based Intensive Care Unit Organizational Practices. A State-Wide Analysis.
abstract: BACKGROUND
  Several intensive care unit (ICU) organizational practices have been associated with improved patient outcomes. However, the uptake of these evidence-based practices is unknown.
  
  
  OBJECTIVE
  To assess diffusion of ICU organizational practices across the state of Pennsylvania.
  
  
  METHODS
  We conducted two web-based, cross-sectional surveys of ICU organizational practices in Pennsylvania acute care hospitals, in 2005 (chief nursing officer respondents) and 2014 (ICU nurse manager respondents).
  
  
  RESULTS
  Of 223 eligible respondents, nurse managers from 136 (61%) medical, surgical, mixed medical-surgical, cardiac, and specialty ICUs in 98 hospitals completed the 2014 survey, compared with 124 of 164 (76%) chief nursing officers in the 2005 survey. In 2014, daytime physician staffing models varied widely, with 23 of 136 (17%) using closed models and 33 (24%) offering no intensivist staffing. Nighttime intensivist staffing was used in 37 (27%) ICUs, 38 (28%) used nonintensivist attending staffing, and 24 (18%) had no nighttime attending physicians. Daily multidisciplinary rounds occurred in 93 (68%) ICUs. Regular participants included clinical pharmacists in 68 of 93 (73%) ICUs, respiratory therapists in 62 (67%), and advanced practitioners in 37 (39%). Patients and family members participated in rounds in 36 (39%) ICUs. Clinical protocols or checklists for mechanically ventilated patients were available in 128 of 133 (96%) ICUs, low tidal volume ventilation for acute respiratory distress syndrome in 54 of 132 (41%) ICUs, prone positioning for severe acute respiratory distress syndrome in 37 of 134 (28%) ICUs, and family meetings in 19 of 134 (14%) ICUs. Among 61 ICUs that responded to both surveys, there was a significant increase in the proportion of ICUs using nighttime in-ICU attending physicians (23 [38%] in 2005 vs. 30 [49%] in 2014; P = 0.006).
  
  
  CONCLUSIONS
  The diffusion of evidence-based ICU organizational practices has been variable across the state of Pennsylvania. Only half of Pennsylvania ICUs have intensivists dedicated to the ICU. Variable numbers use clinical protocols for life-saving therapies, and few use structured family engagement strategies. In contrast, the diffusion of non-evidence-based practices, including overnight ICU attending physician staffing, is increasing. Future research should focus on promoting implementation of organizational evidence to promote high-quality ICU care.
authors.affiliation: 1 Department of Medicine.|2 Center for Clinical Epidemiology and Biostatistics, and.|3 Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.
authors.forename: Rachel
authors.initials: R
authors.lastname: Kohn
authors.affiliation: 2 Center for Clinical Epidemiology and Biostatistics, and.|3 Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.
authors.forename: Vanessa
authors.initials: V
authors.lastname: Madden
authors.affiliation: 4 Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, and.
authors.forename: Jeremy M
authors.initials: JM
authors.lastname: Kahn
authors.affiliation: 1 Department of Medicine.|3 Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.
authors.forename: David A
authors.initials: DA
authors.lastname: Asch
authors.affiliation: 5 Section of Decision Sciences, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
authors.forename: Amber E
authors.initials: AE
authors.lastname: Barnato
authors.affiliation: 1 Department of Medicine.|2 Center for Clinical Epidemiology and Biostatistics, and.|3 Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Halpern
authors.affiliation: 1 Department of Medicine.|2 Center for Clinical Epidemiology and Biostatistics, and.|3 Leonard Davis Institute of Health Economics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; and.
authors.forename: Meeta Prasad
authors.identifier: http://orcid.org/0000-0002-3239-1443
authors.initials: MP
authors.lastname: Kerlin
mesh_terms: D002985:Clinical Protocols; D016638:Critical Illness / Q000451:nursing*; D003430:Cross-Sectional Studies; D055318:Evidence-Based Nursing / Q000592:standards*; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000458:organization & administration*; D033183:Interdisciplinary Communication; D020407:Internet; D018802:Patient-Centered Care; D010414:Pennsylvania; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data* / Q000639:trends; D011795:Surveys and Questionnaires; D000078329:Workforce
keywords: clinical protocols; intensive care units; multidisciplinary communication; patient-centered care; personnel staffing