SCCM Resource Library-STOP-VIRUS Initiative: Best Practices, Reflections From STOP-VIRUS Sites, and Implementation Strategies and Outcomes During COVID-19

Video Transcription

Hello, my name is Alex Niven. I am a consultant in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic in Rochester, Minnesota.  And it is my privilege to introduce today's session entitled, The Stop Virus Collaborative, an initiative to strengthen COVID-19 care in the critically ill.  Early on in the pandemic, two of our investigators, Dr. Agi Gayage from the Mayo Clinic and Dr.  from Boston University, exchanged a conversation on Twitter about the importance of better  understanding how patients with COVID-19 were being cared for across the globe and the outcomes of that care.  The results of that conversation is the SCCM Virus Registry, the preliminary results of which were presented and published in Critical Care Medicine earlier in 2021.  That paper and subsequent publications from other institutions have identified processes of care as perhaps the major modifiable factor that can impact outcomes in patients with  COVID-19. As a result, a collaborative was formed called the Stop Virus Collaborative of institutions  within the virus registry who were interested in participating in a six-month longitudinal learning system to identify best practices in the care of COVID-19 patients and implement  those practices within their institution. At the same time that that collaborative was ongoing, the investigators at Boston University  were conducting a qualitative implementation science exploration of change management strategies  that would help facilitate the strengthening of processes of care in those intensive care units. This session describes that experience and the lessons learned to date.  Thank you for joining us. Hi, my name is Alex Niven. I am a Pulmonary and Critical Care Consultant in the Division of Pulmonary and Critical  Care Medicine here at Mayo Clinic in Rochester, Minnesota. On behalf of the Stop Virus ICU Learning Collaborative, it is my privilege and pleasure to introduce  this session for the 2022 SCCM Congress. What I'd like to do to start off with is give you a little bit of a background on how this  collaborative started, and then I'm going to pass sequentially to my colleagues who are going to explain a little bit about the process that we used for this effort, which  started in the spring of 2021 and continues at the current time. Next slide, please. I need to disclose up front that some of the efforts that have helped to support some of  the content that was used in this work came from the World Health Organization, and specific funding for the Stop Virus Collaborative came through the U.S. Centers for Disease  Control and Prevention with specific administrative support from the Society of Critical Care Medicine. Next slide, please.  I think all of us have experienced over the course of the last two years the challenges of synthesizing and implementing the literal deluge of information that we have received  from all sorts of sources when it comes to the best practices and care of patients with COVID-19.  In response to that need, Ogi Gajic and other members of the SCCM Discovery Network led the development of the Stop the Virus COVID-19 Registry early in 2021, or I'm sorry, in 2020.  This virus registry is now an international registry that includes multiple sites from across the United States and the globe, and to date has collected some 68,000 patients  with COVID-19, collecting fundamental data in terms of their characteristics, the use of different support methods and devices in their care, and their overall outcomes.  More information on this registry can be found by scanning the QR code on this slide. Next slide, please.  The early observations from the registry were published in Critical Care Medicine in the spring of 2021, and probably one of the most striking early findings was a significant  difference in adjusted mortality from center to center that could not be readily explained by acuity of illness or comorbidities.  Said another way, if you were admitted to Hospital 1 versus Hospital 54 on this chart, the hospitals are listed here on the y-axis, you had up to 1.7 times odds of dying if you  were the same patient with the same comorbidities in Hospital 54. So this spoke quite compellingly to the risk of variations in process as a contributing  factor to patient outcomes during the pandemic. Next slide, please. And certainly this has been shown by other investigators outside of our group.  This was a really artfully done analysis that was published in the Blue Journal earlier this year that demonstrated a variety of different outcome determinants for patients admitted  to the intensive care unit with COVID-19. And although certainly physiology, comorbidities, and other patient factors were clear determinants  of clinical outcomes in this setting, almost 20% of these outcomes appear to be modifiable in terms of hospital strain, hospital quality, and the treatments delivered.  So really the interest here was focusing on that 20% to improve the modifiable outcome and determinants in the ICU. Next slide.  I think certainly we have seen a rise across the United States and the world in terms of  increased nosocomial infections and complications, and the themes associated with this have been relatively common.  I think all of us experienced early on in the pandemic the variations in terms of critical  care volume and acuity, the challenges of implementing rapidly changing practice recommendations,  and often the delivery of critical care by personnel who did not routinely practice in that area. And obviously those created processes of variation.  As we've moved from crisis to more conventional or contingency standards of care, I think  the more recent challenges we faced have been longer lengths of stay, the potential barriers  in implementing evidence-based best practices due to enhanced infection control measures. And over time, to speak quite frankly, there has been a lot of challenges in terms of staff  turnover and burnout, which has translated into loss of experience and teamwork that we used to rely on to deliver that team-based care that is so essential in the critical  care environment. Next slide. So this really leads to some of the interests that our certain group here at Mayo has had  for some time, thinking about ways to leverage education and quality improvement to drive  the delivery, the consistent delivery of high-quality supportive care, which I think consistently  over the decades in our young specialty has been one of the most important drivers of that outcome.  And with that, I will move on to the next slide and pass things over to my colleague, Dr. Yue Dong, to talk a little bit about the CERN program and how that served as a foundation  for StopVirus. Yue? Thank you, Dr. Niven. I'm Yue Dong from an assistant clinical care at Mayo Rochester. I'm working with Dr. Niven and other colleagues running this CERN program.  The CERN stands for Checklist for Early Recognition and Treatment of Acute Illness and Injury. This is a program we are launching since 2013, trying to implement the standardized  approach to evaluation, treatment of acute illness based on checklist approach. The material that the checklist was designed and informed by the survey from clinicians  around the world and tried to set up for this can be used for diverse settings. And we try to minimize the quality of life and quality of death in patients with critical illness.  And we were thinking this would be a great approach to improve the quality. Next slide, please.  And we focus our efforts on three elements of the clinical care and daily practice, you  know, stabilization of the patient admission, the system-based plan during the running process, also last but not the most important part is the patient-centered decision-making for  providing humane, compassionate care with patients and family members. So we developed a checklist based on three of those components, and there was materials  available to share with our investigators. Next slide. I think, as Dr. Niven mentioned earlier, and, you know, try to introduce evidence-based  medicine in this complex environment is very challenging because complex technology, electromagnetic records, and often away from patient bedside, you know.  I think those are the term, Dr. Kaj and the other colleagues, you know, according to the term is the intensivist, you know, try to how can we reduce the burden for unnecessary  information, focus on what really matters. And so this is really the fundamental principle behind the design of the checklist. Next slide.  So when we design the checklist, we start a study and try to see how we implement this in a global setting through the virtual simulation training and coaching using Zoom.  Those materials was delivered through the virtual communication. Then we implement this checklist in the 15 countries, so 55 ICUs globally in the last  couple of years, and then we finished that study in 2018. Next slide. So we are glad to report to the team that through this study, we are able not only to  showing the intervention through the virtual coaching and checklist introduction to improving  the process of care for patient in those units, and also actually impact patient outcome regarding  the length of stay, hospital length of stay, ICU length of stay, reduce mortality up to 16% for those patients in ICU setting. This paper was published early this year.  You can scan the chart for the lower right corner, you can find that paper. So after this study published, there are so many hospital asked us how we can really disseminate  this knowledge further. That's where the education program come from. So we developed a certain program with multiple modules, including online modules, including simulation module.  And initially in 2019 and 2018, we developed a course, actually a live course in Rochester, and also we traveled to six countries in order to deliver the contents.  But as you know, the COVID hit early 2020. So we go back to online, actually, that's the original design for our certain program.  So we're keeping growing this program through online modules and remote coaching and simulation. So that's really the foundation for a certain program. Next slide.  I think I'm going to transfer this to our colleague, Dr. Simon Zets, who can help develop this into a stop virus program. Simon? Thank you very much, Dr. Dong.  My name is Simon Zets. I'm a critical care research fellow working at Mayo Clinic in Rochester, Minnesota.  And with the aforementioned slides in mind, early in 2021, our group sought to create a learning collaborative to kind of unify all of the topics that were discussed in the  virus registry. And so with a name such as Stop Virus, the structured team-based optimal patient-centered  care for virus COVID-19 learning collaborative was established in early March 2021.  It was a six-month ongoing learning collaborative, which extends to this day with quality improvement projects that were born from this collaborative.  One imperative that we wanted from the start to have was to incorporate a multi-level,  multi-professional, interprofessional learning community where both the physician, the respiratory therapist, pharmacist, nurses, ancillary staff were all together learning together  because at the end of the day, we practice together in the unit and therefore learning the same material together will provide the best care.  Similarly, the Stop Virus collaborative, sorry about that, the Stop Virus collaborative was based around our sites, our faculty, our subject matter experts, and moderators who  joined our weekly sessions to deliver the material. And so at the beginning of the year, 11 sites were identified from the virus registry.  Sites that were eligible were those that had collected data for three to six months and had the support of sponsor personnel at their individual institution.  As you can see here, the sites were from all across the United States and a total of 68 learners joined our collaborative.  The important thing to mention is that, reiterating back to the previous slide, is that each site  was asked to provide a team consisting of a nurse, a pharmacist, a respiratory therapist, and a physician, and thus to create our interprofessional community.  And as you can see from this graph here on the right, approximately a third were nurses,  a third were respiratory therapists, pharmacists, research fellows, and other staff, and a third were physicians.  And so our weekly sessions were facilitated and moderated by a wonderful group of experts who were handpicked for their savviness with social media, with communication, and their  general work in the past, and thus, sorry about that, and so we'd like to thank them here, but just to highlight that they were instrumental to leading discussions every  week and helping us move forward. And so the curriculum was created after a learning needs assessment, which was sent  to the eligible sites, and after this survey, we identified the following sections, or sorry, the following blocks, which were then delivered during our learning collaborative.  Of course, the first one and the most important one was the approach to respiratory failure,  but the ICU bundle, infectious complications, cardiovascular, and other complications, and of course, shared decision-making, end-of-life, were particularly important.  So our collaborative was structured in six four-week blocks, where the first week was a state-of-the-art update delivered by a subject matter expert who was called from outside  of the collaborative to provide evidence-based, a lecture on the topic at hand, and this was followed by a second week where a case was presented by one of the collaborating sites,  followed by discussion, and it's important to highlight here that this format of providing weekly case-based discussions was something which we'd tried before in the CERN program  remotely and was shown to truly positively influence patient outcomes. Week three was always a community learning session based around QI, quality improvement,  where each of the sites would develop, and together with the assistance of faculty and  our moderators, create a quality improvement project based around findings from our collaborative, and of course, week four was another case.  And at this time, I'd like to pass the baton over to my colleague, Dr. Nika Zorku-Gayrbais. Thank you, Dr. Zitz. My name is Nika Zorku-Gayrbais.  I am a visiting neurocritical care fellow here at Rochester Mayo. I will continue with a discussion on quality improvement project that we did during the collaborative.  As mentioned earlier, for improving patient care, the community puts high priority to quality improvement projects across all the participating sites.  Through weekly collaborative discussions and dedicated quality improvement survey, the participating sites identified several potential areas of improvement.  To facilitate implementing these projects, we grouped two to three different sites together  with similar QI interests, making the collaborative a sounding board for ideas and a tool to receive feasibility and implementation feedback.  We offered centralized support for some of the processes, such as informatics, online tools, data collection, and presentation, but most of the hard work had to be done by  participating sites themselves, of course. The sites were diverse in size and locations of hospitals, and initially, every step of  the DMAIC framework was presented to the entire collaborative. The sites were, with most resources, that is predominantly most personal resources,  served as pilot sites and presented their work initially. Later, the monthly presentations of progressions from all sites were held.  The goal of this was to unify processes and improve patient care. Next slide, please. The participating sites identified several potential improvement projects.  Finally, we had eight quality improvement projects within three groups, with main areas of interest being ventilation, best practices, reduction of nosocomial complications, and  shared decision making. Next slide, please. In ventilation best practices and reduction of nosocomial complications, the focus was  on four projects, ventilator-associated pneumonia bundle adherence and oral hygiene compliance,  facilitation of oral care by proning pill to reduce nosocomial infection, lung protective  ventilation adherence in ARDS, and spontaneous awakening and breathing trials frequency improvement. Next slide, please.  In the shared decision making projects, the focus was on increasing palliative care consultations  in eligible patients, to increase the percentage of patients with power of attorney, and to increase in attendance of family interpreted on rounds.  We found that local champions were pertinent in the progression of any quality improvement project, as well as the support they received locally.  I will hand this off to Dr. Niven, thank you. So in conclusion, we found based on our experience that conducting a virtual interprofessional  learning community, as we briefly described here, is both feasible and at least based on our qualitative experience, successful in improving care to deliver to the critically  ill with COVID-19. I think we have really enjoyed as a group the opportunity to connect with hospitals  in a variety of different practice settings, and seeing the power of the group, especially with a little bit of central coordination, to advance quality improvement initiatives  and accelerate our individual efforts. I think one of the things that we've learned, I think very rapidly over the course of the  pandemic, is how to adopt virtual media, like a Zoom platform, to enhance communication and collaboration.  I think the added benefits of that video-based format is that it can be replicated for many  different diseases and settings. Here we use the CERN framework as at least one evidence-based element of the foundation of our work. I think it has shown to be successful in terms  of reducing just the cacophony of evidence that we've all been inundated and refining it to the key best practices. I think perhaps we'll just advance one slide for a second  here and just extend a thank you to the many, many subject matter experts that we were able  to leverage through Connections and the Society of Critical Care Medicine and participated as expert presenters and helped to curate the up-to-date information that was covered  in our collaborative and is all available through the SCCM Stop Virus Collaborative website. With that, I'd like to stop sharing the screen for right now and open this up  to a little bit of a panel discussion with just a few of the members of our collaborative who would like to share a little bit about their experience. For starters, I'd like  to ask Sarah Chalmers from Mayo Clinic Rochester if she could just share a little bit about  what it was like to be a part of this collaborative and the things that she took home from this  experience. Thank you, Dr. Nibben. Thanks for having me today. I'm Sarah Chalmers. I'm a physician and senior associate consultant at Mayo Clinic in Rochester, Minnesota and  a learner participant of the Stop Virus Collaborative. I had many, many exciting experiences and  benefits from the program, but I think I just want to focus on my experience with the QI initiatives that came out of this project. I think I had a multidisciplinary team that  participated and attended most of the meetings, and then we were able to have a nice structured  framework that was presented by the Stop Virus Collaborative, a strong, supportive nature, including people to help us work through the process and templates that made it easy just  to plug in our own projects to the format. And then I also really enjoyed that each week  we could come back and get real-time feedback. So as we were working through our QI projects,  we were able to come each day and get real-time feedback from multiple centers who may have  different experiences or different situations that could help identify barriers and identify ways to overcome. And I think that that was highly valuable.  Thanks, Sarah. Mike Smith, do you mind if I turn to you next to share a little bit about what you took away from this experience?  Sure. Thanks very much for inviting me today. I'm Mike Smith. I'm a clinical pharmacist from  Concord Hospital Laconia in central New Hampshire. And for us, we didn't have a big wave in the  beginning like was seen in New York and a lot of other places. We had just a handful of patients  at the beginning. We had another wave about a year ago where the local nursing homes had  outbreaks and the patients were in their 80s and 90s, but most of them were DNR, DNI. So all of  those waves up until that point, our staffing was adequate to handle, but we never got the number of  repetitions that some of the big centers had. In addition to that, the Stop Virus Learning  Collaborative really helped sort through, and Dr. Chalmers touched on this, the amount of data that  was coming out and sifting through that to try and apply that and best practices to our patients here.  Other centers that had experienced shortages, what they had done, as an example, I remember one of the lecturers from the UK talked about running out of dialysis solution and how  their pharmacy had compounded dialysis solution using their TPN machine. So these sort of little  tricks or ideas were things that we filed away for our own center.  Also, the case-based presentations were really great to validate how complex some of the patients  we were seeing were, and also the diversity of the lectures were really valuable to me. One of my favorite lectures was about wellness and burnout, and I ended up joining a wellness  task force within our health system based on really after watching that. So I found everything very valuable. So I just have to seize the moment to embarrass Mike a little bit,  because he is a true force of nature in terms of all the things that he has done,  in terms of his accomplishments and contributions within his own hospital system during a  considerable time of administrative change within his practice environment. So Mike is always the  first to answer every email and always the person that goes above and beyond with every single thing  that he takes on. And certainly the example of the wellness task force that he's now a part of  is a graphic illustration of that. Aghi, as one of the two fathers of this program, you and Alan Walkie, would you mind just saying a few words in terms of your perspective on  the collaborative and how it's evolved?  So, you know, stimulated by Sarah and Mike, rather than talking about organizational stuff,  I'll just tell you how I applied what I learned last week when we have the biggest of all waves here. So the first thing, you know, I've never imagined that the Stop Virus  Collaborative will help me personally in my practice as much as it did. So the first thing,  the first thing, you know, I'm coming, so it's a week of service. It's a, you know, 15 mechanically ventilated COVID-19 patients, OK? That's ahead of me for the whole  week. And if a couple of get out, the new two would come in. So the first thing,  the, you know, understanding the burden of the team and what we had, what fantastic lecture, not a lecture really, the testimony of some of our respiratory therapists and  collaboratives showing how much burden they have really taken on, taken upon in different  institutions during parts of the surges, exactly the ones like we had now. So I went from day one  literally to every single respiratory therapist unit. I spent time individually with them discussing the ventilator settings, not trying, you know, not putting orders or, you know,  changing the ventilator settings without them knowing, but spent 10, 15 minutes extra time  to make sure that they are, that the communication is good, that they are supported and that they  are valued fully to the extent that it's necessary now when they do triple the work they've done in  the past. I would have not done it without the testimony of, from the centers who experienced  this surge before. You know, focusing, I literally had to focus, even in a teaching institution,  on the basics, which is certain. So we have done certain checklists for admission of the patient,  for grounding on the patients, and we filled out the Gettemobil board on everyone. So the patient who was all in tattoos was not like a bad, I don't know, 265 unvaccinated COVID  male, but it was tattoo artist from whatever city is coming on, and then suddenly the whole team  approached this patient in a different light, and we were able to extubate him three days before we  would have otherwise done, because the whole team rallied about the person in there. And then,  as a last, this quality improvement in interventions and just the spirit of continuously  improving the way on the go within the pandemics, as I explained to the team and we have residents,  I was blessed to have that this resonated with a family practice resident of all of them. It's just  fascinating. I've never heard of that happen. So one of our family practice residents, designed with a family member on the phone, designed the recovery checklist for another  COVID patients, showing the milestones of waking up, milestones of spontaneous breathing, milestones  of extubation, and listed all the way to taking out the foley catheter and some other beautiful  things that will happen a week or two weeks later. That has been in this ICU, filled out,  and when the patient got extubated, actually after I left, you know, this was very enthusiastically  filled out. So I think the beauty of this is actual practical value, too, that we all can  apply. I think this is much more important than any of the organizational stuff that I think we  can always do better. But you, Alex, really, I have to give you credit for giving the vision of such interprofessional learning that actually works, and it worked for me.  Well, thanks, Agi. You know, it's funny thinking back when we kicked off the collaborative in March, there was actually a little bit of concern whether or not reviewing COVID  practices of care would be relevant anymore. At that point, the vaccination campaign was  in full swing, and unfortunately, we have found ourselves all too acutely aware of the importance  of synthesizing and updating our practice as each of our different locations have experienced waves  at different times. And I think perhaps the first practice that experienced a wave was down in Florida. And maybe, Devang, I'll turn to you next for your thoughts and comments.  So thank you, Dr. Gaj and Dr. Niven. I'm Devang Sanghavi. I'm intensivist here at Mayo Clinic, Florida. And you're absolutely right, Dr. Niven. We were the first in the system,  Mayo system, to have our Delta wave. And what I can tell you from my participation  in this collaborative and virus registry in the last year or so is that not just  when we do QI project, we want to help patients. And what we realized is rolling out a QI project  in midst of a surge was challenging, but the intervention of increasing and adhering to oral  hygiene and following the components of lab bundle was actually going to help our patients during  that surge. And we saw that example put in practice while we were surging. And that was  kind of the most gratifying thing to our practice and to all the participants and to the providers  who were part of the ICU team. We had a lot of ventilated patients, as Dr. Gaj mentioned,  like you see in Rochester right now. And creating this QI project then was really helpful to our patients. So, what was unique? There were a few things that stood out regarding this  Top Virus Collaborative. I think, at least me, I've not seen or read in literature about platform  approach to QI. The platform approach to me is a collaborative where then you have experts,  you have different stakeholders from different hospitals. The resources may vary, but there is  an exchange of ideas and learning in real time. And that was what we could achieve during this  six months of Top Virus Collaborative. I'd never seen multiple QI projects done simultaneously.  We actually had a PDSA cycle every month and kind of real-time learning from experts, as you  showcased in your slides, who gave valuable points which would help the QI projects along  with clinical practice in different hospitals. And as Mike mentioned, he took up the formulation  of PPN and how that would help in terms of dialysate solution. The other part that we  often struggle, data, be it research, be it QI project, be it research or QI project, we all want  data. And having a registry that is a virus registry as a backdrop to our collaborative,  we had the data handy. And as you mentioned in your slide, this could be the template or the  roadmap for many other disease like, say, PE or sepsis or ARDS for future learning. Because I think  that integration with the registry and learning and evolving into multiple QI projects was  amazing. And lastly, I would say the use of social media, Zoom and other things, this was certainly  very unique. The reach of this collaborative was not just the 68 participants, but this was shared  later on on the SCCM website. And thousands of, like, you know, like, you know, doctors, nurses,  RTs, world over saw this, learned from it. And that is the testimony to the value of what we did  in the last six months or so. So thank you, Dr. Niven. Yeah, no, I think we were all acutely aware that many people were Zoomed out by the time we reached the spring of 2021.  And so I think trying to vary the way that we delivered the contents with case-based presentations, posting that content first on Blackboard and then on the SCCM website  to provide the opportunity for people to consume it asynchronously, recognizing just how busy we  all have been over the course of the last two years. And then also leveraging things like social media, the hashtag stop virus collab string, so that again, people could react  to that content and view it in a different platform. Those were all tools that really have evolved from many individuals on this discussion and on the collaborative as a whole.  And I think that experience has been invaluable. Tony, I want to pass the baton to you next,  just to reflect a little bit on your experiences and things that you took away from this.  Thank you very much. First, I'm Tony Martinez from St. Agnes Hospital. I'm probably one of the older intensivists and probably that was practicing up until this December.  And I started my career in the first pandemic of HIV. A lot of lessons learned. And then I ended it with this pandemic, which I never thought would happen. This collaborative is  probably a humbling experience and always a learning experience to me. So you're never too old to learn. And I think this is really important that this could only be accomplished by  visionary leadership that the Mayo Clinic has demonstrated and the might of many. And this group  was nimble enough to change because we knew as data exploded, it was transforming to information  and useful practical solutions, which I think to me is really important. Having been an intensivist  for a long time, a director, and then really focusing a lot of my work on quality and outcomes,  I was amazed at how much I did not know and that the need to structure QI. And this is the  program that has been developed by the Mayo group that I counted the DMACC, which is define,  measure, analyze, improve, and control. I actually structured it during the peak of our pandemic  because what was so important is not only exchanging information, but benchmarking our results. So physicians and clinical people are very proud of the work and they want to do the  best for the patients. As soon as you compare results to one another, I think that changes the playing field and the motivation to even do better. And that was a very important tool  that we can benchmark this. And in addition, the quality programs could be due to the virus  registry could be actually linked to outcomes, which is really important because a lot of process  of care is a lot of information, but it's where does it go? And I think if it links to process  of care, which is a fundos and adherence to the most difficult times like this pandemic,  and you link it to outcomes that you can compare to your colleagues, it is very important. And a  case in point was our ventilator management, where we looked at the lung protective strategies,  adherence to this process, and we saw some disparities. And with that, all I had to do was measure our performance, share with my colleagues. And just that demonstration was  enough power to change practice pretty rapidly. And so I didn't have to focus on it anymore.  And then we started focusing on sedation practices, which were quite variable. And this is a process  we're ongoing right now. And we're taking it to another level where we want to promote resilience  and sustainability of our QI projects, because as mentioned over and over again, the structured QI  approach works. And in during these pandemics and crisis, it's really important to stay true  to the tried and true and proven practice. Don't experiment in a research. When we have our  patients, remember, fall back to the basic practices like Certain has done, structured QI,  adherence to best practice. And that's the best medicine for our patients. And lastly, I want to  mention that I learned from my colleagues, my pediatric colleagues on this team, that taught me  to be a little bit different and view visitation and behavioral aspects of care are so important. And I think the pediatric group was really instrumental, teaching all us a humbling  lesson about visitation. With that, I sign off. Welcome to Puerto Rico, even virtually.  Yeah, I certainly echo your comments there, Tony, especially with the things that I learned  from our pediatric colleagues. And I think you sell yourself very short as someone who is an  expert in terms of ICU outcomes. And we learned certainly many, many lessons from you in terms of  the dashboard that you shared with us from your institution. You know, I wanted to turn things  over to Grace Ortega here for a minute, because I think we've talked about a lot of different  successes that we've enjoyed as a collaborative. But I think the reality is that this remains a work in progress and evolution, and there's always opportunities for improvement.  What are your suggestions for us, Grace, in terms of ways to improve this process for us and for other groups that might be interested in designing similar activities?  Thank you, Dr. Niven, for the opportunity to be part of this group. It has been really a  eye-opening experience, not only for me, but all of the participants within my pediatric group as  well. So I'm Grace Ortega. I'm one of the pediatric intensive care physicians here at Mayo Clinics,  who was lucky enough to be part of the Stop Virus initiative. And I'm here to talk about  this idea. As we move forward, one of the things that attracted us within the PICU was the fact that it was an interprofessional collaboration. And with that idea,  several team members from my group, nurses, RTs, and other physicians decided to become part of  the group. As we move forward, one of the things that we realized was needed was to improve  the shared decision making, not only within patients and physicians, but the inclusion of the families as well. And importantly, the disparity that we have noticed  with different languages and different cultures that visit our ICU.  So as an area that probably we can do much better is to become more inclusive and attract other practices within both nationally and internationally  that can participate in all these endeavors. And the second thing that I think would be important to pay more effort into is having both adult  and pediatric collaborators working together. My team members, even though they were particularly pediatric focused, noticed very soon  that a lot of the practices that the adult groups were talking about actually could be also implemented or studied within a pediatric group.  For example, our obese teenagers were coming with COVID.  Everything that we learned listening to our team members from other institution actually was discussed within our practice and some changes were made.  So I cannot emphasize how strong and useful it would be  if we have different pediatric groups also involved in this type of endeavors.  No, I think incredibly important points, Grace. And I think for me, there's a couple of lessons that I've taken away from this. And I think highlight some opportunities  for continued growth and improvement. You know, I think that the diverse and interprofessional nature of this collaborative  has been something that for me has been one of the most important elements of the learning experience. I've never spent an extended period of time  with a pediatric critical care team talking about the differences in care. And I learned a great deal that way.  I think that in the midst of our day-to-day busy clinical activities, it's also sometimes hard to get thoughtful perspectives from our pharmacy  and nursing and respiratory therapy colleagues that's infused in a little bit of a protected time and discussion like we've had has substantially enriched  and strengthened my learning experience and the appreciation that I have for the different members of my interprofessional team that I work with every day in the ICU.  I think it goes without saying that the opportunity to share and learn from individuals in different practice settings all over the country also provides a very unique perspective  and without the technology platform and the administrative support that we enjoyed from the SCCM and funding from the CDC, none of that would have been possible.  And so I think in many ways, I've been incredibly humbled by the talented group that chose to be a part of this and the incredible learning experience  that they have provided certainly for me and I suspect for all the members of the group as we've gone through this experience.  I think that I'm excited that our collaborative has chosen to continue as we finish our quality improvement projects to ensure that we can share the work  in between our different centers. And the fact that we voluntarily elected to do this past the length of the original grant deadline,  I think also speaks volumes to the potential power and opportunities for expansion for this work in the future.  So with that, I just wanted to perhaps conclude with a heartfelt thanks.  I'm not really sure if any of us were sure that an intensive experience like this meeting on essentially a weekly basis for six months was feasible or the degree of rewards  that we would enjoy from it. And certainly as the volume of our clinical work picked up over the course of the year with the ongoing waves from the pandemic.  But I recognize the time and effort and sacrifices that everybody has made and wanna thank everybody for their support and thoughtful contributions  that have made this collaborative a success. And with that, I think I will conclude our comments and again, we'll direct the listeners who have joined us for this virtual session  to our SCCM Stop Virus Collaborative site, which contains a great more detail with regards to the participating centers and the individuals from the teams  of those participating centers, along with all of the recorded content of our educational sessions. And at the current time, we are currently developing summary content  that highlights the key learning points that we've taken away from this collaborative. And we will continue to post the results  of our quality improvement work on that site over time. So with that, thank you for the faculty for their time in terms of joining this discussion.  And we look forward to seeing you on our websites and in conversations to come. Thanks so much, bye now.  Over the course of the same period of time that the Stop Virus Collaborative has been ongoing, investigators at Boston University have been performing a qualitative  implementation science exploration of change management strategies employed in different ICUs participating in the virus registry.  Here to present the preliminary results of that study is Santana Silver, a research scientist from the Evans Center for Implementation and Improvement Sciences.  Hello, my name is Santana Silver and I'm a research specialist at the Evans Center for Implementation and Improvement Sciences, which is a methodological hub  at the Boston University School of Medicine that uses implementation science to improve healthcare delivery and safety net systems. As part of the Stop Virus Learning Collaborative,  we are conducting research to identify critical care practice changes during COVID-19 and explore organizational factors and strategies  that both facilitated and hindered implementation of these practices. I will be presenting on this research, including the rationale, our methods,  preliminary findings and conclusions, and next steps. Why is this research needed and valuable for the scientific and medical communities and society at large?  The quality of critical care infrastructure and practice is imperative to slowing and preventing morbidity and mortality due to COVID-19. In particular, the pandemic has strained  critical care resources, thereby challenging the maintenance and delivery of high quality care for critically ill COVID patients. Therefore, in order to support overburdened  critical care units in the fight against COVID, it is necessary to identify best critical care practices and effective change implementation strategies.  So what is the role of implementation science in meeting this need? Implementation science, which is the rigorous study of implementation factors  and strategies to integrate best practices across clinical and community settings, is uniquely situated to improve and accelerate the uptake  of evidence-based critical care practices in stressed ICUs. Through improving our understanding of changes to typical ICU clinical practices during COVID,  and factors that facilitate and impede the implementation of these changes, implementation science can provide valuable insight into how to best support clinical leadership  in adopting and adapting new life-saving practices.  Driven by this intended impact, our study objective is to qualitatively explore ICU clinical practices and change management strategies during early COVID-19.  To meet our objective, we aim to first identify ICU practice and policy changes that best respond to COVID, second, explore reasons and methods for implementing these changes,  and third, to describe facilitators and barriers that influence implementation effectiveness. In alignment with our study aims, we use qualitative data collection methods  to learn from the experiences of ICU clinical leaders who were recruited from 20 virus registry ICUs with the highest and lowest COVID-19 mortality rates.  We conducted 31 interviews over Zoom with ICU clinical leaders across 17 facilities. During the interviews, we asked participants open-ended questions  related to ICU practice changes and implementation efforts. After conducting interviews, the members of our evaluation team independently reviewed the interview transcripts  and identified emerging themes. Then the researchers met to compare their individual analyses and draw consensus on themes for each interview transcript.  Using these consensus themes, we developed memo reports to summarize things for each hospital interviewed. Next, we sorted and refined cross-cutting themes  that were evident across sites. To guide our analysis, we use the Consolidated Framework for Implementation Research, or CIFR. The CIFR is a comprehensive framework  that helps researchers identify factors that facilitate and hinder intervention implementation efforts across five domains outlined in this diagram,  including intervention characteristics, outer setting, inner setting, characteristics of individuals, and process. Using this framework provided a systematic way  to organize the qualitative data and group descriptions of implementation lessons learned into distinct categories.  Before presenting our findings organized into the five domains of the CIFR framework, this is an overview of the themes. We identified six major themes  related to implementation facilitators, or factors that promoted the implementation of critical care practice changes, such as strong partnerships with external stakeholders  and staff dedication, resilience, and camaraderie. We also identified six themes related to implementation barriers, or factors that hindered the implementation  of critical care practice changes, such as the increased complexity of critical care due to high volume and acuity of patients, as well as low staff morale and burnout.  Intervention characteristics is the first major CIFR domain, which is related to characteristics of the intervention or practice being implemented.  We found that practice changes that were informed by both external and internal guidance were successfully implemented by staff. A nursing director highlights this theme,  explaining that their ICU leadership got information that they're gleaning from the CDC and their own infection prevention department, and making sure that that information  was consistently communicated.  An implementation barrier related to intervention characteristics was the increased complexity of critical care practices due to the high volume and acuity of patients with COVID.  A medical director emphasized how this increased complexity hindered efficient implementation of care practices, describing that when they intubate somebody, it was an ordeal.  They have to have all their equipment set up, all of their PPE on, and it was a whole process. It just took a lot longer and was a lot more complex than they normally did,  and a lot more resource intensive. The second C4 domain is the outer setting, which generally includes the interaction the hospital has within the larger economic, political,  and social context in which it resides. Within this domain, an emergent theme was that strong partnerships with external stakeholders improved implementation efforts  through promoting community support and cross-facility information and resource sharing. A medical director describes the positive impact  of strong relationships with the surrounding community, recalling that there was really just an outstanding communication between our community leaders  with our organizational leadership. From the frontline worker perspective, it was just such an intense outpouring of support by our community. The community rallied and brought us  just an incredible amount of drinks and food. It was tangible as far as supplies too.  A barrier in the outer setting domain that hampered the delivery of patient-centered care was the strict external infection prevention measures and policies that isolated patients  from providers and families. An ICU nurse highlighted this challenge, describing how the physicians were not going into the rooms, so all the rounding was done outside the room.  So obviously that created some patient-provider relationship problems as well. We felt like the patients still deserved the same quality  or standard of care that they had gotten prior to COVID, and we felt like that was not happening. Another outer setting implementation barrier was the lack of consistent, reliable,  and evidence-based clinical guidance from external sources. Lack of information from typical resources, such as the American Medical Association,  disrupted both staff morale and the implementation process. An ICU provider highlighted this challenge, explaining that with the lack of information, people started speculating.  And if you start speculating, then you begin to distrust the process. People were frustrated and obviously scared because of the unknown.  Contrary to implementation determinants within the outer setting, influencing factors under the inner setting are related to the structural characteristics,  networks and communications, available resources, and culture within a hospital. A strong theme across facilities was that having organized  and collaborative networking communication structures improved implementation of ICU practice changes. A medical director highlighted this implementation facilitator,  claiming that the key to our survival was the communications that were set up between us using the multidisciplinary rounds so that we were able to share information  throughout our hospital system. We were able to pass it along to everyone so we could use a larger brain to troubleshoot ideas or bounce ideas. Another organizational factor  that promoted implementation efforts was strong leadership engagement, accessibility, and physical presence to really support the needs of patients and frontline staff.  An ICU provider reflected on the positive impact of leadership engagement, stating, it was very much a leadership from the front style, literally elbow to elbow with the staff  in proning these patients and intubating these patients and transporting these patients even. There was no hierarchical feel to it.  A major internal barrier faced by critical care units was lack of adequate PPE, medical equipment, ICU trained staff, space, and technology. An ICU nurse described  how this unprecedented resource challenge affected practices, explaining, we're reusing PPE. We never did anything like that before.  We also had to change how often we're changing IV tubing because there was a national shortage of IV tubing. The fourth domain of the CFER is characteristics of individuals involved  with implementing the critical care practice. The significant role of ICU staff in implementation of practice changes was evident throughout interviews,  especially the way in which staff dedication, resilience, and camaraderie promoted successful implementation of practice changes despite barriers.  For example, a medical director described how staff commitment and camaraderie helped address resource and staffing constraints discussed on the previous slide. She claimed that,  the easiest thing was finding people to cover. The vast majority of my colleagues and coworkers would say, yeah, this is our job. And they stepped up to the plate willingly.  I think there was almost a sense of pride in that. We were in it together. And as long as you're working with your friends and colleagues,  they're the people who you go to war with, and we did.  On the other hand, low staff morale and burnout hindered delivery of quality critical care practices. The severity and negative impact of staff burnout  was apparent across interviews, such as when an ICU nurse director revealed that, it wasn't until I felt myself break and say, I have to step away.  Did I realize how bad the burnout was? The staff came and really broke down to me. The burnout is real. The burnout, the PTSD, it's real. And the toll it took in healthcare is real.  The Last Fever domain focuses on factors related to the implementation process itself. Interviews suggested that effectively engaging  frontline staff throughout the implementation process promoted implementation of quality critical care practices. A common effective engagement strategy highlighted  by interviewees was eliciting frontline staff input about care practices. For example, one ICU nursing director described how a lot of the decisions she made,  she didn't make independently either. She consulted with the physician lead or even with the staff nurses. She would say, you do the work. Tell me what's going to work.  Tell me what you think or how you think this is going to work.  Contrarily, a common barrier to implementation effectiveness was when the change process was governed by authoritarian decision-making.  An ICU doctor highlighted this problematic lack of collaboration in the decision-making process, describing how the administrators think, oh, these things are the best idea ever,  but yet they don't come to the bedside and they have no idea about the reality of it. I knew how they would think. And I'm like, you know what? I'm not even talking to them.  Absolutely not. We are clinicians, we're going to make this decision.  Based on the preliminary findings I presented, we can draw a few important conclusions to address our research question regarding effective ICU clinical practices  and change management strategies during COVID. First, a general lack of access to information and data resources hindered implementation efforts overall.  However, despite these barriers, resilient ICU leaders and staff developed innovative solutions to deliver best possible care to COVID patients.  There were several organizational factors that supported staff in this challenge, including one, robust networking and communication with diverse internal and external stakeholders,  two, collaborative and streamlining processes for deciding and implementing changes, and three, engaged and motivated leaders and staff  who supported the needs of patients and colleagues.  The analysis and findings I presented today is only the first stage of this research project. Next, we will sort the participating facilities by their COVID mortality rate  so that we can identify patterns of distinguishing themes between hospitals with low versus high mortality outcomes. This differential analysis will allow us to explore  how variability in ICU practices, organizational factors,  and implementation strategies relate to mortality rates. Ultimately, we aim to harness our findings to support clinical leadership with valuable insight on recommended practices  and change management strategies. Thank you so much for listening and to all of the researchers and partners that made this work possible.  Thank you for joining our session today. If you're interested in learning more about our work, please visit the Society for Critical Care Medicine Stop Virus Collaborative website  that includes more details about this initiative, recordings of all of our educational sessions, and we are currently working on developing summary statements for best practices  along with the supporting evidence and materials that we have used to make those recommendations. This is a living site, and as time goes on, we will also post the results  of our quality improvement initiatives conducted at each of our participating centers along with further analysis of our qualitative explorations.  Thank you very much for your attention, and we hope that you enjoy the rest of SCCM Congress.

Video Summary

The Stop Virus Collaborative is an initiative focused on strengthening COVID-19 care in critically ill patients. The collaborative was formed to better understand global care practices and outcomes for patients with COVID-19. The preliminary results of the SCCM Virus Registry were published earlier in 2021 and highlighted the importance of processes of care in affecting patient outcomes. The collaborative involves institutions within the registry who are interested in identifying best practices and implementing them. In parallel to this collaborative, Boston University conducted a qualitative exploration of change management strategies in ICU settings during the pandemic. The session provides an overview of the collaborative and the lessons learned. It emphasizes the importance of understanding how critical care practices changed during COVID-19 and the factors that facilitated or hindered their implementation. The study used qualitative data collection methods and followed the Consolidated Framework for Implementation Research. The findings highlighted implementation facilitators such as strong partnerships with external stakeholders and staff dedication, as well as barriers like increased complexity of critical care and low staff morale. The session concludes by discussing future steps, including further analysis of qualitative data and exploring patterns of practice differences based on COVID-19 mortality rates. Overall, the Stop Virus Collaborative aims to improve care for critically ill COVID-19 patients by identifying best practices and effective implementation strategies.

Asset Subtitle

Infection, Quality and Patient Safety, 2022

Asset Caption

The COVID-19 pandemic has created unique challenges for critical care teams, who have been forced to synthesize massive amounts of information to identify best practices at a time when ICUs have never been more stressed. This session will describe the key elements and lessons learned from the SCCM STOP-VIRUS Learning Collaborative, a virtual learning community of interprofessional teams from 13 U.S. hospitals participating in the SCCM VIRUS Registry. The goal of the STOP-VIRUS Collaborative was to identify and implement best practices in the care of critically ill patients with COVID-19 through a weekly, 6 month program designed to deliver live and asynchronous state of the art clinical updates, case based discussions, and quality improvement coaching based on the CERTAIN approach. Investigators will also describe the preliminary results of their qualitative implementation science exploration of change management strategies within VIRUS Registry ICUs during the COVID-19 pandemic.

Meta Tag

Content Type Presentation

Knowledge Area Infection

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Evidence Based Medicine

Tag COVID-19

Year 2022

Keywords

Stop Virus Collaborative

COVID-19 care

critically ill patients

global care practices

patient outcomes

SCCM Virus Registry

processes of care

best practices

change management strategies

ICU settings

	Society of Critical Care Medicine 500 Midway Drive Mount Prospect, IL 60056 USA Phone: +1 847 827-6888 Fax: +1 847 439-7226 Email: support@sccm.org	Contact Us About SCCM Newsroom Advertising & Sponsorship DONATE	MySCCM LearnICU Patients & Families Surviving Sepsis Campaign Critical Care Societies Collaborative	GET OUR NEWSLETTER
© Society of Critical Care Medicine. All rights reserved. \| Privacy Statement \| Terms & Conditions The Society of Critical Care Medicine, SCCM, and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.