All together now: Interprofessionally diverse ICU team participation facilitates effective complex care delivery, study shows

Findings point to need for greater coordination among team members to ensure routine implementation of evidence-based interventions Collaborative teamwork among the many healthcare professionals who work in the intensive care unit (ICU) is essential for ensuring better outcomes among critically ill patients. Yet coordination and communication among team members can be difficult in the complex, dynamic, often fast-moving care environment of the ICU. A new study published online ahead of print in the Journal of Critical Care confirms the importance of interprofessional collaboration in standardizing care, finding that a series of interventions performed to manage delirium and weakness among adult ICU patients is more successfully implemented when diverse teams are frequently involved in those activities. But implementing these evidence-based practices reliably is not so simple. “Our data suggest a need for role clarification and complex coordination among ICU team members,” Deena Costa, Ph.D., R.N., an assistant professor in the University of Michigan School of Nursing, and the study’s lead author, says. “Effective interprofessional teamwork needs to consider not only who is part of the team, but how these professions work together to deliver care.”

The “ABCDE bundle” is a collection of four interventions that, when performed individually and together, have been shown to be highly effective in improving pain management, reducing ICU stays and the number of days needed on mechanical ventilators, and preventing long-term consequences for adult patients in ICU settings. Previous research from Costa and her research team identified a range of barriers to ABCDE delivery, from unclear criteria about carrying out the protocol’s different steps within the unit, to lack of clinician knowledge, to patient instability or uncooperativeness. ICU contextual barriers such as poor interprofessional team care coordination can also hinder bundle implementation. While the participation of an interprofessional team is an integral part of ABCDE delivery, less is known about which team members are involved in each bundle component, and how that may facilitate implementation. To learn more, Costa and a team of U-M researchers surveyed ICU healthcare professionals among 61 hospitals that are part of the Michigan Health & Hospital Association (MHA)’s Keystone Center, a Michigan statewide quality collaborative formed in 2003 with an emphasis on improving patient safety. MHA Keystone ICU has been surveying its members at its annual ICU workshop since 2010, and these data have been used to inform local and national practice around evidence-based ICU care. ICU team members, whose roles included registered nurses, physicians, nurse practitioners/physician assistants, respiratory therapists, and physical therapists, were asked each how well they perceived ABCDE was incorporated into their unit’s practice, and how frequently clinicians were involved in the components of the ABCDE bundle. The researchers found great variation in how frequently each team member is involved in ABCDE, with some team members perceived to be more involved in some activities than others. But frequent involvement of multiple team members in different ABCDE components meant the intervention was more likely to be implemented routinely. The findings suggest that coordination, an important factor in effective ABCDE implementation, could potentially be improved through the use of in-person facilitators (who could be a clinician who is already part of the care team) to clarify team member roles and coordinate activities. Further, ensuring that an opportunity exists for the ICU team to consistently discuss ABCDE bundle delivery for each patient, each day may also support effective implementation. Costa and team have also piloted a rating tool to assess interprofessional team interactions around ABCDE that may be used as a guide or a checklist for ICU teams to structure conversations about the ABCDE bundle. “The study clearly shows that patients get better care at ICUs where multiple professionals work together to accomplish hard tasks,” says co-author Theodore J. Iwashyna, M.D., Ph.D., a Michigan Medicine physician who works in ICUs. “What we think this means is: we should be actively managing the culture of our ICU, to promote clinicians working together across the silos of their professions. We know those silos are real, and can be very comforting. But sick patients require us to work together, and that can be a choice, not just a coincidence.” “These ICUs may able to align the unique contributions of each team member by creating an environment in which team members may work from a shared mental model to coordinate ABCDE,” Costa, who is also a member of the Institute for Healthcare Policy & Innovation (IHPI), adds. “This is a key component of effective teamwork – having all the clinicians on the same page, with an awareness of their own abilities and those of other team members, and the shared goals among them.” Quality collaboratives, which are associations of healthcare organizations working together to improve healthcare delivery, also play an important role in improving the implementation of evidence-based practices such as the ABCDE bundle, by providing opportunities to share best practices between institutions, and guiding data collection and analysis for improvement. Of course, another piece is the staffing model ICUs are able to maintain, since there can be wide variation in staffing interprofessionally between institutions, even between different units within the same hospital. Additional research by the U-M team with funding from the Agency for Healthcare Research and Quality is ongoing to determine how to best ensure routine ABCDE implementation within and across ICUs, including qualitative work to better understand and measure how care is delivered within interprofessional teams, and how interprofessional team structure (the "who") and function (the "how") influence high quality critical care. Study senior author Theodore Iwashyna, M.D., Ph.D., and co-authors Milisa Manojlovich, Ph.D., R.N., and Thomas Valley, M.D., M.Sc., are also members of IHPI. This work was supported the Agency for Healthcare Research and Quality, and in-kind research support by the Michigan Health and Hospital Association (MHA) Keystone Center.