Abstract
Background
In order to deliver specialized neurocritical care (NCC) without a dedicated neurological intensive care unit (ICU), we established a virtual NCC unit within an existing mixed level III ICU. This initiative required changes to patient allocation, physician staffing, and care protocols. In advance of its implementation, we gaged readiness, assessed barriers, and solicited feedback from staff.
Methods
Clinicians at our academic hospital and trauma centre in Toronto, Ontario were the subjects of this concurrent mixed methods study. Eighteen stakeholders were individually interviewed. 116 of 217 eligible ICU staff participated in the survey and 36 staff attended the focus group sessions.
Results
From the survey, the most significant barriers to this reorganization were staff anxiety about coping (28 %) and a concern that patients would not receive better care (24 %). Noteworthy obstacles about the use of protocols were their lack of flexibility (19 %) and that implementation was seen as impractical (16 %). Seventeen barriers were proposed through an open-ended survey question. Content analysis revealed general resistance, educational challenges, workflow adjustment to a diagnosis-based rounding pattern and coordination conflicts to be the central barriers. These findings were confirmed in focus group discussions, with a lack of resources as an additional important challenge.
Conclusions
A new workable model for NCC has been developed, facilitated by this analysis. Steps to overcome barriers demonstrated in this study include additional educational measures, changes to the rounding protocols, and patient allocation algorithms.
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Acknowledgments
Funding for this Project was provided through the Innovation Fund from Ontario’s Academic Health Science Centres’ Alternate Funding Plan (AHSC AFP). A.K.S. is supported by the Ontario Neurotrauma Foundation. Thanks to Eman Leung, Ph. D. who is the Manager of the Knowledge Translation Program at the Li Ka Shing Knowledge Institute at St. Michael’s Hospital for his advice on study design. The authors thank registered nurses Lars Kure, Katie Weaver, Andrea Fernandes, and Grace Walter for their efforts throughout the implementation process.
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The authors declare that they have no conflict of interest.
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Appendix
Appendix
See Fig. 6.
Sunnybrook’s algorithm for the assignment of ICU patients to the neurocritical care service (neuro team) or critical care service (MedSurg team), based on diagnosis
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Botting, M.J., Phan, N., Rubenfeld, G.D. et al. Using Barriers Analysis to Refine a Novel Model of Neurocritical Care. Neurocrit Care 20, 5–14 (2014). https://doi.org/10.1007/s12028-013-9905-3
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DOI: https://doi.org/10.1007/s12028-013-9905-3