Interprofessional collaboration in the ICU: how to define

1
Inter-professional collaboration in the ICU how
to define?

• Dr Louise Rose
• BN, ICU Cert, MN, PhD
• Lawrence S. Bloomberg Professor in Critical Care
  Nursing
• University of Toronto

2
Interprofessional Issues

• Effective interprofessional communication and
  collaboration are critical
• Research indicates communication and
  collaboration are NOT effective in many health
  care settings
• Poor communication, teamwork and problem solving
  in ICUs
• Considered more prevalent and important by nurses
  than physicians

Garland et al (2005) Chest 1272151-64 Miler
(2001) Am J Crit Care 10 341-50 Baggs et al
(1997) Am J Crit Care 6 393-9
3
Collaborative Practice

• promotes the active participation of each
  discipline in patient care by optimizing staff
  participation in clinical decision making within
  and across disciplines while encouraging respect
  for the contributions of all professionals.

Herbert, C. (2005). J Interprofessional Care,
Suppl 1, 1-4.
4
Collaboration

• Implies sharing and collective action
• Barriers
• Boundary infringements
• Lack of understanding of roles
• Limited communication
• Poorly coordinated teamwork

5
COLLABORATION
CONFLICT
Authority Education Patient needs Knowledge Resour
ces Time
Lingard et al (2004) Crit Care 8R403-408
6
What about Autonomy?
Collaboration Interdependency NOT Autonomy
Consider autonomy of the team as opposed to
individual members or professions
7
Systemic Determinants of Collaboration
Disparate social status and gender stereotypes
Social system
May foster autonomy over collaborative practice
Cultural system
Perspective that may be in direct opposition to
collaboration
Professional system
Socialization into a profession
Educational system
8
Organizational Determinants of Collaboration
Organizational structure
Hierarchical vs horizontal structures
Participation, interdependence,integrity, trust
Organizational philosophy
Administrative support
Leaders role model collaborative practice
Time, space sharing
Team resources
9
Assessing ICU Performance
Survival ICU, hospital, long-term Complication
rates Medical errors Symptom control
Medical Outcomes
Resource consumption Cost-effectiveness of care
Economic Outcomes
Quality of life Patient and family
satisfaction Concordance with wishes
Psychological Outcomes
Staff satisfaction and turnover Effectiveness of
ICU bed utilization satisfaction with ICU
services Efficiency of ICU services
Institutional Outcomes
10
Benefits of Collaboration

• differences (in actual vs predicted death rates
  of ICUs) occurred within specific diagnostic
  categories, for medical patients alone and for
  medical and surgical patients combined, and were
  related more to the interaction and coordination
  of each hospital's intensive care unit staff than
  to the unit's administrative structure, amount of
  specialized treatment used, or the hospital's
  teaching status.

Knaus et al. (1986) Arch Int Med 104410-8
11
Benefits of Collaboration

• Participants in low SMR/high performing ICUs
  perceived group functioning at a higher level
  than middle to high SMR/low performing ICUs

SMR Standardized mortality ratio
12
Promoting Teamwork

• Communication interventions that promote teamwork
  across professional roles
• Checklists
• ICU daily goals
• Interdisciplinary rounds
• Protocols/guidelines

13
(No Transcript)
14
Checklists/Daily Goals
15

• Unit-based safety program incorporating
• clinician education
• designated central-line cart
• checklist for infection control practices
• daily goals sheet
• monthly feedback
• Sites designated one physician and one nurse team
  leader
• Intervention authorized team members to stop a
  procedure deemed as unsafe

16
(No Transcript)
17
Checklists and Daily Goals

• Considerations and questions
• Who should develop?
• Who polices/ is responsible?
• What are the consequences for non-compliance?
• Potential for interdisciplinary conflict
• Potential for empowerment/power sharing

18
Interdisciplinary Rounds

• Definitional Considerations
• Interdisciplinary vs multidisciplinary
• Its not about WHO is there rather its about the
  collaborative discussion and decision making
  process

WHAT HAPPENS IN YOUR ICU?
19
Protocols and Guidelines Ventilator Weaning -
the Pro Evidence
20
Protocols and Guidelines Ventilator Weaning -
the Con Evidence
21
Protocols and Guidelines Ventilator Weaning the
Con Evidence
22
Protocols and Guidelines Sedation - the Pro
Evidence
23
Protocols and Guidelines Sedation -the Con
Evidence
24
Protocols and Guidelines Considerations

• Can they be considered tools for
  interprofessional collaboration?
• Evidence indicates effect is context-specific
• Potential for influence of
• staff-mix and education
• organizational structure
• existing collaborative decision-making models

25
What should we be aiming for?

• Interdependency as opposed to autonomy
• Patient centred as opposed to profession centred
• Sharing of responsibility, decision making,
  values, planning and interventions, data
• Hierarchical structures should be flattened where
  possible
• Power/decision making responsibility should be
  based on experience and knowledge not function or
  title

• So how do you make this work in your ICU?

26
Thank you, Questions?
louise.rose_at_utoronto.ca