Year : 2021 | Volume
: 5 | Issue : 2 | Page : 13--18
The impact of multidisciplinary team care on decreasing intensive care unit mortality
Amal A Al Khalfan1, Ahmed A Al Ghamdi2, Stephanie De Simone3, Yasser H Hadi4,
1 Department of Respiratory Therapy, Inaya Medical Colleges, Riyadh, Saudi Arabia
2 Department of Critical Care Service, King Fahad Medical City, Riyadh, Saudi Arabia
3 ReMed, Philadelphia, PA, USA
4 Department of Radiological Sciences, Inaya Medical Colleges, Riyadh, Saudi Arabia
Amal A Al Khalfan
Department of Respiratory Therapy, Inaya Medical Colleges, Al Qirawan, Riyadh 13541
Patients with critical illness and high mortality risk are frequently admitted to intensive care units (ICUs). Therefore, improving the quality of healthcare for these patients is essential. Improving overall health and following best practices for patient safety are important goals in the health-care sector; especially in critically ill patients. To achieve these goals, many researches have been conducted to develop procedures, protocols and improve ICU structure and design. To discuss the effectiveness of multidisciplinary team (MDT) implementation in ICUs in the Saudi Arabian hospitals and how would this approach significantly reduce ICU mortality rates and improves the quality of healthcare. This review search of electronic search engines was conducted, including ProQuest, Medline, and Google Scholar. The search was narrowed to a total of 21 articles between 2010 and 2020 articles were included, which were found to match the inclusion criteria. Findings indicated a positive effect of the MDT care on decreasing the ICU's mortality rates. The studies reviewed have documented the necessity of successful MDT care implementation for improved survival rates. A collaborative approach by the various health-care providers-nurses, physicians, intensivists, respiratory therapists, and pharmacists–enhances patient care, improves clinical outcomes, and reduces the mortality rate.
|How to cite this article:|
Al Khalfan AA, Al Ghamdi AA, De Simone S, Hadi YH. The impact of multidisciplinary team care on decreasing intensive care unit mortality.Saudi Crit Care J 2021;5:13-18
|How to cite this URL:|
Al Khalfan AA, Al Ghamdi AA, De Simone S, Hadi YH. The impact of multidisciplinary team care on decreasing intensive care unit mortality. Saudi Crit Care J [serial online] 2021 [cited 2021 Sep 27 ];5:13-18
Available from: https://www.sccj-sa.org/text.asp?2021/5/2/13/319311
Patients with critical illness and high mortality risk are frequently admitted to intensive care units (ICUs). Therefore, improving the quality of health-care services provided in ICUs for these patients is essential to ensure the preservation of life. In the ICU, it is crucial for health-care providers and staff to be able to effectively communicate, quickly access various information systems, and operate life-saving medical equipment for monitoring and treatment of critically ill patients. Each year, millions of patients are admitted to ICUs due to high-risk disorders such as acute lung injury, sepsis, and cardiac diseases. These conditions increase the mortality rate of ICU patients and place additional strain on available medical staff and resources. Furthermore, a prolonged stay in the ICU is associated with a high incidence of complications and a 10% increase in mortality rates. Bolstering overall patient health and wellness, establishing best practices, and improving survival rates are fundamental cornerstones of healthcare in ICU. To achieve these goals and continue progress in ICU care, many researches have been conducted to develop procedures, protocols and improve unit structure and design.
Implementation of a multidisciplinary team (MDT) is an effective method of patient care that significantly improves the quality of healthcare provided in ICUs. These teams were established in many countries after observational evidence identified their better outcomes among patients with various high-risk disorders.,,,, The implementation of MDT protocols has been proven to improve the quality of healthcare and decrease mortality rates in the ICU. The application of MDT's approach in the ICUs allows staff to work cohesively, communicate effectively, reduce adverse events, and utilize best practices for positive outcomes. It also increases patient survival rates and reduces mortality by 29%. Failure to adopt sufficient multidisciplinary and communication protocols between ICU team results in fragmented treatment plans and increases the risk of ICU mortality. There are limited available research demonstrating the importance of MDTs in the Saudi Arabian health-care system.
This literature review hypothesizes that the implementation of MDTs in ICUs in the Saudi Arabian hospitals will reduce ICU mortality rates.
This review evaluated 21 articles between 2010 and 2020 to determine the influence of a multidisciplinary approach on ICU mortality rates among high-risk disorder patients in different countries and health-care systems. This review search of electronic search engines was conducted, including ProQuest, Medline, and Google Scholar. The inclusion criteria included studies conducted on patients aged 18 years and above, and patients admitted to ICUs for at least 48 h with high-risk conditions. Articles without results regarding the impact of a MDT on mortality and those focusing on pediatric patients and patients with short term admissions were excluded.
The Necessity of Providing High-Quality Care for Intensive Care Unit Patients with High-Risk Disorders
In the past decade, health-care systems worldwide have experienced an expansion of the magnitude of ICUs in hospitals due to significant improvements in life-sustaining technologies. The ICU is an integral part of the inpatient setting. It works closely with the other hospital departments. Acknowledging the importance of the ICU's role in the overall hospital health-care systems, decisions regarding hospital budgets and operational plans should take into account the necessity of critical care resources, staff education, and work environment in ICUs that will ensure high-quality patient care.
Quality improvement (QI) assurance in health-care services is essential for patient health and safety. So, many studies involving hospital infrastructure focus on quality and safety in the ICU. Increasing adherence to evidence-based regulations, tracking procedures, and assessing outcomes are significant to enhance the quality of care. The Institute of Medicine in the United States defines quality as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." It also proposes that the quality of care should be safe, reliable, patient-centered, timely-secure, and equitable.,,
Published studies from Canada and the United States discussed the importance of improving health-care quality in medical facilities and supportive medical services. QI initiatives in the ICU started in the late 20th century. These initiatives suggest that hospitals collect data on their results and pinpoint strengths and weaknesses in patient care, stress on the importance of continuous evolution in ICU development, resulting in improved quality in healthcare. Donabedian, a researcher from the School of Public Health, University of Michigan, developed the system, procedure, and result model for improving health care. Bergen, an ICU nurse at Saskatoon City Hospital, applied these concepts to health care and led these initiatives in the USA to improve the quality of care., Mallon and Codman, pioneers of QI in healthcare in the early 20th century, conducted ample research on improving the quality of healthcare in the United States and reported their results in a book titled "The End Result of a Life in Medicine."
The objective of patient care quality in the ICU is to optimize critical care scorecard measures covering various areas of ICU operation. The critical care scorecard is also a tool for comparing characteristics and outcomes within facilities and healthcare systems in various regions over time. Critically ill patient care is resource-intensive, and ICU's often comprise 15%–20% of hospital budgets., Poor quality treatment contributes to increased costs, morbidity and death. QI programs implemented in the ICU aim to improve outcomes and reduce hospital costs by reduction of serious complications such as nosocomial infections.,
The Saudi Arabian healthcare system is continuously developing in accordance with the strategic actions of the 2030 Saudi Vision initiatives. The comparable results and studies documented in other countries must be demonstrated in Saudi Arabia in order to be effectively implemented in the critical care field. The effectiveness of ICU services needs to be thoroughly analyzed to understand problems facing the healthcare system in order to make the decisions that improve the quality of care provided.
Causes of High Mortality Rate in the Intensive Care Unit and Solutions
Despite technological developments in patient care, ICU mortality remains high with significant variances in rates due to differences in patient case, treatment plans, and organization of care., Typically, ICUs admit patients with severe conditions, and resuscitation is often required. The global average of ICU mortality rates ranges from 8% to 20%.
Death of ICU patients may occur secondary to the primary illness, underlying comorbidities, resulting complications, iatrogenic events, refusal of life-sustaining treatments, and the termination of critical care at the discretion of the patients and their family. Additional factors affect the mortality rate such as the percentage of ICU admission relative to hospital admission, the number of critically ill patients, specific treatment modalities administered and length of ICU stay. The key risk factors for mortality in the ICU are central nervous system failure, cardiovascular failure, and multiple organ failure. Mayr et al. from Innsbruck Medical University collaborated with colleagues from multiple Austrian institutions studied the cause of death in 3700 patients admitted to the ICU. Their research focused on the causes of death of patients in the ICU, in-hospital mortality after ICU discharge, and 1-year mortality after ICU entry. Their results indicated that multiple organ failure was the most prevalent cause of death of ICU patients representing 47%. Patients died secondary to CNS failure represented 16.07%, while patients died secondary to cardiovascular failure represented 12.0%. Data also indicated that malignant tumors caused more than a third of hospital deaths in patients discharged from the ICU as well as mortality 1 year after ICU admission.
In order to improve the quality of health-care provided in ICU's and lower its mortality rates, it is imperative to develop new technologies and strategies. The purpose of QI is to improve quality and achieve progress by following regulations and standards, evaluating safety procedures, measuring the success of outcomes, and identifying metrics vital to the development of ICUs.,,
Recent studies have shown that the application of invasive mechanical ventilation (IMV) weaning protocols managed by an MDT could significantly reduce IMV duration, and allow successful extubation in 95.3% of patients.,,, Using the MDT protocols could also reduce the ICU's length of stay compared to other patients not managed by this protocol.,,, The majority of these studies have pursued gradual changes in outcomes through the reorganization of physician staffing.,,, The analysis of changes implemented in low-performing ICU's examines the closed-model for intensivist staffing as well as improvements achieved through the use of 24-h ICU staffing. However, no previous research has assessed how much change a MDT can achieve through implementing and developing a high-intensity organizational model in Saudi Arabia.
The Implementation of Multidisciplinary Team Protocols in Intensive Care Unit
The MDT protocol is adopted to promote cooperation among caregivers and enhance the sharing of pertinent clinical information crucial for patient care. According to Kim et al., the MDT can consist of diverse professions, including physicians, nurses, intensivists, pharmacists, dietitians, physiotherapy, and other health-care providers. Commonly, MDT conducts multidisciplinary rounds to assess patients' conditions. These rounds facilitate the adoption of evidence-based practices while ensuring communication among caregivers. The participation of pharmacists in multidisciplinary rounds has a significant impact on the reduction of adverse drug effects as they ensure proper prescription and administration. Notably, MDT protocol suits organizations that have adequate multidisciplinary staffing to meet patient needs.
Health-care providers emphasize the need for collaboration in the provision of intensive care. Chen et al. indicated that such collaborative practice is characterized by teamwork, accountability, and inter-professional communication. A supportive and collaborative environment is created when teamwork is nurtured, caregivers respect each other's opinions, and multidisciplinary staff work together to provide comprehensive care. Multidisciplinary ICU providers should receive professional development to improve communication and interpersonal skills.
Nurses and physicians are two categories of health-care providers that integrate interprofessional collaboration into their daily patient care. A study by Kvande et al., interviewed nurses and physicians to establish their perception of dialogue. Every caregiver should play his/her role effectively for beneficial collaboration. The nurse should conduct a thorough patient assessment and discuss their clinical findings and assessment with the physicians. Physicians should be ready to listen to the nursing officers in order to have a comprehensive understanding of the patient case. Wang et al. reviewed existing literature on interprofessional communication between physicians and nurses. These two cadres undertake distinct responsibilities with a common objective of augmenting the client's wellbeing. The authors indicated that ICU caregivers should use daily goal sheets to improve communication between different cadres and incorporate team training for a multidisciplinary work structure.
Following the creation of an MDT, the expectation is that the team will ensure strict implementation of the recommended treatment plans. A study by Raine et al. sought to examine the impact of patients' factors, skill mix, and team climate inventory (TCI) on the adoption of cancer treatment plans. Patient factors included conditions such as underlying illness and gender. The skill mix included the number of healthcare cadres represented in the team. The TCI was defined by the vision, accountability, and participative atmosphere. While adherence to the treatment plan was observed in cancer management, the treatment plan was not followed in managing mental health conditions such as dementia. The TCI was also compromised by the dominance of some cadres at others' expense. The perspectives of clinical practitioners were prioritized while disregarding the input of social workers.
Interprofessional differences in the ICU are likely to complicate the implementation of MDTs. Wysham et al. decried the divergent attitudes by nurses and physicians that threaten collaboration by the palliative care team. Some caregivers believed that the inclusion of specialists in the palliative care team would improve the patients' well-being. The authors noted that specialist care is underutilized, and palliative care team members prefer a system that augments their relationship. In addition, the research revealed that some clinicians believe ICU nurses should be less involved in palliative care.
Effects of Multidisciplinary Team Care on Mortality Rates in Intensive Care Units
Numerous studies examining the effects of MDT care on ICU mortality have documented positive clinical outcomes and decreased mortality rates secondary to successful implementation. These studies have included patients with various high-risk conditions and comorbidities. Results include statistics for the reductions of in-hospital and all-cause mortality rates as well as increase in survival rates.
A study conducted in American hospitals documented lower mortality rates in ICU's with the implementation of MDT daily rounds along with a high intensivist to MDT staff ratio (odds ratio of 0.88). Overall, a 16% reduction in odds of death was observed over the course of the study. Mortality rates were also lower with a low intensivist to MDT staff ratio than in an ICU without MDT's (odds ratio of 0.88). ICU patients that participated in this particular study included nonsurgical and noncardiac patients.
Another research conducted in the United States examined the effects of MDT's on 30-day readmission and mortality rates in heart failure patients. After MDT implementation, 30-day readmission rates were 21% lower than the control groups; 30-day mortality rates were 52% lower than the control groups. MDTs also decreased posttransplant mortality rates for heart transplant patients. In-hospital mortality rates decreased from 22.2% to 16.2% and all-cause mortality rates decreased from 25.8% to 18.9% with MDTs. Additionally, a study by Barekatain, Fanari, Hammami et al., monitored critically ill patients admitted to a cardiac care unit. Its results showed that the implementation of MDTs in their critical care unit decreased the mortality rates from 5.9% to 3.5%; adjusted hospital mortality rates decreased from 11.1% to 4.4%.
Regarding to burn patients, a study examined burn patients in critical care units in England and Wales over a 6-year period demonstrated an overall decrease in-hospital mortality rates with the expansion of the use of multidisciplinary care teams.
For critically ill patients with severe acute respiratory failure, research has documented the efficiency of MDT care implementation. A research conducted in South Korea to explore the implementation of MDTs care in patients with severe acute respiratory failure, revealed decreased mortality rates of critically ill patients requiring supportive respiratory therapists in the ICU and decreasing the 1-year mortality rates from 37.8% to 14.3%.
In ICUs, cancer patients are typically subjected to high mortality rates, especially those having lung cancer. Research in hospitals in the United States examined the 5-year mortality rates of lung cancer patients after receiving their initial diagnosis. Lung cancer patients receiving traditional care in the ICU had a survival rate of 23.0%, while those receiving treatment by a MDT had an improved survival rate of 33.6%.
The implementation of MDTs approach in patients with other cancer types has demonstrated an increase in 5-year survival rates. Data collected in China for research examining MDT's effects on gastric and colorectal cancer patients in hospitals showed an increase in 5-year survival rates to 77.23% after being 69.75%.
Another research in Scotland examined the positive effects of the implementation of MDT care for breast cancer patient for 5 years. It showed a decrease in mortality rates by 18% and an 11% decrease in all-cause mortality rates and improved overall survival rates.
Orthopedic patients are also excellent candidates for MDT care. A study conducted in Italy surveyed the use of the multidisciplinary model in geriatric hip fracture patients. The results showed a successful reduction of pre-and post-operative complications and mortality rates after implementing multidisciplinary care. Similar research in Spain assessed the implementation of a multidisciplinary approach to the postoperative care of geriatric hip fracture patients. Its results revealed decreased mortality rates as well as the length of hospital stay after the MDT approach.
Research on the effects of the MDT care for pregnant females with high-risk disorders has also documented decreased in mortality rates. A study conducted in Ghana examining the use of MDT's during the intensive care of pregnant sickle-cell patients demonstrated a reduction in the maternal mortality rate. With the care of an obstetric hematology MDT, the maternal mortality rate was reduced by 89.1% within 13 months after the program implementation.
The scope of the literature reviewed demonstrates the versatility and the positive effects of MDT care on decreasing the ICUs mortality rates. The studies reviewed have documented the necessity of successful MDT care implementation for improved survival rates. MDT care is a flexible patient care model that applies to a vast array of patient populations, geographic regions, and critical care needs.
Conclusion and Recommendations
An MDT is a collaborative approach by the various healthcare providers-nurses, physicians, intensivists, respiratory therapists, and pharmacists– that enhance patient care and improve clinical outcomes. Healthcare providers are expected to work as a team to ensure timely, safe interventions. Consultations and interprofessional communication between the MDT members promote transmission of critical information and insights, resulting in an effective treatment approach and patient care superior to previous care models. Patients also benefit from enhanced monitoring through dynamic interprofessional communication during their care.
Hospitals in Saudi Arabia will benefit from the adoption of multidisciplinary treatment plans for the patient in the ICU. This recommendation is supported by research that has demonstrated the efficacy of collaboration in reducing mortality. However, the ICU healthcare providers will require sufficient interprofessional training to facilitate a dialogue between MDT members that is respectful, effective, and constructive. Caregivers from each cadre should participate in clinical decision-making, provide a rationale for treatment proposals. Moreover, hospital administrators should provide a supportive environment for teamwork. MDT s succeed in facilities with adequate staffing to allow time for consultations between team members. Implementation of multidisciplinary care in the ICU is an evidence-based practice that will improve patient outcomes.
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Conflicts of interest
There are no conflicts of interest.
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