The Power of Unplugged: Improving Care in the ICU

The annual ESICM LIVES Congress has incorporated “Unplugged” sessions for the past several years.  At these sessions, presenters are free to structure the 30-minute session to address topics they identify as relevant.  Many presenters choose to speak to ongoing research or project work they are involved with.  At the 32nd annual LIVES Congress in Berlin, Germany, critical care clinicians from over 20 countries gathered to participate in the session entitled “What I would like to improve in the ICU” as part of an Unplugged” session. This “Unplugged” session used the interactive tool LIVESNote to actively engage participants to identify ideas for improvement.  The session was recorded as a livestream session, and showcased how interaction and dialogue at LIVES can be used to actively engage participants to result in more than just conference discussions.  The attendees, unknown to one another at the beginning the session, were engaged afterwards to collaborate to write this blog.

Why Focus on Improving ICU Care?

A substantial number of acutely ill patients require admission to the intensive care unit (ICU) for critical care conditions, many of which are life-threatening. Globally, ICU care has become more complex and the resources needed to support it continue to escalate. Critically ill patients increasingly receive invasive monitoring with ever more complicated strategies to support oxygenation, breathing, and circulation. Inter-professional teams provide stabilization of acute or life-threatening medical problems including comprehensive and aggressive management of injury and/or illness, with a growing awareness of the burden of an ICU admission on patients and their families. As ICUs provide care for the most critically ill patients and are one of the most resource-demanding areas of the hospital, evaluating ways to improve care is essential.

Recommendations for Improving ICU Care

Through interactive discussion, a number of recommendations for improvements were identified including sedation practices in the ICU; implementing best care practices such as early mobility; promoting sleep hygiene; advocating for patient- and family- centered care; ensuring appropriate ICU staffing, particularly as it relates to nurse:patient ratios; recognizing when care is futile; better strategies to optimize ICU safety including the greater use of safety huddles; improving clinician resilience; and promoting a healthy work environment, among others (See Figure).

Changing the Culture in the ICU

Changing the culture in the ICU to promote these improvements is an essential component. Clinicians often perceive that changing practice will be difficult, or will be met with resistance. Yet, changing practices that can benefit patient care improvement and result in better outcomes is today a requirement and a direct responsibility of all ICU clinicians.

The topics identified in the LIVES session are consistent with literature published on the subject of improving care in the ICU.  Several articles including a two-part series on “improving the ICU” in 2005, have addressed ways the ICU environment, processes of care, patient care management, and promoting team based care can enhance ICU care delivery (and patient outcomes). Current literature emphasizes that improving ICU performance requires a shift from a paradigm that focuses on individual performance to one that emphasizes improvement in ICU systems and processes. This was reflected in the session discussion as participants identified that ICU systems and processes such as adequate resources for promoting early mobilization as an example, would improve care in the ICU. The importance of interprofessional collaboration and teamwork in the ICU to promote and support clinical practice changes was also highlighted and the provision of resources and leadership support were identified as additional requirements for successful care improvement initiatives.  Of additional consideration is the importance of collaboration with former ICU patients and their relatives regarding changing the perspectives of healthcare professionals. It is because of their real life stories, during and after the ICU period, that healthcare professionals gain deeper new insights and often change their behavior in a more humanizing/compassionate way.

It is well acknowledged that at the beginning of the intensive care era, both the identification of leading physiologic disorders and monitoring of the effectiveness of treatment was conducted primarily by clinicians based on their experience. Now more and more ICU functions are related to the use of equipment, which can make intensive care less humanizing and more technical. This is challenging for ICU staff to empathize and feel a personal responsibility for the patient’s outcome.

Useful strategies for implementing care improvements in the ICU were acknowledged by several attendees who shared examples from their own experiences. These included enlisting unit-based champions to help lead clinical change initiatives and provide personal support to colleagues, ensuring that all ICU team members have information on the clinical practice changes. Strategies include communicating and providing updates on an ongoing basis, establishing vlogs and blogs supporting the improvement, discussing the perceived barriers, and measuring and reporting the impact of implementing improvements.

Getting”Unplugged”

The value of an “Unplugged” session was evident by the degree of active discussion and dialogue among critical care clinicians who shared recommendations for improving care in the ICU. Variation in care practices was acknowledged as an existing deficiency in the way in which care is being provided globally for critically ill patients. Strategies identified to implement changes in care include garnering administrative support, enlisting unit-based champions, engaging clinicians in quality improvement and research, and highlighting the impact of implementing improvements in ICU care. This interactive session proved to be a successful way to engage conference attendees to address priority areas for improving care in the ICU, and showcase the power of being “Unplugged!”

References available upon request. Contact: ruth.kleinpell@vanderbilt.edu

Authors:

Ruth Kleinpell PhD RN FCCM, Vanderbilt University School of Nursing, Nashville TN, USA

John W. Devlin, PharmD, BCCCP, FCCM, FCCP, School of Pharmacy, Northeastern University, Boston, MA, USA

Mai S. Hashhoush PharmD, ASHP CCT, King Fahad Specialist Hospital, Dammam, Saudi Arabia

Magdalena Hoffmann, PhD MSc, MBA Medical University of Graz, Austria

Stephanie Hunter CCRN, BN (Hons), MN, PhD (C) Deakin University & Eastern Health, Melbourne, Australia

Katerina Iliopoulou PhD RN Florence Nightgale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, UK

Horace Nowell BS, Rush University, Chicago Illinois USA

Maksym Pylypenko MD PhD, National Medical Academy of Postgraduate Education, Kyiv, Ukraine

M.M.C. (Margo) van Mol PhD. Erasmus MC University Medical Center, Rotterdam, the Netherlands

Dr. Wajihah Saghir, MBBS, MScMedEd, Southend University Hospital, Southend, Essex, United Kingdom

Social Media Team Interviews

It’s two months since ESICM LIVES 2019 in Berlin, which can only mean one thing: time to release the Social Media Team Interviews!

Of course, the Social Media Team were busy gathering, curating and creating content to capture messages and connect audiences around the world. However, as a new member, I was struck by the industry and ingenuity of my seasoned colleagues. Where did they get this phenomenal energy and drive to work so hard? How do they harness the beast of social media to bring about something actually worthwhile? Most of all, they all seem so up to date – and they seem to know everything about everything in the world of ICU research!

Gratefully, I was able to interview all nine members using my coloured pencils. Here are the results! I asked three questions: who are you? You do so much – where do you get the energy to engage? Navigating the digital world is such a challenge, and somehow you are able to keep up with the cutting edge of ICU research using it – what’s your method, your workflow? I’ll summarise as we go…

Adrian Wong: Eurovision and Destiny 2 Lover, Social Media Team leader/hero. He loves ICU and makes his main goal to work with people he’d like to go to the pub with…and the drinks are on him. Twitter should be treated like a newspaper, with something for everyone. Top tip: save articles to Pocket to read later, and save articles to Evernote into labelled folders. Bonus fact: I’m really grateful to Adrian for inviting me on board.

Jonathan Downham: father of twin boys and rugby fanatic. He loves being a geek, and he loves the excitement of it all. He’s missing a few words from his vocabulary. Twitter is there to signpost us to the really important bits of work. He has his own study with lighting, sound desk, triple screen layout, and a roller blind behind him that acts as a green screen. Top Tip: these are much cheaper when bought from a home decorating shop, but just as effective as a professional cinematic bit of kit. Bonus fact: he uses his teaching blog as a way of learning for himself…

Lars Mølgaard Saxhaug: organiser of the UKA festival in Norway, hosting Jay-Z and Franz Ferdinand. He also has two ovens. His social media adventures all sprung out of sheer curiosity, and now he gets to have conversations with people he never would have met without social media…and to read papers he never would have come across. Top Tip: be deliberate and selective in who you follow on social media.

Renske Wiersema: she doesn’t “do” social media…. her real motivations are… how can we stop people getting sick? How can we do good science that allows us to make progress? Her real motivator is teamwork, with mutual learning, laughter and enthusiasm. Bonus fact: this picture does not look like Renske. At all. Sorry, Renske.

Velia Antonini: the personification of ECMO (extra-corporeal membrane oxygenation). Her life goal is a happiness that is a very specific blend of social media, ECMO and FOAM (free open-access medical education). Top tips: Velia’s specific method of staying up to date is to type her search strategy (ECMO) into PubMed on a daily basis and catch up with the latest articles. From there, she summarises the content for social media to engage and connect others. For the really good stuff, she creates infographics using Adobe Illustrator… or Keynote if she’s at a conference. Bonus fact: she is considered by many to be the hardest working person in FOAM…

Aoife Abbey: author, who doesn’t believe she’s an author because she’s only got one bestseller. Her motivation is the desperate need for community that’s so easily lost in modern medicine… she has a couple of Top Tips: if you save articles to Pocket (freely available App), you can even use it to read you the articles while you’re doing the washing up! Aoife uses the Apple Pencil and the Notability App to create her legendary, chart-topping infographics and sketchnotes. Bonus Fact: this, again, doesn’t look anything like Aoife. So sorry, Aoife.

Jamie Strachan: bridge builder between technology and training. He basically likes everything. He is continually improving his work life balance and finding his why. He started out on twitter with flurries of follows but now he uses structure and focus to make sure he’s effective. Bonus fact: he only sends two thirds of the tweets he composes! Top Tips: check out the ALIEM How I work smarter articles for other top tips….his is to try ordering emails and folders by months and years…

David Lyness: he’s another team builder with the goal to democratise medical education. He loves to create and to dig in – whether it’s finding different views or being cynical. He built his own computer in his self-converted garage. It sounds like some sort of Bat Cave. Top tips: again, be very selective in who you follow. Bonus fact: this sketchnote was created over the phone, so I drew both a man in a tux and an octopus, because I couldn’t quite remember what he looked like.

Segun Olusanya: man with six names, all of which are beautiful. He also claims to be the longest serving ICM trainee in the UK. He is powered by two AA batteries called Love and Hope. Social media is, indeed, like trying to drink from a fire hose, but our job is to focus and be a librarian not a library. The workflow is: a page of Tolstoy’s calendar of wisdom in the morning, a quick scroll during breaks at work, and using TweetDeck while on his daily commute. Top Tip: tweetdeck allows you to have multiple open columns with key searches: POCUS, FOAMcc, for example. Top Tip 2: try having a special focus for the season…what are you going to learn that’s new this year?

Sketchnotes at LIVES 2019

This year I had the privilege of joining the ESICM Social Media team as a sketchnote artist. Combining live sketchnotes with a passion for your own specialism brings a whole world of opportunities for engagement and communication – I’ve enjoyed it immensely and I would recommend it to anyone wanting to increase their GCS during a marathon conference! Here are some of the highlights from LIVES 2019:

Annemiek Nooteboom: The Importance of Body Language. A tour de fource of “fun, stereotyping and plagiarism” (her words, not mine!) set alongside a stirring nightclub-style soundtrack, Annemiek Nooteboom demonstrated dominant and subservient body language. We were surprised to see Prof Armand Girbes take the counter-role; it was all a bit real. Key lessons: three phases of training include (1) fake it till you make it – don’t act invisible, (2) multiple personalities – as the boss, sometimes it’s your job to look the part, (3) the Godfather phase – in official leadership, you *must* adopt non-threatening body language to counteract the inevitable intimidation and fear that such a role engenders.

Intoduction and Highlights – Prof Armand Girbes and a pair of magicians… Congratulations are in order for the ESICM leadership, as they demonstrate further steps forward on the path to diversity and transparency. The percentage of female speakers is at its highest yet (27%). It’s possible they’ve been using magic – our entertainers were able to woo the audience “Pen & Teller” style. Most striking was the tic-tac-toe they asked the audience to choose each next move with, only to reveal on the flip-side of the game that their tile choices had spelled out the conference logo…

Subsequently I visited the NEXT Lounge for aspiring young intensivists for a whistle-stop tour of acid-base physiology. Eric Hoste illustrated the basics in this high-tech “blackboard” session, replete with gems of history and clinical applicability. He did well to create an interactive atmosphere with good to-and-fro between him and participants.

In the Tech Lounge, Steve Harris unveiled “How to turn your data into gold.” For me, the most profound insight he stressed was that clinicians may rarely ever be true data science methodology experts. However, clinicians can offer the unique and crucial advantage of being able to ensure data is meaningful for the patients we serve. This is why it’s so important to stay close to your data and ensure it’s trustworthy.

The NEXT lounge offered a thought-provoking debate into the nature of religion and ethics in providing good care. Sharon Einav described some of the profound differences in providing end of life care, in particular, in legal sanctions against withdrawal of life sustaining therapies. A helpful member of our MDT in the future is the religious and cultural anthropologists, assisting in the navigation of these highly complex issues. Furthermore, how far do we distance our own personal ethical code from that of the patients, and what implications does this have – e.g. moral distress in extended futility? A huge set of unanswered questions for consideration in the future of global ICU – with Roland Francis, Sharon Einav, Burcin Halacli and Stefan Schaller.

Peter Pickkers presented the findings of this phase 2 study into a beta-HCG derivative, thought to have immunomodulatory roles in line with the effects of normal pregnancy. An infusion of the drug EA-230 during cardiac surgery was associated with better creatinine clearance and less AKI, as well as a slightly shorter length of stay. Other mechanistic questions – such as an effect on IL-6 or GFR – were negative. It was a pleasure to hear about this group’s work. https://www.ncbi.nlm.nih.gov/pubmed/30724734

I was thrilled to have attended the Global Intensive Care working group meeting, having heard about it but been unable to see it advertised. After picking up the time and date on the grapevine, I had the opportunity to hear about the ongoing early work. Most excitingly, the ALIVE sepsis course has launched in Kampala, Uganda with Mervyn Mer and Arthur Kwizera. It’s set to travel to three other locations in the coming months. It is the first of its kind; one day of mini-modules and another day of bedside teaching in a LMIC setting. Amongst the remaining activity, I was excited to see the publication of the freely available Springer volume, Sepsis Management in Low Resource Settings: https://www.springer.com/gp/book/9783030031428

 

Members of the Global ICU working group included Tim Baker and Carl Otto Schell. They have completed the Critical Illness Prevalence and Outcomes Study (CRISPOS) in Sri Lanka, Sweden and Malawi, demonstrating the point prevalence of several markers critical illness. Furthermore, they have shown a mortality benefit to Vital Signs Directed Therapy where lives were saved “by a piece of paper.” Re-examining the paradigm of critical care in resource limited settings, they continue to develop concepts addressing the need to design services that save lives rather than simply emulate existing strategies.

Georg Trummer discussed the use of ECMO in cardiac arrest as truly “buying time”. Perhaps eCPR should be part of a new chain of survival, opening a new window of opportunity? Experiments in pigs have shown excellent outcomes after a full twenty minutes of proper down time, he tells us. It is possible that eCPR could extend the golden hour, but the huge challenges in research, logistics etc make it difficult to see this should be implemented while questions remain unanswered. I note that Alberquerque, New Mexico, has just now set up the first eCPR service in the USA, arguably.

Lastly, Dominique Benoit discussed “Quality of Life as the Ultimate Goal?” His talk examined aims in treating the very elderly, so often a palliative population. On the other hand, these patients may be more accepting of poorer outcomes. He quoted the 20th century moral theologian George Dunstan, “the success of intensive care is not to be measured only by the statistics of survival, as though each death were a medical failure. It is to be measured by the quality of lives preserved or restored, the quality of the dying of those in whose interest it is to die and by the quality of relationships involved in each death.” https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1365-2044.1985.tb10852.x And in addition, he discussed ethical leadership, “being able to talk to anyone about anything”, composed of humility, vulnerability, altruism and courage, among other things. This was a moving and stirring talk and certainly a huge encouragement to this intensive care doctor.

Trauma: which fluid? when?

Which fluids need to be administered in the trauma patient? when? In trauma patients, fluid resuscitation aims at restoring circulating volume to prevent cardiac arrest due to severe hypovolemia, and at achieving a satisfying level of mean arterial pressure to ensure adequate tissue perfusion, limiting coagulation disorders. Lot of potential secondary adverse effects could be associated to  fluid resuscitation, ie hemodilution, acidosis & coagulation disorders.

In this infographic,  the concepts of permissive hypotension and remote damage control resuscitation RDCR, and some notes on on crystalloids, colloids & blood products.  

graphics by Marta Velia Antonini @FOAMecmo

content based on the talk given by Sophie Hamada, ICU Hôpital Bicêtre University Paris Sud, Groupe Traumabase.EU during the Trauma & surgery session  of the EDIC I Refresher Course at #LIVES2019 Congress