All posts by Adrian Wong

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

The nurse is the cornerstone of nutrition delivery (Nestle Health Science sponsored session)

Nurse driven metabolic care

(Mette Berger)

Pts with lower cumulative protein and energy deficits are 3x more likely to go home

ICU is a changeful environment – multiple factors preventing pts from being fed to prescribed goals, but the MAIN problem is often getting EN prescribed / re-started

Nurse-driven protocols (e.g. insulin infusion, catheter infection prevention, resuscitation etc) have a track record of working well!

–> Can Nutrition be nurse-driven, independent of doctors?

  • focus on glycaemic control
  • initiation / resumption of feeding
  • tube placement / control
  • monitoring of delivery

Clear protocols listing roles with describing their responsibilities

Metabolism and nutritional needs vary through the phases of critical illness / during rehabilitation

Nutritional Risk Score (NRS) to identify pts at risk of nutrition-related complications

Glycaemic control

  • demonstrable improvement in tight glucose control when transferred to the care of nurses
  • nurse immediately available to assess and respond to BMs

Initiation of Feeding

  • gastric residues may prevent feeding first 48 hrs post-op
  • can check using ultrasound
  • try pro kinetics during this time

Tube placement

  • tube checking protocols

Monitoring delivery

  • ESPEN guidelines suggest progressively increasing feeding; aggressive early feeding risks hurting sick gut

  • do NOT aim to cover prescribed feeding goals in the first week
  • nurse is well-positioned to detect signs of pt tolerating / not tolerating feed
  • Beware absent stools – Encourage emollients and fibres in feed upon initiation of feeding – this should not cause significant diarrhoea

 

**Metabolic rationale for starting slow:

Endogenous glucose production is stopped by eating (in healthy people) – this mechanism is lost in critical illness, and therefore there is continuous endogenous glucose production of 200-300g glucose / day = 800kcal even if EN is commenced

–> therefore, starting with a full feed will result in overfeeding

 

A nursing perspective on nutrition

(Beatrice Jenni-Moser, M-M Jeitziner)

Nutrition has a significant impact on a pt’s ability to respond to medical / nursing treatment

Large variation in nursing practices around nutrition (availability of nutritional guidelines, knowledge and leadership)

Nutrition is often prioritised lower than other care needs

** pt’s relatives are often concerned about having ‘enough to eat’

New paradigm of rehabilitation: Start early, not at the end of medical treatment

–> the same should apply to nutrition – need an MDT approach

 

Quality project

  • Setting: Interdisciplinary ICU / 37 beds
  • Approx 4000pts / year
  • Length of stay: 2.4days (mean); 8% of pts stay 7days or more

Aim: Overview of nutrition, diarrhoea and constipation

Method: Chart reviews

Sample: (Neurological disease 40%)

2018 – 97 pts, mean age 61.4 (16-90)

2017 – 93 pts, mean age 60.2 (21-94)

— Protocol designed around existing guidelines for patients and also potentially difficult pts

  • EN as the standard approach, early EN within 48 hrs
  • Continuous rather than bolus EN
  • Contraindication to oral, EN –> PN should start within 3-7 days
  • Early and progressive PN is better than starvation
  • After 3 days, caloric delivery can be increased up to 80-100%

Nutritional Assessment: In-depth evaluation of objective and subjective data related to an individual’s food and nutrient intake, lifestyle, medical history

Combine with Frailty scale in every pt for a baseline frailty score (not just in the older pts / long stay)

Take home message: ICU nurses are in a unique situation to take an active role in promoting the best nutritional outcomes to the pts

  • interprofessional nutrition education
  • nutritional screening and assessment
  • using standardised guidelines / protocols
  • evaluating nutrition support

Nursing & Allied Health Professionals – Post ICU Care: Impact & consequences (Abstracts)

Dealing with the aftermath of critical illness – the ENSURE (ENabling and SUpporting REcovery) intensive care follow up clinic

(Andrew Lockwood)

ICU survivors face long journey beyond hospital discharge

Adoption of InS:PIRE (Glasgow) post-ICU rehab model, incorporating needs of patient and family

  • Included: age >18, ICU stay >4d, self-referral or GP referral, pts from other ICUs living in catchment area
  • Engage primary care team (GPs on average see 1 ICU survivor per year)

 

5 week MDT approach

  • Off site location: parking, refreshments, no associations with hospital
  • checklist for concerns sent prior to identify issues and identify best MDT member to handle
  • weekly session for pt, also Carer session away from ICU survivor
  • Key strength: pt volunteers (previous ICU survivors)
  • Consultant and Psychologist meet with pt 2 out of 5 weeks to cover complex medical and psychological needs

Of note:

  1. Outcome measure score (including personal health rating, control of life etc) to ensure this follow up is adding value –> No drop-off in the score up to 1 year after the first follow-up meeting
  2. Follow-up team able to make direct onward referrals for further specialist input without going via GP
  3. Anecdotal report of pt benefiting greatly from visiting ICU bedspace – nightmares and flashbacks dissipated quickly after this
  4. Important to realise that ICU pts who were not sedated / ventilated can still develop psychological challenges during recovery
  5. Major stressor found not to be ICU admission but ICU discharge to ward –> will lead on to develop study morning for ward staff regarding post-ICU care
  6. Quarterly newsletter for ICU staff to feedback learning points, verbal messages passed to any named ward staff
  7. Noise issue – Noise Ears now installed to monitor and analyse noise levels, address accordingly
  8. Pt diaries previously for long-stayers, but all pts can benefit from diary
  9. Carer session – Carer Strain Index done on first meeting, but limited intervention as carer is not the pt

 

How does healthcare quality influence Care Left Undone in neonatal and paediatric intensive care units?

(Silvia Rossi)

Care Left Undone (CLU) phenomenon gained interest within the past decade – understanding this can contribute to quality improvement

Aim: Investigate which nursing staff and work environment variables could influence the prevalence of CLU in NICUs and PICUs

13 Hospitals: 3 Paediatric free-standing hospitals, 10 General hospitals, 169 Units

13 types of CLU (activity omitted on the nurse’s most recent shift)

Variables considered: Work environment (PES-NWI), Depersonalisation (MBI), Emotional exhaustion (MBI), Intention-to-leave, Quality of Healthcare

6 categories of care activities most at risk of becoming CLU:

  • adequate pt surveillance
  • pain management
  • educating pt and family
  • adequately documenting nursing care
  • planning care
  • frequent changing of pt position

 

Variables that could Increase the risk of omission:

  • Depersonalisation — Oral hygiene (OR=1.065; 95%CI=1.012-1.120)
  • Emotional exhaustion — Develop or update nursing care plans (OR=1.029; 95%CI=1.009-1.050)
  • Intention to leave job (within 1 year) — Prepare pts and families for discharge (OR=1.983, 95%CI=1.243-3.164)

Variables that could Reduce the risk of omission:

  • Good work environment — Develop or update nursing care plans (OR=0.152; 95%CI=0.342-0.768)

NOT taken into account: nursing workload, severity of illness, nurse-pt ratio

Conclusion:

Nurses miss some activities in presence of personal conditions and Environmental conditions including Organisational culture and Unit behaviour

Need to consider the CLU phenomenon in its Entirety

 

Effect of nurse led follow-up consultations to improve Sense of Coherence in patients discharged after intensive care treatment

(Ase Valso)

Pts with delusional and frightening ICU memories have increased risk for Post-traumatic stress (PTS) symptoms –> Constructing an illness narrative to make sense of ICU experiences important for psychological recovery

Sense of Coherence (SOC) reflects ability to cope with stress

  • Comprehensibility: make sense of adversity
  • Manageability: resources to meet challenges
  • Meaningfulness: challenges worth engagement

Included: >18 yo, ICU stay >24hrs

PTS score done shortly post-d/c from ICU – pts with higher scores (>25) randomised:

Standard care (control) or

Nurse-led follow up consultation (Intervention)

  • 1 meeting shortly after d/c (45-60mins), 1 or 2 further meetings (phone or in-person on ward)
  • Structured guide based on trauma focused CBT – aiming to give patient an improved Sense of Coherence, not psychological therapy (intervention nurse is experienced and familiar with ICU care, given 2d training but not experienced in psychology or psychiatry)

Of note:

  1. pts in intervention group scored highly in the SOC score, and nurse-led intervention did not significantly increase SOC compared to control group
  2. No obvious difference in outcome whether follow up was done by phone or in-person
  3. Criticism by author : existing belief is that early intervention to restore SOC may prevent onset of post-traumatic stress, but this study may have been carried out too early with sick patients; duration of intervention period may have been too short to detect any difference

 

Pain occurrence and associated factors after discharge from the intensive care unit to the hospital ward

(Kirsti Toien)

Same pt cohort as prevented in previous abstract on SOC and Nurse-led intervention

Pain is a serious and challenging problem for ICU pts, impacting on respiration, mobilisation and rehabilitation

  • pain management is important part of ICU care
  • focus and research is lacking on pain-related issues post-ICU discharge

 

Aim: To investigate pain intensity and interference with daily activity in pts immediately after ICU discharge, and to explore possible variables associated with worst pain and pain interference among demographic and clinical variables

Results (pain location) n=469

Abdomen  202 (43%); Lower back 132 (28%); Shoulder / forearm 102 (22%); Chest 82 (18%); Neck 76 (16%); Pelvis 71 (15%); Knee 70 (15%)

 

Physical and Psychological Outcomes of patients discharged from a rehab-active Critical Care Unit in the United Kingdom

(Fiona Howroyd)

Post-intensive Care syndrome (PICS):

  • physical (e.g. weakness, pain)
  • functional
  • psychosocial (e.g. anxiety, depression)
  • cognitive (memory impairment)

Aim: To identify levels of anxiety, depression, psychological stress and mobility, and to explore the impact of mobility levels upon psychological outcomes

Data collection over 3 months

Outcomes:

  • Hospital Anxiety Depression Scale (HADS)
  • Intensive Care Psychological Assessment Tool e.g. hallucinations, flashbacks, sleep problems (IPAT)
  • Manchester Mobility Scale (MMS)

Conclusions:

  1. High prevalence of psychological morbidity
  2. Increased mobility associated with less anxiety
  3. Increased mobility associated with shorter length of stay on ward

Of note: Structured ward follow up including physiotherapist, nurse and psychological support

Mobile pts can still have PICS and should be supported as required

Proteins – Is more better for all?

Enteral or Parenteral – Any difference?

(Olav Rooyackers)

Clear ESPEN recommendations: Normal way of eating is best = Oral > EN > PN

If EN / PN done well, with equal calories delivered — NO significant difference in outcomes of mortality 

Small RCT by Ferrie et al: PN with higher levels of amino acids (1.2g/kg) give small improvements in different measures e.g. grip strength, muscle thickness compared to PN with lower levels of amino acids (0.8g/kg)

FEED trial: to compare effect of standard EN formula vs. EN formula with higher protein supplementation on muscle mass and strength amongst other outcomes

Both EN and PN protein supplementation likely to affect muscle in some way.

  • currently no direct comparison between EN and PN in ICU pts
  • EN protein is partly taken up by the gut; PN protein bypasses splanchnic circulation – does this feed muscles directly and is it better??
  • Liebau et al. Critically ill pts handle protein differently – the critically ill gut is ‘selfish’ and extracts more amino acids compared to the gut in healthy volunteers, though initiation of EN causes a small but detectable improvement in whole body protein balance

Small study in 14 elderly pts comparing EN and PN amino acids administration showed muscle protein synthesis was not affected by route of administration

  • note: high doses amino acids used, unclear if a difference in muscle protein synthesis stimulation would be seen at lower doses of EN and PN administration

 

Relation between protein intakes and frailty

(Zudin A. Puthucheary)

Frailty is a complex interplay of factors: age, comorbidity, socio-economic status

Early days of critical illness: Immobility + Illness –> muscle protein synthesis (MPS) is decreased

Ageing population – increased age of pts admitted to ICU

  • MPS rate is similar in young and old men- however the MPS RESPONSE to exercise differs with age
  • Following resistance exercise in younger men, there is faster increase in MPS, with longer duration of persistent MPS compared to older men

 

Comorbidities contribute to Frailty: most studies performed in COPD pts

 

  • By day 9 of critical illness, Age and Premorbid health become more important in determining outcome

Socio-economic status is NOT corrected for in any trials for Nutrition

  • related to disparity in nutrition
  • significant contributor to frailty
  • pts below poverty threshold unlikely to have balanced diet
  • elderly males more likely to have energy dense meals (high CHO, low protein)

 

Functional assessment in 12 questions on social history

Note: pts usually not asked about shopping, finances, meal prep but these relate to ‘nutritional disability’!

 

Should protein and energy goals be separated?

(Jan Wernerman)

Short answer: Yes, but it’s complicated

No RCTs, only circumstantial evidence

 

How much room do we have for nutritional volume without causing overload?

  • many commercial formulae available, commonly 25kcal/gram protein

  • for most pts admitted >1 week, needing >2500kcal, a uniform algorithm can be used
  • for outliers (length of admission, body weight, energy expenditure) consider the patient separately with individualised feeding prescription

 

No hard evidence that protein under- or over-feeding do harm on short and medium term basis (very little long term data)

Avoid deliberate excessive protein feeding especially in malnourished pts as they have been protein-deficient for long time and may be at greater risk of harm from protein-overfeeding

Observational data in critically ill pts: more protein feeding appears to improve survival

Monitoring protein feeding:

  • Use nutrition chart and serum urea
  • imaging muscle mass with ultrasound or CT are technically difficult to interpret due to fluctuations in muscle water content