Category Archives: Year in Review

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

Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France

Hot Topics Session

It is well recognised that critically ill elderly patient have a higher mortality and therefore the beneficial effect of intensive care unit (ICU) admission variable ICU use among this population have let to significant difference in uptake.

Guidet and colleagues performed a cluster, randomised trial of admission versus standard care in 3036 elderly patients aged 75 years and above. In their multicentre randomised trail, suitable patients were allocated to routine or non-routine admission as per the following:

CONSORT Diagram

Outcome Measures

  • Primarily 6 months
  • Secondarily ICU admission rate, in-hospital death, functional status and quality of life.

 

Results

Results

 

  • Disappointingly there was no difference seen in any of the outcome measures, even after adjustment for differences in illness severity and patients admitted to ICU had an INCREASED risk of death at six months despite an increase ICU admission rates.
  • Functional status and physical quality of life at six months did not differ significantly.

 

What does this mean?

  • As our ICU population changes it may be that a systematic approach which admits all elderly patients has no effect upon outcome.
  • Further international trials are needed before we know whether this is applicable to other populations.

ICM year in review: respiratory, cardiodynamics and renal

This first session of the day in room Lisbon was a rapid run through of the journals’ most important papers of the last year  – a bumper year as the journals impact factor has soared.

Some notes below:

Respiratory papers

IC-GLOSSARI, the Intensive Care Global Study on Severe Acute Respiratory Infection which was a great ESICM project led by Yasser Sakr and is described as “a multicenter, multinational, 14-day inception cohort study”, in which I admit a COI in that i was involved on one of the sites, but a good paper in that it crossed continents and showed that admission to the ICU for severe lung infection is not only common but also associated with high morbidity and mortality rates.

http://link.springer.com/article/10.1007%2Fs00134-015-4206-2

ECMO epidemiology, this German study showed an increase in ECMO use especially amongst more elderly patients, since 2007.  VV ECMO seems to have reached a “plateau” in use. Mortality has decreased over time – the authors attribute this to experience – but is still stunningly high –  58 and 66 % for vv-ECMO and va-ECMO respectively.

http://link.springer.com/article/10.1007%2Fs00134-016-4273-z

ARDS rehabilitation – Pfoh and colleagues examined “physical declines occurring after hospital discharge” in people who survive ARDS and followed up patients for 5 years.  The headline is that most people decline, and older people and those with co-morbidities decline more.

http://link.springer.com/article/10.1007%2Fs00134-016-4530-1

Lung US training – This paper followed 11 respiratory therapists who had never used ultrasound before over 9 months and claims that 12 scans is the magic number to attain competence.  The jury is out…

http://link.springer.com/article/10.1007%2Fs00134-015-4102-9

The TRACHUS trial looked at ultrasound for tracheostomy – a good idea surely.  Anyway the paper says that it is safe and useful.  As @PhilMcglone said in his review for The Bottom Line – Why choose between bronchoscopy and ultrasound when we can use both?

http://link.springer.com/article/10.1007%2Fs00134-016-4218-6

Finally in the respiratory section this directions-type paper from Jeremy Beitler and the ARDSnet group (now ARDSne(x)t – see what they did there…) on personalising ARDS treatment. The research agenda is going to ask simultaneously both “whether a treatment affords clinically meaningful benefit and for whom.” Watch this space. Or read the paper:

http://link.springer.com/article/10.1007%2Fs00134-016-4331-6

Cardiodynamics and Ultrasound

Antoine Vieillard-Baron discussed the most important papers from this excitingly titled topic.

The FENICE trial was another landmark “global inception cohort study” and looked at fluid management and fluid boluses ( et al).  It showed massive variation in what a fluid bolus is and how it is used.  The question posed by AVL was why did only 2% of physicians use echo to manage fluid? Not enough trainers? Too difficult? Maurizio himself weighed in on the twitter chat below:

Then a study from 3 countries on point of care ultrasound use was presented.  Adrian has reviewed it nicely here for the NEXT journal club – or read the paper.  POCUS is underused generally, and only half the CVC insertions were performed under US guidance.

http://link.springer.com/article/10.1007%2Fs00134-015-3952-5

Finally a nice review article (authored by the presenter) on how to use ultrasound in ventilation management – 4 key areas:

  1. Assessment of cardiac function
  2. Assessment of diaphragmatic function
  3. Assessment of lung function
  4. Identification of pleural effusion

http://link.springer.com/article/10.1007%2Fs00134-016-4245-3

Kidneys

Matt wrote a nice blog on this yesterday, so briefly some of the papers discussed today were:

Statins in heart valve surgery

http://link.springer.com/article/10.1007%2Fs00134-016-4358-8

The kidney injury epidemiology study (AKI-EPI)

http://link.springer.com/article/10.1007%2Fs00134-015-3934-7

And the Truche study – looking again at continuous vs intermittent RRT:

http://link.springer.com/article/10.1007%2Fs00134-016-4404-6

LIVES 2016: Opening Presentations

Daniel De Backer – President ESICM

What has happened in 2016?

7 key points

  1. Members: 8550 now (continuous increase)
  2. NEXT committee: 115 fellowships since 2014 – trainees and young specialists from across Europe. New Pain/Agitation/Delerium (PAD) and Bayer Fellowships rolling out. ICE-mentoring – 28 mentors/58 mentees
  3. Education: academy and interactive e-learning. EDIC preparation course with mock exam. New courses. New courses e.g. Mechanical ventilation + EDIC 1 and 2 preparation courses. EDEC (Extending knowledge of the diagnosis of cardiac dysfunction and advanced use of echo) – new diploma. 64 intensivists enrolled. Webinars e.g new sepsis definitions, LUNG SAFE study
  4. Research: Increasing investment in research~ €600,000. ESICM Trials Group – 10 studies and 20K patients. JAMA/ICM Journal publications. Protocol Library
  5. Journal: ICM – highest impact factor yet ~ 10.125 currently. Monthly webinars and ICM Pulse related to most relevant publications. ICMx – experimental research
  6.  Communications: Social Media, Blog
  7. Coming soon: EuroAsia 6-8 April 2017. ESICM eBook series on Lessons in ICU. Surviving Sepsis Campaign – revision of SSC Guidelines 2016 coming soon. Paediatrics SSC, Sepsis in resource limited countries.

A new physiology: Caring for the extraterrestrial (Michael Barratt)

Space medicine meets intensive care

  • Three training programs in US for space medicine – board certified
  • On cusp of commercial space flight so ?expanding
  • Informs overall knowledge base of physiology
  • Accelerates avenues of medical and tech development e.g. USS
  • Thriving international community – work closely together

Radiation – by far the biggest limitation of human space travel

International space station the main destination – much roomier than one would imagine!

Basically a functioning laboratory with centrifuge, freezer, gas analyser (VO2 max etc), EEG, animal research etc

Most common issue needing adaptation is WEIGHTLESSNESS

Most changes adaptive and not harmful but can become maladaptive on return to earth

Seconds to minutes to occur:

  • Anthropometry – neutral body posture
  • Fluid shift – headward direction. Expect CVP to increase. PAC inserted in space – decreases!
  • Neurosensory adaptation  – proprioception altered. Tremendous conflict neurovestibular and occular systems. Sensory conflict but adapt in days

Lung: evening out of V/Q distribution (though incomplete)

VT decreases, RR increases —> net decrease of 7% in ventilation overall. DLCO increases

SUBACUTE (first 10 days)

  1. Fluid regulation
  2. Blood volume
  3. Neurosensory adaptation

ACUTE (3 weeks)

20% decrease in MVO2. CO normal/contractility normal

Bone loss – starts immediately but takes while to take effect. Muscle loss too

Neuro issues too: increased ICP (likely but hard to test in space…), ophthalmic disc oedema, choroidal folds —-> USS: x2 increase in optic sheath diameter. But unsure why?

ESICM Society Medal – Rui Moreno

Extremely well deserved – huge contribution to ICM – both clinically and through research

Terror victims in the ICU (Serge Jennes)

Description of the ICU and burns management of the Brussels terror attacks this year

Hospital built as disaster hospital – entrance corridor has drop down panels with O2 and suction

Incredible response – hard hearing about paediatric admissions with severe burns. And families who lost parents – just tragic

1/3 of patients from outside of Belgium – families needing to be reunited in hospital so transfers arranged

18 admissions overall – 6 years to 49 years

9 surgical procedures

120 radiological investigations

20 dressing changes a day for 15 days

Key message: computers are not fast enough. Use paper. Whiteboard for movement of pts

Additional workload: VIP visits (King and Queen of Belgium), insurance company, arrange transfers

Plus – dont forget hospital becomes target itself. Security issues

Take home messages:

  1. Be prepared: know your enemies and treat first what kills first
  2. Rebuild: practice drills, training, improve protocols
  3. Apply and practice protocols learned from recent conflicts in the prehospital and ICU settings