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