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JICS Volume 11, Number 1,January 2010 69

Comment The Intensive Care Society 2010

The mnemonic FAST HUG1 was proposed almost five years

ago by Jean-Louis Vincent as a way of assisting healthcare

workers looking after critically ill patients. The mnemonic

stands for: Feeding, Analgesia, Sedation, Thromboembolic

prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, and

Glucose control. All the components are evidence-based and

have been used the world over. Although there has not been a

study of the concept of FAST HUG as a bundle for critical care,

common sense would dictate that rigorously using a package of

proven therapies can only enhance outcomes. However, while I

embrace the concept, I have since noticed that on its own, it

misses fundamental aspects of critical care, which are equally

important.

Often simple things like fluid balance, investigation results,

constipation, and other treatments are overlooked to the

patients detriment. With the current medical training

programme whereby sometimes very junior trainees review

patients, or in very busy units, it is vital that a simple,

comprehensive systematic approach to reviewing a critically ill

patient is engendered. I propose a small extension to Vincents

mnemonic to: FAST HUG FAITH. FAITH is a mnemonic for

Fluid balance, Aperients, Investigation and results, Therapies,

and Hydration.

Fluid balance

Fluid resuscitation is an essential component of management

of critically ill patients. The amount of fluid administered is

dependent on the diagnosis and the patients response to it.

Patients admitted with severe sepsis or septic shock require a

much larger volume of fluid than other conditions. Inevitably

such patients rapidly develop a positive fluid balance. Fluid

balance has been shown to be an independent predictor of

survival, especially in the first three days of admission.2,3 These

retrospective studies have shown that a negative fluid balance

is associated with better survival. This trend has, however,been confirmed by the SOAP study, which also found that

positive fluid balance was among the strongest prognostic

factors for death.4 McNeils et al found that a positive fluid

balance in the first 24 hours of admission was associated with

the development of abdominal compartment syndrome.5 A

positive fluid balance in mechanically ventilated patients with

ALI/ARDS has been shown to be associated with worse

outcome.6 It is, therefore, an essential part of good critical care

management that an accurate daily and cumulative fluid

balance is maintained and judiciously reviewed and an early

negative (or neutral) fluid balance be achieved when possible.

AperientsThe true incidence of constipation in critical care patients

depends on the type of intensive care unit studied, but ranges

from 5 to 83%.7-9 There are many causes of constipation

including, dehydration, immobility, electrolyte abnormalities,

neurological injuries, hypothyroidism, bowel pathology and

opioid-based sedation. Aperients are commonly used to

prevent or relieve constipation. Aperients fall into four groups;

bulking agents (eg fibre supplements); lubricants/stool

softeners (eg microlax enema); gut stimulants (eg senna); and

osmotic agents (eg lactulose). Constipation in critically ill

patients is not a benign condition. Mostafa et al have shown

that constipation can lead to failure to wean from mechanical

ventilation and increase length of stay.7 One other important

but yet not easily recognisable complication of constipation isabdominal pain.10-12 Judicious use of aperients may reduce the

incidence of constipation and associated complications.

Investigations and results

The majority of admissions to intensive care are unplanned or

emergencies. Consequently most of these critically ill patients

will not have had full investigation of their primary condition

prior to admission. It is incumbent upon intensivists to

investigate such patients in order to institute correct

management. Any tests or investigations ordered must have

results reviewed and acted upon daily. Included is inspection

of lines, catheters, insertion sites and wounds as potential

sources of infection.13,14 A record of the duration of these lines

and catheters should be kept and made easily available for

daily review. The Institute of Health Improvement (IHI) in the

USA in its central line bundle recommends a daily review of

line necessity with prompt removal of unnecessary lines.15

Therapies

A daily review of clinical progress is essential in order to assess

the effectiveness of the therapies rendered. In the case of

antibiotics a review of clinical progress as well as

microbiological results should lead to de-escalating antibiotics.16

Severe sepsis and septic shock have high mortality and the early

administration of an appropriate antibiotic is associated withimproved outcome and reduced length of stay.17,18 The Surviving

Sepsis Campaign guidelines (2008) recommend administration

of an appropriate antibiotic within one hour of admission.14 It

has been estimated that for every hour of delayed antibiotic

therapy there is a mean decrease in survival of 7.6%.18

The management bundle of the Surviving Sepsis

Campaign(SSC)14 recommends intensive insulin therapy, low

dose corticosteroids, low tidal volume ventilation and activated

protein C.

It is of paramount importance that as the patient begins to

recover that they should be commenced on their essential

medications they were taking prior to current illness.

There is a tendency for polypharmacy in critical care

management. Drug interactions may occur. The intensivist

should review the drug chart daily in order to scale down and

rationalise the patients therapy.

Letters to the editor

Extend FAST HUG with FAITH

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Volume 11, Number 1,January 2010 JICS70

Comment

Hydration

Assessment of the hydration status of critically ill patients is

fraught with difficulties. Often these patients are grossly

oedematous but intravascularly fluid depleted. In addition,

some of these patients have cumulative positive fluid balance.Diuretics may have been used prior to current illness leaving

the patient overall fluid depleted. Insensible fluid loss is always

difficult to estimate. This may increase with pyrexia to 2 to

2.5 mL/kg/day for every degree temperature rise above normal.

Although both parenteral and enteral nutrition bags contain

water, additional water may still be needed to compensate for

excessive insensible loss, wound loss, diarrhoea, vomiting and

diabetes insipidus. Hypernatraemia and uraemia are common

signs of dehydration in the ICU patient. For the perioperative

patient, the British Consensus Guidelines Group (GIFTASUP)

have recently published guidelines on choice of intravenous

fluid to be administered.19

Addition of these five components of critical care makes

sense and a replete mnemonic FAST HUG FAITH enhances

Vincents FAST HUG approach by encompassing a more

comprehensive bedside review of everything happening with

the critically ill patient. In addition to a sense of closeness to

your patient (FAST HUG), adding FAITH brings another

dimension of believing in the right things you are doing to get

them back home. As is increasingly becoming obvious, it is not

high technology medicine that is making the biggest positive

impact on our patients, but remembering the simple, easy-to-

do things.

References1. Vincent JL: Give your patient a fast hug (at least ) once a day. Crit Care

Med 2005;33:1225-29.

2. Schuller D, Mitchell JP, Calandrino FS, Schuster DP. Fluid balance

during pulmonary oedema. Is fluid gain a marker or a cause of poor

outcome? Chest 1991;100:1068-75.

3. Alsous F, Khamiees M, De Girolamo A et al. Negative fluid balance

predicts survival in patients with septic shock. A retrospective pilot

study. Chest 2000;117:1749-54.

4. Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European intensive care

units: Results of the SOAP study. Clinical Investigations. Crit Care Med

2006;34:344-53.

5. McNeils, Marini C, Jurkiewicz A et al. Predictive factors associated with

development of abdominal compartment syndrome in surgical intensive

care units.Arch Surg 2002;137:133-36.

6. Sakr Y, Vincent JL, Reinhart K, et al. High tidal volume and positive fluid

balance associated with worse outcome in outcome in acute lung injury.

Chest 2005;128:3098-08.

7. Mostafa SM, Bhandari S, Ritchie G et al. Constipation and its

implications in the critically ill patient. Br J Anaesth 2003,91:815-19.8. Mostafa SM, Bhandari S, Ritchie G. Constipation and its implications in

the critically ill: A national survey of United Kingdom intensive care

units. Br J Anaesth 2001;87:343P.

9. Montejo JC, for the Nutritional and Metabolic Working Group of

Intensive Care Medicine and Coronary Care Units. Enteral nutrition-

related gastrointestinal complications in critically ill patients; Multicentre

study. Crit Care Med 1999;27:1447-53.

10.Cameron JC. Constipation related to narcotic therapy. A protocol for

nurses and patients. Cancer Nurs 1992;15:372-77.

11.Held JL. Cancer care: preventing and treating constipation. Find out

your role in managing this common symptom. Nursing 1995;25:26-27.

12.Manara L, Bianchetti A. The central and peripheral influences of opioids

on gastrointestinal propulsion.Ann Rev Pharmacol Toxicol 1985;25:249-73.

13.Burke JP. Infection control a problem for patient safety. NEJM 2003;348:561-66.

14.OGrady NP, Alexander M, Dellinger P et al. Guidelines for the

prevention of intravascular catheter-related infections. CDC MMWR

Recomm Rep 2002;51:1-29.

15.Institute for Healthcare Improvement. Implementing the Central Line

Bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/

Changes/ImplementtheCentralLineBundle.htm Accessed December 2009.

16.Dillinger RP, Levy MM, CarletJM, et al. Surviving Sepsis

Campaign:International guidelines for management of severe sepsis and

septic shock:2008. Intensive Care Med 2008;34:17-60.

17.Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and

appropriate antibiotic selection reduce length of hospital stay of patients

with community acquired pneumonia:link between quality of care and

resource utilisation.Arch Intern Med 2002;162:682-88.

18.Kumar A, Roberts D, Wood KE et al. Duration of hypotension before

initiation of effective antimicrobial therapy is the critical determinant of

survival in human septic shock. Crit Care Med 2006;34:1589-96.

19.Powell-Tuck J, Gosling P, Lobo D et al. Summary of the British

Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical

Patients (GIFTASUP)- for comment.JICS 2009;10:13-15.

Moses Chikungwa Consultant Anaesthetist/Intensivist,

Mid Staffordshire NHS Foundation Trust

mchikungwa@yahoo.co.uk

For patients treated in critical care units, it is easy to assume

that, having survived the acute illness, recovery will be

quick and problem-free. Unfortunately, patients are often left

with significant long-term problems but it is widely accepted

that these complications can be reduced with careful handover

during discharge.1 Despite this, adequate follow-up is rare.2 In

July 2007, NICE published Clinical Guideline 50: Acutely ill

patients in hospital: recognition of and response to acute

illness of adults in hospital, aiming to overcome these failings

in communication and documentation.3

The guidelines advocate a formal structured handover of

care...supported by a written plan to ensure continuity of care,

including a summary of the critical care stay, plans for ongoing

treatment and any needs identified.3 On discharge from critical

care, medication should be reviewed to ensure that all

medication is still required and discontinued medication is

reassessed to ensure optimal patient therapeutics.4 Physical

weakness and long-term psychological distress are common

complications of a prolonged admission but correct

rehabilitation and follow-up is proven to reduce the impact of

these problems.5 Proper and systematic summaries, therefore,

must be completed to initiate correct follow-up and allow

preventable problems to be pre-empted.An audit was performed in two tertiary and two district

hospitals in Wales to assess the implementation of the

guidelines. Data was collected from critical care discharge

An audit of compliance of critical care discharge summaries with NICE guidelines

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JICS Volume 11, Number 1,January 2010 71

Comment

summaries from 218 live adult discharges (average 55 per

hospital) from critical care between 1st September and 30th

November 2008.

The results (Figure 1) demonstrate that discharge summaries

have been widely implemented by the four hospitals. Though

there were inconsistencies, the areas most relevant to ongoing

patient care were collectively completed thoroughly, such as

case summary (86%), ongoing treatment (82%) and nutritional

plan (89%) but had room for improvement. Infection status

(40%) and language needs (6%) were consistently poorly

completed. Infection status is of particular concern as it

suggests that current high profile campaigns, such as the

Welsh 1,000 Lives Campaign, are not having the desired effect

and may demonstrate a continued and needless risk topatient safety.

The audit highlighted substantial disparities in form

completion between the hospitals studied, with Singleton and

Morriston Hospitals in the Abertawe Bro Morgannwg (ABM)

University Health Board performing considerably better than

both University Hospital of Wales (UHW) in the Cardiff and

Vale University Health Board and Ysbyty Gwynedd Hospital

(YG) in the Betsi Cadwaladr University Health Board. The

authors believe the use of an electronic discharge summary in

the ABM Trust contributed significantly to this, as the

electronic format was clearly legible, easily accessible, well-

organised, expandable and gave guidance on completing each

section. In comparison, the paper forms used by both UHW

and YG had limited space and a more unstructured layout,

providing little assistance for those completing the form. The

documentation used in UHW and YG has been updated since

the audit.

This audit demonstrated the ability of a structured

electronic discharge form to achieve consistent standards,

which can improve patient safety. The full implementation of

NICE Clinical Guideline 50 will ensure continuity of care and

reduce patient complications.

Acknowledgement

The authors would like to thank their supervising tutor Dr.

Brian Jenkins and Dr. Dave Hope for their help and support in

completing this audit

References

1. Metnitz P, Fieux F, Jordan B et al. Critically ill patients readmitted to

intensive care units lessons to learn? Intensive Care Med 2003;29:

241-48.

2. Day V and the Department of Health Expert Group . Comprehensive

Critical Care: a review of adult critical care services. 2000.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/

PublicationsPolicyAndGuidance/DH_4006585. Accessed Dec 2008.

3. National Institute for Health and Clinical Excellence. Clinical guideline 50:

Acutely ill patients in hospital. Recognition of and response to acute illness

in adults in hospital. NICE; London: July 2007. http://www.nice.org.uk/

nicemedia/pdf/CG50FullGuidance.pdf Accessed Oct 2008.

4. Campbell A, Bloomfield R, Noble D. An observational study of changes

to long-term medication after admission to an intensive care unit.Anaesthesia 2006;61:1087-92.

5. Scragg P, Jones A, Fauvel N. Psychological problems following ICU

treatment.Anaesthesia 2001;56:9-14.

Figure 1 Overall audit results.

Complete

20% 80%40%0% 100%

Case summary

Diagnosis

Treatment summary

Ongoing therapyNutritional plan

Infection status

Physical & rehab needs

Psychological needs

Language needs

Incomplete

60%

Dischargesumm

arycriteria

Olivia Curtis, Denise Duignan, Sheena Durnin

durnins@cardiff.ac.uk, William Kenyon, Rebecca Thomas,

Katherine Trigg, Simon Trundle,

Medical Students, Cardiff University

We read with interest Dr Astles survey on iatrogenic

anaemia and frequency of blood testing in the intensive

care unit (ICU).1 The NHS Next Stage Review2 focuses on

quality at the heart of patient care in the National Health

Service. The survey is a fine example of simple interventions

improving quality of patient care. It reiterates that improving

quality can reduce cost.

In health, haematopoiesis replaces about 50 mL blood per

day,3 but this is suppressed in the critically ill. Not surprisingly,

almost 95% of the patients admitted to the ICU have a

haemoglobin level below normal by day three.4

The factors influencing sampling in the ICU are:5

The ease of access to arterial blood

The work pattern prevalent within the unit

The belief that patients are critically ill enough to require

regular investigations.

The controllable variables to minimise iatrogenic anaemia in

the ICU are:

Reduction in sampling frequency (by education)

Reduction in discarded volume.

In previous research conducted in the UK, we have

established the role of education in reducing unnecessary

blood sampling.6 In addition, closed sampling systems, now

available in the UK, have a significant positive impact.

Modifying blood sampling technique7 while using an openarterial sampling system is beneficial.

The survey correctly highlights that more experienced

nursing staff take samples less frequently. It is important

Correspondence regarding: Iatrogenic anaemia in the critically ill, JICS 2009;10:279-81.

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Volume 11, Number 1,January 2010 JICS72

Comment

to avoid ritualistic practice, especially for more inexperienced

staff.

The intended benefits are

improvement in the quality of care

increased patient safety

reduction in workload

cost saving.

It is important that we continue to educate staff to achieve

the above-mentioned benefits.

References

1. Astles, T. Iatrogenic anaemia in the critically ill: A survey of the frequency

of blood testing in a teaching hospital intensive care unit.JICS

2009;10:279-81.

2. Darzi, A. The Next Stage Review. NHS, London 2009 http://www.dh.gov.uk/

en/publicationsandstatistics/publications/publicationspolicyandguidance/

DH_085825 Accessed November 2009.

3. Bhaskaran NC, Lawler PG. How much blood for a blood gas?Anaesthesia

1988;43:9:811-12.

4. Rodriguez RM, Corwin HL, Gettinger A et al. Nutritional deficiencies

and blunted erythropoietin response as causes of the anemia of critical

illness.J Crit Care 2001;16:36-41.

5. Roberts D, Ostryzniuk P, Loewen E et al. Control of blood gas

measurements in intensive care units. Lancet 337;1991:1580-82.

6. Hegde PS, Tarsey K, Blunt MC. Education reduces unnecessarydiagnostic blood sampling in the intensive care unit. Crit Care

2003;7(Suppl 2):P241.

7. Hegde PS, Tarsey K, Blunt MC. A modification of the blood sampling

technique in critical care to reduce blood wastage. Crit Care 2003;7

(Suppl 2):P240.

Thejas Bhari Specialist Registrar, Alexandra Hospital, Redditch

Prashant S Hegde Consultant in Anaesthesia and Intensive

Care, Worcestershire Acute Hospitals NHS Trust

prashant.hegde@worcsacute.nhs.uk