Introduction to Medical ICU: Part II

David Oxman, MDAssistant Professor of Medicine

Pulmonary & Critical CareThomas Jefferson University Hospital

July 19, 2013

Topics•Communication in ICU•ABCDE Protocol•ICU Data Collection•Infection Control in ICU

ICU: “The Ineffective

Communication Unit”

• One day cross-sectional study of ICU clinicians• Conflicts perceived by 72% of respondents• Physician-nurse conflict most common at 32%.• Most common conflict causing behaviors

– Personal animosity– Mistrust– Communication gaps

Azoulay AJRCCM 2009

Interdisciplinary Communication in ICU

•Bad Communication associated with:– Job dissatisfaction– Burnout– Misperception of patient care goals– Medical errors

•Tools to improve interdisciplinary communication in ICU

– Creating safe atmosphere to speak up – Willingness to listen– Leveling Hierarchy (Interdisciplinary rounds)

Role of the MICU Fellow in Promoting Good ICU

Communication•At center of daily activities of ICU•Can foster good communication between disciplines

•Often aware conflicts first.•Set an example for the residents

Respiratory

PT/OT

Physicians

Nursing

Pharmacists

Patient

It Takes A Team

A Multidisciplinary Approach to the Mechanically Ventilated

Patient:The ABCDE Bundle

Changing Paradigm of ICU Care

When I was resident Now

Why an Integrated approach?We Need Coordinated Care

• Many tasks and demands on critical care staff

• About aligning the people, processes, and technology already existing in ICUs

• ABCDE bundle is interdisciplinary, and designed to:

• Improve collaboration among clinical team members • Standardize care processes• Break the cycle of oversedation and prolonged ventilation

What are the components of the ABCDE Bundle?

Awakening and Breathing Coordination

Choice of Analgesics and Sedatives

Delirium Identification and Management

Early Exercise and Mobility

AB

D

E

C

Daily Awakening TrialsWhy Is Interruption of Sedation Effective?

•Less accumulation of sedative drug and metabolites

•Less sedative medication used overall

•Opportunity for more effective weaning from mechanical ventilation

Sessler CN. Crit Care Med 2004

Kress et al. NEJM. 2000

•Shorter duration of mechanical ventilation

•Shorter ICU LOS

• Fewer tests for altered mental status

Kress et al. N Engl J Med 2000; 342:1471-7

Results

“SAT + SBT” Was Superior to Conventional Sedation + SBT

Girard et al. Lancet 2008; 371:126-34

P = 0.02

P = 0.01

Extubated faster Discharged from ICU sooner

Spontaneous Awakening Trial (SAT)

Spontaneous Breathing Trial (SBT)

Choice of Analgesics and

Sedatives

C

Using the Right Drugs is Important –It’s a Balancing Act

Calm Alert

Free of pain and anxiety

Lightly

sedated

Deeply

sedated

Pain,

anxiety

Agitation, vent

dyssynchrony

Spectrum of Distress/Comfort/Sedation

Dangerous

agitation

Unresponsive

LOS

Dost

Delirium

VAP

Self-harm

Caregiver assault

Stress

MI

Over sedation

Patient Comfort and

Venti latory Optimization

Consequences of Suboptimal Sedation

Inadequate sedation/analgesia

• Anxiety• Pain• Patient-ventilator

dyssynchrony • Agitation

– Self-removal of tubes/catheters

• Care provider assault• Myocardial ischemia• Family dissatisfaction

Excessive sedation

• Prolonged mechanical ventilation, ICU LOS

– Tracheostomy– DVT, VAP

• Additional testing• Added cost• Inability to communicate• Cannot evaluate for

delirium

The Ideal ICU Sedative•Rapid onset of action and rapidly cleared.

•Predictable dose response

•Easy to administer

•Minimal drug accumulation

•Few adverse effects

•Minimal drug interaction

•Cheap 1. Ostermann ME, et al. JAMA. 2000;283:1451-1459.

2. Jacobi J, et al. Crit Care Med. 2002;30:119-141.

3. Dasta JF, et al. Pharmacother. 2006;26:798-805.

4. Nelson LE, et al. Anesthesiol. 2003;98:428-436.

Does not exist

CChoice of

Analgesics and Sedatives

Assessing and Targeting Sedation

Richmond Agitation Sedation Scale

Score RAAS Description

+4 Combative, violent, danger to staff

+3 Pulls or removes tube(s) or catheters; aggressive

+2 Frequent non-purposeful movement, fights ventilator

+1 Anxious, apprehensive, but not aggressive

0 Alert and calm

-1 Awakens to voice (eye opening/contact) >10 sec

-2 Light sedation, briefly awakens to voice (eye opening/contact) <10 sec

-3 Moderate sedation, movement or eye opening. No eye contact

-4 Deep sedation, no response to voice, but movement or eye opening to physical stimulation

-5 Unarousable, no response to voice or physical stimulation

TJUH Pain and Agitation Algorithm

Choice of Analgesics and Sedatives

The choice driven by:

Goals for each patient

Clinical pharmacology

Costs

C

Key Points on Sedation

• Assess and target.

• Bolus first and

then consider

continuous

infusion.

• Daily interruption

D

Delirium Monitoring and Management

72% of ICU Delirium Undiagnosed??

Gets our attention “Ideal patient”

Delirium KillsDuration and Mortality

Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097.

Kaplan-Meier

Survival Curve

Each day of delirium in the ICU increases the hazard of mortality by 10%

P < 0.001

Patient Factors

Increased age

Alcohol use

Male gender

Living alone

Smoking

Renal disease

Environment

Admission via ED or

through transfer

Isolation

No clock

No daylight

No visitors

Noise

Use of physical restraints

Predisposing Disease

Cardiac disease

Cognitive impairment

(eg, dementia)

Pulmonary disease

Acute Illness

Length of stay

Fever

Medicine service

Lack of nutrition

Hypotension

Sepsis

Metabolic disorders

Tubes/catheters

Medications:

- Anticholinergics

- Corticosteroids

- Benzodiazepines

Less Modifiable

More Modifiable

DELIRIUM

Van Rompaey B, et al. Crit Care. 2009;13:R77.

Inouye SK, et al. JAMA.1996;275:852-857.

Skrobik Y. Crit Care Clin. 2009;25:585-591.

Delirium: What Can We Do?

Diagnosis is Key !!Confusion Assessment Method for the ICU (CAM-ICU)

Feature 1: Acute change or fluctuating

course of mental status

And

Feature 2: Inattention

And

Feature 3: Altered level of

consciousnessFeature 4: Disorganized thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1

Ely, et. al. CCM 2001; 29:1370-1379.4

Ely, et. al. JAMA 2001; 286:2703-2710.5

Letter A test• “SAVEAHAART”•Say above 10 Letters & instruct patient to squeeze hand every time you say letter “A”

• Inattention PRESENT if > 2 errors

Diagnosing Delirium in Patient on

Mechanical Ventilation

Early Progressive

Exercise and Mobility

E

Early Progressive Exercise and Mobility

Early progressive mobility programs result in:

Better patient outcomes Shorter hospital stays Decreased development of

hospital acquired complications

The level of exercise and mobility is individualized and incrementally progressed

E

Early Mobility“Move It Or Lose It”

Immobility not beneficial and associated with harm

–Myopathy/neuropathy–Delayed weaning from

ventilator–Delirium– Infections–Pressure ulcers

E

Early Exercise in the ICU

• Early exercise = progressive mobility• Study design: paired SAT/SBT protocol with PT/OT from

earliest days of mechanical ventilation

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Wake Up, Breathe, and Move

Early Exercise Study Results

OutcomeIntervention

(n=49)Control(n=50) P

Functionally independent at discharge 29 (59%) 19 (35%) 0.02

ICU delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-7.0) 0.03

Time in ICU with delirium (%) 33 (0-58) 57 (33-69) 0.02

Hospital delirium (days) 2.0 (0.0-6.0) 4.0 (2.0-8.0) 0.02

Hospital days with delirium (%) 28 (26) 41 (27) 0.01

Barthel index score at discharge 75 (7.5-95) 55 (0-85) 0.05

ICU-acquired paresis at discharge 15 (31%) 27 (49%) 0.09

Ventilator-free days 23.5 (7.4-25.6) 21.1 (0.0-23.8) 0.05

Length of stay in ICU (days) 5.9 (4.5-13.2) 7.9 (6.1-12.9) 0.08

Length of stay in hospital (days) 13.5 (8.0-23.1) 12.9 (8.9-19.8) 0.93

Hospital mortality 9 (18%) 14 (25%) 0.53

Schweickert WD, et al. Lancet. 2009;373:1874-1882.

Early Progressive Exercise and Mobility

•All patients are candidates for mobilization if:– No clinical contraindications to physical

activity– Pass a safety screen for participation

• Patients initially not eligible mobilization or who have had interruptions in exercise will continually reassessed for participation

• The level of exercise and mobility is individualized and incrementally progressed

ICU Data Collection

Just Count Something

“No matter what you ultimately do in medicine a doctor should be a scientist in his or her world. In the simplest terms, this means that we should count something…It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you.”

Atul Gawande

ICU Database

•Let’s us look above the daily grind.•Illuminates random experiences.•Concrete uses:• Measuring utilization• Measuring performance• Platform for clinical research

MICU Database

MICU Database

• 95% of data entered by nursing/clerical staff• Fellows responsible for:

– Primary MICU diagnosis– Select comorbidities (yes or no)– APACHE scores

• Coming to Methodist• Regular feedback of data

Infection Control

ICU Infection Control

• Key Performance Measure for ICU• Hospital Compensation from Payors at Risk• Intensivist’s Bonuses at Risk!!!

Infections with Surveillance Programs1. Central Line Associated Bloodstream Infections

(CLASBI)2. Ventilator-Associated Pneumonia (VAP)3. Catheter-Associated Urinary Tract Infection (CAUTI)4. Clostridium Difficile Colitis

Reducing ICU-Acquired Infections• CLASBI

– Insertion bundle– Avoid femoral site– No blood draws through catheter– Good catheter maintenance– Remove when not needed

• VAP– Shorten duration of mechanical ventilation: Daily SAT/SBT– VAP Bundle

• CAUTI: – Don’t place foley if not necessary– Get Foley’s out when not needed

• Clostridium Difficile: Limit unnecessary antibiotics

Be Careful Out There