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Strategies to Prevent Complications of ICU Stay

Strategies to Prevent Complications of ICU Stay. Robert Cohen, M.D., F.C.C.P Chairman, Pulmonary and Critical Care Medicine Cook County Health and Hospitals System. ICUs are complicated Donchin Y et al (2003). Quality Safety Health Care; 12:143.

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Strategies to Prevent Complications of ICU Stay

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  1. Strategies to Prevent Complications of ICU Stay Robert Cohen, M.D., F.C.C.P Chairman, Pulmonary and Critical Care Medicine Cook County Health and Hospitals System

  2. ICUs are complicatedDonchin Y et al (2003). Quality Safety Health Care; 12:143 • Engineers observed patient care in ICUs for twenty-four hour periods • They found that the average patient required a hundred and seventy-eight individual actions per day • e.g., administering a drug, suctioning, ventilator decision making • RNs and MDs were observed to make an error in only one per cent of these but: • An average of two errors a day with every patient.

  3. Knowing vs. Doing the Right ThingYoung MP et al (2004). Critical Care Medicine; 32:1260 • Intensivists are familiar with the “ARDSNet” guidelines for lung protective strategies. • How often was it being followed for patients in the ICU? • Evaluated the ventilator settings and the patient to see if it was being followed • 85% of ICU physicians believed they were using lung protective strategies • 11% of patients were receiving Vt < 8 ml/kg PBW • How can compliance with “Best Practices” be insured?

  4. If not smart, be organized • Every complicated task in the US military has a “Protocol Authorization” • Deviations are NOT allowed • Airline Industry • “Go - no go” • Medicine • Protocols • Historically, not our model

  5. ChecklistsWinters BD et al (2009). Critical Care 13:210 • Static sequential: Single person follows • e.g. order sets, “bundles” • With verification: Operator reads, another verifies • e.g. central line insertion checklist • With verification and confirmation: multi-disciplinary • one operator reads, responsible party verifies • e.g. OR “time out” with verification of equipment, etc. • Dynamic: flowcharts with multiple “if-then” paths • e.g. American Society of Anesthesiologists “Difficult airway” algorithm

  6. The Checklist Manifesto – How to get things right Atul Gawande Metropolitan Books 2009

  7. Teamwork and Culture Change • Physician-led multi-disciplinary rounds • Daily bed management meeting • “Bundles” and compliance • Cultural change: team decision-making • Miller JM et al (2006). Quality Safety Health Care;15: 235

  8. Teamwork and Communication • Crew Resource Management • Model: Airline cockpit procedures • Multi-disciplinary: all participants have equal “say” • EXPECTED to speak up if protocol not followed or “something just isn’t right” • AND STOP PROCEDURE • NO retribution

  9. Teamwork and Checklists Require a Cultural Change • “MD is NOT always right” • Institutional support STRONGLY needed with sanctions for deviations • Bosk CL et al (2009). Lancet 374:445 • Protocols and procedures are “hard-wired”, checked and verified • Minimizes practice variations

  10. “Intensive Care: A Culture of Communication” • Data suggest high performing ICUs have distinctive characteristics in their units’ culture • Key to that culture’s definition is good communication • Arguably, nowhere in medicine is communication as valued as in the ICU • Mitchell Levy,Critical Connections,December 2009

  11. Structured Daily RoundsGuidelines:When: Begin0800, at 0700 Res will get expected flow to night charge beginning with post call patients.Who: All pertinent team members including CCI, Res, Fellow, RN, RT, Pharmacy, Dietician, Discharge Planner, etc. will attend with the exception of emergent event. If unable to attend, team member will meet with another team member to give inputs before and receive summary brief after rounds.

  12. Passed SBT / extubate Sedation goal and score CAM ICU positive/negative Adequate pain control Glucose/insulin drip issues D/C Foley Prophylaxis (VTE, SRMD*) Lines and drains: review need *Stress Related Mucosal Disease Skin breakdown/wound consult/ specialty bed Out of bed Increase activity Nutrition Family issues Transfer / Length of Stay Order clarifications ICU RN Rounds Crosscheck

  13. Extent and Cost of Errors2008 Cost of errors: $ 19.5 billion Number of measurable injuries: 6.3 million (1.5 million associated with error) Excess deaths: 2500 Short term disability (missed work) : > 10 million excess days Shreve J, et al. (June 2010). “The Economic Measurement of Medical Errors” report of the Society of Actuaries Health Section

  14. Complications • Review • Catheters, • vascular and urinary • Ventilator-associated pneumonia • Sedation-related • Other Complications • Transfusions • Thrombosis • Gastric “stress ulceration”

  15. How do catheters get infected? • HCW hands Infected catheter hubs Sadfar and Maki (2004). Intensive Care Med 30:62-67

  16. Catheter Colonization: Sites Gowardman, et al (2008). Intensive Care Medicine 34:1038-1046

  17. Risk Factors for Bloodstream Infection Safdar, Kluger and Maki (2002). Medicine 81: 466

  18. Making Lines Less “Difficult”Karakitsos et al (2006). Critical Care 10:R162

  19. Ultrasound Devices

  20. Central Line GuidelinesMMWR (9 August 2002) 51, RR-10 • Insertion • Staff and operator education • ESPECIALLY HAND WASHING • Chlorhexidine 2% (not 0.5%) antiseptic • Maximum barrier precautions • Minimum number of ports • Antibiotic-impregnated if > 5 days expected and high institutional baseline rates of infection • Subclavian preferred over IJ or femoral to minimize infection

  21. Chlorhexidine use • Skin prep delays catheter colonization compared to providone-iodine • Mimoz et al (2007). Archives Internal Medicine 167: 2066-2072 • Bathing patients with chlorhexidine prevents line infections • Bleasdale et al (2007). Archives Internal Medicine 167:2073-2079

  22. Central Line GuidelinesMMWR (9 August 2002) 51, RR-10 • Changes: No routine changes • NO GUIDEWIRE EXCHANGES IF INFECTION SUSPECTED • DO NOT CHANGE FOR FEVER ALONE • GUIDEWIRE CHANGE OK if site clean • i.e. dysfunctional port • NEW GLOVES FOR NEW CATHETER • If bacteremic, new catheter site if old tip infected • B- II recommendation Clinical Infectious Diseases (2009) 49: 1 • Dressing changes • Gauze q2d, Transparent q7d (unless soiled)

  23. Intense Guideline AdherencePronovost et al (2006). NEJM 355:2725 • Guidelines • Wash hands before procedure • 2% (not 0.5%) Chlorhexidine skin prep • Full barrier precautions • Avoid femoral venous catheterization • Remove lines when no longer needed • Staff empowered to stop procedure if not followed

  24. Appropriate Frequent (q 1-2 hr) output monitoring Urinary tract obstruction Urinary retention Prolonged (>2 hr) procedure Recent surgical/invasive procedure In situ epidural catheter Deep sedation/paralysis Stage III or IV skin ulcers Surgical repair of skin ulcer Intolerance to movement Terminal illness or severe impairment Inappropriate Non-essential output monitoring Diuresis Incontinence without other indications fecal or urinary RN concern for patient comfort Patient preference Urinary Catheter Indications Elpern et al (2009). Am J. Critical Care 18:535

  25. Catheter-associated UTIElpern et al (2009). Am J. Critical Care 18:535 • RN-driven process -- 6 month intervention • Daily evaluation of indications • 337 patients (1432 catheter-days) • 456 (32%)catheter-days inappropriate • Inappropriate catheters removed

  26. Catheter-associated UTIElpern et al (2009). Am J. Critical Care 18:535

  27. Ventilator-associated Pneumonia • Epidemiology • 3-4 days after intubation • ~ 9% prevalence • Increases • ICU and hospital length of stay • Mortality • Time on ventilator • Health care cost (double) Rello et al (2002). Chest 122: 2115

  28. ATS Guidelines 2005Am. J. Respiratory and Critical Care Med (2005) 171: 388 • Level I Recommendations : Non-Pharmacologic • Infection control: education (HAND WASHING) and isolation • Avoid intubation (use NIPPV) • Avoid nasal intubations (endotracheal and gastric) • Continuous aspiration of subglottic secretions • Semi-recumbent positioning (30-45°) • Avoid ventilator circuit changes • Use heat-moisture exchanger (HME) to avoid colonization • NO ROUTINE chest physiotherapy

  29. ATS Guidelines 2005Am. J. Respiratory and Critical Care Med (2005) 171: 388 • Level I Recommendations : Pharmacologic • GI bleeding prophylaxis, either H2-blockers or sucralfate • Tight glucose control • Prophylactic parenteral antibiotics at time of emergent intubation (24-48 hrs only, head injury)

  30. ATS Guidelines 2005Am. J. Respiratory and Critical Care Med (2005) 171: 388 • Level II Recommendations : Non-Pharmacologic • Infection surveillance and antibiograms • Avoid aspiration of enteral feeds(cuff pressure > 20 cm H2O) • Caution with ventilator circuit condensate (empty it!) • Protocols for sedation and weaning • Avoid heavy sedation and paralysis • Daily interruption and awakening • Adequate ICU staffing • No kinetic therapy beds • Pharmacologic • Restrictive transfusion policies • Shorter courses of antibiotics

  31. Surgical ICU one year period Sodium monofluorophosphate brushing, tap water rinse and 0.12% chlorhexidine application q12 hr Reduced vent-associated pneumonia 46% Savings: $140,000-500,000 (expense < $3000/yr) RN Initiative 547 patients, 3 ICUs Chlorhexidine swab (0.12%) Toothbrushing Both Usual care Chlorhexidine but NOT toothbrushing reduced progression to CPIS > 6 and pneumonia at day 3 Oral Care Sona CS et al. (2009). J Int Care Med 24:54 Munro CL et al (2009). Am. J. Crit.Care 18:428

  32. Weaning RN- and RT-driven MD-independent until later MD Input here

  33. Sedation • Prevents self-harm (extubation) • Decreases risk of post-traumatic stress disorder • Facilitates nursing care • Masks neurological changes • Prolonged intubation due to oversedaton • When prolonged, evaluation for “mental status changes” with (often) CT, LP, EEG, Neurology • Drug clearance rates important factor • (age, organ dysfunction/failure)

  34. Sedation • Daily awakenings (Kress et al (2000). New Eng. J. Med. 342: 1471) • Decreased time on ventilator (4.9 d vs. 7.3 d) • Decreased ICU stay (6.4 d vs. 9.9 d) • Fewer evaluations for “mental status changes” • No increase in PTSD • Fewer complications • Coupled with SBT: better ventilator, ICU, hospital and long-term outcomes (Girard TD et al (2008). Lancet 371:126) • Use of guidelines • SCCM (Critical Care Medicine (2002). 30:119) but new ones “soon” • Institutional or unit-specific

  35. Daily Sedation Interruption and ComplicationsSchweickert WD et al (2003). Critical Care Medicine 32:1272-1276

  36. Sedation Interruption vs. Algorithm • 74 patients single site, stopped early • Increased hospital mortality in daily awakening group • Daily awakenings vs. protocol-driven • Increased time on ventilator (6.7 vs. 3.9 d) • Increased SOFA resolution (0.70 vs. 0.23 U/d) • Increased ICU stay (15 vs. 8 d) • Increased hospital stay (23 vs. 12 d) deWit M et al (2008). Critical Care 12:R70

  37. So in the end…….. • Standardize procedures with checks and cross checks • Careful attention to catheters • Insertion procedures • Site • Dressing care • Early removal • Prophylactic measures for VTE and SRMD • VAP preventive measures: early wean and extubation • Sedation to prevent PTSD yet avoid “snowing” • use established or institutional guidelines • Minimize transfusions

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