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Introduction to Medical ICU: Part II David Oxman , MD Assistant Professor of Medicine Pulmonary & Critical Care Thomas Jefferson University Hospital July 19, 2013. Topics. Communication in ICU ABCDE Protocol ICU Data Collection Infection Control in ICU.

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  1. Introduction to Medical ICU: Part IIDavid Oxman, MDAssistant Professor of MedicinePulmonary & Critical CareThomas Jefferson University HospitalJuly 19, 2013

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

  3. ICU: “The Ineffective Communication Unit”

  4. 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 AJRCCM2009

  5. 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)

  6. 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

  7. Respiratory PT/OT Nursing Physicians It Takes A Team Patient Pharmacists

  8. A Multidisciplinary Approach to the Mechanically Ventilated Patient:The ABCDE Bundle

  9. Changing Paradigm of ICU Care When I was resident Now

  10. 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

  11. 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 C D E

  12. 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

  13. Results • 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

  14. “SAT + SBT” Was Superior to Conventional Sedation + SBT Extubated faster Discharged from ICU sooner P = 0.01 P = 0.02 Girard et al. Lancet 2008; 371:126-34

  15. Spontaneous Awakening Trial (SAT)

  16. Spontaneous Breathing Trial (SBT)

  17. C Choice of Analgesics and Sedatives

  18. Using the Right Drugs is Important –It’s a Balancing Act Over sedation Patient Comfort and Ventilatory Optimization Self-harm Caregiver assault Stress MI LOS Dost Delirium VAP Agitation, vent dyssynchrony Pain, anxiety Calm Alert Free of pain and anxiety Lightly sedated Deeply sedated Dangerous agitation Unresponsive Spectrum of Distress/Comfort/Sedation

  19. Consequences of Suboptimal Sedation Inadequate sedation/analgesia Excessive sedation Prolonged mechanical ventilation, ICU LOS Tracheostomy DVT, VAP Additional testing Added cost Inability to communicate Cannot evaluate for delirium • Anxiety • Pain • Patient-ventilator dyssynchrony • Agitation • Self-removal of tubes/catheters • Care provider assault • Myocardial ischemia • Family dissatisfaction

  20. 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 C • Choice of Analgesics and Sedatives Doesnot exist 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.

  21. Assessing and Targeting Sedation

  22. TJUH Pain and Agitation Algorithm

  23. C Choice of Analgesics and Sedatives The choice driven by: • Goals for each patient • Clinical pharmacology • Costs Key Points on Sedation • Assess and target. • Bolus first and then consider continuous infusion. • Daily interruption

  24. D Delirium Monitoring and Management

  25. 72% of ICU Delirium Undiagnosed?? Gets our attention “Ideal patient”

  26. Delirium KillsDuration and Mortality Kaplan-Meier Survival Curve P < 0.001 Each day of delirium in the ICU increases the hazard of mortality by 10% Pisani MA. Am J Respir Crit Care Med. 2009;180:1092-1097.

  27. Patient Factors Increased age Alcohol use Male gender Living alone Smoking Renal disease Delirium: What Can We Do? Predisposing Disease Cardiac disease Cognitive impairment (eg, dementia) Pulmonary disease Less Modifiable • Acute Illness • Length of stay • Fever • Medicine service • Lack of nutrition • Hypotension • Sepsis • Metabolic disorders • Tubes/catheters • Medications: • Anticholinergics • Corticosteroids • - Benzodiazepines DELIRIUM Environment Admission via ED or through transfer Isolation No clock No daylight No visitors Noise Use of physical restraints 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. More Modifiable

  28. 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 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 Feature 3: Altered level of consciousness Feature 4: Disorganized thinking Or

  29. Diagnosing Delirium in Patient on Mechanical Ventilation Letter A test • “SAVEAHAART” • Say above 10 Letters & instruct patient to squeeze hand every time you say letter “A” • Inattention PRESENT if > 2 errors

  30. E Early Progressive Exercise and Mobility

  31. 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

  32. 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

  33. Early Exercise in the ICU • Early exercise = progressive mobility • Study design: paired SAT/SBT protocol with PT/OT from earliest days of mechanical ventilation Wake Up, Breathe, and Move Schweickert WD, et al. Lancet. 2009;373:1874-1882.

  34. Early Exercise Study Results Schweickert WD, et al. Lancet. 2009;373:1874-1882.

  35. 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

  36. ICU Data Collection

  37. 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.” AtulGawande

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

  39. MICU Database

  40. 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

  41. Infection Control

  42. ICU Infection Control • Key Performance Measure for ICU • Hospital Compensation from Payors at Risk • Intensivist’s Bonuses at Risk!!! Infections with Surveillance Programs • Central Line Associated Bloodstream Infections (CLASBI) • Ventilator-Associated Pneumonia (VAP) • Catheter-Associated Urinary Tract Infection (CAUTI) • Clostridium Difficile Colitis

  43. 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

  44. Be Careful Out There

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