The New PICU – from a Toxic to a Healing Environment

Dr. Karen Choong MB, BCh, FRCP(C)Professor, Dept. of Pediatrics and Critical Care,

Health Research Methods, Evidence and Impact

McMaster University

@karen_choong

#PedsICU # PICULiber8# ICURehab

Disclosure

✔️AFP Innovation Grant - PICU Liber8, an Implementation

Study

Patient images provided with consent

Clinicaltrials.gov NCT03573479

Outline

1. What’s happening to critically ill children

2. What’s Toxic - understanding Harm

3. The New PICU – from Resuscitation to Rehabilitation and Recovery

Traditional Focus of Critical Care

Early Recognition Resuscitation Survival Discharge

Improved PICU Survival

Chan, J Peds 2016; Cremer CCM 2009Pinto PCCM 2017; Choong PCCM 20181997 2006 2013 - present

12%7%

2-3%

30%41%

53-68%

- 79% PICU Days

- 81% PICU cost

- 77-89% invasive

therapies

Chronic Complex Disease

Noncomplex Chronic Disease

Previously Healthy

PICU POPULATION

PICU Mortality

Chronic Complex Patients

⇢Population Shift

HOSPITAL READMISSIONS 12%

PICU-ACQUIRED COMPLICATIONS (PAC)

20%

2008 2018

63%Iatrogenic Withdrawal

25%-53%Delirium

23%PICU-acquired

Weakness

13%

17%

2%

Amigoni, PCCM 2017; Traube, CCM 2017; Choong PCCM 2018;

D Caldwell CCCF 2018

↑ mechanical ventilation

↑ Length of Stay

↑ Mortality

↑ Poor Functional outcomes

↑ Parental Stress

Decreased Mortality ⇢ Increased PICU Morbidity

2008 2018

35%

61% develop 1/more PAC

Decreased Mortality⇢ Increased Post-PICU Morbidity

Pollack, PCCM 2014; Pinto, PCCM 2017;

Choong PCCM 2018;Knoester, Int Care Med 2008

25% 30%

82%

93%

50%

FUNCTIONAL DISABILITY

POOR QUALITY OF LIFE

POST PICU MORTALITY

Longterm Outcomes

Then Now

Post-Intensive Care Syndrome–pediatrics

(PICS-p); PICS-familiesHigh

Parental Stress

Poor Functional Recovery

↓PICU Mortality - ↑Post-PICU Mortality

• Mortality is higher AFTER PICU discharge

Author (Year)PICU

Mortality

Cumulative Mortality

at 6mths

Jones; UK (2001-2002) 7.8% 9.3%

Pinto; US (2012) 3.9% 7.8%

Choong; Canada (2014-2016) 1.5% 3.3%

IMPROVED PICU Survival

↑ Chronic Complex Survivors xs 2

↑ PICU-acquired Complication x’s 3

Protracted RECOVERY

Survival is only the beginning….Success in Pediatric Critical Care ⇢ Improved Survival

↑ POST-PICU MORTALITY X’s 2

↑ POST-INTENSIVE CARE SYNROME-

Pediatrics

LEGACY of CRITICAL ILLNESS

The Old PICU – SurvivalThe New PICU - Survivorship

Understanding Harm

PICU Practice Paradigm

Choong, PCCM 2018; Traube, CCM 2017; Smith H, CCM 2017

70%Withdrawal

25-53%Delirium

23%PICU-acquired

Weakness

Failure to recognize

PICU-acquired complications (PACs)

→ Sedation-Immobility Harm

Cycle

The PICU Paradigm - Culture of Sedation

SAFETY PRIORITIES

#1: Accidental extubation

↓Anxiety and stress

Cardiorespiratory Instability

Conflicting attitudes

Understand the S/E of sedation

Desire for Deeper Sedation

Perceived ↑Workload

Knowledge Gaps

Comfortable Sedating, Uncomfortable Mobilizing

Lack of understanding of Delirium

Misconception that Sedation = SleepChoong et al, PCCM 2014

Long, Australian Critical Care 2016

Belovedblake.wordpress.com

Sleep in the PICU

CRITICAL

ILLNESS

PSYCHOLOGICAL

EMOTIONAL

DELIRIUM

AGITATIONINSOMNIA

DISTRUPTED

SLEEP

WITHDRAWAL

PARENTAL

STRESS

Benzodiazepines and

opioids ↓restorative sleep,

↑arousal frequency

PHARMACOLOGICALENVIRONMENT

Kudchadkar Sleep Med Rev 2014; Traube, CCM 2017

The Old PICU - Culture of Sedation

ADVERSE EVENTS ARE UNCOMMON:

Self-extubation: 0.5%

Patient discomfort : 16 vs 14%

Mobility related adverse events: 0.4-2.6%

No Urgency to address over-sedation, delirium, mobilization

Sedation and Immobility are prioritized over Rehabilitation

Curley et al, JAMA 2015; Nydahl, Ann Am Thorac Soc 2017; Cuello-Garcia J Peds 2018

SAFETY PRIORITIES

Accidental extubation

Discomfort

Cardiorespiratory Instability

PACs are very common - 61%

The Old PICU - Toxic Environment

• Light pollution: Harsh, artificial → disrupts day-night rhythm

• Noise pollution: 84 dB, up to 100 dB impairs healing, activates SNS, hormonal dysregulation

Sleep disruption, Delirium, PTSD

• Clinician convenient Routines:- 4 am bed bath, 4:30 routine Xrays, 6 am routine labs

Bad for Staff, Toxic for patients, stressfull for Families

De-personalization of Patients

Computer-as-surrogate for patient

The New PICU

Rehabilitation - the process of Recovery

Harm Reduction

Risk factors for PACsOdds Ratio

(95% CI)

Time to Mobilization 1.11 (0.96 – 1.28)

IV Sedation duration 1.07 (1.00 – 1.14)

Benzodiazepine use 5.2 (3.7 – 7.5)

New/Progressive MODS 1.78 (1.18 – 2.67)

Weecover study, Choong et al, PCCM 2018

FRONT End

STRATEGIES

BACK End

STRATEGIES

Rethink Safety Priorities

SAFETY PRIORITY

EXCESSIVE SEDATION

DELIRIUM

IMMOBILITY

SAFETY PRIORITY

Unplanned Extubation

Cardiorespiratory

Instability

Discomfort

HARM prevention

Operationalizing Rehabilitation

Choong, PCCM 2018; Smith, CCM 2017; Mody, CCM 2018

PICU

LIBER8FAMILY

EARLY MOBILIZATION

DELIRIUM

COMFORT

BREATHING

AWAKE-ASLEEP

GOOD NUTRITION

HUMANISM

Figure 1. PICU Liber8: An early rehabilitation bundle to reduce harm

Choong 2018

Less immobilisation

Less sedation depth & duration

Less benzodiazepines

LESS IS MORE

PICU

Liber8

Good Nutrition

Humanism

AwakeAsleep cycles

Breathing

Comfort

Deliriumprevention

Early Mobilization

Familyengagement

A Rehabilitation Bundle is effective

PICU

LIBER8FAMILY

EARLY MOBILIZATION

DELIRIUM

COMFORT

BREATHING

AWAKE-ASLEEP

GOOD NUTRITION

HUMANISM

MD

PTRT

RNPHARM

FAMILY

CCM Oct 2018

Rehabilitation is Effective…

It made me aware that he’s not dying, it seems like he’s

going to liveYou knew there was some

physical benefit to it but for her, it was something to look

forward to

Emotionally we don’t get much around here, so psychologically,

it (mobilization) was so beneficial

PCCM 2018

”“It gave me hope.

HUMANISMCreating a Healing

Environment

PICU

LIBER8FAMILY

EARLY MOBILIZATION

DELIRIUM

COMFORT

BREATHING

AWAKE-ASLEEP

GOOD NUTRITION

HUMANISM

Humanism: Creating a Healing Environment

• Noise reduction

• Cluster care

• Lighting policy, Quiet time

• Sleep routine, adjuncts

• Assisted communications

• Patient Diaries

• Pet Therapy

Humanism = Patient Engagement in Rehabilitation

Music Therapy

Child Life

Adjuncts to Rehabilitation in the PICU

Patients Engaging Patients

H: Hounds

Family Engagement is KEY to Rehabilitation

The NEW PICU – Focus on Healing

1. HARM reduction - Less is More

2. Non-pharmacological 1st line interventions

3. Personalized, goal-targetted patient care

Rehabilitation

Early

Recognition

Bridging Survival with Survivorship

ABC’s of

STABILISATION

Resuscitation

SAVING LIVES with

BETTER QUALITY

ABC’s of

RECOVERY

Thank you

@karen_choongchoongk@mcmaster.ca

#PedsICU #ICURehab