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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 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.
Knowing vs. Doing the Right Thing Young 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 strategies11% of patients were receiving Vt < 8 ml/kg PBW
How can compliance with “Best Practices” be insured?
If not smart, be organizedEvery complicated task in the US military
has a “Protocol Authorization”Deviations are NOT allowed
Airline Industry“Go - no go”
MedicineProtocols
Historically, not our model
ChecklistsWinters BD et al (2009). Critical Care 13:210
Static sequential: Single person followse.g. order sets, “bundles”
With verification: Operator reads, another verifiese.g. central line insertion checklist
With verification and confirmation: multi-disciplinaryone operator reads, responsible party verifiese.g. OR “time out” with verification of equipment, etc.
Dynamic: flowcharts with multiple “if-then” pathse.g. American Society of Anesthesiologists “Difficult
airway” algorithm
The Checklist Manifesto – How
to get things right
Atul Gawande
Metropolitan Books
2009
Teamwork and Culture Change
Physician-led multi-disciplinary roundsDaily bed management meeting“Bundles” and complianceCultural change: team decision-making
Miller JM et al (2006). Quality Safety Health Care;15: 235
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
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
“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
Who What Attending Introductions
Introduce new team members / visitors Resident Present Patient
Background – history past few hours Situation – current status Assessment – vitals, physical, etc.
CCI Solicit input from other team members RT / Pharmacy / Dietician / Discharge Planner
RN Rounds Crosscheck Discuss items not addressed
Res/CCI Recommendations / Daily Goals / POC
RN New Orders Clarifications
CCI Questions / Concerns? Safety Statement
If anyone has any concerns at any time, I expect you to speak up immediately.
Structured Daily RoundsGuidelines:When: Begin 0800, 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.
ICU RN Rounds Crosscheck
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
Extent and Cost of Errors2008
EVENT Number Cost/event ($) Total Cost ($)
Catheter-Associated UTI ~13000 24,901 344,000,000
Pressure ulcers ~380,000 8730 3,858,000,000
Catheter-associated bacteremia
~7000 83,365 589,600,000
Iatrogenic Pneumothorax ~26000 22,256 617,000,000
Shreve J, et al. (June 2010). “The Economic Measurement of Medical Errors” report of the Society of Actuaries Health Section
Cost of errors: $ 19.5 billionNumber of measurable injuries: 6.3 million
(1.5 million associated with error)Excess deaths: 2500Short term disability (missed work) : > 10 million excess days
Complications• Review
• Catheters, • vascular and urinary
• Ventilator-associated pneumonia• Sedation-related
• Other Complications• Transfusions• Thrombosis• Gastric “stress ulceration”
How do catheters get infected?
Sadfar and Maki (2004). Intensive Care Med 30:62-67
HCW hands Infected catheter hubs
Catheter Colonization: Sites
Gowardman, et al (2008). Intensive Care Medicine 34:1038-1046
Risk Factors for Bloodstream Infection
Colonization of insertion site 6.3-56
Colonization of catheter hub 18-44
RN : patient staffing ratio
1:2 61
1:1.5 15.6
1:1.2 4.0
Active infection at another site 8.7-9.2
“Difficult” insertion 5.4
Guidewire exchange 1.0-3.3
Site of insertion
Subclavian 0.4-1.0
Internal jugular 1.0-3.3
Femoral 3.3-4.8Safdar, Kluger and Maki (2002). Medicine 81: 466
Making Lines Less “Difficult”Karakitsos et al (2006). Critical Care 10:R162
Ultrasound (%) Landmark (%)
Success 100 94.4Carotid puncture 1.1 10.6Hematoma 0.4 8.4
Hemothorax 0 1.7
Pneumothorax 0 2.4
Attempts 1.1 ± 0.6 2.6 ± 2.9
BSI 10.4 16
Ultrasound Devices
Central Line GuidelinesMMWR (9 August 2002) 51, RR-10
InsertionStaff and operator education
ESPECIALLY HAND WASHING
Chlorhexidine 2% (not 0.5%) antisepticMaximum barrier precautionsMinimum number of portsAntibiotic-impregnated if > 5 days expected and high
institutional baseline rates of infectionSubclavian preferred over IJ or femoral to minimize
infection
Chlorhexidine use
Skin prep delays catheter colonization compared to providone-iodineMimoz et al (2007). Archives Internal Medicine 167: 2066-2072
Bathing patients with chlorhexidine prevents line infectionsBleasdale et al (2007). Archives Internal Medicine 167:2073-2079
Central Line GuidelinesMMWR (9 August 2002) 51, RR-10
Changes: No routine changesNO GUIDEWIRE EXCHANGES IF INFECTION
SUSPECTEDDO NOT CHANGE FOR FEVER ALONEGUIDEWIRE CHANGE OK if site clean
i.e. dysfunctional portNEW GLOVES FOR NEW CATHETER
If bacteremic, new catheter site if old tip infected B- II recommendation Clinical Infectious Diseases (2009)
49: 1
Dressing changesGauze q2d, Transparent q7d (unless soiled)
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
Urinary Catheter Indications
AppropriateFrequent (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 movementTerminal illness or severe impairment
InappropriateNon-essential output monitoring
Diuresis
Incontinence without other indications
fecal or urinary
RN concern for patient comfort
Patient preference
Elpern et al (2009). Am J. Critical Care 18:535
Catheter-associated UTI Elpern 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
Catheter-associated UTI Elpern et al (2009). Am J. Critical Care 18:535
Ventilator-associated Pneumonia
Epidemiology3-4 days after intubation~ 9% prevalenceIncreases
ICU and hospital length of stayMortalityTime on ventilatorHealth care cost (double)
Rello et al (2002). Rello et al (2002). ChestChest 122: 2115 122: 2115
ATS Guidelines 2005Am. J. Respiratory and Critical Care MedAm. J. Respiratory and Critical Care Med (2005) 171: 388 (2005) 171: 388
Level I Recommendations : Non-Pharmacologic
Infection control: education (HAND WASHING) and isolationAvoid intubation (use NIPPV)Avoid nasal intubations (endotracheal and gastric)Continuous aspiration of subglottic secretionsSemi-recumbent positioning (30-45°)Avoid ventilator circuit changesUse heat-moisture exchanger (HME) to avoid colonizationNO ROUTINE chest physiotherapy
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)
ATS Guidelines 2005Am. J. Respiratory and Critical Care MedAm. J. Respiratory and Critical Care Med (2005) 171: 388 (2005) 171: 388
Level II Recommendations : Non-PharmacologicInfection surveillance and antibiogramsAvoid 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 paralysisDaily interruption and awakening
Adequate ICU staffingNo kinetic therapy beds
PharmacologicRestrictive transfusion policiesShorter courses of antibiotics
Oral Care
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)
Sona CS et al. (2009). J Int Care Med 24:54
RN Initiative
547 patients, 3 ICUsChlorhexidine swab (0.12%)
Toothbrushing
Both
Usual care
Chlorhexidine but NOT toothbrushing reduced progression to CPIS > 6 and pneumonia at day 3
Munro CL et al (2009). Am. J. Crit.Care 18:428
Evaluate Patient During SBT(Titrate Fi02 to maintain SpO2 @ 95% during SBT)RR less than 36RSBI less than 106 (F/Vt)HR less than 140 or 20% of baselineSBP 90 180mm HgNo c/o distressNo anxiety or diaphoresis
Continue SBT for 30 minutes Successful?(f/vt < 100)
Advise MDReturn to previous vent settingsWait 24 hours to initiate Guidelinesagain
CPAP OATC or PS off
Notify physician
Borderline(f/vt > 100)
(After 30 min.)Successful?
*Patients may also be potentially weaned with a sedation score of 6 or 7, but a physician must intervene todetermine the cause of agitation. The physician may give approval to wean according to guidelines dependingon the cause of agitation for a patient with a score of 6 or 7.Correlate SpO2 with PaO2 prior to initiating SBT. Draw arterial sample if no ABG in the last 24 hours. (propose it)Consider ABG after 30 minutes of SBT for borderline patients.If patient fails SBT three days in a row, weaning becomes physician directed.Document SBT values at SBT start and Q15 minutes thereafter on the ventilator flow sheet.
Yes
No
No
Yes
RUSH-PRESBYTERIAN-ST. LUKE’S MEDICAL CENTER INTENSIVE CARE UNIT
VENTILATOR WEANING GUIDELINES
Assess Readiness to Initiate Weaning Process DailyUpward titration of pressorsNo more than 10 mcgs/min of dopamine or LevophedStable mean systolic pressureNo significant dysrhythmiasFiO2 less than 0.51.PEEP less than 11cmH20pH > 7.29 and < 7.51 if a.m. ABG availableSedation scale (3 to 5)
Evaluate for Exclusion Criteria20% Hgb drop in less than 24 hoursRecorded ICP greater than 20 mmHg X 2 consecutive hoursImminently planned procedure requiring constant supportQ-I hour suction for copious tracheal secretions
Initiate Spontaneous Breathing Trial (SBT)Maintain current FIO2CPAP 5 cwp100% ATC (Evita/PB840) or PS of 5 (PB7200)Flow Trigger (Flow-By 5/3, if on PB 7200)
No
Yes
Maintain usualventilatory support
No
Yes
No
Ver. 1 06/06
Head of Bed Elevated 30 Degrees
Yes
RN to contact MD andrequest extubation
OptionalPa02/Fi02 less than 200NIF/SVC Done
MD Input here
WeaningRN- and RT-drivenMD-independent
until later
Sedation
Prevents self-harm (extubation)Decreases risk of post-traumatic stress disorderFacilitates nursing care
Masks neurological changesProlonged intubation due to oversedatonWhen prolonged, evaluation for “mental status
changes” with (often) CT, LP, EEG, NeurologyDrug clearance rates important factor (age, organ dysfunction/failure)
SedationDaily 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 PTSDFewer complicationsCoupled with SBT: better ventilator, ICU, hospital and
long-term outcomes (Girard TD et al (2008). Lancet 371:126)
Use of guidelinesSCCM (Critical Care Medicine (2002). 30:119) but new ones “soon”
Institutional or unit-specific
Daily Sedation Interruption and ComplicationsSchweickert WD Schweickert WD et alet al (2003). (2003). Critical Care MedicineCritical Care Medicine 32:1272-1276 32:1272-1276
COMPLICATION INTERRUPTION USUAL
VAP 2 5
UGI BLEED 5 4
BACTEREMIA 4 7
BAROTRAUMA 0 3
VTE 2 5
CHOLESTASIS 0 1
SINUSITIS 0 1
TOTAL 13 26
Rule out /correct reversible causes Set goals for delirium control Use nonpharmacologic treatment
Set analgesia goal (default PSS = 3 or less) Assess PSS per unit policy Titrate medications toachieve goal PSS
Set sedation goal (default RASS= 0) Assess RASS per unit policy Titrate medications to achieve goal RASS
Avoid oversedation Assess CAM-ICU per unit policy Optimize the environment
Preferred agent: Haloperidol (3,4) Loading dose: 0.5-2mg IVP q 30 min until at goal Then 25% of loading dose q 6hr for 24 hours then revaluate NOTE: OBTAIN Baseline EKG (if QTc greater then 500 msec then avoid antipsychotics)
Preferred Agent: Fentanyl Initial dosage: 25-50mcg IVP q 10-15 min. *Once controlled, consider continuous infusion if pt. requires IVP more frequently than q2hrs.
Preferred agent: Midazolam (2) Initial Dosage: 1-4mg IVP q30 min until at goal *Once controlled, consider continuous infusion if pt. requires IVP more frequently than q2 hrs.
ANALGESIA
SEDATION DELIRIUMM MMmM
Preferred agent: Propofol (1) Initial Dosage: 5 mcg/kg/min, titrate q 5 min until at RASS goal
Hemodynamically Stable?
YES NO
If CAM-ICU +
If pt poses risk to self or others
Acute episode of Unknown Etiology Fentanyl 50-100 mcg IVP x 3 until acutely controlled or consider Midazolam: 2-5mg IVP q 10 min (up to 10 mg) until acutely controlled
General opioid/sedation considerations : 1. For patients maintained on propofol, monitor for bradycardia
and hypotension. If on propofol for greater than 5 days, consider checking a triglyceride level.
2. For pts with renal insufficiency, avoid agents with renally- excreted active metabolites (morphine, midazolam, diazepam).
3. Use cautiously in patients with a known history of Parkinson’s Disease.
4. Geriatric patients require special consideration (dosing/agent selection)
Reassess delirium goals daily Daily Spontaneous Awakening Trial at 4AM (if continuous infusion) Stop sedative and analgesic infusions UNLESS:
1. RASS = +2 to +5 (then continue sedative infusion) 2. Uncontrolled pain (then continue analgesic infusion) 3. Elevated ICP, active seizures, EtOH withdrawal, or
myocardial ischemia 4. Duration of infusion more than 7 days (wean per MDorders)
Resume infusion at HALF prior dose if:
1. Anxiety, agitation, or pain 2. Cardiac arrhythmia 3. Respiratory distress, respiratory rate >35/min , or SpO2 <88%
*Otherwise, discontinue infusion
Sedation Interruption vs. Algorithm
74 patients single site, stopped earlyIncreased hospital mortality in daily awakening group
Daily awakenings vs. protocol-drivenIncreased 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
So in the end……..Standardize procedures with checks and cross checks
Careful attention to cathetersInsertion proceduresSiteDressing careEarly removal
Prophylactic measures for VTE and SRMDVAP preventive measures: early wean and extubationSedation to prevent PTSD yet avoid “snowing”
use established or institutional guidelinesMinimize transfusions