1. Introduction to Medical ICU: Part II David Oxman, MD Assistant Professor of Medicine Pulmonary & Critical Care Thomas Jefferson University Hospital July 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 AJRCCM 2009

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 Physicians Nursing Pharmacists Patient It Takes A Team

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 D D E E C C

12. Daily Awakening Trials Why 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. 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

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

15. Spontaneous Awakening Trial (SAT)

16. Spontaneous Breathing Trial (SBT)

17. Choice of Analgesics and Sedatives C C

18. 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 Ventilatory Optimization

19. 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

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 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 C C Choice of Analgesics and Sedatives

21. 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 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

22. TJUH Pain and Agitation Algorithm

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

24. D D Delirium Monitoring and Management

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

26. Delirium Kills Duration 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

27. 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?

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 Feature 3: Altered level of consciousness Feature 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

29. 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

30. Early Progressive Exercise and Mobility E E

31. 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 E

32. Immobility not beneficial and associated with harm – Myopathy/neuropathy – Delayed weaning from ventilator – Delirium – Infections – Pressure ulcers E 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 Schweickert WD, et al. Lancet. 2009;373:1874-1882. Wake Up, Breathe, and Move

34. Early Exercise Study Results Outcome Intervention (n=49) Control (n=50)P Functionally independent at discharge29 (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 discharge75 (7.5-95)55 (0-85)0.05 ICU-acquired paresis at discharge15 (31%)27 (49%)0.09 Ventilator-free days23.5 (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 mortality9 (18%)14 (25%)0.53 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.” Atul Gawande

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

45. 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

46. Be Careful Out There