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