ISICEM 2015 Blog Day 2

adrianAdrian Wong is at the International Symposium on Intensive Care and Emergency Medicine in Brussels and summarises his second day here for OXICM

Edited by Jamie Strachan

ICU Organisation

How much intensive care do we need? (G Rubenstein)

Huge variation in ICU bed provision. Not all patients at the same risk of death have the same chance of benefit from the ICU due to individual hospital variation.

In some cases, patients are admitted to ICU because you don’t want to admit them to the ward.

THERE IS NO MAGIC NUMBER OF ICU BEDS/HOSPITAL BEDS or POPULATION

Studies are limited by the fact that its difficult to define what is an ICU bed or even what is an intensivists.

References

Variation in critical care services across North America and Western Europe – http://www.ncbi.nlm.nih.gov/pubmed/18766102

Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis – http://www.bmj.com/content/339/bmj.b4353

Access to urban acute care services in high- vs. middle-income countries: an analysis of seven cities – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938845/

Pros and Cons of separate step-down beds (H Wunsch)

Discharging a patient from ICU to the ward somethings feels like pushing the patient off a cliff.

Potential benefits of step down bed

  • Better outcomes
  • Better flows
  • Cheaper
  • Reduce need for ICU beds

Cons

  • More care transitions
  • More expensive
  • Patient distress

Conclusion

  • Profoundly understudied
    • Terminology remains a problem
  • Very mixed results so far
    • Mortality
    • Length of stay
    • Patient experience
  • Challenges of varied configuration
    • Hospitals with separate stepdown units may be fundamentally different in many ways

References

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study – http://ccforum.com/content/18/5/551

Does intermediate care improve patient outcomes or reduce costs? – http://ccforum.com/content/19/1/89

Setting up an ICU Echo service (S Huang)

Governance profoundly important

Implementing an Echocardiography Service in the Intensive Care Unit –http://healthmanagement.org/s/implementing-an-echocardiography-service-in-the-intensive-care-unit

Keep quality of sleep (JP Mira)

Few studies and highly heterogeneous

ICU patients have a marked reduction in REM Sleep

Integrated strategy to promote sleep

  • Noise reduction
  • Diurnal lighting practices
  • Use of sleep-promoting pharmacological agent
  • Minimising use of pharmacological agents that inhibit sleep
  • Uninterrupted time for adequate sleep
  • Appropriate physiological support
  • Active promotion of patient orientation
  • Patient-ventilator synchrony
  • Relaxation techniques

References

Sleep in the Intensive Care Unit – http://www.atsjournals.org/doi/abs/10.1164/rccm.201411-2099CI#.VQm6X9KsUlI

Feasibility Of Conducting 24-Hour Polysomnography Studies In The Medical Intensive Care Unit: http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A1617

The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients – http://ccforum.com/content/16/3/r73

Light in the ICU (M Rosengart)

Conclusion

  • Photoperiodism exists in humans
    • Optimal photoperiod to alter human biology in the context of illness remains to be defined
  • Blue spectrum can alter the biology of critical illness
    • Is there human relevance
  • A light of optimal spectrum, intensity and duration of light can be identified and applied to alter human biology and the course of critical illness

References

The effect of window rooms on critically ill patients with subarachnoid hemorrhage admitted to intensive care – http://ccforum.com/content/15/2/R81

Light and the outcome of the critically ill: an observational cohort study – http://www.ncbi.nlm.nih.gov/pubmed/22827924

The optimal ICU design (Halpern)

Showcasing some truly beautiful and functional ICUs. Utrecht ICU looks stunning

Modern rooms – e-glass, booms, environment sensors, webcams, etc

Cost – $1,000,000 per room

Conclusion

  • Optimal ICU design requires extensive planning, simulation and attention to detail
  • The focus of ICU design should be on all aspects of
    • The patient room
    • Family needs both inside and outside the patient room

References

http://www.criticalcaredesigns.com/pub_design.html

All patients should walk (J Mancebo)

References

Functional Disability 5 Years after Acute Respiratory Distress Syndrome – http://www.nejm.org/doi/full/10.1056/NEJMoa1011802

ICU-Acquired Weakness and Recovery from Critical Illness – http://www.nejm.org/doi/full/10.1056/NEJMra1209390

Staffing and work culture (D Angus)

Considerable amount of variation – some easily measured and some less easily measured.

Less easily measured

  • Hierarchy
  • Leadership
  • Followership
  • The ‘it’ factor

BUT caveats

  • I’ll know it when I see it
    • A large part of ICU culture has strong ‘smell’ but remains difficult to define
    • You can tell how good a unit is by the ‘feel’
  • Chicken or egg
    • Optimal patient outcome is likely affected by
      • Number and type of staffing composition
      • Competency of staffing
      • Degree of timework and integration
      • Morale and attitudes
    • Easier said than done
      • From easy to hard
        • Provision and training of staff
        • Coordination and integration of care
        • Sense of teamwork and camaraderie
        • Reversing ‘burn-out’ and ‘getting to great’

Conclusion

  • ICU staging, organisation and culture varies a lot
    • Workforce composition, competency and morale
    • Team interaction, cohesiveness and behaviour
  • These factors appear to affect outcome
    • And many can be positively influenced
  • BUT
    • Some of the largest perceived attributes are hard to capture
    • Bi-directional relationship of cause and effect
    • Some important domains are extremely resistant to change

Keep the ICU doctor happy (M Ramsay)

ICU and ED jobs are stressful

Burnout is a syndrome of emotional exhaustion, de-personalisation, and a sense of low personal accomplishment that leads to decreased effectiveness at work – http://archinte.jamanetwork.com/article.aspx?articleid=1351351

Sleep deprivation

  • Deceased efficiency
  • Instability
  • Recent memory deficit
  • Depersonalisation
  • Inappropriate humour

Struggling in silence

  • 300-400 physicians die each yer by suicide
  • Methods: OD, firearms
  • Risk factors: depression, alcohol abuse
  • Higher completion/attempt ratio

High reliability organisation

  • Leadership committed to zero harm
  • Safety culture embedded in organisation
  • Robust process improvement
  • Risk management proactive and not reactive
  • Blame free for small errors but accountability for adhering to safe practice

Emotional Intelligence – out of control emotions make smart people stupid

Conclusion

  • Healthcare is 24 hour operation
  • Understanding how fatigue affects doctor is critical to patient safety, performance and productivity
  • An impaired physician is a waste of a valuable resource
  • An impaired physician is a liability to the organisation and medical staff

Pro/Con debate HFOV

OSCAR – http://www.nejm.org/doi/full/10.1056/NEJMoa1215716

OSCILLATE – http://www.nejm.org/doi/full/10.1056/NEJMoa1215716

Pro (N MacIntyre)

HFOV makes conceptual sense

HFOV has considerable supportive clinical evidence (but in paeds population)

Recent negative clinical trials problematic

  • Lack of expertise
  • High Paw protocol in the setting of high vasopressor use

Con (N Ferguson)

Not for routine lung protection in moderate ARDS

Carefully selected patients with severe ARDS

  • After consideration of prone, NMB

Assess response to HFOV initiation

  • Significant increase in pressor requirements
  • No significant improvement in oxygenation
Adrian Wong is a CUSIC fellow at the John Radcliffe Hospital, Oxford.
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