Principles of triage of ICU admission (Gomersall)
- Only when necessary
Balancing supply and demand
- Cut staff ratio
- Temporary increase in beds; but can increase in adjusted odds ratio as needs to be staffed e.g. temporary staff; quality vs quantity
- Teaching acute care
- Decreasing length of stay e.g. early discharge post CABG. Van Mastright Crit Care Med 2006 34 65
Ethics – mainly beneficence and distributive justice. No role for autonomy in triage?
Triage – Egalitarian (first come first serve vs utilitarian (benefit most)
Benefit = probability of survival in ICU – without ICU. Effects of ICU may be overestimated.
ELDICUS study – http://www.ncbi.nlm.nih.gov/pubmed/21926598
Risk factors for death – >60, refereral location, dependent on ADLs, cirrhosis, AKI
BUT equation needs to also factor in Life expectancy (quality adjusted) – old ppl have a lower life expectancy!
Improving the ICU Environment (Curley)
Hospitals are dangerous places
Post-hospital syndrome – http://www.nejm.org/doi/full/10.1056/NEJMp1212324
What can we do?
Restore resilience (R2)
Circadian rhythm assessment
Align family with care plan – decision making and care
Noise contamination and thus containment is good for patients and staff
ICU diaries Crit care 2010 14 r168 – http://ccforum.biomedcentral.com/articles/10.1186/cc9260
Nurses and pts/families knowing each other – synergy and continuity
Optimal Alarms (JD Chiche)
Alarms in the ICU – why do much noise?
Nurse Crit Care 2007 12 188 Noise levels in a general intensive care unit – http://onlinelibrary.wiley.com/doi/10.1111/j.1478-5153.2007.00229.x/abstract
Crit Care Med 2016 44 147 Noise levels in Surgical ICU are consistently above recommended standards – http://journals.lww.com/ccmjournal/Abstract/2016/01000/Noise_Levels_in_Surgical_ICUs_Are_Consistently.17.aspx
Alarms are the main cause of noise
We are not very good at identifying them – http://inc.sagepub.com/content/13/2/122.refs
Bad alarm – desensitisation, disruption of workflow, sleep disruption
72-99% of alarm false or non-clinically significant
Alarm fatigue – http://www.ncbi.nlm.nih.gov/pubmed/26539788
Smarter alarm algorithm – adaptive time-delays e.g. derangement needs to be sustained to trigger alarm – http://www.ncbi.nlm.nih.gov/pubmed/26621389
False Alarm Identification and Reduction (FAIR Study)
Evaluating the risk state of the ICU (Talmor)
Traditional approach to safety – checklist e.g. CLABSI, VAP
Openness and transparency
Root-cause-analysis for all preventable harm
Safety in Healthcare – traditional vs systems (pic)
Reengineering the ICU (Brown)
- Medical errors
- Communication poor
- Respect and dignity threatened
- Fragmentation of information
Developing a comprehensive model of intensive care unit processes – http://www.ncbi.nlm.nih.gov/pubmed/25909826
Technology – Accelerometers to document pt mobility or agitation?
Observations of respect and dignity in the intensive care unit. – http://www.ncbi.nlm.nih.gov/pubmed/25772729
Emotional harm from disrespect: the neglected preventable harm – http://qualitysafety.bmj.com/content/early/2015/06/17/bmjqs-2015-004034.full