ISICEM 2016 Day 3

The 3rd instalment in the quadrumvirate of oxicm blogs by Dr Wong from Brussels. JS

Principles of triage of ICU admission (Gomersall)

Principles

  • Only when necessary
  • Fair
  • Transparent

Balancing supply and demand

Maximising supply

  • 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

Decreased demand

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

http://icudelirium.org/

Post-hospital syndrome – http://www.nejm.org/doi/full/10.1056/NEJMp1212324

What can we do?

Change paradigm

Restore resilience (R2)

IMG_7560

Circadian rhythm assessment

Align family with care plan – decision making and care

Noise contamination and thus containment is good for patients and staff

Protocolized Sedation vs Usual Care in Pediatric Patients Mechanically Ventilated for Acute Respiratory Failure

 

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)

IMG_7562

IMG_7571

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)

IMG_7573

Reengineering the ICU (Brown)

Problems

  • 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

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