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“Have you been treated with respect in the ICU today?”November 2nd, 2016
“What do you worry about, or fear the most, during your stay in the ICU?” Michael Gropper, MD, PhD, once asked a patient. “That the hospital will kill me,” replied the patient, using an iPad to tap out the answer since he was intubated and unable to speak.
That answer isn’t an unreasonable fear, Dr. Gropper told the audience during his Grand Rounds presentation on Wednesday, November 2. Dr. Gropper, who chairs the Department of Anesthesiology and Perioperative Medicine at UCSF, spoke on the topic of “Preventing Harm in Critically Ill Patients” as part of our Patricia A. Kapur, MD, Visiting Professor Program. He pointed to evidence that between one-half and one percent of hospital admissions are associated with a preventable, potentially lethal adverse event, such as a hospital-acquired infection.
“This is an opportunity for us,” Dr. Gropper said. “So many of these things happen in the perioperative environment.” Among the other complications that can occur in the course of an ICU stay, he said, are ventilator-associated harms, ICU-acquired weakness, delirium, deep venous thrombosis or pulmonary embolism, and post-traumatic stress disorder (PTSD) suffered by patients and sometimes by family members.
Even after surviving an ICU stay, Dr. Gropper said, patients frequently suffer long-term cognitive impairment of memory, attention, executive function, vision, and/or mental processing speed. Physically, they may note long-term pulmonary problems and neuromuscular weakness. Mentally, both patients and families may endure long-lasting anxiety, PTSD, depression, and complicated grief reactions.
However, we are not helpless to improve conditions in our ICUs and reduce the incidence of these complications, Dr. Gropper said. He spoke in detail about “Project Emerge”, a joint effort between UCSF and the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, to redesign the ICU, eliminating the most common causes of preventable harm and improving the experience of patients, families, and clinicians.
“Less is more,” Dr. Gropper advised. As a general rule, he believes ICU patients should receive less tidal volume, insulin, sedation, fluid, blood products, catheter insertions, colloids, nutrition, benzodiazepines, antibiotics, corticosteroids, and even oxygen. “We all want to achieve 99-100 percent on everything we do,” he said, “but 100 percent O2 saturation is not a good goal! It should be more like 95 percent.”
Handwashing, communications, PEEP, and mobilization are the only things most ICU patients need more of, Dr. Gropper said. Early mobilization within 48 hours of ICU admission is key, he believes, to avoiding over-sedation, delirium, and severe physical deconditioning. “If you go into an ICU and all the patients are in bed, in a coma, then it’s not a good ICU,” he said. “If you’re mobilizing every day, then you’re probably not over-sedated.”
Dr. Gropper acknowledged that changing the culture in an established ICU may not be easy. It takes a concerted effort to change the practice patterns of ICU personnel across disciplines, starting with the nurses. In his experience, increasing the presence of physical therapists has been key to implementing early mobilization, as they are likely to be more motivated than the nursing staff, at least initially. He showed slides of ceiling lifts used to move patients from bed to chair, portable treadmills that can be placed at the bedside, and tilt tables that slowly tilt patients upright to enable gentle weight-bearing. Though staff members fear unintended extubation or lines being pulled out, he said, these events haven’t occurred any more frequently since the early mobilization efforts began.
The costs of ICU care don’t stop at discharge, Dr. Gropper said, pointing to studies that show huge cumulative post-discharge costs accruing long afterward, especially in patients with more than one co-morbidity. Only half of survivors of critical illness return to work within a year, he said. One study that examined the outcomes of ARDS patients found that even five years later, the survivors still had significant physical impairment, and the distance they could walk plateaued at about 60 percent of what would otherwise be expected for their age. Another study looked at the cognitive function of elderly patients after an ICU stay, and found that global cognition scores were comparable to those with traumatic brain injury or Alzheimer’s disease. Outcomes were even worse in patients with a diagnosis of in-hospital delirium.
CUSP: Comprehensive Unit-based Safety Program
For the culture in an ICU to change, Dr. Gropper said, it’s critical to train all staff in the science of safety, and engage the staff in identifying defects. Once a problem is uncovered, it must be fixed promptly whenever possible. Sometimes, he said, “We need to shame people in the C-suite to participate in this!”
“There is too much time spent at the computer,” Dr. Gropper said, to general agreement. Workflow redesign can’t involve more work, more clicks at the computer, or it will fail, he predicted. “People will embrace it if it makes their jobs easier.”
Encouraging the audience to involve family members more in patient care, Dr. Gropper said that families love to help when they’re allowed to do so, and he showed photos of family members helping patients with physical therapy. In turn, positive interactions with family members benefit the morale of the clinical staff, help them avoid the error of “depersonalizing” patients, and help align the goals of the patient, the family, and the clinical team.
Perhaps the most important question to ask the patient and the family, Dr. Gropper said, is, “Have you been treated with respect in the ICU today?”
In the question-and-answer session following the lecture, Joseph Meltzer, MD, said, “I am re-inspired in the ICU yet again!” However, it can be hard to understand why ICU teams can accomplish some goals that seem very difficult, he said, but “we can’t seem to do some of the easy ones.” Why are some ICUs so much more resistant to change?
“Cardiac ICUs are the last frontier,” Dr. Gropper replied, noting that some senior physicians will never change their beliefs and practices. “Doing the training with nurses is the best thing you can do,” he advised. Once the nurses and the house staff have been trained in new methods, it becomes harder for any single physician to resist the trend. “But choose your battles,” he concluded.
Karen Sibert, MD
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