Less sedation, more physical therapy and standardized care help critically ill patients be 'alert, awake and out of bed'
The intensive care unit of the future looks and feels remarkably different from today's ICU. Patients on ventilators are alert more often than not and some are even up and moving. Much of the care is standardized so that when a patient responds in an unexpected way, the staff notice immediately and intervene. Critical care-certified intensivists serve as managers overseeing unit performance, but are involved in direct patient care when needed.
This sounds far off, but leading ICUs already have made pieces of this picture a reality.
At Johns Hopkins Medicine in Baltimore, the multidisciplinary Outcomes After Critical Illness and Surgery group is looking beyond patient mortality and focusing on the impact of critical illness on ICU survivors' longer-term outcomes. "We really need to reinvent how we deliver care in the ICU because there is a legacy of critical illness, and it's not a good one," says Dale M. Needham, M.D., associate professor and practicing ICU physician at Johns Hopkins. "ICU survivors have a legacy of muscle weakness, impaired physical function, delayed return to work, impairments in cognition, and high rates of post-traumatic stress disorder and depressive symptoms."
The problems result, in part, from the common practice of keeping critical care patients deeply sedated and on bed rest. These practices were adopted with patients' best interests in mind, Needham says. The worry was that critically ill patients might pull out a tube or a line or feel intense pain. However, no one had proved heavy sedation and bed rest are good for patients. Studies published in the last decade have begun to show just the opposite.
Newer research, at Hopkins and elsewhere, indicates that early rehabilitation and less use of sedation is feasible and safe. For example, in 2006 and 2007, Needham led a quality-improvement project for acute respiratory-failure patients requiring mechanical ventilation in one of Hopkins' medical ICUs.
The project aimed to change ICU culture to adopt findings from recent research studies. The initiative involved reducing heavy sedation and increasing physical and occupational therapy. It included guidelines regarding PT and OT consultations and when it was safe for patients to receive those therapies. A full-time PT and OT were dedicated to the MICU, as was a part-time rehabilitation assistant. Sedation practice was changed from use of continuous intravenous infusions of benzodiazepines and narcotics to "as needed" bolus doses.
The project's results, published in the April 2010 issue of Archives of Physical Medicine and Rehabilitation, were dramatic. The proportion of MICU days in which patients received benzodiazepines fell from 50 percent to 26 percent. Patients were alert more often, the incidence of delirium dropped, and pain scores remained low. The proportion of days in which patients did not get PT and/or OT decreased from 41 percent to just 7 percent. Meanwhile, average lengths of stay fell 2.1 days in the MICU and 3.1 days in the hospital.
"It was truly a win-win—better for patients and better for the hospital from a financial perspective," Needham says.
These findings prompted Hopkins to fund the Critical Care Physical Medicine & Rehabilitation Program, of which Needham is medical director. Although the institution is investing more money in ICU rehabilitation, the idea is that the hospital will see an overall savings with improved patient outcomes and increased MICU patient volume, he says.
The program's goals are to provide early physical medicine and rehabilitation to all MICU patients and to translate ongoing research findings into the everyday clinical practice in the hospital system's ICUs. The program has focused on revising the sedation protocol to aim for all patients to be awake and alert, introducing a twice-daily delirium assessment, and improving patients' sleep quality.
The various changes turn the traditional clinical practices ICU doctors and nurses have been taught on their head by saying, "in fact, we want your critically ill patient who's on life support to be awake, alert, out of bed and walking around," he says. "It's like telling an ICU doctor or nurse that the earth is flat."
Some ICUs, like the MICU in which Needham works, have been quick to implement the changes. Other Hopkins ICUs are at various stages of adoption.
While interest in early rehab in the ICU is just starting to catch on, other quality efforts are more commonplace. Many critical care departments have turned to patient-safety bundles to improve care and reduce variation.
In Illinois, Provena Health is one such system. "The ICU is a chaotic environment," says Margaret Gavigan, senior vice president and chief clinical officer. "You need checklists and protocols because that is what is going to give the safest and best care to patients."
In 2006, the six-hospital system joined the international Surviving Sepsis Campaign and implemented its package of steps to diagnose and treat severe sepsis and septic shock. The effort decreased Provena's ICU mortality from septic shock from 40 percent to 22 percent.
Three years later, the system launched "Wake Up and Breathe," an evidence-based quality initiative aimed at weaning patients off sedation and ventilators in an effort to reduce ventilator-associated pneumonia and shorten ICU and hospital lengths of stay. Systemwide, the project has decreased hours per ventilator episode by 20 percent.
Provena's eICU, by Philips VISICU, aids protocol compliance. "If an eICU nurse sees a patient didn't get measures to prevent deep vein thrombosis, that nurse is able to call the bedside nurse and say, 'The head of the bed isn't elevated; the stockings aren't on,'" Gavigan says. "We write algorithms and protocols so that at each shift we're looking to see if those clinical leading practices have been implemented."
Perhaps the most well-known ICU quality initiative is the Michigan Health & Hospital Association's Keystone project to reduce central line-associated blood stream infections and VAP. Eighty ICUs are participating in the effort, which began in 2003. The approach includes promoting a culture of patient safety, use of daily patient goals sheets to improve clinician-to-clinician communication, and a checklist to ensure adherence to infection-control practices.
Between March 2004 and March 2010, the project saved more than 1,830 lives, avoided more than 140,700 excess hospital days, saved more than $300 million in health care spending and reduced the VAP rate by 70 percent, according to Keystone data. Findings published in the May 9 Archives of Internal Medicine show that 60 percent of participating ICUs went at least one year without a central line infection and 26 percent went two years or more. "Hospitals should strive to emulate these results and implement similar interventions," the authors write.
At Emory Healthcare in Atlanta, the ICU quality program includes the usual bundles, but goes beyond those protocols and toward a more comprehensive standardization of care. The effort resulted from a process through which all the critical care stakeholders identified and then ranked the important ICU attributes, says Timothy G. Buchman, M.D., founding director of the Emory Center for Critical Care. Three attributes—quality, value and access—floated above the rest and became the program's centerpiece. The core strategy settled upon to drive progress in those areas was to transform ICU care from an "every-patient-is-a-masterpiece" approach to a high-reliability model, Buchman says. That meant implementing consistent clinical practices with predictable outcomes.
Looking at the ICU workforce with its mix of steady, cyclic and temporary clinicians, Buchman determined a new class of provider was necessary to carry out a standardized model of care. He established teams of affiliate providers, nurse practitioners and physician assistants with extra training, who are present 24/7 in the ICU.
"The advantage of bringing this group of workers into the mix is that their clinical training has always encouraged adherence to practice standards,," he says. "The affiliates are socialized to do things consistently and to recognize when things are going in an unexpected fashion. It changes the flavor of the environment. They know the rituals, the procedures, the protocols."
Meanwhile, the critical care physician's role is evolving to that of a manager, stepping in when protocols fail or when a patient's condition warrants it. "Our physician leaders need to be focused not only on how the patient in Bed 5 is doing, but how we did for the 120 patients this month," Buchman says. "How closely did we adhere to our processes? Did we recognize the deviations? What were the results of the deviations?"
Practices and processes are being standardized across the system's eight critical care units, with adaptations made depending on the type of ICU. For example, each MICU has the same treatment approach for community-acquired pneumonia. "We don't want the physician to be wondering, 'I've got a community-acquired pneumonia, what antibiotic should be prescribed?' " Buchman explains.
Although standardization could seem in conflict with the push toward individualized medicine, the two are complementary, Buchman says. With uniform interventions, clinicians quickly notice when a patient is veering from the expected outcome. They know either something is different or the patient is missing something, and then they can adjust the treatment plan rapidly.
Standardization helps ICU staff keep tabs on broader quality issues. Buchman uses the example of standardized antibiotics for pneumonia. If one patient's culture comes back as a bad match for the drug, the patient's medication can be changed. If many cultures come back that way, the protocol should be re-examined.
Although many hospitals are moving forward with ICU quality initiatives, some are not where they should be, says Pamela Lipsett, M.D., president of the Society of Critical Care Medicine. "We know that very few of the evidence-based guidelines that are published are done in practice," she says. "Translating what we know from clinical trials into actual permeation to every ICU is ridiculously slow and ineffective."
Hospital CEOs can help to jump start quality improvement in the ICU first by getting the pertinent stakeholders—from hospital leaders to front-line staff—in the same room, Buchman and Needham say.
"It's really important that hospitals look at their own patient populations, their own practices, and say, 'What should we focus on first?' " Buchman says. For example, if a community hospital's ICU sees a lot of patients after percutaneous coronary interventions, a goal could be to adopt a uniform approach to managing post-PCI patients.
Another area in which many hospitals are behind is having critical care-certified physicians in their ICUs. Research has shown that intensivist-managed ICU care improves patient outcomes. As a result, the Leapfrog Group, a coalition of public and private payers interested in patient safety, recommends that these physicians be present in the ICU during the day, as well as quickly reachable and able to arrange care at night. A 2010 Leapfrog Group survey found that only 34.5 percent of responding hospitals met that standard. The reasons include a national shortage of intensivists, the lack of economies of scale at some facilities, and some physicians' reluctance to relinquish management of their patients during the ICU stay.
One alternative, albeit imperfect, is to find hospitalists interested in and dedicated to critical care, Buchman says. Another option is to contract with a tele-ICU to gain remote access to intensivists, he says. That route can be expensive, notes Lipsett, but interest in it is growing.
Ultimately, hospitals might have to decide for which critical care patients they have the competency and personnel to provide care, and which should be sent to a facility with greater skills and resources, Buchman says. "We've regionalized trauma. We've regionalized a lot of cardiac care. Doesn't this make sense?"
Geri Aston is a contributing editor to H&HN.