Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

Impact of Sedation Practices on Mortality in COVID-19-Associated Adult Respiratory Distress Syndrome Patients: A Multicenter Retrospective Descriptive Study

Background: Reduction in sedation exposure is an important metric in intensive care unit (ICU) patients. However, challenges arose during the coronavirus disease-2019 (COVID-19) pandemic in adhering to this practice, driven by concerns on transmission and disease severity issues. Accordingly, diverse sedation approaches emerged, although the effect on mortality has not been studied thoroughly. Methods: Retrospective cohort study in the medical ICU of seven hospitals within a major Health System in Northeast Ohio. We included all adult patients admitted with COVID-19 requiring invasive mechanical ventilation (IMV) from March 2020 to December 2021. Results: Study included 2394 COVID-19 patients requiring IMV. Across waves, sample included 55-63% male subjects, with an average age of 61-68 years (P < 0.001), Acute Physiologic and Chronic Health Evaluation (APACHE)-III score 65.8-68.9 (P = 0.37), median IMV duration 8-10 days (P = 0.14), and median ICU duration 9.8-11.6 days (P = 0.084). Propofol remained the primary sedative (84-92%; P = 0.089). Ketamine use increased from the first (9.7%) to fourth (19%) wave (P = 0.002). Midazolam use decreased from the first (27.4%) to third (9.4%) wave (P = 0.001). Dexmedetomidine use declined from 35% to 27-28% (P = 0.002) after the first wave. A multivariable regression analysis indicated clinical variables explained 34% of the variation in hospital mortality (R2). Factors associated with higher mortality included age [aOR = 1.059 (95% CI 1.049-1.069); P < 0.001], COVID-19 wave, especially fourth wave [aOR = 2.147, (95% CI 1.370-3.365); P = 0.001], and higher number of vasopressors [aOR = 31.636, (95% CI 17.603-56.856); P < 0.001]. Addition of sedative medications to a second model led to an increase in the R2 by only 1.6% to 35.6% [aOR = 1 (95% CI 1-1); P > 0.05] for propofol, ketamine, and midazolam. Dexmedetomidine demonstrated a decrease in the odds of mortality [aOR = 0.96 (95% CI 0.94-0.97); P < 0.001]. Conclusion: Mortality in critical COVID-19 patients was mostly driven by illness severity, and the choice of sedation might have minimal impact when other factors are controlled.

Health care professionals' experiences of pain management in the intensive care unit: a qualitative study

Despite the existence of evidence-based guidelines for the assessment and management of pain in the critical care setting, the prevalence of acute pain remains high. Inadequate pain management is associated with longer duration of mechanical ventilation, reduced capacity for rehabilitation and long-term psychological sequelae. This study aimed to describe the experiences of pain management from healthcare professionals working in intensive care units. Healthcare professionals were recruited from intensive care units in London, UK using a purposive sampling technique. Semi-structured interviews were transcribed verbatim. Transcripts were analysed using an inductive thematic analysis technique. Thirty participants were recruited from eight diverse intensive care units. Five themes were identified. First, there was a lack of consensus in pain assessment in the ICU where nursing staff described more knowledge and confidence of validated pain measures than physicians, and concerns over validity and usability were raised. Second, there was a universal perception of resource availability impacting the quality of pain management including high clinical workload, staff turnover and availability of certain pain management techniques. Third, acknowledgement of the importance of pain management was highest in those with experience of interacting with critical care survivors. Fourth, participants described their own emotional reaction to managing those in pain which influenced their learning. Finally, there was a perception that, due to the complexity of the intensive care unit population, pain was de-prioritised and there were conflicting views as to whether standardised analgosedation algorithms were useful. This study provides evidence to suggest interdisciplinary training, collaboratively designed decision-making tools, prioritisation initiatives and research priorities are areas that could be targeted to improve pain management in critical care.

Delirium Associated with COVID-19 in Critically ill Children: An Observational Cohort Study

OBJECTIVE

Delirium is an under-recognized problem in critically ill children. Although delirium is common in adults hospitalized with COVID-19, the relationship between pediatric COVID-19 and delirium has not been described. To address this gap, we characterized delirium in critically ill children with different manifestations of COVID-19 and investigated associations among demographic, disease, and treatment factors. We hypothesized that multisystem inflammatory syndrome in children (MIS-C) would be associated with a higher incidence of delirium given its underlying pathophysiology of hyperinflammation.

DESIGN

Retrospective, single-center cohort study.

SETTING

Quaternary-care pediatric intensive care unit (PICU).

PATIENTS

Children less than 18 years of age hospitalized in the PICU between March 2020 and March 2023 with either active SARS-CoV-2 infection or serological evidence of prior infection.

MEASUREMENTS AND MAIN RESULTS

The cohort included 149 PICU hospitalizations among children with evidence of COVID-19. Patients were categorized by reason for PICU admission: 75 (50%) for COVID-19 respiratory disease, 36 (24%) MIS-C, and 38 (26%) any other primary reason with positive COVID-19 testing. Delirium was diagnosed in 43 (29%) patients. Delirium incidence was highest in patients requiring invasive mechanical ventilation (IMV) (56% vs 7.5% in patients who did not require IMV, p < .001). Patients who were exposed to opioids, dexmedetomidine, paralytics or benzodiazepines more frequently experienced delirium compared to those unexposed (p < .001, p < .001, p < .001 and p  =  .001, respectively). After multivariable adjustment, delirium was associated with IMV (HR 3 [95% CI 1.5-5.7]), female sex (HR 2.4 [1.2-4.7]), and developmental disability (HR 3.4 [95% CI 1-11.1]). There was no association between delirium and reason for PICU hospitalization.

CONCLUSIONS

Delirium was common among children hospitalized with COVID-19. The overall incidence was much less than has been reported in adults with COVID-19. Delirium reduction efforts should focus on children with developmental disability and minimizing ongoing risks during IMV.

Feasibility and Inter-rater Reliability of the Japanese Version of the Intensive Care Unit Mobility Scale

Purpose The purpose of this study was to verify the feasibility and inter-rater reliability of the Japanese version of the Intensive Care Unit Mobility Scale (IMS). Methods A prospective observational study was conducted at two intensive care units (ICUs) in Japan. The feasibility of the Japanese version of the IMS was assessed by 25 ICU staff (12 physical therapists and 13 nurses) using a 10-item questionnaire. Inter-rater reliability was assessed by two experienced physical therapists and two experienced nurses working with 100 ICU patients using the Japanese version of the IMS. Results In the questionnaire survey assessing feasibility, a high agreement rate was shown in 8 out of the 10 questions. All respondents could complete the IMS evaluation, and most respondents were able to complete the scoring of the IMS in a short time. The inter-rater reliability of the Japanese version of the IMS on the first day of physical therapy for ICU patients was 0.966 (95% CI: 9.94-9.99) for the weighted kappa coefficient and 0.985 (95% CI: 9.97-9.99) on the ICU discharge date assessment. The weighted κ coefficient showed an "almost perfect agreement" of 0.8 or higher. Conclusion The Japanese version of the IMS is a feasible tool with strong inter-rater reliability for the measurement of physical activity in ICU patients.

Early Rehabilitation in Critically ill Children: A Two Center Implementation Study

OBJECTIVES

To implement an early rehabilitation bundle in two Canadian PICUs.

DESIGN AND SETTING

Implementation study in the PICUs at McMaster Children's Hospital (site 1) and London Health Sciences (site 2).

PATIENTS

All children under 18 years old admitted to the PICU were eligible for the intervention.

INTERVENTIONS

A bundle consisting of: 1) analgesia-first sedation; 2) delirium monitoring and prevention; and 3) early mobilization.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were the duration of implementation, bundle compliance, process of care, safety, and the factors influencing implementation. Secondary endpoints were the impact of the bundle on clinical outcomes such as pain, delirium, iatrogenic withdrawal, ventilator-free days, length of stay, and mortality. Implementation occurred over 26 months (August 2018 to October 2020). Data were collected on 1,036 patients representing 4,065 patient days. Bundle compliance was optimized within 6 months of roll-out. Goal setting for mobilization and level of arousal improved significantly (p < 0.01). Benzodiazepine, opioid, and dexmedetomidine use decreased in site 1 by 23.2% (95% CI, 30.8-15.5%), 26.1% (95% CI, 34.8-17.4%), and 9.2% (95% CI, 18.2-0.2%) patient exposure days, respectively, while at site 2, only dexmedetomidine exposure decreased significantly by 10.5% patient days (95% CI, 19.8-1.1%). Patient comfort, safety, and nursing workload were not adversely affected. There was no significant impact of the bundle on the rate of delirium, ventilator-free days, length of PICU stay, or mortality. Key facilitators to implementation included institutional support, unit-wide practice guidelines, dedicated PICU educators, easily accessible resources, and family engagement.

CONCLUSIONS

A rehabilitation bundle can improve processes of care and reduce patient sedative exposure without increasing patient discomfort, nursing workload, or harm. We did not observe an impact on short-term clinical outcomes. The efficacy of a PICU-rehabilitation bundle requires ongoing study. Lessons learned in this study provide evidence to inform rehabilitation implementation in the PICU setting.

Improving Outcomes in Mechanically Ventilated Adult ICU Patients Following Implementation of the ICU Liberation (ABCDEF) Bundle Across a Large Healthcare System

OBJECTIVES

To measure how the ICU Liberation Bundle (aka ABCDEF Bundle or the Bundle) affected clinical outcomes in mechanically ventilated (MV) adult ICU patients, as well as bundle sustainability and spread across a healthcare system.

DESIGN

We conducted a multicenter, prospective, cohort observational study to measure bundle performance versus patient outcomes and sustainability in 11 adult ICUs at six community hospitals. We then prospectively measured bundle spread and performance across the other 28 hospitals of the healthcare system.

SETTING

A large community-based healthcare system.

PATIENTS

In 11 study ICUs, we enrolled 1,914 MV patients (baseline n = 925, bundle performance/outcomes n = 989), 3,019 non-MV patients (baseline n = 1,323, bundle performance/outcomes n = 1,696), and 2,332 MV patients (bundle sustainability). We enrolled 9,717 MV ICU patients in the other 28 hospitals to assess bundle spread.

INTERVENTIONS

We used evidence-based strategies to implement the bundle in all 34 hospitals.

MEASUREMENTS AND MAIN RESULTS

We compared outcomes for the 12-month baseline and bundle performance periods. Bundle implementation reduced ICU length of stay (LOS) by 0.5 days (p = 0.02), MV duration by 0.6 days (p = 0.01), and ICU LOS greater than or equal to 7 days by 18.1% (p < 0.01). Performance period bundle compliance was compared with the preceding 3-month baseline compliance period. Compliance with pain management and spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) remained high, and reintubation rates remained low. Sedation assessments increased (p < 0.01) and benzodiazepine sedation use decreased (p < 0.01). Delirium assessments increased (p = 0.02) and delirium prevalence decreased (p = 0.02). Patient mobilization and ICU family engagement did not significantly improve. Bundle element sustainability varied. SAT/SBT compliance dropped by nearly half, benzodiazepine use remained low, sedation and delirium monitoring and management remained high, and patient mobility and family engagement remained low. Bundle compliance in ICUs across the healthcare system exceeded that of study ICUs.

CONCLUSIONS

The ICU Liberation Bundle improves outcomes in MV adult ICU patients. Evidence-based implementation strategies improve bundle performance, spread, and sustainability across large healthcare systems.

Post-intensive care syndrome: Recent advances and future directions

Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.

The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters

BACKGROUND

Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon.

OBJECTIVES

We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection.

METHODS

We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release.

RESULTS

After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027).

CONCLUSION

We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.

Awakening and Breathing Coordination: A Mixed-Methods Analysis of Determinants of Implementation

Rationale: Routine spontaneous awakening and breathing trial coordination (SAT/SBT) improves outcomes for mechanically ventilated patients, but adherence varies. Understanding barriers to and facilitators of consistent daily use of SAT/SBT (implementation determinants) can guide the development of implementation strategies to increase adherence to these evidence-based interventions. Objectives: We conducted an explanatory, sequential mixed-methods study to measure variation in the routine daily use of SAT/SBT and to identify implementation determinants that might explain variation in SAT/SBT use across 15 intensive care units (ICUs) in urban and rural locations within an integrated, community-based health system. Methods: We described the patient population and measured adherence to daily use of coordinated SAT/SBT from January to June 2021, selecting four sites with varied adherence levels for semistructured field interviews. We conducted key informant interviews with critical care nurses, respiratory therapists, and physicians/advanced practice clinicians (n = 55) from these four sites between October and December 2021 and performed content analysis to identify implementation determinants of SAT/SBT use. Results: The 15 sites had 1,901 ICU admissions receiving invasive mechanical ventilation (IMV) for ⩾24 hours during the measurement period. The mean IMV patient age was 58 years, and the median IMV duration was 5.3 days (interquartile range, 2.5-11.9). Coordinated SAT/SBT adherence (within 2 h) was estimated at 21% systemwide (site range, 9-68%). ICU clinicians were generally familiar with SAT/SBT but varied in their knowledge and beliefs about what constituted an evidence-based SAT/SBT. Clinicians reported that SAT/SBT coordination was difficult in the context of existing ICU workflows, and existing protocols did not explicitly define how coordination should be performed. The lack of an agreed-upon system-level measure for tracking daily use of SAT/SBT led to uncertainty regarding what constituted adherence. The effects of the COVID-19 pandemic increased clinician workloads, impacting performance. Conclusions: Coordinated SAT/SBT adherence varied substantially across 15 ICUs within an integrated, community-based health system. Implementation strategies that address barriers identified by this study, including knowledge deficits, challenges regarding workflow coordination, and the lack of performance measurement, should be tested in future hybrid implementation-effectiveness trials to increase adherence to daily use of coordinated SAT/SBT and minimize harm related to the prolonged use of mechanical ventilation and sedation.

Practices of the ABCDEF care bundle in intensive care units as reported by nurses: A cross-sectional study from Turkey

BACKGROUND

Recent critical care guidelines recommended the evidence-based ABCDEF care bundle for intensive care unit (ICU) patients. However, limited information is available on the implementation of the bundle in Turkish ICUs.

AIM

To assess the current practices of the ABCDEF care bundle as reported by ICU nurses.

STUDY DESIGN

A cross-sectional study using a web-based survey was conducted. Researchers invited nurses with at least 1 year of ICU experience to participate by sending the link to the research questionnaires they created in Google Forms to the one ICU nurse association and one communication group of which they are members.

RESULTS

A total of 342 ICU nurses completed the survey. Although 92% of the participants performed pain assessments in their ICUs, 52.7% reported not using protocols. Based on the responses of the nurses, spontaneous awakening and breathing trials are performed in 88.8% and 92.4%, respectively, of ICUs. Fewer than half of the participants reported following a sedation protocol in their ICUs. Only 54.7% of ICU nurses surveyed reported routinely monitoring patients for delirium. It was reported that early mobilization was practised in 68.7% of ICUs, but non-ventilated patients were mobilized more frequently (70.2%), and 9.7% of ICUs had mobilization teams. Family members were actively involved in 95% of ICUs; however, 9.7% used dedicated staff to support families and 3.5% reported that their unit was open 24 h/day for visits.

CONCLUSIONS

While the implementation of most pain and sedation evaluations in ICUs were reported by nurses, many of them did not use structured delirium assessments. There is a need to encourage early mobilization programs and family participation.

RELEVANCE TO CLINICAL PRACTICE

Health institutions can improve patient care and outcomes by establishing and standardizing a protocol for each component of the ABCDEF care bundle in ICUs.

Rehabilitation Therapy Allocation and Changes in Physical Function Among Patients Hospitalized Due to COVID-19: A Retrospective Cohort Analysis

OBJECTIVE

Limited staffing and initial transmission concerns have limited rehabilitation services during the COVID-19 pandemic. The purpose of this analysis was to determine the associations between Activity Measure for Post-Acute Care (AM-PAC) mobility categories and allocation of rehabilitation, and in-hospital AM-PAC score change and receipt of rehabilitation services for patients with COVID-19.

METHODS

This was a retrospective cohort study of electronic health record data from 1 urban hospital, including adults with a COVID-19 diagnosis, admitted August 2020 to April 2021. Patients were stratified by level of medical care (intensive care unit [ICU] and floor). Therapy allocation (referral for rehabilitation, receipt of rehabilitation, and visit frequency) was the primary outcome; change in AM-PAC score was secondary. AM-PAC Basic Mobility categories (None [21-24], Minimum [18-21], Moderate [10-17], and Maximum [6-9]) were the main predictor variable. Primary analysis included logistic and linear regression, adjusted for covariates.

RESULTS

A total of 1397 patients (ICU: n = 360; floor: n = 1037) were included. AM-PAC mobility category was associated with therapy allocation outcomes for floor but not patients in the ICU: the Moderate category had greater adjusted odds of referral (adjusted odds ratio [aOR] = 10.88; 95% CI = 5.71-21.91), receipt of at least 1 visit (aOR = 3.45; 95% CI = 1.51-8.55), and visit frequency (percentage mean difference) (aOR = 42.14; 95% CI = 12.45-79.67). The secondary outcome of AM-PAC score improvement was highest for patients in the ICU who were given at least 1 rehabilitation therapy visit (aOR = 5.31; 95% CI = 1.90-15.52).

CONCLUSION

AM-PAC mobility categories were associated with rehabilitation allocation outcomes for floor patients. AM-PAC score improvement was highest among patients requiring ICU-level care with at least 1 rehabilitation therapy visit.

IMPACT

Use of AM-PAC Basic Mobility categories may help improve decisions for rehabilitation therapy allocation among patients who do not require critical care, particularly during times of limited resources.

Psychological Morbidity After COVID-19 Critical Illness

Survivors of ICU hospitalizations often experience severe and debilitating symptoms long after critical illness has resolved. Many patients experience notable psychiatric sequelae such as depression, anxiety, and posttraumatic stress disorder (PTSD) that may persist for months to years after discharge. The COVID-19 pandemic has produced large numbers of critical illness survivors, warranting deeper understanding of psychological morbidity after COVID-19 critical illness. Many patients with critical illness caused by COVID-19 experience substantial post-ICU psychological sequelae mediated by specific pathophysiologic, iatrogenic, and situational risk factors. Existing and novel interventions focused on minimizing psychiatric morbidity need to be further investigated to improve critical care survivorship after COVID-19 illness. This review proposes a framework to conceptualize three domains of risk factors (pathophysiologic, iatrogenic, and situational) associated with psychological morbidity caused by COVID-19 critical illness: (1) direct and indirect effects of the COVID-19 virus in the brain; (2) iatrogenic complications of ICU care that may disproportionately affect patients with COVID-19; and (3) social isolation that may worsen psychological morbidity. In addition, we review current interventions to minimize psychological complications after critical illness.

[The intensive care diary-a communication tool]

Diaries in intensive care units (ICU) are mostly written by families and nurses for patients with impaired consciousness. In the diary, the development of the patients is described in plain language by daily reports. Patients can read the diary later and process their experiences and, if necessary, reframe them differently. ICU diaries reduce the risks of psychosocial sequelae of patients and families and are now used worldwide. Diaries have different purposes and also serve as a communication tool: words are written to a person who will hopefully read them later. This can help families to stay connected and cope better with the situation. However, writing a diary can also be perceived as a burden by some relatives and nurses due to lack of time or because it seems to be too close. ICU diaries can serve as a tool for patientand family-centered care.

Delirium in Adults With COVID-19-Related Acute Respiratory Distress Syndrome: Comparison With Other Etiologies

BACKGROUND AND OBJECTIVES

Neurologic complications have been associated with COVID-19, including delirium. Such complications have been reported to be frequent among intensive care unit (ICU)-admitted patients. We hypothesized that the rate of neurologic complications would be higher in COVID-19 associated acute respiratory distress syndrome (ARDS) than those who develop ARDS from a different cause.

METHODS

We conducted a retrospective cohort study in the adult ICU of Lausanne University Hospital, including all consecutive patients fulfilling the Berlin criteria for ARDS hospitalized between December 2017 and June 2021, stratifying exposure between COVID-19 or not. The primary outcome was delirium onset during ICU stay, defined by the confusion assessment method (CAM-ICU). Exploratory outcomes included development of neurologic complications of the central nervous system (stroke, hemorrhage, and vasculitis), critical illness weakness, and 30- and 180-day all-cause mortality.

RESULTS

Three hundred eleven patients were included in the study (253 with COVID-19 and 58 with other causes) and CAM-ICU could be assessed in 231 (74.3% in COVID-19 vs 74.1% in non-COVID-19). The proportion of patients developing delirium was similar in patients with COVID-19 and controls in univariate comparison (69.1% vs 60.5%, p = 0.246). Yet, patients with COVID-19 had a higher body mass index, lower ICU severity, longer mechanical ventilation, and higher sedation doses (propofol and dexmedetomidine). After adjusting for these factors in a multivariable analysis, the risk of delirium remained comparable across groups (adjusted OR [95% CI]: 0.86 [0.35-2.1]). Similarly, COVID-19-related ARDS had no effect on all-cause mortality at 30 days (adjusted OR: 0.87 [0.39-1.92]) and 180 days (adjusted OR: 0.67 [0.33-1.35]). Finally, neurologic complications affecting the CNS (adjusted OR: 1.15 [0.25-5.29]) and critical illness weakness (adjusted OR: 2.99 [0.97-9.1]) were not higher in the COVID-19 group.

DISCUSSION

Compared with other etiologies, patients with COVID-19 did not have higher incidence of delirium and other neurologic complications, after accounting for underlying disease severity in patients with ARDS. Management of COVID-19-associated ARDS needed longer invasive ventilation and higher sedation, which could explain higher rates of delirium in uncontrolled studies.

Interprofessional Team Collaboration and Work Environment Health in 68 US Intensive Care Units

BACKGROUND

Safe, reliable, high-quality critical care delivery depends upon interprofessional teamwork.

OBJECTIVE

To describe perceptions of intensive care unit (ICU) teamwork and healthy work environments and evaluate whether perceptions vary by profession.

METHODS

In August 2015, Assessment of Interprofessional Team Collaboration Scale (AITCS) and the American Association of Critical-Care Nurses Healthy Work Environment Assessment Tool (HWEAT) surveys were distributed to all interprofessional members at the 68 ICUs participating in the ICU Liberation Collaborative. Overall scores range from 1 (needs improvement) to 5 (excellent).

RESULTS

Most of the 3586 surveys completed were from registered nurses (51.2%), followed by respiratory therapists (17.8%), attending physicians (10.5%), rehabilitation therapists (8.3%), pharmacists (4.9%), nursing assistants (3.1%), and physician trainees (4.1%). Overall, respondents rated teamwork and work environment health favorably (mean [SD] scores: AITCS, 3.92 [0.64]; HWEAT, 3.45 [0.79]). The highest-rated AITCS domain was "partnership/shared decision-making" (mean [SD], 4.00 [0.63); lowest, "coordination" (3.67 [0.80]). The highest-scoring HWEAT standard was "effective decision-making" (mean [SD], 3.60 [0.79]); lowest, "meaningful recognition" (3.30 [0.92]). Compared with attending physicians (mean [SD] scores: AITCS, 3.99 [0.54]; HWEAT, 3.48 [0.70]), AITCS scores were lower for registered nurses (3.91 [0.62]), respiratory therapists (3.86 [0.76]), rehabilitation therapists (3.84 [0.65]), and pharmacists (3.83 [0.55]), and HWEAT scores were lower for respiratory therapists (3.38 [0.86]) (all P ≤ .05).

CONCLUSIONS

Teamwork and work environment health were rated by ICU team members as good but not excellent. Care coordination and meaningful recognition can be improved.

Prevalence and Risk Factor Analysis of Post-Intensive Care Syndrome in Patients with COVID-19 Requiring Mechanical Ventilation: A Multicenter Prospective Observational Study

Introduction: Post-intensive care syndrome (PICS) is an emerging problem in critically ill patients and the prevalence and risk factors are unclear in patients with severe coronavirus disease 2019 (COVID-19). This multicenter prospective observational study aimed to investigate the prevalence and risk factors of PICS in ventilated patients with COVID-19 after ICU discharge. Methods: Questionnaires were administered twice in surviving patients with COVID-19 who had required mechanical ventilation, concerning Barthel Index, Short-Memory Questionnaire, and Hospital Anxiety and Depression Scale scores. The risk factors for PICS were examined using a multivariate logistic regression analysis. Results: The first and second PICS surveys were obtained at 5.5 and 13.5 months (mean) after ICU discharge, with 251 and 209 patients completing the questionnaires and with a prevalence of PICS of 58.6% and 60.8%, respectively, along with the highest percentages of cognitive impairment. Delirium (with an odds ratio of (OR) 2.34, 95% CI 1.1–4.9, and p = 0.03) and the duration of mechanical ventilation (with an OR of 1.29, 95% CI 1.05–1.58, and p = 0.02) were independently identified as the risk factors for PICS in the first PICS survey. Conclusion: Approximately 60% of the ventilated patients with COVID-19 experienced persistent PICS, especially delirium, and required longer mechanical ventilation.

The future of intensive care: delirium should no longer be an issue

In the ideal intensive care unit (ICU) of the future, all patients are free from delirium, a syndrome of brain dysfunction frequently observed in critical illness and associated with worse ICU-related outcomes and long-term cognitive impairment. Although screening for delirium requires limited time and effort, this devastating disorder remains underestimated during routine ICU care. The COVID-19 pandemic brought a catastrophic reduction in delirium monitoring, prevention, and patient care due to organizational issues, lack of personnel, increased use of benzodiazepines and restricted family visitation. These limitations led to increases in delirium incidence, a situation that should never be repeated. Good sedation practices should be complemented by novel ICU design and connectivity, which will facilitate non-pharmacological sedation, anxiolysis and comfort that can be supplemented by balanced pharmacological interventions when necessary. Improvements in the ICU sound, light control, floor planning, and room arrangement can facilitate a healing environment that minimizes stressors and aids delirium prevention and management. The fundamental prerequisite to realize the delirium-free ICU, is an awake non-sedated, pain-free comfortable patient whose management follows the A to F (A-F) bundle. Moreover, the bundle should be expanded with three additional letters, incorporating humanitarian care: gaining (G) insight into patient needs, delivering holistic care with a 'home-like' (H) environment, and redefining ICU architectural design (I). Above all, the delirium-free world relies upon people, with personal challenges for critical care teams to optimize design, environmental factors, management, time spent with the patient and family and to humanize ICU care.

Efficacy of Physiotherapy Interventions on Weaning in Mechanically Ventilated Critically Ill Patients: A Systematic Review and Meta-Analysis

Mechanical ventilation (MV) is currently considered a life-saving intervention. However, growing evidence highlighted that prolonged MV significantly affects functional outcomes and length of stay. In this scenario, controversies are still open about the optimal rehabilitation strategies for improving MV duration in ICU patients. In addition, the efficacy of physiotherapy interventions in critical ill patients without positive history of chronic respiratory conditions is still debated. Therefore, this systematic review of randomized controlled trials (RCTs) with meta-analysis aimed at characterizing the efficacy of a comprehensive physiotherapy intervention in critically ill patients. PubMed, Scopus, and Web of Science databases were systematically searched up to October 22, 2021 to identify RCTs assessing acute patients mechanical ventilated in ICU setting undergoing a rehabilitative intervention. The primary outcomes were MV duration, extubation, and weaning time. The secondary outcomes were weaning successful rate, respiratory function, ICU discharge rate and length of stay. Out of 2503 records, 12 studies were included in the present work. The meta-analysis performed in 6 RCTs showed a significant improvement in terms of MV duration (overall effect size: −3.23 days; 95% CI = −5.79, −0.67, p = 0.01; Z = 2.47) in patients treated with a comprehensive physiotherapy intervention including early mobilization, positioning, airway clearance techniques, lung expansion and respiratory muscle training. The quality assessment underlined 9 studies (75%) of good quality and 3 studies of fair quality according to the PEDro scale. In conclusion, our results provided previously unavailable data about the role of comprehensive physiotherapy intervention in improving MV duration in critical ill patients without chronic respiratory conditions. Further studies are needed to better characterize the optimal combination of rehabilitation strategies enhancing the improvements in critical ill patients without chronic respiratory disorders.

[The intensive care diary-a communication tool]

Tagebücher auf Intensivstationen werden meist von Familien und Pflegenden für Patient:innen mit Bewusstseinsstörungen geschrieben. In dem Tagebuch wird in laienverständlicher Sprache die Geschichte der Patient:innen anhand täglicher Berichte beschrieben. Patient:innen können später das Tagebuchbuch lesen und ihre Erfahrungen und Erlebnisse verarbeiten und ggf. anders bewerten. Intensivtagebücher senken die Risiken für psychosoziale Folgeschäden bei Patient:innen und Familien und sind mittlerweile weltweit verbreitet. Tagebücher haben unterschiedliche Zwecke und dienen auch der Kommunikation: Es werden Worte an eine Person geschrieben, die sie später hoffentlich lesen wird. Dies kann Familien darin unterstützen, verbunden zu bleiben und die Situation besser zu bewältigen. Gleichzeitig kann das Schreiben eines Tagebuchs auch von einigen Angehörigen und Pflegenden als Belastung empfunden werden, weil keine Zeit verfügbar ist oder es zu nahe scheint. Intensivtagebücher können als ein Mittel zur patienten- und familienzentrierten Versorgung genutzt werden.