CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) is designed and developed to standardize the approach to the evaluation and treatment of acutely decompensating patients. The design and content was informed by the survey of clinicians from diverse international settings. Available in electronic (laptop/mobile) and paper formats, CERTAIN provides evidence based diagnostic checklists, clinical decision support, educational modules on performing critical procedures, and has the ability to time and document real-time interventions. CERTAIN prompting has been shown to improve performance of clinical providers faced with simulated emergencies.
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Structured Approach to Critically Ill and Injured Patient
1. Structured Approach to Critically Ill and
Injured Patient
Dr Ognjen Gajic
Mayo Clinic
Rochester MN USA
Rochester MN, USA
Multidisciplinary Epidemiology and Translational Research in
Intensive Care (M.E.T.R.I.C.)
@ gajic.ognjen@mayo.edu
2. Critical care support for
potentially reversible acute illness
One of the most cost-effective healthcare
interventions
Incomplete
knowledge
Delayed, error-prone
care
delivery
3. Consequence of Error and Delay
“The most sophisticated intensive care
becomes unnecessarily expensive terminal
care…”
Peter Safar
Safar P. Critical care medicine – Quo Vadis? Crit Care Med 1974; 2:1–5
9. Hypothesis / Mission Statement
The care
assisted by prompting with decision
support tool (CERTAIN)
will improve the process and
outcome of acute critical illness
10. CERTAIN: Checklist for Early Recognition and
Treatment of Acute Illness
ELITE
Stabilization Module
ROUNDS
Optimization Module
Admission
Resuscitation
Rounding
http://www.icertain.org/
21. Remote education of bedside providers
• Baseline assessment
• Online training
• Video-assisted coaching and certification
– Transcontinental “screen share”
– Remote video communication (Google+)
22. Video-assisted coaching and certification
– Refreshing key aspects of online teaching
– Video assisted team training
Training Participant 1 Participant 2 Participant 3
Test Case 1A Team Leader Prompter Team Member
Test Case 2A Team Member Team Leader Prompter
Test Case 3A Prompter Team Member Team Leader
– Certification (scoring)
Certification Participant 1 Participant 2 Participant 3
Test Case 1B Team Leader Prompter Team Member
Test Case 2B Team Member Team Leader Prompter
Test Case 3B Prompter Team Member Team Leader
– Survey
23. Refining, customizing and updating decision
support content
• Systematic review of practice guidelines
– checklist drafts by investigators from various
backgrounds (anesthesiology, trauma surgery,
pediatrics, emergency and internal medicine)
• International survey of acute care providers
• Iterative review through a structured feedback
by users
25. PDSA (Plan-Do-Study-Act) quality improvement
Patient
Betterment
Concept
Introduction
Identification
of local
champions
Education
and Training
Data
Tool
Refinement
gathering and
Quality
improvement
and
Validation
26. Outcome assessment
Better
care
Adherence to basic critical care processes
(i.e. low tidal volume mechanical ventilation)
Better
health
Lower
cost
ICU, hospital and 28 days mortality
ICU and hospital length of stay
27. Advisory board
US Critical Illness and Injury Trials Group AACN
Outcome assessment
M Kojicic, Y Dong, D Talmor
ATS International Committee
ESICM Global Working Group
Refining, customizing and updating decision support
B Bonneton, C Schmickl, L Garcia, M Schultz, N Adhikari, R Kashyap
L Bucher, M Dunser, R Fowler, G Diverti, P Park, P Hou, S Senkal,
S Gavrilovic, O Kilickaya, O Gajic, all site investigators
Study Center I
Study Center II
Study Center III
Technical development
Lei Fan, O Kilickaya, V Herasevich, B Pickering
Education and Implementation
Y Dong, L Garcia, R Kashyap, M Kojicic,
K Harder, J O’Horo, M Gong
Study Center IV
Study Centers …N
A Gawande, Y Donchin, K Hillman, T Clemmer
CERTAIN Executive Committee
M Vukoja – Principal Investigator
R Kashyap – Co-PI (Project Manager)
L Bucher –Co-PI (AACN)
N Adhikari – Co-PI (ATS)
M Schultz – Co-PI (ESICM)
JC Farmer – Co-PI (SCCM)
O Gajic – Co-PI (USCIITG)
M Gong – Co-PI Implementation
D Talmor – Co-PI Outcome
L Fan – Technical Lead
Y Dong – Education and Training
Ancillary Projects
Simulation R Sevilla-Berios, J O’Horo
Cost effectiveness H Omanic
Commercialization Al Benning
29. - Unconscious
AND
- Apneic or gasping
CPR
Conceptual framework
Primary
Survey Address immediate life threats (ABCDE): Airway, Work of
Breathing, Poor Circulation (shock, arrhythmia), Disability (neuro-deficit,
seizure), Exposure (bleeding, acute abdomen, rash)
Focused history -
- Patient / EMS/
family
Point of care
diagnostics
- Ultrasound,
ECG, laboratory
Interventions
- Emergency interventions in
parallel with evaluation (Oxygen,
fluid, vasopressor, antiarrhytmic,
ventilator, cardioversion, pacing)
-Targeted intervention as
syndrome is defined (antibiotics)
-Refine based on response to
therapy and information
-Assure timely completion
Secondary
survey Syndrome recognition
- Generate problem list
- Review CERTAIN recommended
interventions for specific scenario
- Review differential diagnosis
When
Stabilized
System-based assessment and plan
Kilickaya O, Bonneton B, Gajic O. Yearbook of Intensive Care and Emergency Medicine 2014
30. Evaluate if you need to start CPR
• If the patient is unconscious and
gasping/apneic, STOP and move to BLS
protocol (CPR)
– These interventions are immediate and
should precede any further diagnostic
workup
31. • Organize your team
– Role assignment
– Assure effective communication
• Close loop communication
• Safety culture: speak up!
– Team dynamics
32. Start basic procedures as you inspect the patient
• Vital signs
• ECG monitor
• Pulse oximetry
• Obtain IV access
• Administer oxygen
• Point-of-care labs (glucose, pH, PaCO2, Hb, K+, Ca++, lactate)
37. • Exposure
• Abdomen distended?
• Obvious sources of blood loss?
• Gross rashes and wounds?
• Edema?
– Temperature
• Fever?
• Hypothermic?
38. • Always keep an eye on the
patient
• Communicate compassionately
to patient and/or family
– Hand holding and reassurance
• If an immediate threat is
detected at any time, go back
to primary survey
39. • Focused history
– Why are they here?
– Any relevant history?
– Relevant meds?
– Allergies?
48. Rounding Choreography
•Getting started
•Introduce self, establish roles
•Engage patient and/or family
•Explain rounding process
•Give permission to ask questions
•Encourage engagement
•Assign a prompter (=team member filling out CERTAIN checklist)
•Patient Presentation
•One-sentence summary of reason for ICU
•e.g. 56 year old man with background of alcoholic cirrhosis hospital day 7 for
septic shock from cellulitis complicated by ARDS and AKI
•One-sentence summary of last 24 hours events
•e.g. Emergent ETT exchange last night for acute obstruction by thick mucus
plug, otherwise uneventful
•Discuss pertinent findings, including negatives
•Systems based assessment and plan
•Daily goals of care
49. Rounding Choreography
•Systems based assessment and plan
•Before/during presentation
•Engage prompter to fill out CERTAIN checklist and to speak up if items are missed
•Encourage input from team members (close loop communication)
•Plan of care: Set specific goals
•Discuss items with the appropriate team members, e.g.
•Respiratory System: VAP bundle with RT and nurse
•Need for intravascular devices/urinary catheter and skin assessment with nurse
•Physical therapy with physical therapist
•Medications with pharmacists
•Goals of care, need for palliative consult, disposition with all team members
50. Rounding Choreography
•Systems based assessment and plan
•Assessment and plan by systems:
•CNS
•Assessment: Slowly resolving coma secondary to hepatic encephalopathy,
sedative/opioid accumulation and a small hemorrhagic stroke
•Plan: Observe off all sedative agents, continue lactulose, MAP goals per neurology
(~150/90)
•CVS
•Respiratory
•Renal/Fluid status
•GI/ Endocrine (incl. stress ulcer prophylaxis, nutrition, glucose control)
•Hematology (incl. DVT prophylaxis)
•ID
•Skin and wound care issues
•Medications
•Devices
•Physical therapy
•Goals of care/psychosocial Issues
•Discharge planning
51. Rounding Choreography
•Systems based assessment and plan
•After presentation:
•Ask prompter to double check if any checklist items are missing
•Engage patient/family
•compassionately explain assessment and plan of care in layman terms
•ensure their concerns have been addressed
•schedule family meetings to discuss plan of care as needed
53. PROMPTER
•SIMULTANEOUSLY with admission and/or rounding:
•Check off items discussed and document assessment and plan in CERTAIN
- Speak up if items on the checklist are missed or need clarifications
•Document ordered and completed medications and interventions
54. PROMPTER (con’t)
•After admission and/or rounding
• Edit the automated admission or
progress note for printing or saving (pdf)
55.
56. Disclosure
• Research support from NIH, CMS, Philips Research North
America and Mayo Clinic
• IP rights for critical care related software tools
- The related research has been reviewed by the Mayo Clinic Conflict of
Interest Review Board and is being conducted in compliance with Mayo
Clinic Conflict of Interest policies. Mayo Clinic and Dr Gajic, Dr
Herasevich and Dr Pickering hold the patent application on AWARE
technology (US 2010/0198622, 12/697861, PCT/US2010/022750).
AWARE is licensed to Ambient Clinical Analytics Inc.
• No other financial relationships with commercial companies
and no other relevant disclosures
57. We need to be CERTAIN
…to prevent
DEATH
kojicic.marija@gmail.com
kashyap.rahul@mayo.edu
gajic.ognjen@mayo.edu
certain.tool@gmail.com
http://www.icertain.org/
(Diagnostic Errors and Therapeutic Harm)
Editor's Notes
We all know that critical care support for potentially reversible acute illness is one of the most cost effective interventions.
But, incomplete knowledge of best practices by frontline health care providers and delay or error-prone care delivery process sometime offsets the potential benefits of critical care support.
What we have learned from the practice in ICU care to date is if you do the right action at the right time especially early in the course of critical illness, the patients survive. Otherwise errors and delays in appropriate care is mostly related with poor outcomes and costly complications.
This is also a very well known issue since years and briefly emphasized in 1974 by Dr. Safar.
So, unfortunately we are just too late to implement the checklist approach in early hours of critical illness.
I will share the video soon. But I just want to underline some of the features of CERTAIN.
This is the main interface. There are three sections up to down. On the top, patient demographics, below that assessment section. And the rest is basically for the plan and recommendations.
Then, after a couple of different versions, we come up with this current version.
CERTAIN has two modules.
The ELITE module is mostly focuses on stabilization of the patient. Here, ELITE is the acronym for the evaluation of life threatening emergencies.
CERTAIN Rounds is the optimization module to be used during rounds.
I will share the video soon. But I just want to underline some of the features of CERTAIN.
This is the main interface. There are three sections up to down. On the top, patient demographics, below that assessment section. And the rest is basically for the plan and recommendations.
Under the assessment section, the user has a chance to highlight the current situation of the patient with regards to life threatening emergencies, ABCDEs along with the vitals and point of care labs.
Once a problem is identified, the user can access the decision support cards along with an orderset including suggested medications and interventions.
The medications and the interventions have also links to corresponding decision support cards, like the problems.
It is possible to order a medication or an intervention through those decision support cards and keep track of actions whıch are completed or which are not completed yet.
There is a timer embedded in the tool for timely actions like Intubation or CPR.
For now we have 15 ICUs from 4 contınents.
Initially we are planning to start in one in Serbia.
As an outcome assessment we will look for better care, better health and lower cost.
We make errors while managing patients because we are unaware of what is really going on and we are uncertain about what to do.
AWARE does an amazing job to fulfill the needs of the providers in terms of packaging and representing the relevant patient data.
But we also need a checklist for early recognition and treatment of acute illness, which is CERTAIN to prevent diagnostic errors and therapeutic harm.
