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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
- 4. Challenges during golden hour Runciman et al. Qual Saf Health Care 2005
- 5. Applied Physiology in Critical Illness O2 CO2 What can kill the brain? • Local damage –Head injury –Stroke • Cardiopulmonary dysfunction –Airway –Lungs/chest/diaphragm –Heart • Muscle dysfunction • Arrhythmia (coronary obstruction, preload, afterload, contractility, acidosis, electrolyte disturbance poisoning)
- 6. Applied Physiology in Critical Illness Mechanical ventilation Analgesia & sedation Paralysis Fever control/Hypothermia Fluid bolus Inotrope Imbalance between O2 supply and demand Cell injury and organ failure Increased O2 consumption •Stress response •Pain •Dyspnea Decreased tissue O2 delivery preload / contractility / afterload • Cardiac output = stroke volume x heart rate • Anemia, Hypoxemia • Decreased perfusion pressure (coronaries) • Mechanical heart support (VAD, ECMO) O2 Hgb Vasopressor Pacemaker
- 7. Approach to acutely ill unstable patient Basic Clinical Examination ESICM PACT module 2005
- 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/
- 12. Assessment
- 13. Decision support
- 14. Keeping track of interventions
- 15. Checklist with timer for critical procedures
- 17. Online data collection • Before and after educational intervention
- 18. Cloud computing and/or local server
- 19. (Back up) Paper Version
- 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
- 24. Users’ feedback with screen capture
- 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
- 28. Initial EVALUATION of critically ill patients with CERTAIN
- 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)
- 33. • Airway • Stridor • Wheezing • Airway compromise
- 34. • Breathing: • Air entry • Crackles • Work of Breathing – Respirations; increased, decreased or normal? – SpO2/Cyanosis
- 35. • Circulation • Pulse • Skin mottling/pallor/cyanosis/prolonged capillary refill? • Rhythm on ECG monitor – Heart rate • Fast • Slow – Blood pressure • High • Low – Urine output • Low/adequate?
- 36. • Disability (neuro) • AVPU/D – Awake, Verbal response, Pain only, Unresponsive, Delirium • Seizure/clonus? • Focal deficits/eyes/pupils • Pain
- 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?
- 40. • Bedside diagnostics – Ultrasound – ECG – Laboratory – Other testing
- 41. • Emergent interventions – Anything you need to do immediately – Simultaneously with diagnostic work up – Emergent consults (surgery/endoscopy)
- 42. • Review differential diagnosis – Identify syndromic diagnoses for problem list – Perform emergent activities based on possible diagnoses
- 43. • Review checklist for each problem identified – What else should you be doing? – Plan based on problem list/working diagnosis
- 44. • Seek decision support – Antibiotics guidance – Medication suggestions/doses – Checklist with timer for critical procedures (intubation…)
- 45. • Reassess frequently – ABC’s still OK? – Are the test results back? – Are your orders completed?
- 46. • After stabilization: – Review possibilities; are you missing anything? – Complete detailed system-based assessment and plan (CERTAIN Rounds)
- 47. ROUNDING on critically ill patients with CERTAIN
- 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
- 52. PROMPTER
- 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)
- 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.