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Neilo wrote 01-11-2014 10:02:39 am
SCCM - Presidential Address

Well here I am on Day 1 of the SCCM Annual Congress in beautiful San Francisco. Although I've had a day to try and shake the obligatory long haul jet and learn some interesting facts (it would have been a lonely and raw life as the doctor on Alcatraz, the WWII military hospital in the Presidio, a place that must have seen a great deal of suffering, is now the home of Lucas Entertainment)

The opening address at 8am certainly blows out any remaining cobwebs, with loud music blaring, a disco ball, a rousing rendition of the national anthem, and a funked up EGDT video of "your sepsis and you know it", all to a 2000 patient auditorium that applauds at every opportunity. It feels big, keen, almost evangelical, a culture that is different to the understated Aust/NZ environment. Yet once the glitter settles, it seems we are experiencing and reflecting on the same issues, in the same way. This is articulated by the incoming SCCM president, Professor Christopher Farmer from the Mayo Clinic, who starts by asking us to identify and challenge the traditional boundaries of ICU, including;

1. Identify and locate critically ill patients, ie the care finds the patient, overcoming human error and location
2. Prevent critical care "badness prevention", in patients with genetic predisposition, preventable illness, chronic critically ill, and end of life decisions
3. Who is on the ICU team, ie how do we include primary physicians, families etc in an integrated model?
4. How do we meet growing demand for ICU services? How and to whom do we define competencies, provide and integrate new technologies, provide outreach?
5. Do we continue to create "works of arts"? Our sickest patients become resource intensive masterpieces. This may not be the best solution for patients, how do we balance the provision of predictable and efficient care vs the individual, many provider, resource intensive, masterpiece
6. How do we provide post-ICU care to patients, families?

He finishes by exhorting us to appreciate our loved ones, provide "sharp mind and soft heart"

Neilo wrote 01-11-2014 10:05:34 am
SCCM Plenary - Peter Pronovost

Time Magazine most important 100 people in 2008, regularly addresses Congress, all for his work on quality and harm prevention that started with checklists to prevent CLABSI.

Starts by asking us to change the world.

He says the "pay for quality" or "regulatory" approach to quality are all extrinsic motivators that are no longer working. They were effective, as we didn't self regulate, but now we need internal motivation.

We are taken on his own, and John Hopkins, journey, starting with CLABSI reduction by checklists, CUSP, feedback results. These programs worked. However there are many other harms, eg DVT, yet we pat ourselves on the back for preventing one harm (CLABSI), while allowing others to continue. An engineering view would say that we should aim for zero harm, and work backwards, ie stopping the space shuttle blowing up for 1 reason, but watching it happen for 12 others is not success.

Perhaps a major issue is technology. Despite spending billions on technology development, we have devices and technology that don't communicate with each other, are clunky, and is controlled by the vendor, not the user. For instance, we don't have EMRs, monitors, and medications communicating with each other, resulting in error, and wasted FTE. The engineering analogy is Boeing accepting that the landing gear company and the cockpit company refuse to share data, so the pilots have to look out the window to see of the landing gear is up or down. Why do we accept this in health? (Lots of applause from audience). We are then asked to move on to a revolution in care deliver based on love! He then tells us not to worry about getting all emotional, he means that moment of caring are what matters (more applause).

So to change the system we must firstly define our goal?
1. Eliminate preventable harm
2. Identify correct therapy and reliably deliver
3. Monitor performance

He provides an example of how John Hopkins is trying to achieve these goals with a computer based system "Harms Monitor". This is impressive, a bedside program for health care workers, families and patients that includes patients centred care goals, family information and the ability to be involved in patient care, preventable harms measures (VAP, CLABSI, delirium - with sensors recognise if strategies not met), patient story and photos that can be shared online etc. All displayed in an interactive and multi-platform way ( bedside flat screen, ipad for health teams and families ).

Session over, applause, back to loud funk music and strobe lights

Neilo wrote 01-11-2014 10:07:22 am
Post ICU Syndrome (PICS) Session


Burden of Survivorship (Ramona Hopkins- EDEN trial followup Investigator):



We start with a reminder of the data about post-ICU function, loss of muscle, loss of physical and cognitive function, with gradual but incomplete recovery over 6-12 months. The point prevalence of psychological disorder is approx 30%, with PTSD prevalence (approx 20%) higher than war veterans. Also families have stress (70% anxiety, 35% depression, PTSD, 40% at 1-yr after relative in ICU dies have disorder. There is a lack of long term data). A PICS task force was convened in 2012, aim to increase awareness and implement and identify strategies to address PICS. This was point no. 6 in the president address, ie a successful ICU outcome is not surviving ICU. They have developed tools, ie MyICUCare.org , youtube.com/sccm500 , Aug/Sept Critical Connections devoted to PICS. Ramona goes on to discuss the breadth of the PICS problem, risk factors, time lines, strategies to prevent, research areas.



Cost of PICS care to family and survivors (Theodore Iwashyna):



Context: 790,000 pts ventilated annually in US, 1,000,000 with severe sepsis. Both much more than AMI, much less spending. Survival is good, hard to improve much further. As an example there are 637,867 sepsis survivors, with >100,000 with cognitive impairment. These survivors have all the problems discussed in previous talk.



Families: We start with learned helplessness (Giora Netzer, Chest 2012) prevalent in >50% of ICU family members, higher than patients with spinal cord injury, alcoholics starting 12-step program. The PICS family issues are described by Judy Davidson in CCM. Looking at families before and after ICU (Dimitry Davydow, 2012 CCM) there is an increase in depression from before to after, that gradually decreases, following sepsis. This is independent of survival, ie it's more than grief. Hallie Prescott (2014 prepublication data) has conducted a study comparing the year before and after sepsis in Michigan. Patients spend more time in hospital in year after sepsis than before, and 3x more time in hospital than septic patients. 80% of pts with sepsis spend at least 1-week in hospital or die in the yer after hospital. Also Vincent Liu (2014 prepub) showed similar results in California.



Society: we don't really know the full effect on cost and productivity to society. The yearly cost of dementia is approx $60,000 (formal and informal). We need to establish this for ICU survivors



How do we make it better ? We are given the 5-step system ...prevent, protect, remediate, compensate, enhance. In practice - 1. family meetings: listen more, have nurse present, allows family to express wishes, can improve psychological outcomes for family. 2. Involve families more in the ICU (SCCM guidelines being revised). 3. Provide skills to families and patients, ie train them. 4. Learn by experience - should we provide ICU support groups, where learn from patients and families who have been through it. There is very little out there, @sepsissurvivors. 10% of Keystone Group have support group while in ICU, only 2% after. Support groups work, there are significant family and patient problems after ICU.....@iwashyna

Neilo wrote 01-11-2014 10:08:39 am
SCCM: ICU Occupancy

What is the right ICU occupancy (Scott Halpern)



Operations management recognises a sweet spot where you have a mix of responsiveness and efficiency, it looks like optimal occupancy is 85% range. What about ICU? Firstly in the US the number of ICU beds are higher than any other country (25:100,000 pop), with 30% ventilated. Also 20% of ICUs have 4 or more beds available 100% of the time, while some never have free beds, so there is a lot of variability. The ability to get patients into ICU, and decision to discharge, vary with "strain", and arguably there is not a lot of difference in outcome (there are differences seen, but not consistent across ICUs). Overall a glut of ICU beds in US, larger units less efficient, closed units more susceptible to strain, strategic contractions of the ICU bed supply might be more efficient



Can we reduce ICU cost with high quality end of life care (Randall Curtis)



First point is to separate palliative care and EOL care, as they are different. The options are to provide a consultative model (refer to pall care specialists ), a model ( provided by or an integrated model (preferred by speaker ). Does providing palliative care in ICU reduce costs: A systematic review ? (Khandelwal, under review, 2014).

- Palliative care seems to reduce ICU admissions and ICU LOS (mean reduction 3-days)

- ICU costs: up to 84% of ICU costs are fixed, however this might reduce needs for further ICU expansion, and more efficient use of current resource . Studies of palliative care consults suggest reduced cost. Palliative care will only save money if patients are receiving more expensive care than they would choose if fully informed.



What is the role of long term acute care hospitals (Jeremy Kahn)



The central tension is of mismatched supply and demand. Onto long term acute care hospitals (LTAC). The Medicare prospective payment system led to this, where patients with LOS >25 days were defined as long term. So the question is, would more LTAC beds be a good thing, ie free up ICU beds, are they good for chronic be ventilated patients ? LTACs are used more and earlier if they are close, or LTAC in the acute hospital. However oversupply leads to inefficiency, as create more ICU beds, and use them for less sick patients who do not benefit. Quotes the Stelfox paper (2012), on high "strain" days, more METs are left on ward with comfort care, the low strain days, when more are admitted to ICU. However there is no different in outcome, so the ICU admission doesn't help patient, more likely to harm them.

Neilo wrote 01-11-2014 10:11:57 am
And that's lunch!

You can follow the rest of my reports on the SCCM annual congress here, and for live updates, check out the twitter feed at #ccc43

See you back here soon!

Ian from Australia wrote 01-11-2014 10:17:43 am
Outstanding work Neil! I'm loving reading the comments, almost like I was there!

Neilo wrote 01-11-2014 10:22:34 am
Okay, here we go again, with the afternoon session - Four Century's of Biomedical Research in the US Army Medical Corps: Benefits and Challenges (Professor Basil Pruitt)

Neilo wrote 01-11-2014 10:22:48 am
This plenary by a legend of trauma surgery gives us the history of medicine,war, and the US. We are told there has only been a maximum of 30 years between conflicts over this time, and Prof Pruitt suggests the US may not be as peaceful as it think! It starts in the 1700s , when the US Army Director General / Surgeon General was appointed around the Civil War. We see the evolution of surgery for penetrating abdominal trauma ( 0 survival in 1889, to recognition in the 1900s that time to surgery was key to success). In WWI the mortality for abdominal trauma was approx 50% (other casualties much less). We meet Harvey Cushing, and the origins of trauma neurosurgery, Robertson pioneering transfusions on the battlefield. The introduction of penicillin in the US on wounded soldiers (burned victims of cocoanut grove), including Florey convincing the Govt to go in to mass production at a mould factory, and the recrystallisation of penicillin from patients urine as supply was low! What else did we see in WWII- well trained surgeons, IV fluid, continuum of care, and research (effect of these treatments on physiology and outcome). . We skip forward to Vietnam, Korea, MASH, and the advances in combat casualty care, including prevent and treatment of renal failure, forward helicopter retrieval, and direct vascular repair of vessels rather than amputation (Frank Spencer and Carl Hughes, disobeying the Surgeon-General directive to amputate).

Unfortunately war has provided a lot of experience in thermal injury and burns, the physiology, multi organ effect, and treatment, particularly WWII and nuclear devices. Current research in burns conducted by the US Army includes direct current bandages to try and reduce fluid leak from skin in burns, burn real time decision assist algorithms, platelet aggregation inhibitors for inhalational injury, early diagnosis and treatment of invasive fungal skin infection, use of cultured keratinocytes for temporary skin cover. The mortality for burns is down to 6%.

He finishes with the statement that integrated clinical and laboratory research by the military is successful. There seems little doubt that this is the case, that these are great medical achievements, with ingenuity, application, and care meeting demand. However it is hard to shake the sense of despair at the suffering caused by human conflict that provided this theatre of opportunity.

Neilo wrote 01-11-2014 03:30:23 pm
Evening session - Project dispatch - Sharing patient entered strategies to improve care at the bedside

Training the whole team to enhance family communication in the ICU (Judy Davidson)

A San Diego based program to improve communication, included feedback, prereading, 2-hr training in teams (nurse,doctors, chaplain, therapist). course included Buckmann (Spikes) protocol, key elements of conference, role playing, debriefing. In the end 98 providers (52.7%) accepted invite, 100% of intensivists, 1/3 of nurses). There was significant improvement in family's perception of communication (frequency and honesty). This is a limited study, single site, small, nonrandomised etc, but positive.

We move on to how do we get over staff concerns about increasing family involvement in ICU, such as family presence on rounds. We talk about family presence on rounds, and the results of a study they performed in San Diego. A 15-bed teaching ICU, with a lot of attendings, nurses etc. The traditional round was led by attending, residents present (overnight resident), RN interjects if assertive, outside the glass room, with families excluded. Problems about transfer of information, nurses and families not getting information.

Moved to family centred round ( standard round "script", including family). agreed that nurse would start rounds (up-to-date vitals, introduce family), then resident presents, then family input requested (defined this, short questions could be answers on round, if more complex discussion would organise meeting), then plan made and move on. They had a user meeting, everyone agreed it was a good idea.....but without a "conductor" present on the round, it didn't happen! So they developed a Rounds Audit Tool (RN present, in circle, spoke, MD asked questions, eye contact with RN, family present, family included). Discovered lots of problems to work on. The next steps are to overcome the barriers.

Transforming care - Developing a patient-centred ICU (Pauline Park)

This story of UMHS, Ann Arbor, Michigan's journey to develop a patient/family centred ICU in a trauma / ECMO SICU. They s tarted in 2005 using the SCCM guidelines, and in 2011 and 2012 won awards. This included;
- Patient family centred care: a committee was formed to create guidelines for open communication and involvement.
- Inclusion in rounds
- Debrief meetings
- Diary project: journal project to try and decrease PTSD, all patients with an ICU LOS >24 hrs, families use it while patient unconscious, the used by patient. Includes questions they have, what has happened etc .
- End of life care: protocol to address goals of care in timely fashion. Also bereavement blanket, keepsakes (terminal handprints, pottery hearts )and mementos etc.

All very soft be nice,so does it improve hard outcomes? They present reductions in blood transfusion, VAP, compliance with ARDS outcomes, a decrease in mortality despite increasing acuity. They don't claim they are direct effects, but it certainly suggests a change in culture of patient and family centred behaviour and outcomes.

Panel Discussion

How did speakers get involved? Judy tells us how she experienced her daughters critical illness (cerebritis), and was excluded actively from ICU rounds as a mother, on one side of the glass door while rounds occurred on other. Her daughter recovered (now has PhD). Another story of a speakers niece with TBI, who subsequently died. The nursing staff treated her with care and affection, and she has never forgotten.

How long does it take? A long time, 5-yrs plus, because it is behaviour change

Open visitation the challenges - when you open the doors do you limit the number of visitors, etc? Staff perception? Judy made it mandatory as a nurse leader, and actively managed it. There weren't families camping at every bed. They created rules, ie visitors must wear shoes, no camping/sleeping on the floor, approach to food in the ICU, numbers of visitors etc. it can't be done passively, their will be resistance. Usual change management stuff.

Food for thought.

That's it for the day

Todd Fraser from Australia wrote 01-11-2014 04:33:23 pm
Great work Neil, excellent summaries. Looking forward to more tomorrow!

Neilo wrote 01-12-2014 08:57:36 am
As I approach the Moscone Centre through the Yueba Buena Gardens in downtown San Francisco for Day 2 of the SCCM Congress, it seems that every cafe within a 500m radius has queues out the door of attendees ensuring they meet the needs of the morning, caffeine. There are tightly suited presenters with posters under their arm, leaders with a buzz of activity around them, small groups of colleagues and friends laughing together, the delighted exclamations of colleagues surprised to run into each other, and the hordes of individuals taking it all in. This rich mix creates a buzz, a sense of Congress. Bring it on Day 2

Neilo wrote 01-12-2014 08:58:32 am
SCCM Day 2 Plenary: Tackling Brain Injury - A Little Out of Focus

Professor Kochanek, the Editor of Paediatric Critical Care Medicine, gives the Peter Safar lecture. Peter Safar was "arguably the father of modern day resuscitation, and one of the founders of critical care medicine". Prof Kochanek is the Director of the Safar centre.

This is a fast moving and broad agenda lecture. He starts by postulating that the brain is the last frontier of critical care, the lecture will focus on traumatic brain injury, of which we have an epidemic, accelerated by the effects of the wars in Iraq and Afghanistan. In addition there is a huge paediatric TBI population, an area of interest for the Safar Centre.

1. Severe TBI is not a single disease, so we should recognise and treat different "phenotypes". Progress in this area includes studies looking at mild TBI (team TBI), aimed at targeted evaluation, action, and monitoring of TBI. He argues this strategy is overdue for severe TBI.

2. Background care is still heterogenous. What about identifying an ideal background therapy for severe TBI. ADAPT, a large comparative efficacy trial of what we currently do in paed TBI in 30 or so centres is underway. It might help tighten the guidelines, and identify therapy that need further investigation.

3. Alternately, what about personalised medicine? The example given is post traumatic seizures (PTS). We have the GABA and adenosine systems, inhibitory neurotransmitters and endogenous anticonvulsants. A multiple genotype risk analysis reported that subjects with 2 specific adenosine risk genotypes have a 50% risk of late PTS. These patients could be targeted early.

4. What about new therapies? The example given is prevention of the development of brain edema. The mechanistic studies tells us that astrocyte swelling is the problem. HMGB-1, toll, and aquaporin antagonists may help prevent edema.

5. Infants with TBI do badly, perhaps 50% with poor outcomes, despite the absence of a high ICP. What else can be targeted? What about fibre tract injury from shearing? (Highlighting the difference between hypoxia brain injury and TBI). High definition fiber tracking does highlight this occurs, so there is clear evidence, but as yet no therapy that targets this.

6. This leads to the Operation Brain Trauma Therapy- a large US, multidisciplinary consortium, involving research groups, industry, military, government, trying to better understand biochemical markers and therapies in animal models of different type of brain injury. The therapies tested to date involve low hanging fruits (existing agents) and new agents. To date nicotinamide, EPO, simvaststin, and cyclosporin A have not yielded cognitive benefit, or robust benefit, despite some histological benefit. He argues this shows the benefit of the consortium, by testing and excluding these agents it allows focus to move on. Levetiracetam has just yielded benefit in the fluid percussion model in mild injury, so maybe it has a role in this specific situation?

7. What about a "hammer?". The spliceosome, mRNA splicing, is discussed. If you splice mRNA you create good and bad "guys", antiapoptotic and apoptotic RNA. RBM5 is responsible for this, and is up regulated by inflammatory mediators, and TBI, so perhaps manipulating this to make more good guys is possible?

8. What about getting drugs that work, across the BBB? A NAC + probenecid study in paed TBI aims to use probenecid to increase NAC penetration of BBB and act as an antioxidant.

9. What about the electron transfer chain? Research going on on antioxidant drugs that target specific mitochondria, show successful evidence of agents penetrating BBB, in cytoplasm, and having beneficial effects.

10. Post ICU? The NEJM study of amantadine vs placebo showed benefit of amantadine in rehab in mod and severe TBI. Animal studies show that placing rats with TBI in an enriched environment, no drugs, improves recovery. This may be an area where a lot of benefit can be gained by working on surviving axons.

11. Chronic neurone generation, traumatic encephalopathy - the evidence in repetitive mild TBI is clear of build up of hyperphosphorlyated tau, must be important in severe TBI. There is evidence of amyloid deposit early in severe TBI, so there is a possible area of intervention.

12. Abusive head trauma accounts for 1/3 of paed TBI in US. Often presents prior to major head injury with other diagnosis, giving an opportunity to prevent. Is there a marker to identify "silent brain injury", and prevent severe injury occurring? A study in US suggests serum NSE is located, and these children have nonspecific gastro signs when they present early. A prospective, 1000 pt, "rule out" study is occurring, to test if using common signs and NSE can identify children who should have CT or MRI, identify their mild injury, and prevent progression.

13. PANGEA - a study aimed at understanding the demographic of critical care neurology world wide. The top 3 are cardiac arrest, status epilepticus, then TBI. More to com

Wow, what an hour!

Neilo wrote 01-12-2014 09:01:20 am
SCCM Day 2: Year in Review - Paediatrics

Prof Jessica Moreland - Basic Science

Brain injury:
- Duke University research into stem cell mediated recovery from brain injury. Replacing neural cells also creates glial cells, not wanted. Stem cells from postnatal brain created astrogenesis, prevented bleeding, seems good.
- Progesterone and neuroprotection, based on observation that pseudo pregnant rats did better after TBI. This is not a new concept, but there are better mechanistic models, ie impact acceleration model that simulates DAI. Progesterone therapy in rat have led to enhanced BBB integrity (aquaporin 4), enhanced neuronal survival (controversial ), attenuation of pro info pathways, reduced oxidant stress product, increased endothelial progenitors cells. How to move to humans? 2 phase II studies of progesterone have shown promise, there are 2 large phase III studies in progress (adult)
- Hypoxic brain injury: goal directed CPR in pigs suggests higher CPP was better, this could be trialled in PICU? Therapeutic hypothermia studies have focused on down regulation, but a new study looked at up regulation of small subset cold shock proteins (RBM3), and cold brain slices have more dead cells.

Sepsis:
- SIRS and CARS (counter antiiflammatory response). NADPH oxidase (NOX2), is pro inflammatory (pathogen killing, host tissue injury), also anti inflammatory in murine model. So overall it may be that oxidant have benefits, and giving antioxidants may be harmful (as seen in clinical trials), and we need more understanding and directed therapy
- microRNA (miR-466I) critical in regulation of adaptive and innate immunity, have important role in progress and resolution of sepsis inflammation.

Genomics: Time magazine article discusses article that challenges the use of mouse models, suggesting genomic response in murine model to inflammation is not representative of human. Why? There is a million dose difference in lethal dose of endotoxin in mice and humans, the pathways and response are difference.

Ass Prof Fola Odetola - Clinical Science - the studies that caught his eye.

General Paediatric Intensive Care: refer to Dutch study of IV paracetamol and morphine requirements after major surgery in infants. Showed significant reduction in morphine use in paracetamol arm, ie opioid sparing effect. Ok it is single centre, there are limits, but it is an important effect.

Cardiac Surgery: the Dutch again, with an RCT of restrictive (<8 g/dl) vs traditional transfusion ( <10.8 g/dl) strategy in children having surgery for non-cyanotic congenital heart disease. At baseline there was an imbalance of gender, and this was included in the cox regression analysis. There was more blood and a higher Hb in liberal group (treatment effect). There was a reduced LOS (the primary endpoint) in the restrictive group, but it did not exist after multiple regression.

Traumatic Brain Injury: the US the Kiwis and Oz. The cool kids study (early TH (<6 hrs) to 32-33C for 24-48hrs, then slow rewarm). Primary outcome 30-day mortality, 77 enrolled, no difference in survival or cerebral outcome. Problems with slow recruitment, high rate of refusal to consent, trend for falling rate of death in US, but a good study

Hyperglycaemic control: the very recent TGC vs CGC in PICU (https://www.crit-iq.com/index.php/Journal_Club/Journals/2014/01/929/Hyperglycaemia-intensive-insulin-therapy-paediatric-RCT-critical-care-glycemic) . The outcomes, no difference in primary (days alive and VFD), less RRT in TGC, more hypos in TGC with associated mortality. From 30-90 days the TGC had lower costs in non-cardiac surgery group, this persisted to 12-months.

Prof Martha Curley - Current Studies

Searched all available registries, contacted institutes and research groups, and came up with..

THAPCA: Therapeutic hypothermia after paed cardiac arrest. TH (32-24C, mantain 48hr slow rewarm for 16 hrs, maintain normothermia for 160 hrs standard, 2 strata (in and out-hospital). Primary outcome 1-yr status. Anticipate publication in June for out-of-hospital, in-hospital slower, looking for new sites in UK.

Half-Pint: Heart and lung failure pediatric insulin titration trial. Compare TGC vs CGC in noncardiac surgery patients with cardiac / resp failure, use continuous glucose monitoring, randomised 112 of 1880 patient, expect to complete 2017.

CALIPSO: Calfactant for acute lung injury post stem cell transplant, recruits ventilated patients, aiming for 140 patients, 28 enrolled. Looking for new sites.

LAPSE: Life after paediatric sepsis study, measure incidence, magnitude and duration of HRQL/FS changes, n=500, follow up to 12-months. Start enrolment 2014, complete enrolment June 15.

ABC-PICU: Age of blood in children, multinational RCT of <7-days blood vs standard issue, n=1538 patients with expected ICU LOS >24 hrs, primary outcome MODS, start enrolment now, end Jan 2018.

Communication in end of life care: adapting nurse led intervention to improve communication, n=404, 2 centres in Chicago, 3 yrs to finish.

RESTORE: Multicenter cluster RCT of sedation protocol (team based intervention), primary outcome duration of mechanical ventilation, enrolment completed Dec 2013 (n=2449), 1373 for followup, primary paper planned for mid Feb.


Prof Ken Tegtmeuer (Section Chair) - Safety and Clinical Practice

In house call / burnout:
- Online survey of US and Canadian ICUs, 1323 responses. If you work in an in house model you have positive perceptions of it, if home call preferred that, better supervision with in house.
- A study to be published in paed CCM Feb 14... Lots of results, again preference for type of call you are doing, looks at perceptions of continuity, nonclinical responsibilities, effect on family, all subjective.
- However burnout measures suggest the more nights of in house call you do the more burnout, and fellows protect attendings. There is a perception that in house causes burnout, yet that is not clearly borne out in objective measure.
- effect of in house cover on code outcomes...unclear, outcomes improved, but a lot more codes in the ICU, so it is not clear if codes were called for "lesser reasons", explaining better outcome

Telemedicine: 2 studies by Dharmar, first demonstrated improvements in measured quality of care and family perception, second showed reduction in dosing errors (telemedicine vs telephone vs no consult). Have also shown increase in transfers, hospital, and billing fees.

Simulation use:
- simulation for paed residents and CVC placement in St Louis, 60-90 min training session with US. Showed that they got better, 3-months later this benefit had disappeared, but their confidence stayed high ! Show need frequent simulation if volume low.
- interactive tabletops, looked cool
- team training: Sweden ICU got entire ICU through simulator over 2 years. Observers found nurses felt empowered after, doctors failed to show up to followup. The observers became too familiar with staff, and less objective

High reliability PICU: the 6-sigma, high reliability organisation (HRO) type of move. Discuss proactive vs reactive (RCA). Need everyone involved, leadership etc.

Neilo wrote 01-12-2014 09:23:16 am
SCCM Plenary Session: Don't just do something - stand there

Rosemary Gibson: Senior Advisor to the Hasting Center, Editor for JAMA. She is the recipient of the Lifetime Achievement Award from the American Academy of Hospice and Palliative Medicine.

At the Robert Wood Johnson Foundation in Princeton, NJ, Ms Gibson led national health care quality and safety initiatives for 16 years. She was chief architect of the foundation’s decade long strategy that successfully established palliative care in more than 1600 hospitals in the U.S.

There is a lot of change in palliative care, what enabled it ? It wouldn't have occurred on its own, and she believes there was an external force. There was data but no drive to change, and she suggests it was public perception through agents such as Jack Kavorcian (recognised by 90%of adult Americans) that was the catalyst. She argues there is a rising tide of overuse of medicine, that ignores the the needs and wishes of the person, consumed by the medical machine.

She gives numerous examples of "overuse", the "treatment traps", illustrating the widespread over treatment of people by medicine. For the first time in the history of medicine, a subset of the population is saying no to medical care , not cavalierly , but in an informed and thoughtful way.

We continue through the idea of the marinated mind - our minds have been marinated to believe more is better. She believes we have been disconnected from the reality of what we let others do to our body. Can we expect patients to make difficult decisions at the end if life if they have not been making informed health care decisions that are far less inconsequential?

The Critical care societies collaborative top 5 lists reflect this (http://www.choosingwisely.org/doctor-patient-lists/critical-care-societies-collaborative-critical-care/)

1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 mg/dL.
3.Don’t use parenteral nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay.
4.Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
5.Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

A great example of an 82-yr old with stable angina, who was recommended cardiac surgery. He went to multiple providers, who all suggested he should have the surgery. He finally found a surgeon who said "there is no evidence this will prolong your life, but it may alter the quality of your life". They then discussed quality, and established he had a good quality of life, so he bypassed the bypass, and continued with medical therapy, lived another 8-years. There seems to be a lack of effective, thorough communication with consumers, and there is not time for providers to do this. The public want this (Ms Gibson gives heavily subscribed public lectures about this), but it doesn't happen.

How can we deal with overuse?
- can we capture patients experiences at the end-of-life, in their own words, about overuse?
- transparency of data of overuse: the Medicare public reporting of double CT scans has been effective
- the economic impact: this conversation should occur separately to care, but it is important. With the projected health spending (%GDP), sees total health care spending 46% of GDP by 2050, and continuing to rise. If we don't deal with overuse, add remove things that don't add value, there will be indiscriminate cuts across the board, that will see useful therapies lost as well.

She finishes with a quote from Gandhi "whenever you are in doubt, or when the self becomes too much with you, apply the following test. Recall the face of the poorest and the weakest man whom you may have seen, and ask yourself, if the step you contemplate is going to be of any use to him. Will he gain anything by it? Will it restore him to a control over his own life and destiny? In other words, will it lead to swaraj [freedom] for the hungry and spiritually starving millions? Then you will find your doubts and your self melt away.

Neilo wrote 01-12-2014 11:55:48 am
SCCM Year in Review - Surgery

This rapid fire presentation of the studies that caught the eye of the 3 speakers is an interesting experience, and I have to say it is problematic. The 1-slide, 1 sentence summary means that if you haven't read the study, you will come away with a very superficial understanding and conclusion. If you have read the studies, you don't benefit.

Perhaps the benefit for those who don't regularly scan journals, or subscribe to journal clubs, is that it directs you to interesting trials you should read and form your own opinion. On reflection the lesson for me is that it is vital to critically analyse the literature, to participate in group debate using online and local forums, and to avoid taking one sentence summaries as the conclusion of a trial.

A brief taste;

Terence O'Keefe (A/Prof Surg, Arizona)
- SICU daily rounds checklist reduced CLABSI, improved quality over 2-yrs
- VASQIP: time of antibiotics not so important for prevent infection (15th of 16 variables measured)
- chlorhexidine daily wash reduced nosocomial infection in SICU
- PICCs didn't reduce CLABSI compared to CVC
- Clinical decision models better than individuals at identifying trauma injuries
- In-house trauma surgeon better than home call
- Centres of excellence for bariatric surgery did not reduce complications although...
- Tracman shows no difference with early trache
- PROSEVA says proning good
- Lots of study about change to call rosters and effects on trainees, were treated in a very tongue in cheek way. Is this suggestive of change resistance?
- New York has as many clinicians as 29 other states combined
- Early cholecystectomy did better than late, gallstone pancreatitis had high recurrence if not removed, better outcomes if remove early in pancreatitis, and laparoscopic is better than small incision
- discussed early PN, EDEN, glutamine, antioxidants
- Early operation has better outcomes for SBO

Baback Sarani (A/Prof Surg, GWU)
Guidelines
- Clinical Practice Guidelines for Pain, Agitation, Delirium in ICU (SCCM). Michelle Balas article on implementing delirium / sedation protocol , including champions, mandatory policy, etc.
- Surviving Sepsis Guidelines 2012
Transfusion
- Promitt: as tighten the FFP:RBC ratio to 1:1 showed reduction in short-term mortality, although brain injury was factor. He suggests it was not a platelet study. Limits were 90% patients excluded, and 1 unit in 6 hrs was considered massive
- Whole blood vs transfusion in 100 trauma pts reports benefits
- TEG directed resusc vs no TEG in trauma, reports end up with 1:1:1 picture without TEG, perhaps should use TEG to define coagulopathic patient who gets massive transfusion protocol
- NEWS (national early warning systems), ViEWS score, and predicting death in ICU

Douglas Naylor
Statistics
- UK : 14.8% emergency surgery mortality overall
- US: 4% mortality for sternal fracture, ER thoracotomies do really badly
- metformin may be protective in type 2 DM
- tcp in 14% patients ICU, heparin effect- less with LMWH
- military: freeze dried plasma being used

Neilo wrote 01-12-2014 02:19:35 pm
SCCM: Delivering healthcare to those who are underserved

Strategy to eliminate healthcare disparity (Gregory Kerr, New York)

Life expectancy in the US is 26th out of 36 OECD countries.

Starting with race, by 2060 there will be no majority group. Currently there is a dominance of non-white ethnic groups who are uninsured , and as the percentages change, this will be a huge problem. It is worth noting that uninsured whites remain the biggest group by number. The problem is that uninsured wait until they are sicker, then present to ED, and have more complicated, more expensive care. We are not sure what effect the affordable care act will have, will people move to access primary care providers.

In terms of the complex reasons behind this, an example of asthma is given, comparing east (Latino) and west Harlem (African American). They are next to each other, but there is a 2x increase in asthma in East Harlem kids compare to west. It is due to housing and mould. In breast cancer, there is an increasing mortality rate gap between African American and white women. However when compared by state, there are large differences, ie Illinois 11% vs NY 3%. Again, location is important. To address this we need insurance equality, improve income gap, address housing and geographic issues, and educate patients.

We move on to implicit bias, the evidence that health providers and decision makers have subconscious bias, are more likely to interact, advocate, intervene with their own cultural groups. This introduces bias against race groups that are underrepresented or underserved. There are solutions, liking teaching cultural competency, and a national task force that is trying to end these disparities.

At an institutional level, hospitals that serve higher proportions of Latinos or African Americans have worse risk-adjusted outcomes. Some of this is identifying therapies that may not be effective in some ethnic groups.

Finally at a government level. 1/3 more spent on felons in prison per capita than on Native Americans. The Broken Promises commission in 2004 showed the terrible outcomes in this community.

Using telemedicine - Where there are no intensivists (Bela Patel, Houston)

6,500 ICUs, 95,000 ICU beds, 1% GDP, 30% hospital budget - wow. But half of them don't have intensivist coverage. The conclusion is that there is a shortage of intensivists. To provide 24/7 would need 1000's more. Currently there are 900 intensivists qualifying per years. Add to this concerns about burnout.

So we move to telemedicine, maybe it is the solution? The argument is it might improve cover, compliance, reduce burnout, etc. There is not great take up of telemedicine by rural hospitals. The speakers evidence from a reasonable big telemedicine study was no effect on outcome overall, but the subgroup of high acuity patients in small units had a 50% decrease in mortality. A meta-analysis showed an overall benefit in terms of mortality and LOS with telemedicine.

Is telemedicine going to rescue us? The rational put forward is that intensivists save lives, and telemedicine might achieve this. There are lots of barriers (cost, physician resistance, shared care issues). A potential research and progress agenda is proposed.

With an antipodean perspective it seems there are lesson we can all learn from the US experience. It is hard to ignore the repeatedly quoted statistic that there are up to 5x as many beds per capita compared to other western countries. .... With concerns about burnout, cost, is the answer really trying to expand the current workforce's coverage geographically?

Could they aim for all closed units with dedicated intensivists and dedicated fellows/trainees (arguably reduces the need for 24/7 cover and burnout risk), transferring high acuity patients from all the smaller units, and where possible reclassifying small ICUs as HDUs, that don't need in house intensivists (an ongoing hub and spoke relationship to up escalate care in a timely fashion could remain). Of course there are many other issues to consider, but when you are consuming 1% of GDP ongoing expansion seems open to question.

Well that is it for the day, see you tomorrow

Neilo wrote 01-13-2014 07:40:45 am
SCCM Day 3 What's new and what's cool (Geoffrey Ling, Walter Reed Army Medical Center)

Another living legend, famous for many things, including development of the bionic arm, and research into prevention of blast neurotrauma. He served as a U.S. Army Medical Corps officer for 27 years, including combat tours to Afghanistan (2003) and Iraq (2005) and four visits to theater inspecting treatment of brain injury on behalf of the Chairman of the Joint Chiefs of Staff. He retired from the Army in 2012 at the rank of Colonel.He is currently the Deputy Director of DARPA. He starts with disclosures, "I've spent 27 years in the army, I'm a neurologist, I'm poor as a church mouse, that's my disclosure!"

A moving video of the 86th CSH, 44th Medical Command (Airborne), 30 physicians, 60 RNs, 9000 trauma pts, 16,000 non-trauma, 96% survival. This is devastating evidence of the injuries incurred in the wars in Iraq and Afghanistan.

He takes us on a remarkable journey into upper arm prosthetic device development. The lower limb prosthesis are pretty good, but upper limbs are still just a hook. "People don't want to look like Captain Cook, they want the Luke Skywalker prosthetic hand."Think about doing personal hygiene with a hook not a hand, you see a colorectal surgeon regularly ".

So we need a paradigm shift, legs are just levers, but upper arm prosthesis all need a hand, very complex. The best we can do with residual muscles in the upper arm is a hook tat opens and closes. What we need is....neural control of the hand. They started (Dr Miguel Nicholls) with primate studies (monkeys performing mechanical exercises with electrodes in motor cortex), what they found is the brain doesn't say "flex hand", it initiates a grasp to an area in the visual field. They managed to train the monkey to feed itself with a robotic arm by thinking!

The next challenge is to make an artificial arm. There are 2 issues, arms are amazing, weigh 8-pounds, powered by 2 tablespoons olive oil a day, and you have to tap into the brain. So 7-years later how are they going ? The DEKA GEN 3 is a production arm, modular design can work for wrist, trans-radial, trans-humeral, shoulder dis articulation amputees, with generic controls. They think they will be in production in Feb. We are shown a video of people with artificial arms, using posture control (like Segway bike), eating oatmeal, M&Ms, sushi with chopsticks, rock-climbing.

What about brain control ? (Motor and sensory). They are progressing, and show video of monkey with prosthetic arm playing piano, and people sensing sandpaper etc. Then a video of 2 high-quads, with brain electrode, showing first time brain control of artificial hand, they just think about moving, shaking hands etc, and it happens. This is very moving, as we see the joy the patients and their relatives experience from this change in function. He argues this will go from a clunky, early breakthrough, to anthropormophically correct, trans cortical limbs.

Trans cortical? He thinks we should move on from cortical implants, and aim for transcortical electrodes, which would open up not only artificial limb control.....the ability to drive a car with thought etc!

He finishes by telling us he doesn't wake up and wonder why he goes to work, because treating the injured American soldier, who is out there defending their freedom, is a reward in itself.

In summary, I'll state the obvious, this is a remarkable man, who is achieving remarkable things, and perhaps displays what the US is really good at, having big ideas, and getting the people and the resources to make them happen

Neilo wrote 01-13-2014 07:41:36 am
SCCM Day 3: Session 1 Palliative Care in the ICU

Integrating Palliative Care: Overcoming the Barriers (Zara Cooper)

We start with the problem of our misunderstanding and fear of palliative care, and the barriers to delivering this, ie silos (disease based care), time, unprepared families, untrained medical staff) etc.

So suggests 3-steps;
1. Understand what it is: WHO definition "Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." Ie it makes patients feel better.

2. Integrate into ICU...
- Identify patients and decision makers: raises the "surprise question", ie would I be surprised if this patient will die in a year, if the answer is yes, patient may benefit from a palliative care discussion.
- Deal with pain and symptoms
- Identify goals and treatment preference
- Frequent family communication
- Spiritual care and psychosocial support
- Bereavement support

Presents evidence of benefits of better palliative care (Nelson, CCM), ie improved satisfaction, reduced ICU LOS, etc

3. Normalise: Discusses integrative and consultative models, the fact that probably need all. Raised the issue that studies have had poor triggers for palliative care referral, based on the idea that palliative care only for patients that are definitely dying.

Using Evidence Based Palliative Medicine to Improve ICU Quality (Rebecca Aslakson)

Rebecca is an anaesthetist who works in SICU, and palliative care doctor.
What is palliative care: Again raises the issue of health professionals thinking that palliative care= giving up and dying, while the public had no idea. When a definition was given to the public, more than 85% wanted it for their loved ones.

Discusses the origin of palliative care in ICU literature in 1980's in CHEST, offering it for "hopelessly ill", to more interventions in the 90s, to 2000s. We see themes of educational strategies, nurse led consultation, triggered ethics consults, triggered palliative care consultations, brochures to patients and family, protocols and pathways, increased family involvement and support. There is also a theme of no change in mortality, decreases in LOS, improved communication, with variable effects on satisfaction.

Presents hers systematic RV (not yet published) on pall care in ICU. 21 studies included, generally led to decrease ICU and hospital LOS. Also compared integrative (ICU only involved) vs consultative (any outside input), it seems both may work depending on setting, ie large open units probably do better with consultative, integrative successful in closed units. Also overall palliative care programs did not increase mortality, ie doesn't "kill" people, with reference to non-ICU evidence that it may improve survival

Palliative Care Through Teamwork (Randall Curtis)

Starts with Teno evidence (JAMA, 2013,309:470), showing 30% of patients who die in the US spend time in an ICU in the last 30-days of life, and that there has been very little improvement from 2003 to 2008 (DeCato, CCM, 2013;41:1405).

We then move onto the model, integrative vs consultative vs mixed. He argues the evidence shows interdisciplinary collaboration is good, leads to reduced ICU mortality, LOS, conflict, and increased satisfaction. A case is built that conflict with colleagues causes burnout (evidence to support this), and that poor palliative care is a common source of conflict. Therefore good interdisciplinary communication around palliative care could help reduce burnout. A before and after interdisciplinary QI led to improvements in a single centre pilot ( his hospital), but not a 12-centre trial, perhaps suggesting that there is a lot about culture. The Curtis "VALUE" study was very positive;
V = Value comments made by the family
A = Acknowledge family emotions
L = Listen
U = Understand the patient as a person
E = Elicit family questions

So tools for improving this type of communication, with the idea of nurse presents data on rounds: gives most up to date data, can't round if nurse not there, empowers nursing staff, and improves relationships.

Little People and their Families (Christine Zawistowski)

The world of paediatric ICU, with different expectations, range of ages and maturity in patients, and a low mortality. There is a significant population of children with chronic disease, complex disease, much higher use of hospital, and higher mortality. The NEJM article (Himelstein, 2004:350;1752) defines the paediatric pall care population, and paediatric palliative care triggers and protocols developed.

The demographic of the paediatric palliative care population shows predominant genetic/congenital, neuromuscular, or cancer as disease , many technology dependent (particularly feeding tube), high 1-year mortality, many with cognitive deficit. They want honest and complete communication, ready access or staff, emotional support (want to feel that the child is special to staff), and preserve the parent-child relationship (many parent tasks are removed by staff, trying to restore this relationship). There is often a mismatch around perception of QOL between family and providers, introduces the idea of the "new normal", what is normal for this child. Prognostication is a problem in paediatrics, with varying progress of chronic disease, and difficulty identifying the "terminal" hospitalisation.

On a higher level, 69% of institutions have paed pall care service, but most are inpatient only, office hours, without community based support, so this is a problem. With regards to providers, there is a large proportion of paediatricians that don't recognise a need for palliative care.

Onto resources that help
- Seattle decision making communication tool: designed for outpatients, but useful. http://www.seattlechildrens.org/pdf/Decision_Making_Tool.pdf
- 5-wishes aging with dignity http://www.agingwithdignity.org/five-wishes.php
- digging deep illness journal http://resonancehouse.org/purposes.html

Neilo wrote 01-13-2014 10:00:09 am
SCCM - The William Schumacher Lecture

Artificial Intensigence - The Merger of Man and Machine in the ICU
(C Hanson, Professor of Anethesiology and Critical Care Chief Medical Information Officer)

We start with the Asiana flight that crashed at SF airport last year, the challenges of landing a commercial plane, and contributing factors (difficult airport, visual landing aid off, pilot inexperienced on this plane, autothrottle and autopilot, 3rd pilot in jumpseat voiced concern but didn't call to abort).

Why do we always look to aviation industry? Both high intensity, high stakes, fast paced, data rich, airline industry very good at self governance)

Current ICU has over 9 computers, all with separate display, as well as chair, desk, paper based documents. A 1950's cockpit was similar! Now cockpit has mantra of "simple, redundant, automatic", with malfunctions brought on a hierarchical basis, automated checklists are presented to resolve the problem, information on needed replacements sent ahead of time. There is also a single, standardised presentation of data to pilot. The simplification of flight procedures and design, has led to a decrease In crew size from 5 to 3.

What should we do in critical care;
1. Digitalise data and mobilise: move from current transcription of data from monitor to paper, to automated e-storage in EMR. There are a number of projects working on this (OpenICE, Emerge, Aware)
2. Data visualisation: need to find a way to present data that is intuitive, givens info, not just a table of results.
3. Decision Support: algorithms that recognise patterns of data and suggest diagnosis and or treatment
4. Data Enabled Treatment Automation: the artificial pancreas, AICD
5, Robotics: early steps Che occurred. Ie TUG the robot drug delivery system, a German robot that delivers drinks in nursing homes, a a lifting robot..DARPA believe they will have robotic prehospital care in peacekeeping zones by 2025!

So there is still a way to go, but on the journey

Neilo wrote 01-13-2014 01:00:31 pm
SCCM Day 3 Session: Bridge to the Future: Extracorporeal Support in Adult Respiratory Failure

Bridge to Regionalisation: Interfacility Transport (Dan Brodie)
1970s: ECMO v1.0 - salvage therapy for ARDS, with bad outcomes
2009-2014: since H1N1 and CESAR, with better technology, there has been an increase in use, although evidence not resolved.

So we are seeing more retrieval of ECMO to more regional centers. The first 100 transports at U Mich in 90s, had many complications, while recent data shows close to zero cannulations.

Do you transport on ECMO? Some patients are too sick to transport off ECMO, so discussed the 2 options. First the referring team cannulates and you pick up, or the retrieval service cannulates and retrieves. Discussion included team composition, essentials (power, oxygen,meat, Medes, backup equipment), checklist for each step, specialised stretchers, platforms (road, rotor aircraft, fixed wing- including large military transport plane!).

Be organised, over prepared, realistic.

Bridge to Recovery: COPD and ARDS (Marco Ranieri)
Why ECMO
1. Conventional answer: saves from hypoxia, provides time to recover from disease
2. Non-conventional answer: protect from side effects of mechanical ventilation
- ARDS: discusses evidence from ARDSNET that shows linear relationship between plat press D1 and mortality. Currently aim for <30cmH2O plat press, but if we aim for "super protective strategy" (<25 cmH2O and 4ml/kg Vt), could further reduce mortality. However if we do this will cause more hypercapnia and reps acidosis. In Turin, they used low flow V-V ECMO to treat this, and in a small RCT showed less inflammation compared to protective (<30cmH2O, 6 ml/kg), while a German study showed reduced VFDs. The extension would be avoid ventilation,use ECMO early.

- COPD: the problem of hypercapnia from airflow resistance, flow limitation, hyperinflation, with rapid shallow breathing, and resp muscle fatigue, with superimposed infection or failure. We currently apply NIV, unload resp muscle, and increase minute ventilation, which increase dynamic hyperinflation. The theory is that by removing CO2 reduce demand. In 200 patients with COPD, type 2 failure, not improving after 6-hrs NIV randomised to standard care or NIV-ECCOR, and showed the ECCO group had reduced CO2, improved pH, no effect P/F, and reduced intubation, no difference in ICU and hospital LOS, and signal suggest reduced mortality. Needed blood flows of 255 ml/min, 24 hrs treatment. There was a high incidence of mechanical problems (clots in machine)(36%) and significant bleeding (16%)

This is clearly early data. The use of ECCOR as a treatment for COPD to prevent intubation, needs to be shown to be safe, perhaps have a short-term mortality benefit, but perhaps have a positive effect on quality of life, mortality, and hospital admission on the subsequent year?

Bridge to Transplantation in End Stage Lung Disease (James Blum)

In 1981 the first survivor made it to 8-years, after many attempts. The problem then it was about rejection, now it is about not enough lungs. The lung allocation score makes intubated patients score highly, and should move up list. However there are absolute and relative contraindications, including ongoing mechanical ventilation. The problem is 1-yr survival of lung transplant drops from 90 to 50% if ventilated! a big disincentive. If you survive 6-months after mechanical ventilation then are transplanted, survival goes back to normal. Why? It is probably self-selective, those who can survive the "critical care syndrome" , you are "stronger".

Does ECMO bridge help you avoid this problem ?

If you put everyone without contraindications to lung transplant on ECMO, you will end up winter wing on awake, pink, young patients, thought. If you don't you deny survival opportunity.

So perhaps choose well by quick screen - good preintubation physical status, no rare blood types etc that make donor unlikely, patient and family ready to go through rocky course, accept all transplant issues.

Then only do it when you are experienced with technology, have secure cannulas, tolerate hoxia, avoid blood if possible (auto-immunisation), usual ICU care, good physical therapy for extubated patient (standing, recumbent bike). Goals are avoid iatrogenesis, make sure they satay listed (so avoid RHF and organ dysfunction, if occurs treat with pharmacotherapy, them consider V-A or atrial septostomy). The outcomes are encouraging, with good survival of patients extubated on ECMO who are then transplanted.

Neilo wrote 01-13-2014 01:01:01 pm
SCCM Day 3: Hot Topics and Late Breaking Science

Last one for the day.....

Do ICU Beds Create their own Demand (Rebecca Gooch)

https://www.crit-iq.com/index.php/Journal_Club/Journals/2014/01/932/ICU-bed-Utilization-health-Care-Spending-Demand-Elasticity-resource-critical-care

In summary USA compared to UK, USA spends more money on ICU (perhaps 10x) has more ICU beds (5x per capita) , and has lower acuity (73% patients not ventilated compared to approx 30%), the Stelfox Archives showing on low demand days more METs come to the ICu with no difference in outcome. The problem is that excess ICU bed supply leads to overutilisation, prolonging of death and non-patient centred care approach.

How do we contain this? We can't make explicit rationing laws for political reasons, so could achieve implicit rationing by closing beds at low demand. She argues that the ICU bed supply needs to decrease in the US.

The evidence that the increased use of beds for terminal hospitalisation is increasing. It sounds like a human problem, ie admitting the wrong patients.

I have a question. Are we failing to deal with end of life needs of patients proactively to provide appropriate non-ICU care, avoiding saying no to surgeons requesting unnecessary admissions because we don't want to cause conflict? Are we using bed availability as a hidden way of dealing with this? Or is is just too hard to say no when we have excess beds? Do we need to do both?

Patient Safety and Resident Well Being: Evaluating 3 Duty Schedules for ICU Residents (Christopher Parshuram)

This is a preliminary report of a trial under review. Starts with earlier evidence that junior doctors have fatigue, ketonuria! That 16 hr vs 32 hr shifts reduce error, and no difference in consultant call.

The objective was to compare 3 schedules;
1. 24 hr (8-8am)
2. 16 hr (4:30pm-8am)
3. 12 hr (night and day, long day)

Decrease in hours and increase recovery as shifts shorten. Also obviously more hangovers. They enrolled residents on 2-month rotation

Outcomes and Results: around 1000 admissions, 5900 patient days, 61% ventilated, 47 residents
Resident
1. Sleepiness - no difference, although all getting sleepier from midnight to 4am
2. Symptoms - more than half had no moderate symptoms, with a signs can't increase in mode symptoms in 24-hr group
3. Burnout - no difference

Patient
1. Adverse events - no difference
2. Preventable adverse events - 8 events, 7 occurred in 12-hr schedule
3. Mortality - no difference

Trend that 16-hr schedule associated better outcomes, 12-hr worse, unexpected, and hard to interpret due small numbers.

This is the biggest trial of roster, limited by underpowered, resident bias affecting outcome. The implications are shorter is the same or worse, and the residents are tired in all schedules. There are high burnout rates, not due to schedule, and perhaps due to more fundamental issues.

Reactions from Tim Buchmann: the name resident came from the idea of residing in hospital, and the issue is how does the learner partition time between work and home. We don't ask if they effectively learn, rather we concentrate on duty. We don't learn from others, nurses, pilots, who provide around the clock care.

Question: Did you track napping and activity? They did, and sleep was common, and many were asleep at 4am.

Neilo wrote 01-14-2014 08:53:02 am
SCCM Congress Day 4 Plenary: Critical Care Around the World: Global Challenges (Jean-Louis Vincent)

It is the last morning of the Congress, San Francisco has provided a stunning blue sky morning, and although the crowd has thinned a little, the promise of Jean-Louis's charismatic delivery has ensured a good turnout. We are not disappointed, in an entertaining hour he discusses;

ECMO: the new intervention everyone asks about, "do you do ECMO", as opposed to 20 years ago "do you do dialysis"

Design differences: we see pictures of the 5-star ICUs with large single rooms, beautiful public areas to crowded ward like units. He points out that people are proud to work in all, of them, and perhaps that is what matters.

Disease, Process, and Outcome:
Do you treat malaria or dengue fever, what processes do you have?
EPIC II 2007
- 75 countries, 14,400 patient point prevalence study.
- Australia and NZ have lowest mortality, this may be because of effective triage, don't accept anyone.
- 71% of pts on antibiotics on day of study, of which half were continued although clinician thought infection no longer active. Staph was the most common organism, although gram negatives were more than 50 %.

World Federation invited all countries with Society to collect data for entire ICU stay for a 10-day enrolment period
- 10,000 patients, 84 countries
- overall mortality 16%, Aust/NZ lowest 10.3%, and shortest LOS
- 58% ventilated, 40% vasopressors, 13% RRT (23% in USA)
- infections 42% at any time, gram negative are predominant except for Nth America (50:50)
- mortality vs severity : severity lowest in South Asia and North America hunger in Aust/NZ, with lower mortality in Aust/NZ, same for sepsis.
- analysis by socioeconomic status of region shows low and lower middle income countries have lower severity and low mortality, upper middle have high severity and high mortality, high income babe high severity but lower mortality.

Closed vs open ICU: A recent article (US) suggests higher OR death with closed units compared to open, but other evidence agains this. He discusses the Munich alternate day vs daily dialysis trial showing a decrease in mortality with daily. It was almost retracted from the NEJM as the study was performed by nephrologist so without the knowledge of the intensivists. He argues ICU needs 1 boss who knows what is going on, a closed model.
He presses on with thoughts on separation of ICUs by specialty, a very US model, is this good? Do we really believe that neuro pts don't have CVS and resp problems, even medical vs surgical, "a surgical patient is a medical pt with a scar". Why not mix them all in closed ICUs?

Ethical Issues: As a global speciality we are struggling. Discussed withholding vs withdrawing, the international variation in dealing with this. Because this ethical issue is difficult for regions, people, we say "we will see tomorrow", and go on and on. The Israel approach of timers on ventilator because of Halakha. There are huge differences when comparing Japan, Turkey, US, Brazil, Southern and Northern Europe, Canada, Australia and New Zealand, about approach to resuscitation patients with non reversible disease, so patients receive vastly different treatment. There are issues around culture, eg Navajo Indian belief that if speak of bad outcomes they will happen, so must be careful in how we deal with culture. Even the approach to active euthanasia, where it is acceptable in Belgium, France, not discussed in Portugal or Greece.

Epidemics: in 1919 people died in tents with flu epidemics. What now, do we have enough ICU beds enough ECMO, a timely question given the H1N1 epidemic currently sweeping US, no doubt soon to spread to Europe.

Neilo wrote 01-14-2014 08:53:51 am
SCCM Day 4: Session 1 It's Just Saline How Can It Be Harmful

Why Would Saline Be Harmful (John Kellum)

We start in the early 1900s, when Cushing described the "poisonous" effect of saline. He reflects on the marketing win of calling it "normal", and making it cost a few cents. He posts put 9 grams of sodium (1 L NS) is the same as 25 packets of chips. There are important effects on acid-base balance, with increasing plasma NaCl leads to an acidosis (saline acidosis, gives strong ion difference explanation), and if you take way the chloride in these solutions you remove the acidosis (Bellomo et al). Does it matter? Animal evidence of worse hemodynamics in sepsis with saline acidosis, and increased inflammatory response, as well as textbook adverse effects of metabolic acidosis generally. In particular the renal effects appear to be important, particularly saline acidosis. There also appears to be a dose-reponse relationship between saline acidosis, renal injury, and mortality, a relationship that was observed in a balanced vs saline study in major study (Shaw, 2012). Old work in greyhounds suggests this may be due to decreased RBF, with recent animal work showing hyperchloraemia led to acidosis, decreased GFR, increased NGAL and cystatin C, pathological change to kidney, and survival (Zhou, CCM). In human models, as little as 1 L saline leads to changes in RBF, RVR, and GFR.

In conclusion resuscitation with saline may lead to acidosis, worsening blood pressure, is pro inflammatory..

Saline Boluses and Increased Mortality in Paediatric Sepsis (Eric Williams)

The first goal of sepsis resuscitation in children is to give up to 60 ml/kg of fluid (guideline), is this one size fits all adequate for the many different types of sepsis that present? 2 studies of ED based sepsis protocol (Larsen and Cruz, Paediatrics) show better compliance with guidelines if clear protocols, and better outcomes, reinforced by other studies (Paul, paediatrics). A lot of back slapping about doing well, then we get FEAST....

Why did 40 ml/kg of saline or albumin vs no bolus lead to worse outcomes. Of course the developed world critical care community were critical, this was malarial low Hb, poor systems etc. the investigators went back and looked at terminal events, and found that rapid fluid caused cardiovascular collapse, with absence of clinical fluid overload, across all subgroups. Perhaps in developed countries we treat the CVS side effects, explaining why we still see a reduction in mortality when adhere to sepsis guidelines that advocate early fluid.

We go on to the problems of fluid overload, AKI, and need for RRT. His group went back and looked at the relationship between AKI and exposure to sepsis protocol, and found a reduction in AKI post-protocol.

In conclusion I think we are told that it is complex, all the answers aren't clear, that early fluid resuscitation in sepsis protocols in developed countries is probably OK and reduces AKI and improves outcome, but what to do between the first few hours and recovery is less clear.

Saline and Risk of Acute Kidney Injury (Rinaldo Bellomo)

If we continue from John Kellum's arguments around hyperchloraemic acidosis, and move on to trials in humans. We have 2, double blind, RCT, showing changes in time to micturition and urine volume favouring balanced solution to saline in healthy humans, with evidence that a reduction in cortical perfusion is the cause of this. "If you believe that cortical hypo perfusion is the cause of AKI in your patient, and you are going to fix it with saline, you are intellectually deranged".

We go on to data from his hospital, where an observational period (n=760) was followed by a chloride restrictive policy (n=760) in a tertiary ICU. They found a treatment effect (massive decrease in use of saline, gelatin, albumin (chloride rich), to high use balanced solution), with an associated significant decrease in renal injury, time to RRT etc. At the same time John Kellum's group looked at a large operative database and performed a matched cohort analysis of patients tears with balanced solution vs saline, and found the same outcomes, more renal injury with saline.

Where next? More studies needed, but Rinaldo suggests that at the moment it seems prudent to avoid the administration of saline

Neilo wrote 01-14-2014 08:54:26 am
SCCM Day 4: Session 2 Novel Applications in Tele-Medicine

Integrating Telemedicine in the ICU: Hub and Spoke Model (Miles Ellenby)

This is a paediatric perspective, in the US children are 27% of ER visits, only 6% of institutions have paed speciality, and there is evidence that kids do better when paed specialty available. In Portland (authors region), there are a lot of children transferred towed centre from regional hospital, and many don't need it. In contrast there are providers who see only a handful of sick children a year, choosing not to refer. Finally there are comforts levels of families and institutions, the inconvenience of being relocated, risks around transport, and financial issues. So we have a problem.

The theoretical advantage of telemedicine is that a routine, anonymous phone call with issues around telephone transfer of information, is replace with a video and it's associated intimacy, and ability to gain information. In Oregon they are providing a reactive "case-by-case" model, as opposed to "bunker"or "scheduled", so although a bit of extra work for on-call doctor, it doesn't need a lot of resource. They have been able to prevent unnecessary transports (febrile convulsion), aid in resuscitation, and manage critically ill patients locally where bad weather prevented retrieval. This has taken 5-years from idea to established successfully with 276 consults, averted 23% transports! no adverse outcomes. Miles goes on to give examples.

Getting Drugs Online (Allison Fomi)

In a similar theme, telepharmacy was successful at implementing best practice guidelines in remote ICU, eg sedation, glycemic control, aminoglycoside, anticoagulation. The dole also promoted communication between teams/transition with an online information portal.

Telemedicine: Outreach to the Community (Marc Zubrow)

Reinforces the social challenges you confront with telemedicine. He discusses the "bunker" model, where remote patients are all monitored, and there is proactive management and mangagement of issues that arise?

(Zawada, Post Grad Med, 2009) 1 million patients over 1500 square miles in Dakota. Telemedicine led to 37.5% reduction in transfer! with high score for ease of use of technology (90%), and family and provider comfort (90%).

The next example is Maryland eCare LLC. A consortium of 6 small hospitals with problems attracting and retaining intensivists, got a $3,000,000 grant to find a provider to supply telemedicine. There model cost $5,000,000 and has saved $8,000,000. They provide all out of hours care, with 1 eCare physician per 100 to 120 patients. There are rules, particularly "the local doctor always wins". Also staffed 24/7 with critical care nurses (experienced, communication strategies etc). All hospitals have to have the same ventilator weaning, sedation/analgesia, glycemic control, sepsis, and hypothermia protocols. Working on electrolyte replacement protocol. Lots of problems dealing with "non-aligned" hospitals, with different EMRs, PACs, logons. They performed an interrupted time series analysis, and showed sign finds t reductions in ICI and hospital mortality, LOS, and reduction in transfers