too sick to be in the icu? toxic or healing environmentstoo sick to be in the icu? toxic or healing...

Too Sick to be in the ICU?

Toxic or Healing Environments

Martha A.Q. Curley, RN, PhD, FAAN

Ruth M. Colket Endowed Chair in Pediatric Nursing

Children’s Hospital of Philadelphia

Professor, School of Nursing

Anesthesia Critical Care Medicine

Perelman School of Medicine

University of Pennsylvania

Objectives

• Answer the question – are most ICUs toxic or healing? … what

about yours?

• Describe several strategies that can be used to create and/or

support healing ICU environments.

• Envision a “new normal” where the ICU is a healing milieu.

“What we must do … to put the

patient in the best condition for

nature to act upon him.”Florence Nightingale

Notes on Nursing, 1859

Create care environments that sustain and support the patient’s and

family’s capacity to heal.

“The very first requirement in a hospital

is that it should do the sick no harm.”

What ICU Nurses Do…

Domains of Practice • Diagnose and manage life-sustaining physiologic functions

• Manage crises

• Provide comfort measures

• Face death, provide end-of-life care and decision making

• Care for patients’ families

• Prevent hazards in a technological environment

• Communicate clinical assessments and improve teamwork

• Monitor quality, prevent, manage breakdown

• Provide clinical and moral leadership

Clinical Wisdom and Interventions in Acute and Critical Care (2011)

Delirium

ICUDelirium.org

But, given how we provide ICU care ….

who wouldn’t exhibit symptoms?

Manning, J.C., Pinto, N.P., Rennick, J.E., Colville, G., Curley, M.A.Q. (2018). PCCM, 19, 298–300.

PICS-pediatrics

Examples of success:

• Enhancing patient comfort

while reducing the need to

manipulate consciousness

• Advancing nutritional support

Priority – Nurse-led

interventions that manage

“fundamental” activities

What can we do?

Change the paradigm

Creating healing ICU

milieus.

RESTORE Resilience

“R2”

Ann & Robert H. Lurie Children's Hospital of Chicago

1. Circadian rhythm & sleep history on PICU

admission (personalized sleep and activity

intervention)

2. Cycled day-night lighting and modulation of

sound to match the child’s routine

3. Minimal yet effective sedation

4. Night fasting with bolus enteral daytime

feedings

5. Early, developmentally-appropriate,

progressive exercise and mobility

6. Continuity in nursing care

7. ICU Parent diaries

R2 RESTORE Resilience

R21 HD093369

MPI: Curley, Kudchadkar, Zuppa

R2 RESTORE Resilience

R21 HD093369

MPI: Curley, Kudchadkar, Zuppa

• SPECIFIC AIM: To pilot-test RESTORE

resilience, an individualized chronotherapeutic

bundle, in pediatric patients supported on

mechanical ventilation for acute respiratory

failure in the PICU.

• Hypothesis: Pediatric patients managed per

RESTORE resilience will experience a more

restorative circadian rhythm evidenced by an

improved temporal sleep-wake pattern than

patients receiving usual care.

Secondary outcomes (exploratory):

1. Salivary melatonin levels on PICU day two and five

2. Nighttime EEG slow-wave activity during

endotracheal intubation

3. R2 feasibility, adherence, system barriers

4. Levels of patient comfort: PICU days free of pain,

agitation, delirium, iatrogenic withdrawal

5. PICU exposure to sedative medications (total dose

and length of exposure)

6. Time to physiological stability (time on vasoactive

medication, duration of mechanical ventilation,

PICU and hospital length of stay)

7. Parent perception of being well-cared-for

Primary outcome: Circadian activity ratio (daytime

activity/total 24-hr activity) after endotracheal

extubation.

#1 – Circadian rhythm & sleep history on

PICU admission

R2

1st Step: Feasibility of Sleep/CR

Assessment on AdmissionCHILDREN’S SLEEP

HABITS QUESTIONNAIRE

(CSHQ)

1. Bedtime

2. Sleep behavior

3. Waking during the

night

4. Morning wake-up

5. Daytime sleepiness

Please write down your

child’s usual daytime

routine (include timing

of meals, naps, play,

specific activities)

R2

? CHILD’S ROUTINE

Feasibility Sleep/CR

Assessment on Admission?R2

CHILD’S ROUTINE

2nd Step

Matching “usual’ routine in the ICU R2

✔

✔

✔

✔

✔

✔

(Get OOB)

(Childlife)

(Cycled Feedings)

(Cycled Feedings)

(Cycled Feedings)

Decision-making

Participation

in Care

Aligns with Family Centered Care

R2 #2 Cycled day-night lighting and modulation of

sound to match the child’s routine

Cycled day-night lighting – building evidence

• Early morning bright light may enhance sleep, decrease

circadian rhythm disruption and decrease delirium.

• Optimizing physiologic light-dark patterns may decrease

sedative-analgesic needs and support recovery from critical

illness.

R2 #2 Modulation of sound to match the child’s

routine & developmental level

Noise verses Meaningful Sound

• ICUs for all patient populations are too loud

– WHO recommendations: <35dBA (average), <45dBA (max)

– NICU specific: <45dBA (average), <65dBA (max)

– According to the EPA a 70dBA sound can cause awakening

• PICUs are loud! (Yu Kawai, J of ICM, September 2017)

– Median: 53 dB [IQR: 45-56]

– Hourly maximum: 68 dB [64-72]

– Peak: 123 dB

– Bed spaces louder during the day than at night [54 vs. 52 dB]

– Bed spaces closest to common areas were louder when occupied [55 vs. 53 dB]

and when unoccupied [51 vs. 44 dB]

Noise verses Meaningful Sound

• Patient care equipment is a major noise contributor in all ICUs

in all patient populations

• Staff-education interventions are effective in reducing noise

levels in ICUs for all patient populations

R2#2 Noise containment also good for staff

#3 Minimal but effective sedation

RESTORE: Nurse-Led Goal-Directed Sedation

R2

#3 Minimal but effective sedation

18

Goal:

Minimum yet

effective dose

19

Q8H: Adjust

Sedative Doses

15

Patient’s SBS more positive (+)

than prescribed*

Exclude reversible causes of

agitation & provide comfort

measures.

If ineffective, administer a morphine

and/or midazolam rescue dose.

If 3 total nonprocedural rescue doses

are administered in ≤8H then

increase

morphine infusion by 10-20% and/or

benzodiazepine by 10-20%.

20

Patient’s SBS more negative (-) or

as prescribed

If <3 total nonprocedural rescue

bolus in 8H then decrease

morphine infusion by 10-20% and/or

benzodiazepine by 10-20%

17

Daily (on Day 2)

If SBS -3,

complete an

Arousal

Assessment

If SBS -2

complete a

Modified

Arousal

Assessment

12

Every Day

1.Identify the patient’s

trajectory of illness

2.Test for extubation

readiness (ERT) if

criteria are met*

16

Titration Phase

(Goal SBS = -1 or 0)

Curley et al; JAMA 2015; 313(4):379-389

R2

#4 Night fasting with

bolus enteral daytime feedings (per child’s routine feeding schedule)

• Compared to slow continuous feedings, bolus feedings are

physiologic and a known driver of CR.

• There are little data supporting the benefits of continuous

versus bolus feeding in critically in children.

Passive ROM TID

Turn Q 2 hrs.

Active resistance PT

Sitting position 20 mins. TID

Passive ROM TID

Turn Q 2 hrs.



Sitting on edge of bed

Passive ROM TID

Turn Q 2 hrs.




Active transfer to chair 20 mins./day

Passive ROM TID

Turn Q 2 hrs.




Active transfer to chair 20 mins./day

Ambulation (marching in place, walking in halls)

Able to

move arm

against

gravity

Able to

move leg

against

gravity

#5 Early progressive mobility

Adult Protocol

Safety Screening (Patient must meet all criteria)

M – Myocardial stability

• No evidence of active

myocardial ischemia x 24

hrs.

• No dysrhythmia requiring

new antidysrhythmic

agent x 24 hrs.

O – Oxygenation adequate on:

• FiO2 < 0.6

• PEEP < 10 cm H2O

V - Vasopressor(s) minimal

• No increase of any

vasopressor x 2 hrs.

E – Engages to voice

• Patient responds to verbal

stimulation

Level

1

Level

2

Level

3

Level

4

R2

Morandi A, et al.

Curr Opin Crit Care. 2011;17:43-49.

Benefits of the ABCDEF Bundle

#5 Early, developmentally-appropriate, progressive

exercise and mobility

Sapna Kudchadkar

R2

#6 Continuity in Nursing CareModels of nursing care that allow reciprocal nurse-patient /family relationships

• Nurse “knowing” patients and families

– Limit the number of different clinicians assigned to care for each

patient; continuity in nursing care (CINC)

• Patients and families “knowing” nurses

– Unburden patients and families; preserve emotional energy, enhanced

communication and coordination of care

• Allow synergyPatient and family stability, complexities, predictability, resiliency. vulnerability,

participation in decision-making & care, resource availability

Fostering nursing clinical judgment, inquiry, caring practices, response to diversity,

advocacy, facilitator of learning , collaboration, and systems thinking.

R2

R2 Continuity in Nursing Care (CINC)

Total # of different nurses

Total # of shifts experienced

Example: LOS 7 days, 12 hour shifts

• 5 different nurses (5/14) CCI = 0.36




Better

Worse

#7 ICU Parent diaries R2

ICU Parent Diaries

“Fiona (Lynch) is a nurse in the paediatric intensive care unit”

R2

Benefits of creating healing milieus?

• Symptom management (agitation, delirium)

• Maintenance of circadian rhythms, sleep

• Time to physiologic stability

• Patient perception of being well-cared-for (FCCS)

• Short-term outcomes (lengths of stay, ventilator days)

• Long-term outcomes (post intensive care syndrome)

Example: Better Outcome Measures Composite Measure on Comfort in Critically Ill Children

Pediatric Measurement Center of Excellence (PMCoE)

Practice of Critical Care

• Shaped by multiple perspectives

• Core values

– Primacy of patient and family

– Spirit of inquiry

– Innovation

ICU Nursing Practice

• One that is patient and family centered

• One where nurses create healing environments for patients and

their families

• One where the practice of nursing is supported by systems that

enhance nursing’s capacity to optimize patient and family

outcomes.

Let’s continue

to “challenge

the givens”

Thank You

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