the new picu – from toxic to healing environment · the new picu –from a toxic to a healing...
TRANSCRIPT
The New PICU – from a Toxic to a Healing Environment
Dr. Karen Choong MB, BCh, FRCP(C)Professor, Dept. of Pediatrics and Critical Care,
Health Research Methods, Evidence and Impact
McMaster University
@karen_choong
#PedsICU # PICULiber8# ICURehab
Disclosure
✔️AFP Innovation Grant - PICU Liber8, an Implementation
Study
Patient images provided with consent
Clinicaltrials.gov NCT03573479
Outline
1. What’s happening to critically ill children
2. What’s Toxic - understanding Harm
3. The New PICU – from Resuscitation to Rehabilitation and Recovery
Traditional Focus of Critical Care
Early Recognition Resuscitation Survival Discharge
Improved PICU Survival
Chan, J Peds 2016; Cremer CCM 2009Pinto PCCM 2017; Choong PCCM 20181997 2006 2013 - present
12%7%
2-3%
30%41%
53-68%
- 79% PICU Days
- 81% PICU cost
- 77-89% invasive
therapies
Chronic Complex Disease
Noncomplex Chronic Disease
Previously Healthy
PICU POPULATION
PICU Mortality
Chronic Complex Patients
⇢Population Shift
HOSPITAL READMISSIONS 12%
PICU-ACQUIRED COMPLICATIONS (PAC)
20%
2008 2018
63%Iatrogenic Withdrawal
25%-53%Delirium
23%PICU-acquired
Weakness
13%
17%
2%
Amigoni, PCCM 2017; Traube, CCM 2017; Choong PCCM 2018;
D Caldwell CCCF 2018
↑ mechanical ventilation
↑ Length of Stay
↑ Mortality
↑ Poor Functional outcomes
↑ Parental Stress
Decreased Mortality ⇢ Increased PICU Morbidity
2008 2018
35%
61% develop 1/more PAC
Decreased Mortality⇢ Increased Post-PICU Morbidity
Pollack, PCCM 2014; Pinto, PCCM 2017;
Choong PCCM 2018;Knoester, Int Care Med 2008
25% 30%
82%
93%
50%
FUNCTIONAL DISABILITY
POOR QUALITY OF LIFE
POST PICU MORTALITY
Longterm Outcomes
Then Now
Post-Intensive Care Syndrome–pediatrics
(PICS-p); PICS-familiesHigh
Parental Stress
Poor Functional Recovery
↓PICU Mortality - ↑Post-PICU Mortality
• Mortality is higher AFTER PICU discharge
Author (Year)PICU
Mortality
Cumulative Mortality
at 6mths
Jones; UK (2001-2002) 7.8% 9.3%
Pinto; US (2012) 3.9% 7.8%
Choong; Canada (2014-2016) 1.5% 3.3%
IMPROVED PICU Survival
↑ Chronic Complex Survivors xs 2
↑ PICU-acquired Complication x’s 3
Protracted RECOVERY
Survival is only the beginning….Success in Pediatric Critical Care ⇢ Improved Survival
↑ POST-PICU MORTALITY X’s 2
↑ POST-INTENSIVE CARE SYNROME-
Pediatrics
LEGACY of CRITICAL ILLNESS
The Old PICU – SurvivalThe New PICU - Survivorship
Understanding Harm
PICU Practice Paradigm
Choong, PCCM 2018; Traube, CCM 2017; Smith H, CCM 2017
70%Withdrawal
25-53%Delirium
23%PICU-acquired
Weakness
Failure to recognize
PICU-acquired complications (PACs)
→ Sedation-Immobility Harm
Cycle
The PICU Paradigm - Culture of Sedation
SAFETY PRIORITIES
#1: Accidental extubation
↓Anxiety and stress
Cardiorespiratory Instability
Conflicting attitudes
Understand the S/E of sedation
Desire for Deeper Sedation
Perceived ↑Workload
Knowledge Gaps
Comfortable Sedating, Uncomfortable Mobilizing
Lack of understanding of Delirium
Misconception that Sedation = SleepChoong et al, PCCM 2014
Long, Australian Critical Care 2016
Belovedblake.wordpress.com
Sleep in the PICU
CRITICAL
ILLNESS
PSYCHOLOGICAL
EMOTIONAL
DELIRIUM
AGITATIONINSOMNIA
DISTRUPTED
SLEEP
WITHDRAWAL
PARENTAL
STRESS
Benzodiazepines and
opioids ↓restorative sleep,
↑arousal frequency
PHARMACOLOGICALENVIRONMENT
Kudchadkar Sleep Med Rev 2014; Traube, CCM 2017
The Old PICU - Culture of Sedation
ADVERSE EVENTS ARE UNCOMMON:
Self-extubation: 0.5%
Patient discomfort : 16 vs 14%
Mobility related adverse events: 0.4-2.6%
No Urgency to address over-sedation, delirium, mobilization
Sedation and Immobility are prioritized over Rehabilitation
Curley et al, JAMA 2015; Nydahl, Ann Am Thorac Soc 2017; Cuello-Garcia J Peds 2018
SAFETY PRIORITIES
Accidental extubation
Discomfort
Cardiorespiratory Instability
PACs are very common - 61%
The Old PICU - Toxic Environment
• Light pollution: Harsh, artificial → disrupts day-night rhythm
• Noise pollution: 84 dB, up to 100 dB impairs healing, activates SNS, hormonal dysregulation
Sleep disruption, Delirium, PTSD
• Clinician convenient Routines:- 4 am bed bath, 4:30 routine Xrays, 6 am routine labs
Bad for Staff, Toxic for patients, stressfull for Families
De-personalization of Patients
Computer-as-surrogate for patient
The New PICU
Rehabilitation - the process of Recovery
Harm Reduction
Risk factors for PACsOdds Ratio
(95% CI)
Time to Mobilization 1.11 (0.96 – 1.28)
IV Sedation duration 1.07 (1.00 – 1.14)
Benzodiazepine use 5.2 (3.7 – 7.5)
New/Progressive MODS 1.78 (1.18 – 2.67)
Weecover study, Choong et al, PCCM 2018
FRONT End
STRATEGIES
BACK End
STRATEGIES
Rethink Safety Priorities
SAFETY PRIORITY
EXCESSIVE SEDATION
DELIRIUM
IMMOBILITY
SAFETY PRIORITY
Unplanned Extubation
Cardiorespiratory
Instability
Discomfort
HARM prevention
Operationalizing Rehabilitation
Choong, PCCM 2018; Smith, CCM 2017; Mody, CCM 2018
PICU
LIBER8FAMILY
EARLY MOBILIZATION
DELIRIUM
COMFORT
BREATHING
AWAKE-ASLEEP
GOOD NUTRITION
HUMANISM
Figure 1. PICU Liber8: An early rehabilitation bundle to reduce harm
Choong 2018
Less immobilisation
Less sedation depth & duration
Less benzodiazepines
LESS IS MORE
PICU
Liber8
Good Nutrition
Humanism
AwakeAsleep cycles
Breathing
Comfort
Deliriumprevention
Early Mobilization
Familyengagement
A Rehabilitation Bundle is effective
PICU
LIBER8FAMILY
EARLY MOBILIZATION
DELIRIUM
COMFORT
BREATHING
AWAKE-ASLEEP
GOOD NUTRITION
HUMANISM
MD
PTRT
RNPHARM
FAMILY
CCM Oct 2018
Rehabilitation is Effective…
It made me aware that he’s not dying, it seems like he’s
going to liveYou knew there was some
physical benefit to it but for her, it was something to look
forward to
Emotionally we don’t get much around here, so psychologically,
it (mobilization) was so beneficial
PCCM 2018
”“It gave me hope.
HUMANISMCreating a Healing
Environment
PICU
LIBER8FAMILY
EARLY MOBILIZATION
DELIRIUM
COMFORT
BREATHING
AWAKE-ASLEEP
GOOD NUTRITION
HUMANISM
Humanism: Creating a Healing Environment
• Noise reduction
• Cluster care
• Lighting policy, Quiet time
• Sleep routine, adjuncts
• Assisted communications
• Patient Diaries
• Pet Therapy
Humanism = Patient Engagement in Rehabilitation
Music Therapy
Child Life
Adjuncts to Rehabilitation in the PICU
Patients Engaging Patients
H: Hounds
Family Engagement is KEY to Rehabilitation
The NEW PICU – Focus on Healing
1. HARM reduction - Less is More
2. Non-pharmacological 1st line interventions
3. Personalized, goal-targetted patient care
Rehabilitation
Early
Recognition
Bridging Survival with Survivorship
ABC’s of
STABILISATION
Resuscitation
SAVING LIVES with
BETTER QUALITY
ABC’s of
RECOVERY
