Intensive Care Unit Protocol Research Articles

BENCHMARKED COMMUNITY HOSPITAL VENTILATOR MANAGEMENT: THE EFFECT OF MULTIDISCIPLINARY PROTOCOLS ON VENTILATORY DAYS IN AN OPEN MEDICAL/SURGICAL INTENSIVE CARE UNIT

PURPOSE: Studies have demonstrated the value of intensive care unit (ICU) protocols on the duration of mechanical ventilation. These were performed primarily at teaching institutions. We utilized benchmarked severity adjusted data to demonstrate the value of protocols, a multidisciplinary team, and a part-time medical director to monitor and achieve a reduction in severity adjusted ventilator days in a community hospital open ICU.

A Pilot Study of the SPRINT Protocol for Tight Glycemic Control in Critically Ill Patients

Stress-induced hyperglycemia is prevalent in critical care, even in patients with no history of diabetes. Increased counter-regulatory hormone response increases gluconeogenesis and effective insulin resistance, which can be exacerbated by drug therapy. Control of blood glucose levels to the 4.0-6.1 mmol/L range has been shown to reduce mortality and improve clinical outcomes. The Specialized Relative Insulin and Nutrition Tables (SPRINT) protocol is a simple alternative intensive care unit protocol for modulating insulin and nutritional input to gain tight blood glucose control in the 4.0-6.1 mmol/L target band. The look-up tables, implemented in a wheel-based format, are used by nurses to determine glycemic control actions based on hourly or 2-hourly blood glucose measurements and nutrition and insulin administration rates. An 11 patient pilot study was conducted comprising 2,152 hours of blood glucose level control using the SPRINT protocol. The patient cohort average Acute Physiology and Chronic Health Evaluation II score was 22, which was higher than previous intensive insulin clinical studies. Overall, 64% of measurements were in the 4.0-6.1 mmol/L band, 89% in the 4.0-7.0 mmol/L band, and 96% of all measurements in the 4.0-7.75 mmol/L band. The average value was 5.8 +/- 0.9 mmol/L. Only 1.4% of all measurements were below 4 mmol/L, with a minimum of 3.2 mmol/L. The maximum value recorded was 11.8 mmol/L. Control of blood glucose level was achieved using a protocol implemented by the nursing staff without the need for physician intervention or interpretation, where control is defined as maximizing time within a desired band. The results led to a high level of support for the SPRINT protocol among clinical staff and acceptance of the frequent measurement requirement for effective control. The ease-of-use of the protocol resulted in minimal noncompliance by clinical staff.

Improving Adherence to a Mechanical Ventilation Weaning Protocol for Critically Ill Adults: Outcomes After an Implementation Program

Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation. To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit. A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff's understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol. After the intervention, the rate of unsuccessful extubations decreased, and staff's understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff's perceptions of the practice safety climate did not change significantly. Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.

Clinical Results of an Updated Insulin Infusion Protocol in Critically Ill Patients

Strict glycemic control has recently been shown to improve clinical outcomes in critically ill patients. In the February 2004 issue of Diabetes Care , we reported our early experience implementing an insulin infusion protocol (IIP) in a medical intensive care unit (MICU).1 To facilitate early acceptance by our critical care physicians and nurses, we initially selected a conservative blood glucose target of 100–139 mg/dl. We subsequently published similar (indeed, slightly better) results using this same IIP in two cardiothoracic intensive units (CTICUs).2 Following this work, based on the primary literature,3 a position statement from the American College of Endocrinology (ACE),4 and a technical review by the American Diabetes Association (ADA),5 we decided to lower our target further into the normal range. Rather than abruptly drop to the 80–110 mg/dl target espoused by both the ACE and ADA, we elected to gradually lower our blood glucose target range in order to carefully study the impact of lowering the target on both glycemic control and rates of hypoglycemia. To this end, we present here our updated experience with a new, more stringent IIP, which differs from our old protocol in three fundamental ways: 1. Target blood glucose levels are lowered to 90–119 mg/dl, 2. To facilitate more rapid glycemic control, the initial insulin bolus is increased by ∼ 40%, and, 3. The protocol language is now in compliance with the Joint Commission on Accreditation of Healthcare Organizations. The complete, updated IIP is shown in Figure 1. We first studied 54 consecutive patients receiving intravenous (IV) insulin in our CTICU, who, because of their typically brief lengths of stay in the unit, remained on the IIP for …

Intensive Glycemic Management in Critically Ill Patients

The effect of an intensive glycemic management protocol was assessed in a heterogeneous population of critically ill adult patients. Patients representing 800 consecutive admissions following the institution of the protocol were compared with the 800 admissions immediately preceding the institution of the protocol in a 14-bed mixed medical-surgical intensive care unit (ICU). The protocol used intensive monitoring and treatment to maintain blood glucose values >140 mg/dl. Continuous intravenous insulin was used if glucose values were >200 mg/dl on two successive occasions. Mean glucose decreased from 152.3 mg/dl to 130.7 mg/dl (p < .001), marked by a 56.3% reduction in the percentage of glucose values > or =200 mg/dl, without a significant change in hypoglycemia. There were decreases in the development of new renal insufficiency (p = .034) and in the number of patients receiving transfusion of packed red blood cells (p = .035) during the protocol period. Hospital mortality decreased 29.3% (p = .002), and ICU length of stay decreased 10.8% (p = .011) after institution of the protocol. The 29.3% relative reduction in hospital mortality seen among the treatment patients following institution of the protocol probably exceeded the expectations of the initiative's champions. The culture of the ICU regarding glycemic control changed definitively. The protocol was extended to an intermediate care unit, resulting in improvement in glycemic control without an increase in hypoglycemia.

Adherence to simple and effective measures reduces the incidence of ventilator-associated pneumonia

Several modalities have been shown to be individually effective in reducing the incidence (and hence associated morbidity, mortality, and costs) of ventilator-associated pneumonia, but their implementation into clinical practice is inconsistent. We introduced an intensive care unit protocol and measured its effect on ventilator-associated pneumonia. A multidisciplinary team constructed a multifaceted protocol incorporating low risk and low cost strategies, many of which had independent advantages of their own. Some components were already in use, and their importance was emphasized to improve compliance. New strategies included elevation of the head of the bed, transpyloric enteral feeding, and antiseptic mouthwash. The approach to implementation and maintenance included education, monitoring, audits and feedback to encourage compliance with the protocol. The implementation of this prevention protocol reduced the incidence of ventilator-associated pneumonia from a baseline of 94 cases per year or 26.7 per 1,000 ventilator days to 51.3 per year or 12.5 per 1,000 ventilator days, i.e., about 50% of the pre-protocol rate (P < 0.0001). Adherence to simple and effective measures can reduce the incidence of ventilator-associated pneumonia. The protocol described was inexpensive and effective, and estimated savings are large. Implementation and maintenance of gains require a multidisciplinary approach, with buy-in from all team members, and ongoing monitoring, education, and feedback to the participants.

Staff perceptions on the use of a sedation protocol in the intensive care setting

Sedation protocols are increasingly being investigated as a method of achieving improved patient outcomes whilst guiding the decision making of both nursing and medical practitioners. However, only a limited number of studies have investigated the perceptions of staff towards a sedation protocol during its implementation. This study was designed to survey the perceptions of staff regarding the implementation of a sedation protocol in an Australian intensive care unit (ICU). Questionnaires were distributed to all multidisciplinary team members who had used the sedation protocol. The response rate was 50% (n=70). The questionnaire combined the use of visual analogue scales plus a comments section to obtain qualitative data. The results revealed that staff perceived sedation management to be enhanced with the use of a protocol and therefore should be incorporated into routine clinical practice. Staff perceived that providing clear guidelines that facilitated decision making and assisted beginner practitioners enhanced sedation management. In addition, there was a perceived improvement in the patient outcomes, including a decrease in the frequency of over-sedation resulting in a reduced ICU stay. Positive perceptions may assist in the introduction of other interventional protocols. Other protocols may target areas where variability in clinical decision making exists, despite research evidence that supports specific therapeutic interventions. Further studies addressing protocol implementation for clinical interventions are warranted in other ICU settings.

Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass

The study was designed to investigate and quantify nutritional support, and particularly enteral nutrition (EN), in critically ill patients with severe hemodynamic failure. Prospective, descriptive study in a surgical intensive care unit (ICU) in a university teaching hospital: patients aged 67+/-13 yrs (mean+/-SD) admitted after cardiac surgery with extracorporeal circulation, staying 5 days in the ICU with acute cardiovascular failure. Severity of disease was assessed with SAPS II, and SOFA scores. Variables were energy delivery and balance, nutrition route, vasopressor doses, and infectious complications. Artificial feeding delivered according to ICU protocol. EN was considered from day 2-3. Energy target was set 25 kcal/kg/day to be reached stepwise over 5 days. Seventy out of 1114 consecutive patients were studied, aged 67+/-17 years, and staying 10+/-7 days in the ICU. Median SAPS II was 43. Nine patients died (13%). All patients had circulatory failure: 18 patients required intra-aortic balloon-pump support (IABP). Norepinephrine was required in 58 patients (83%). Forty patients required artificial nutrition. Energy delivery was very variable. There was no abdominal complication related to EN. As a mean, 1360+/-620 kcal/kg/day could be delivered enterally during the first 2 weeks, corresponding to 70+/-35% of energy target. Enteral nutrient delivery was negatively influenced by increasing dopamine and norepinephrine doses, but not by the use of IABP. EN is possible in the majority of patients with severe hemodynamic failure, but usually results in hypocaloric feeding. EN should be considered in patients with careful abdominal and energy monitoring.

Evaluation of simple criteria to predict successful weaning from mechanical ventilation in intensive care patients

There is increasing evidence that weaning protocols improve outcome from mechanical ventilation, but it is unclear how best to implement such protocols in large intensive care units. We evaluated a checklist of simple bedside criteria to determine whether it could be used reliably to predict successful discontinuation of mechanical ventilation. We carried out a prospective observational cohort study in a 12-bedded general intensive care unit (ICU). We developed a checklist of metabolic, cardiorespiratory and neurological criteria that suggested that patients should start the weaning process. We performed daily assessments throughout ICU stay and recorded whether the criteria were met. Ultimate ventilator independence was used as the reference standard. We studied 325 sequential admissions to the ICU. Data were available for 98% of patients; 97% of admissions were mechanically ventilated on admission to ICU. Overall, 205 of the 308 ventilated patients (67%) achieved ventilator independence during ICU admission; the other patients died or were transferred ventilated to other ICUs. Eighty-three per cent of the patients who achieved ventilator independence met the set criteria. Fulfilling the criteria was a moderately strong predictor of ultimate ventilator independence: specificity 89%, positive predictive value 94%, positive likelihood ratio (LR) 7.6. When we analysed data by the day from admission on which patients were examined, the test was a strong predictor of subsequent ventilator independence when criteria were met by day 1 (LR 11.1) or day 2 (LR 6.9), but weaker when met by more than/equal to 4 days (LR <3). Patients who met criteria after more than/equal to 4 days often had prolonged weaning and a high incidence of re-intubation. Patients who achieved ventilator independence without fulfilling the criteria (n=35) had a short duration of mechanical ventilation (median 2 days, interquartile range 1-3 days). The most frequent reason for failing criteria before ventilator independence was a Pa(O(2))/FI(O(2)) ratio less than 24 kPa (49% of cases). A simple checklist can assist nurse assessment of suitability for weaning and could be used as a trigger to commence a weaning protocol. The day on which criteria are met is a useful way of stratifying patients for likely patterns of weaning.

Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit.

In a recent randomized controlled trial, lowering blood glucose levels to 80-110 mg/dl improved clinical outcomes in critically ill patients. In that study, the insulin infusion protocol (IIP) used to normalize blood glucose levels provided valuable guidelines for adjusting insulin therapy. In our hands, however, ongoing expert supervision was required to effectively manage the insulin infusions. This work describes our early experience with a safe, effective, nurse-implemented IIP that provides detailed insulin dosing instructions and requires minimal physician input. We collected data from 52 medical intensive care unit (MICU) patients who were placed on the IIP. Blood glucose levels were the primary outcome measurement. Relevant clinical variables and insulin requirements were also recorded. MICU nurses were surveyed regarding their experience with the IIP. To date, our IIP has been employed 69 times in 52 patients admitted to an MICU. Using the IIP, the median time to reach target blood glucose levels (100-139 mg/dl) was 9 h. Once blood glucose levels fell below 140 mg/dl, 52% of 5,808 subsequent hourly blood glucose values fell within our narrow target range; 66% within a "clinically desirable" range of 80-139 mg/dl; and 93% within a "clinically acceptable" range of 80-199 mg/dl. Only 20 (0.3%) blood glucose values were <60 mg/dl, none of which resulted in clinically significant adverse events. In general, the IIP was readily accepted by our MICU nursing staff, most of whom rated the protocol as both clinically effective and easy to use. Our nurse-implemented IIP is safe and effective in improving glycemic control in critically ill patients.

Patients with impending abdominal compartment syndrome do not respond to early volume loading

Background It is recommended that patients with impending abdominal compartment syndrome (ACS) should be volume loaded to insure the adequate preload. We evaluated our prospective resuscitation database to determine how patients who developed ACS differ from non-ACS patients in response to early volume loading. Methods Over 36 months, 152 consecutive high-risk patients were resuscitated by a standard intensive care unit (ICU) protocol that escalates interventions in nonresponders. Interventions, responses, and outcomes are prospectively collected and the characteristics of ACS and non-ACS patients were compared. Results Twenty-three patients (15%) developed ACS and were decompressed 8 ± 1 hours after ICU admission. The ACS and non-ACS patients had similar demographics and injury severity. The severity of pre-ICU shock tended to be greater in the ACS patients. During the first 8 hours of ICU resuscitation, patients who developed ACS received more blood transfusions (11 ± 2 versus 2 ± 0.2 units; P<0.05) and crystalloids (13 ± 2 versus 4 ± 0.3 L; P<0.05). As a result, pulmonary capillary wedge pressure increased more in the ACS patients (20 ± 1.5 versus 15 ± 0.5 mm Hg; P<0.05), but comparatively the cardiac index did not (3.2 ± 0.2 versus 4.2 ± 0.1 L/min/m 2; P<0.05) and the ACS patients developed pathologic elevations of gastric regional CO 2 pressures (70 ± 7 versus 48 ± 1 mm Hg P<0.05). Conclusions Conventional preload directed resuscitation to enhance cardiac function is not effective in patients with impending ACS, and this traditional resuscitation strategy is detrimental in this subgroup of patients.

Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management

The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations. Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury. Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function. As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function. Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function. The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.

Combined medical and surgical treatment after acute spinal cord injury: results of a prospective pilot study to assess the merits of aggressive medical resuscitation and blood pressure management.

The optimal management of acute spinal cord injuries remains to be defined. The authors prospectively applied resuscitation principles of volume expansion and blood pressure maintenance to 77 patients who presented with acute neurological deficits as a result of spinal cord injuries occurring from C-1 through T-12 in an effort to maintain spinal cord blood flow and prevent secondary injury. According to the Intensive Care Unit protocol, all patients were managed by using Swan-Ganz and arterial blood pressure catheters and were treated with immobilization and fracture reduction as indicated. Intravenous fluids, colloid, and vasopressors were administered as necessary to maintain mean arterial blood pressure above 85 mm Hg. Surgery was performed for decompression and stabilization, and fusion in selected cases. Sixty-four patients have been followed at least 12 months postinjury by means of detailed neurological assessments and functional ability evaluations. Sixty percent of patients with complete cervical spinal cord injuries improved at least one Frankel or American Spinal Injury Association (ASIA) grade at the last follow-up review. Thirty percent regained the ability to walk and 20% had return of bladder function 1 year postinjury. Thirty-three percent of the patients with complete thoracic spinal cord injuries improved at least one Frankel or ASIA grade. Approximately 10% of the patients regained the ability to walk and had return of bladder function. As of the 12-month follow-up review, 92% of patients demonstrated clinical improvement after sustaining incomplete cervical spinal cord injuries compared to their initial neurological status. Ninety-two percent regained the ability to walk and 88% regained bladder function. Eighty-eight percent of patients with incomplete thoracic spinal cord injuries demonstrated significant improvements in neurological function 1 year postinjury. Eighty-eight percent were able to walk and 63% had return of bladder function. The authors conclude that the enhanced neurological outcome that was observed in patients after spinal cord injury in this study was in addition to, and/or distinct from, any potential benefit provided by surgery. Early and aggressive medical management (volume resuscitation and blood pressure augmentation) of patients with acute spinal cord injuries optimizes the potential for neurological recovery after sustaining trauma.

Implementing and Evaluating a Pressure Sore Policy

This paper is based upon analysis of retrospective data and will describe a pressure sore prevention protocol in a general intensive care unit. Implementation of this protocol resulted in a cost reduction from £50 per patient episode to £22. Concurrently, a decrease was seen in patients sustaining full skin thickness sores. The rationale and research behind the choice of equipment for the protocol will be examined, and measures taken to evaluate the success outlined.

Evaluation and revision of a vasopressin/nitroglycerin protocol for use in variceal bleeding

Continuous infusion of IV vasopressin have been widely used to lower portal pressure and reduce bleeding from esophageal varices. Recently, the combination of vasopressin and nitroglycerin has been noted to be superior to vasopressin alone. This is due to the ability of nitroglycerin to reduce the detrimental effects of vasopressin while preserving its beneficial effects. In September 1989 the authors initiated a protocol in the medical intensive care unit of a large university teaching center that directed caregivers in the simultaneous use of vasopressin and nitroglycerin for use in variceal bleeding. To determine whether the protocol was being used correctly and whether the addition of nitroglycerin produced the desired cardiovascular effects. Nineteen patients (25 separate episodes) assigned to the vasopressin/nitroglycerin protocol were monitored retrospectively over a 20-month period for a total of 1068 hours of vasopressin/nitroglycerin infusion. Twenty-four patients received nitroglycerin at 10 to 50 micrograms per minute, 13 at 50 to 100 micrograms per minute and 6 at 100 to 400 micrograms per minute. Nitroglycerin dosage was not advanced appropriately in 78% of episodes despite evidence of bradycardia, hypertension and peripheral vasoconstriction. Revision of the protocol, giving additional guidance to clinicians on assessment and nitroglycerin advancement, was necessary and was accomplished.