ICU - National Initiative 2016-2017 Topic Selection Webinar

NATIONAL INITIATIVE 2016-17 TOPIC SELECTION WEBINAR

November 17, 2015

Canadian ICU Collaborative Faculty

Denny Laporta, MC, FRCPC

Claudio Martin, MD, FRCPC

Yoanna Skrobik, MD, FRCPC

Paule Bernier, Dt.P., M.Sc.

John Muscedere, MD, FRCPC

Cathy Mawdsley, RN, M.Sc.

Bruce Harries, Improvement Associates

Leanne Couves, Improvement Associates

Carla Williams, CPSI

Ardis Eliason, Improvement Associates

ICU Faculty Those who expressed interest in

participating (via survey) Others

Welcome!

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Who’s Online? Qui est en ligne?POINTER

What professions are represented?Quelles professions sont représentées?

Nurse MD

Educator / Quality Improvement Professional

Infection Control

Administrator / Senior Leader

Other

POINTER

RespiratoryTherapist

Nutritionist

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Summary of Survey Results Context and Approach Potential Topic 1: End of Life Care Potential Topic 2: Pain, Agitation,

Delirium (PAD) Decision Next Steps

Today’s Agenda

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Summary of Survey Results

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Which topics would you rate as your top THREE choices that your ICU would be interested and committed to working on in 2016-17?n=85

1st Choice 2nd Choice 3rd Choice(weight = 9) (weight =3) (weight =1)

Nutrition 8 8 23 39 119Pain, Agitation & Delirium 33 26 10 69 385Sepsis 14 12 16 42 178End of Life Care 24 22 13 59 295Med Rec 2 8 8 18 50VAP 2 8 10 20 52Pneumothorax 0 1 1 2 4

Total Weighted

et pour lesquels elle serait prête à s'engager en 2016-17?n=8

1st Choice 2nd Choice 3rd Choice(weight = 9) (weight =3) (weight =1)

Nutrition 0 1 0 1 3Pain, Agitation & Delirium 2 2 3 7 27Sepsis 2 1 1 4 22End of Life Care 4 3 1 8 46Med Rec 0 1 3 4 6VAP 0 0 0 0 0Pneumothorax 0 0 0 0 0

Total Weighted

Veuillez indiquer quels seraient vos trois (3) sujets préférés et sur lesquels votre USI aimerait travailler

Q1: Comments (Potential Topics)

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Q2: What issues and challenges in your ICU keep you awake at night?

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Q3: What opportunities keep you coming back to work each day?

11/17/2015

10Canadian ICU Collaborative

POTENTIAL TOPIC 1: END OF LIFE CARE IN THE ICU

Dr. Claudio MartinCathy Mawdsley

End of Life Care Across the ICU Continuum

ICU AdmissionICU Trajectory“Cure vs Care”

End of Life Care or ICU Discharge

Patient and Family Experience

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Communicating & Understanding Patients and Families Across the Continuum

ICU Admission

• Conversations prior to admission• High risk• Frequent

readmissions• Targeted sources

of admissions

• Initial discussions about patient values and wishes

ICU Trajectory

• Trigger of when “cure changes to care”

• Learning about the patient values

• Separating update meetings from the process of Goals of Care

• Offering treatment plans mirroring patient values and wishes

• Team consensus

EOL Care or ICU Discharge

• Standardized protocols

• Individualizing EOLC as per patient values

• Higher PTS scores after death

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Accreditation Canada

• Complete and accurate information is shared with the client and family in a timely way, in accordance with the client's desire to be involved

• The team verifies that the client and family understand information provided about their care

2.1. Engage patients or substitute decision-makers in a discussion of risks and benefits of investigations and treatments to obtain informed consent

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Some of the evidence

Time-Limited Trials of Intensive Care for Critically Ill Patients With CancerHow Long Is Long Enough?

Association of Intensive Care Unit Admission With Mortality Among Older Patients With Pneumonia

Alignment of Do-Not-Resuscitate Status With Patients’ Likelihood of Favorable Neurological Survival After In-Hospital Cardiac Arrest

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Some review of evidence

Canadian Critical Care Society Guidelines for the Withdrawal of Life Sustaining Measures

Withholding or Withdrawing Life Sustaining Therapy: The Canadian Critical Care Society Position Paper

Choosing Wisely Canada Campaign– Organ donation (missed opportunity = lives lost)– Goals of care for patients with progressive and

untreatable end-stage or terminal illness

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Some of the evidence

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How are we doing?

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How are we doing?

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How are we doing?

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Why this topic? Why now?

Examples of harm through poor communication: Mismatch between preferences and actual care

– Information and Consent Language of ICU Team can make things worse

• Despite best intentions – “want vs choose” (Schwarze et al., 2015)

• Science to framing discussions (Downar et al, 2010)

• ACP – interpreted differently between family and ICU team (Leder, 2015)

Moral distress for staff Post ICU Syndrome with families

• Depression and PTSD• Influenced by coping style and patient outcome

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Why not this topic?

- Scope- Is this a patient safety issue?- Where on the continuum do you fit?

- Emotion and value laden topic- Resources required to change culture

and systems around communication, treatment and consent processes

- Ethics consultation

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POTENTIAL TOPIC 2: PAIN, AGITATION AND DELIRIUM

Dr. Yoanna Skrobik

Consistent pain assessment paired with pain-assessment analgesic management improves ICU LOS, MV duration outcomes

Less drug and more ‘range’ adapt to individual patient needs

Sedation titration is key in minimizing LOS and MV complications, and may be associated with mortality

Sedating patients for sleep or asynchrony is ineffective

Delirium screening is important for patient reassurance and management choices (mobility, dexmedetomidine)

Review of the evidence

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How are we doing?

In ICUs across Canada systematic assessment and management protocols vary, as does caregiver buy-in (as low as 40%)

There are predictable ‘winner’ combinations to make it work

Implementation with the collaborative allows tangible tracking of success

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Why this topic? Why now?

Because of the experience and lessons learned from doing it over the last 10 years

More and more metrics to suggest that addressing PAD also enables mobility and sleep, the two determinants of physical and mental health for survivors

There are novel ways to engage families in this patient care dimension (particularly with delirium)

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The only reason why not is the overwhelming amount of ‘bundles’ and evidence-driven practice we are expected to integrate… so perhaps a resigned view of impotence when faced with challenge would be appropriate

Why not this topic?

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DECISION

Raise your hand if you agree with the following statement

“I like WebEx webinars”

Practice Question

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Our ICU would be willing to commit to working on improvement of _______ in

2016-2017

PICK ONE: Raise Hand

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Call to Action Enrolment Process First virtual Learning Session in late

January / early February

Next Steps

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THANK YOU MERCI