Post Intensive Care Syndrome
ABCDE Bundle for Caregivers
While different ICUs can organize their care in very different ways, there are many ICUs that are implementing the most widely used set of clinical care guidelines based on the most recent evidence of “best care.” Those guidelines are called the PAD (Pain, Agitation, Delirium) Guidelines published by the Society of Critical Care Medicine (SCCM), or the SCCM’s PAD Guidelines. These guidelines are always in the process of being updated as new data emerge, and it is important to stress that just because guidelines are published doesn’t meant that your doctor or ICU team agrees with all elements of those guidelines.
We mention this to avoid you reading something here that your team may not be doing or may disagree with, and we endorse the importance of local physicians within your institution having the autonomy to do what they believe is right for your loved one even it that is counter to the guidelines, because they know their patient best and because no set of guidelines should be applied as a “one shoe fits all” set of rules.
Having said that, there are some extremely robust and highly well-conducted studies that have taught us numerous ways of improving ICU care over the past two decades, and those studies have been logically assembled into a set of steps now known as the ABCDEF Bundle. The first 5 letters of the bundle represent the actual “medical monitoring and interventions” while the last letter introduced the most important member of the ICU team – the Family, which obviously includes the main person on the team, the PATIENT.
These steps are outlined in-depth on the medical professional portal of this same website, and here we are only making sure that you understand the basic concepts behind this bundle of care that your loved one is going to be receiving.
Every medical center wants to have highly functioning ICU interdisciplinary teams that partner with patients and families to create a safe and comfortable patient environment. To do this, one route supported by the most up-to-date medical science, is to implement the PAD guidelines, and one way to get those guidelines implemented with success is to use the ABCDEF bundle.
Many ICUs are now measuring teamwork by how well and how consistently they coordinate the steps of this entire bundle:
What are the components of the ABCDEF bundle?
Assess and Treat Pain
There are validated tools that are recommended that can be used in every patient every day.
Both Spontaneous Awakening Trials (SAT) & Spontaneous Breathing Trials (SBT)
This means providing these powerful medications when needed but stopping them when unnecessary to avoid over-use and unwanted side effects.
Choice of Sedation and Analgesia
Published evidence helps the team decide which are the safest sedatives and analgesics to use and which are the most important medications to avoid for a specific patient’s circumstances.
Delirium Monitoring and Management
There are validated tools that are recommended that can be used in every patient every day. We will dive deeper into this aspect, DELIRIUM, in the page below.
Early Mobility and Exercise
This step involves optimizing mobility and exercise for every patient to the best of her or his ability (through the help of any member of the team assigned to perform this piece of care) and advancing that daily as clinically able.
Good communication with the family is critical at every step of a patient’s clinical course, and empowering the family to be part of the team to ensure best care is adhered to diligently will improve many aspects of the patient’s experience.
(January 18, 2017)
Evidence-Based Recommendations to Be Introduced at SCCM 2017. Critical illness is a stressful and traumatic experience that may have lasting effects on the health of patients and families, even months after discharge from the intensive care unit (ICU). A new set of guidelines for promoting family-centered care in neonatal, pediatric, and adult ICUs will be presented at the Society of Critical Care Medicine's (SCCM) 46th Critical Care Congress, to be held January 21 to 25, 2017, at the Hawaii Convention Center, Honolulu. The guidelines also appear in Critical Care Medicine, SCCM's official journal, published by Wolters Kluwer.
"These guidelines identify the evidence base for best practices for family-centered care in the ICU," comments lead author Judy E. Davidson, DNP, RN, FAAN, FCCM, of the University of California San Diego Health. The new guidelines are based on evidence showing that family-centered care may prevent or lessen the impact of post-intensive care syndrome—lingering physical and mental health effects that can occur in family members as well as patients. The guidelines and supporting work tools are now available on the SCCM and Critical Care Medicine websites. They also are available at the Society's ICU Liberation website at www.ICULiberation.org/Family.
Family-Centered Care in the ICU: Evidence and Recommendations
Based on analysis of more than 450 qualitative and quantitative studies, a multidisciplinary international expert panel developed a series of evidence-based recommendations for family-centered care in the ICU. Defined as "an approach to healthcare that is respectful of and responsive to individual families' needs and values," family-centered care recognizes the central importance of the family to the patient's recovery.
The expert panel followed a rigorous, objective, and transparent approach to evidence analysis, including steps to incorporate the perspectives of former ICU patients and family members. Examples of the 23 recommendations, grouped into five areas, include:
Family presence in the ICU. "Open or flexible" family presence in the ICU, along with support and positive reinforcement for staff in partnership with families.
Family support. Family education and instruction on how to assist with care.
Communication with family members. Family conferences to promote communication and trust between family members and clinicians and lower the risks of anxiety, depression, and posttraumatic stress symptoms.
Specific consultations and ICU team members. Palliative and ethics consultations, as well as the roles of psychologists, social workers, family navigators, and spiritual advisors.
Operational and environmental issues. Policies and procedures to support family-centered care, for example, considering space for family members to sleep.
The report includes a summary of the supporting evidence for each recommendation. The expert panel highlights areas for further research to strengthen the evidence base." One of the key findings from these guidelines is that there are many important areas of family-centered care where the evidence-base is inadequate. The guidelines highlight key areas for future research," comments senior author J. Randall Curtis, MD, MPH, of the University of Washington, Seattle. The guidelines have been endorsed by nine leading critical care and family-centered care specialty organizations in North America and Europe.
The panel, in collaboration with a task force led by David Y. Hwang MD, of Yale University, has also developed a guide to help in planning and implementing steps to improve family-centered care in ICU settings. This document lists tested resources for translating the recommendations into practice. A gap analysis tool was also developed for use in developing hospital-specific priorities for change to enhance family-centered care. This video offers instruction on how to use the gap analysis tool
At the Critical Care Congress presentation titled "Family-Centered Care: Translating Research into Practice," panel members will introduce and discuss the recommendations, including the use of the gap analysis and other work tools. "Family presence, improved communication and family engagement in care may reduce post-intensive care syndrome for both patients and their family members, ultimately improving the health of our community," Judy Davidson comments. "Families in the ICU aren't visitors—they should be an integral part of the care and the care team." The session will be broadcast live at www.sccm.org/live.
Endorsing Agencies: American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, British Association of Critical Care Nurses, European Society of Intensive Care Medicine, Institute for Patient- and Family-Centered Care, Pediatric Cardiac Intensive Care Society, Society of Critical Care Anesthesiologists, World Federation of Societies of Intensive and Critical Care Medicine.
Note to editors: For further information, contact Curtis Powell, Director of Marketing and Communications for SCCM: phone +1 (847) 827-7282 or +1 (312) 285-6551; or email email@example.com.
About the Society of Critical Care Medicine
The Society of Critical Care Medicine (SCCM) is the largest nonprofit medical organization dedicated to promoting excellence and consistency in the practice of critical care. With members in more than 100 countries, SCCM is the only organization that represents all professional components of the critical care team. The Society offers a variety of activities that ensures excellence in patient care, education, research and advocacy. SCCM's mission is to secure the highest quality care for all critically ill and injured patients. Visit www.sccm.org for more information. Follow @SCCM or visit us on Facebook.
All of the late-breaking literature releases from the 46th Critical Care Congress are available at www.sccm.org/literature.
About Critical Care Medicine
Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the intensive care unit and critical care unit, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient. Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research and advances in equipment and techniques. Follow @CritCareMed.
About Wolters Kluwer
Wolters Kluwer is a global leader in professional information services. Professionals in the areas of legal, business, tax, accounting, finance, audit, risk, compliance and healthcare rely on Wolters Kluwer's market leading information-enabled tools and software solutions to manage their business efficiently, deliver results to their clients, and succeed in an ever more dynamic world.
Wolters Kluwer reported 2015 annual revenues of €4.2 billion. The group serves customers in over 180 countries, and employs over 19,000 people worldwide. The company is headquartered in Alphen aan den Rijn, the Netherlands. Wolters Kluwer shares are listed on Euronext Amsterdam (WKL) and are included in the AEX and Euronext 100 indices. Wolters Kluwer has a sponsored Level 1 American Depositary Receipt program. The ADRs are traded on the over-the-counter market in the U.S. (WTKWY).
Most major decisions in the intensive care unit (ICU) regarding goals of care are shared by clinicians and someone other than the patient. Multi-center clinical trials focusing on improved communication between clinicians and these surrogate decision makers have not reported consistently improved outcomes. We suggest that acquired maladaptive reasoning may contribute importantly to failure of the intervention strategies tested to date. Surrogate decision makers often suffer significant psychological morbidity in the form of stress, anxiety, depression, and post-traumatic stress disorder. Family members in the ICU also suffer cognitive blunting and sleep deprivation. Their decision-making abilities are eroded by anticipatory grief and cognitive biases, while personal and family conflicts further impact their decision making.
We propose recognizing a family ICU syndrome to describe the morbidity and associated decision-making impairment experienced by many family members of patients with acute critical illness (in the ICU) and chronic critical illness (in the long-term, acute care hospital). Research rigorously using models of compromised decision making may help elucidate both mechanisms of impairment and targets for intervention. Better quantifying compromised decision making and its relationship to poor outcomes will allow us to formulate and advance useful techniques. The use of decision aids and improving ICU design may provide benefit now and in the near future. In measuring interventions targeting cognitive barriers, clinically significant outcomes, such as time to decision, should be considered. Statistical approaches, such as survival models and rank statistic testing, will increase our power to detect differences in our interventions.