Judy E. Davidson

Clinical practice guidelines for support of the family in the patient-centered intensive care unit : American College of Critical Care Medicine Task Force 2004-2005

Objective:To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. Participants:A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. Evidence:The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. Consensus Process:The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. Conclusions:More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Benzodiazepine versus nonbenzodiazepine-based sedation for mechanically ventilated, critically ill adults: a systematic review and meta-analysis of randomized trials.

Background:Use of dexmedetomidine or propofol rather than a benzodiazepine sedation strategy may improve ICU outcomes. We reviewed randomized trials comparing a benzodiazepine and nonbenzodiazepine regimen in mechanically ventilated adult ICU patients to determine if differences exist between these sedation strategies with respect to ICU length of stay, time on the ventilator, delirium prevalence, and short-term mortality. Methods:We searched CINAHL, MEDLINE, the Cochrane databases, and the American College of Critical Care Medicine’s Pain, Agitation, Delirium Management Guidelines’ literature database from 1996 to 2013. Citations were screened for randomized trials that enrolled critically ill, mechanically ventilated adults comparing an IV benzodiazepine-based to a nonbenzodiazepine-based sedative regimen and reported duration of ICU length of stay, duration of mechanical ventilation, delirium prevalence, and/or short-term mortality. Trial characteristics and results were abstracted in duplicate and independently, and the Cochrane risk of bias tool was used for quality assessment. We performed random effects model meta-analyses where possible. Results:We included six trials enrolling 1,235 patients: midazolam versus dexmedetomidine (n = 3), lorazepam versus dexmedetomidine (n = 1), midazolam versus propofol (n = 1), and lorazepam versus propofol (n = 1). Compared to a benzodiazepine sedative strategy, a nonbenzodiazepine sedative strategy was associated with a shorter ICU length of stay (n = 6 studies; difference = 1.62 d; 95% CI, 0.68–2.55; I2 = 0%; p = 0.0007) and duration of mechanical ventilation (n = 4 studies; difference = 1.9 d; 95% CI, 1.70–2.09; I2 = 0%; p < 0.00001) but a similar prevalence of delirium (n = 2; risk ratio = 0.83; 95% CI, 0.61–1.11; I2 = 84%; p = 0.19) and short-term mortality rate (n = 4; risk ratio = 0.98; 95% CI, 0.76–1.27; I2 = 30%; p = 0.88). Conclusions:Current controlled data suggest that use of a dexmedetomidine- or propofol-based sedation regimen rather than a benzodiazepine-based sedation regimen in critically ill adults may reduce ICU length of stay and duration of mechanical ventilation. Larger controlled studies are needed to further define the impact of nonbenzodiazepine sedative regimens on delirium and short-term mortality.

Exploring the scope of post-intensive care syndrome therapy and care: engagement of non-critical care providers and survivors in a second stakeholders meeting.

Background:Increasing numbers of survivors of critical illness are at risk for physical, cognitive, and/or mental health impairments that may persist for months or years after hospital discharge. The post–intensive care syndrome framework encompassing these multidimensional morbidities was developed at the 2010 Society of Critical Care Medicine conference on improving long-term outcomes after critical illness for survivors and their families. Objectives:To report on engagement with non–critical care providers and survivors during the 2012 Society of Critical Care Medicine post–intensive care syndrome stakeholder conference. Task groups developed strategies and resources required for raising awareness and education, understanding and addressing barriers to clinical practice, and identifying research gaps and resources, aimed at improving patient and family outcomes. Participants:Representatives from 21 professional associations or health systems involved in the provision of both critical care and rehabilitation of ICU survivors in the United States and ICU survivors and family members. Design:Stakeholder consensus meeting. Researchers presented summaries on morbidities for survivors and their families, whereas survivors presented their own experiences. Meeting Outcomes:Future steps were planned regarding 1) recognizing, preventing, and treating post–intensive care syndrome, 2) building strategies for institutional capacity to support and partner with survivors and families, and 3) understanding and addressing barriers to practice. There was recognition of the need for systematic and frequent assessment for post–intensive care syndrome across the continuum of care, including explicit “functional reconciliation” (assessing gaps between a patient’s pre-ICU and current functional ability at all intra- and interinstitutional transitions of care). Future post–intensive care syndrome research topic areas were identified across the continuum of recovery: characterization of at-risk patients (including recognizing risk factors, mechanisms of injury, and optimal screening instruments), prevention and treatment interventions, and outcomes research for patients and families. Conclusions:Raising awareness of post–intensive care syndrome for the public and both critical care and non–critical care clinicians will inform a more coordinated approach to treatment and support during recovery after critical illness. Continued conceptual development and engagement with additional stakeholders is required.

Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU.

Objective: To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU. Methods: We used the Council of Medical Specialty Societies principles for the development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development. Results: The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice. Conclusions: These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.

Shared Decision Making in ICUs: An American College of Critical Care Medicine and American Thoracic Society Policy Statement.

Objectives:Shared decision making is endorsed by critical care organizations; however, there remains confusion about what shared decision making is, when it should be used, and approaches to promote partnerships in treatment decisions. The purpose of this statement is to define shared decision making, recommend when shared decision making should be used, identify the range of ethically acceptable decision-making models, and present important communication skills. Design:The American College of Critical Care Medicine and American Thoracic Society Ethics Committees reviewed empirical research and normative analyses published in peer-reviewed journals to generate recommendations. Recommendations approved by consensus of the full Ethics Committees of American College of Critical Care Medicine and American Thoracic Society were included in the statement. Main Results:Six recommendations were endorsed: 1) Definition: Shared decision making is a collaborative process that allows patients, or their surrogates, and clinicians to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values, goals, and preferences. 2) Clinicians should engage in a shared decision making process to define overall goals of care (including decisions regarding limiting or withdrawing life-prolonging interventions) and when making major treatment decisions that may be affected by personal values, goals, and preferences. 3) Clinicians should use as their “default” approach a shared decision making process that includes three main elements: information exchange, deliberation, and making a treatment decision. 4) A wide range of decision-making approaches are ethically supportable, including patient- or surrogate-directed and clinician-directed models. Clinicians should tailor the decision-making process based on the preferences of the patient or surrogate. 5) Clinicians should be trained in communication skills. 6) Research is needed to evaluate decision-making strategies. Conclusions:Patient and surrogate preferences for decision-making roles regarding value-laden choices range from preferring to exercise significant authority to ceding such authority to providers. Clinicians should adapt the decision-making model to the needs and preferences of the patient or surrogate.

Multidisciplinary team training to enhance family communication in the ICU.

Objectives:Current guidelines from the U.S. Society for Critical Care Medicine state that training in “good communication skills...should become a standard component of medical education and ... available for all ICU caregivers”. We sought to train multidisciplinary teams of ICU caregivers in communicating with the families of critically ill patients to improve staff confidence in communicating with families, as well as family satisfaction with their experiences in the ICU. Design:Pre- and postintervention design. Setting:Community hospital medical and surgical ICUs. Patients:All patients admitted to ICU during the two time periods. Intervention:Ninety-eight caregivers in multidisciplinary teams of five to eight individuals trained in a standardized approach to communicating with families of ICU patients using the Setup, Perception, Invitation, Knowledge, Emotions, Strategy (or Subsequent) (SPIKES) protocol followed by participation in a simulated family conference. Measurements:Staff confidence in communicating with family members of critically ill patients was measured immediately before and 6–8 weeks after training sessions using a validated tool. Family satisfaction using seven items measuring effectiveness of communication from the Family Satisfaction in the ICU (24) tool in surveys received from family members of 121 patients admitted to the ICU before and 121 patients admitted to the ICU after trainings was completed. Main Results:Using 46 matched pre- and postsurveys, staff confidence in communicating with family members of critically ill patients increased significantly (p < 0.001) in each of 21 separate measures. Family satisfaction with communication showed significant (p < 0.05 or better) improvement in three of seven individual items compared with those same items pretraining. There was no decline in any individual item. Conclusions:A simple intervention resulted in improvement in staff confidence, as well as in multiple measures of family satisfaction with communication. This intervention is easily reproduced.

Postintensive Care Syndrome: Right Care, Right Now…and Later.

Since critical care began over 50 years ago, there have been tremendous advances in the science and practice that allow more severely ill and injured patients to survive. Each year, millions of people are discharged back to the community. The recognition of long-term consequences for ICU survivors a

Implementation of the Pain, Agitation, and Delirium Clinical Practice Guidelines and promoting patient mobility to prevent post-intensive care syndrome.

Surviving critical illness is associated with persistent and severe physical, cognitive, and psychological morbidities. The Society of Critical Care Medicine has developed pain, agitation, and delirium guidelines and promoted mobility to improve care of critically ill patients. A task force has developed tools to facilitate and rapidly implement the translation of guideline care recommendations into practice. The Society of Critical Care Medicine has also assembled a task force to assess the long-term consequences of critical illness. This article will explore relationships between the pain, agitation, and delirium guidelines, mobility recommendations, and post-intensive care syndrome initiative. Implementation of the pain, agitation, and delirium guidelines taking into account current data regarding post-intensive care syndrome outcomes and potential interventions are an important first step toward improving outcomes for patients and their families. Research is needed to reduce the impact of long-term negative consequences of critical illness and to fully understand the best within- and post-ICU interventions, along with the optimal timing and dose of such interventions to produce the best long-term outcomes.

Effect of intermittent pneumatic leg compression on intracranial pressure in brain-injured patients

ObjectiveTo evaluate the effect of intermittent pneumatic leg compression on intracranial pressure and cerebral perfusion pressure in brain-injured patients. DesignProspective, sequential patient study. SettingSurgical/trauma ICU of a community hospital providing regional trauma care. PatientsTwenty-four adult, brain-injured patients (mean Glasgow Coma Scale score = 6) who required hemodynamic and intracranial pressure monitoring. InterventionsPlacement of intermittent sequential pneumatic leg compression devices for prevention of venous thrombosis. MeasurementsMean arterial pressure (MAP), heart rate, central venous pressure, and intracranial pressure were measured at baseline, and at 0,10, 20, and 30 mins of intermittent pneumatic leg compression. Cerebral perfusion pressure was calculated as the difference between MAP and intracranial pressure. ResultsNo significant changes in MAP, central venous pressure, or intracranial pressure occurred during the study interval. Calculated cerebral perfusion pressure remained unchanged. A total of 23 of 24 study patients had intracranial pressure controlled by hyperventilation or pharmacologic measures within the normal range at the time of study. ConclusionIntermittent pneumatic leg compression results in no significant changes in intracranial pressure or cerebral perfusion pressure in stable, brain-injured patients who have intracranial pressure controlled by medical means. (Crit Care Med 1993; 21:224–227)

Identifying factors inhibiting or enhancing family presence during resuscitation in the emergency department.

The purpose of this qualitative study was to explore inhibitors and enhancing factors surrounding the practice of allowing family presence in the emergency room. Staff and physician interviews were transcribed and decoded for themes. A visual model was built to depict the results. Inhibitors and enhancing factors included the following drivers: staff emotions, personalizing the patient, seeing/hearing everything, closure, emotional support of the family, and “if it were me.” The following staff needs were also identified as important issues that needed to be addressed before practice could change further: staff education, optimize environment for privacy, and implementation of a family liaison. The use of qualitative research methods was effective in identifying organizational barriers to transition of evidence into practice.