Komal Patel

The implementation of an early rehabilitation program is associated with reduced length of stay: A multi-ICU study

Introduction Survivors of critical illness face many potential long-term sequelae. Prior studies showed that early rehabilitation in the intensive care unit (ICU) reduces physical impairment and decreases ICU and hospital length of stay (LOS). However, these studies are based on a single ICU or were conducted with a small subset of all ICU patients. We examined the effect of an early rehabilitation program concurrently implemented in multiple ICUs on ICU and hospital LOS. Methods An early rehabilitation program was systematically implemented in five ICUs at the sites of two affiliated academic institutions. We retrospectively compared ICU and hospital LOS in the year before (1/2011–12/2011) and after (1/2012–12/2012) implementation. Results In the pre- and post-implementation periods, respectively, there were a total of 3945 and 4200 ICU admissions among the five ICUs. After implementation, there was a significant increase in the proportion of patients who received more rehabilitation treatments during their ICU stay (p < 0.001). The mean number of rehabilitation treatments per ICU patient-day increased from 0.16 to 0.72 (p < 0.001). In the post-implementation period, four of the five ICUs had a statistically significant decrease in mean ICU LOS among all patients. The overall decrease in mean ICU LOS across all five ICUs was 0.4 days (6.9%) (5.8 versus 5.4 days, p < 0.001). Across all five ICUs, there were 255 (6.5%) more admissions in the post-implementation period. The mean hospital LOS for patients from the five ICUs also decreased by 5.4% (14.7 vs. 13.9 days, p < 0.001). Conclusions A multi-ICU, coordinated implementation of an early rehabilitation program markedly increased rehabilitation treatments in the ICU and was associated with reduced ICU and hospital LOS as well as increased ICU admissions.

A Novel Picture Guide to Improve Spiritual Care and Reduce Anxiety in Mechanically Ventilated Adults in the Intensive Care Unit

RATIONALE Hospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited. OBJECTIVES To determine the feasibility and measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU). METHODS We conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, we performed semistructured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, we measured anxiety (on 100-mm visual analog scales [VAS]) immediately before and after the first chaplain visit, and we performed semistructured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS). MEASUREMENTS AND MAIN RESULTS The mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7-29 d), and 15 (30%) died in-hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, -20; 95% confidence interval, -33 to -7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semistructured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semistructured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, -72 to -24) and no significant change in physical pain that they attributed to picture-guided spiritual care. CONCLUSIONS Chaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission.

1009: A BIG BLEED FROM A SMALL PILL

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Diffuse pulmonary hemorrhage (DAH) results from damage to the small pulmonary vessels which can disrupt gas exchange, the consequences can be fatal if not treated. Dabigatran, a newer oral anticoagulant, works as a direct thrombin inhibitor and is indicated for use in non-valvular atrial fibrillation, deep venous thrombosis and pulmonary embolus. Methods: A 66 year old Caucasian male with a medical history of hypertension, diabetes mellitus type 2, atrial fibrillation on dabigatran, and abdominal aortic aneurysm presented to the ED with complaints of hemoptysis. Patient reported fever, cough, and dyspnea on exertion for 2 weeks which worsened the night prior to presentation. Initial labs showed leukocytosis 13.6, lactate 2.9, APTT 50.1 and hemoglobin 13.4. CT scan of the chest showed bilateral perihilar consolidation and ground glass opacity associated with interlobular septal thickening consistent with DAH. Given continued hemoptysis and labored breathing, the patient was intubated. Idarucizumab was administered to reverse the anticoagulation effects of dabigatran. Less than 48 hours following intubation, repeat CT scan showed clearing of the hemorrhage and he was successfully extubated. Respiratory cultures grew Streptococcus Pneumoniae, Escherichia Coli and Klebsiella Pneumoniae, and he treated with ceftriaxone. Vasculitis work up including ANA, c-ANCA, p-ANCA, C3, C4, total complement and Myeloperoxidase antibody, was negative. Additionally anti-gm antibody, mycoplasma pneumonia IgM and mixing studies were also negative. No other cause of the pulmonary hemorrhage could be identified, and it was attributed to the use of dabigatran. Results: Our research did not identify any reported case of the use of praxbind to reverse DAH secondary to dabigatran in the setting of pneumonia. Another case of DAH secondary to dabigatran was reported in Japan in 2012 before the advent of idarucizumab. DAH is fatal if not treated in a timely manner. This case raises the importance of identifying risk factors such as an underlying pneumonia, which can increase the risk of hemorrhage while on an oral anticoagulant. The use of a reversal agent in a timely manner can drastically alter clinical course.

426: ARE PATIENTS IN THE ICU UNDERFED? ENTERAL NUTRITION GOAL ATTAINMENT IN ICU PATIENTS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Actual delivery of 60% to 70% of enteral feeding goals within the first week of ICU admission is associated with a shortened length of stay, duration on mechanical ventilation and fewer infectious complications. However, only about half of critically ill enterally fed patients receive their energy requirements. Our objective was to study how effectively daily caloric goals are achieved with enteral nutrition (EN) in the ICU and what the barriers may be to attaining caloric goals. Methods: A retrospective chart review of all patients admitted to a medical/surgical ICU at a community hospital over a 3 month period who were started on EN was performed. The amount of calories delivered on a daily basis and the average number of calories delivered on days 3, 7, and throughout ICU stay was calculated. Data was compared to registered dieticians (RD) recommendations & statistical analysis was performed to measure the deficit. Potential barriers to effective delivery of EN were identified. Results: The average number of calories delivered when compared to RD’s recommendations was deficient by 658 Kcals/day (36.5% deficient; p < 0.001) on day 3, 515 Kcals/day (30% deficient; p = 0.006) on day 7 and 488 Kcals/day (27% deficient; p < 0.001) throughout ICU stay. Study population consisted of predominantly elderly (mean age=69 years), male (55%), AfricanAmerican (55%) patients. 29% patients had delay in initiation of EN with 73% of them having no identifiable reason for delay in initiation. 84% patients had a lower rate of initiation and 26% patients had an inappropriate goal rate. 71% had interruptions in EN with 33% of them having no identifiable reason for interruption. Conclusions: Our study quantitatively demonstrated how often we achieve intended caloric goals, as well as some barriers to doing so. We plan to use this knowledge to educate our ICU multidisciplinary team on these findings to develop refined pathways in which to overcome real or perceived barriers to optimal nutrition in the ICU.

1739: WARFARIN-INDUCED SEPTIC SHOCK? A RARE CASE OF DELAYED-ONSET WARFARIN-INDUCED SKIN NECROSIS.

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) in the differential diagnosis of conjugated hyperbilirubinemia in a young infant. This can lead to delay in diagnosis and treatment of a potentially fatal disease. Our case highlights this possibility and reminds clinicians to consider malignancy while evaluating similar patients to facilitate early recognition and prompt referral to the Pediatric Oncologist to initiate appropriate therapy.