Sharon Dickinson

Albumin Use Guidelines and Outcome in a Surgical Intensive Care Unit

HYPOTHESIS Restrictive albumin use guidelines in the surgical intensive care unit (SICU) will not increase mortality and will result in cost savings. DESIGN Prospective cohort study. SETTING Tertiary teaching hospital. PATIENTS All patients admitted to the SICU from July 1, 2004, through July 1, 2005, were included in this study. INTERVENTIONS Patients in the first 3 quarters of the study were treated with no restriction on albumin use. An organized educational program was initiated by the new intensivist-led critical care team and directed toward the residents, nursing staff, and primary surgical teams. Appropriate albumin use guidelines were instituted in the last quarter. MAIN OUTCOME MEASURES Prospective clinical and outcome data were collected. Albumin use data and costs were obtained from the pharmacy prospective database. RESULTS A total of 1361 patients were included in the study. A statistically significant reduction in albumin use (54%) was found in the fourth quarter (P = .004), and a substantial cost saving was realized (56% reduction in cost) with the albumin use guidelines. Restrictive use of albumin had no negative impact on ICU mortality. Mean Acute Physiology and Chronic Health Evaluation III scores on ICU day 1 were not different. No significant difference in mean ICU length of stay was noted. Maintained reduction in the use of albumin was documented during the next 6 quarters. CONCLUSIONS The implementation of albumin use guidelines during critical care resuscitation using an educational approach in a SICU is associated with reduced albumin use, significant cost savings, and no negative impact on ICU outcome. Continued educational efforts promoting evidence-based practices in the ICU are warranted.

Prone-Positioning Therapy in ARDS

The prone position has been used to improve oxygenation in patients with severe hypoxemia and acute respiratory failure since 1974. All studies with the prone position document an improvement in systemic oxygenation in 70% to 80% of patients with acute respiratory distress syndrome (ARDS), with maximal improvement seen in the most hypoxemic patients. This article reviews data regarding efficacy for use of the prone position in patients with ARDS. Also described is a simple, safe, quick, and inexpensive procedure used to prone patients with severe ARDS on a standard bed in the intensive care unit at the University of Michigan.

Building a protocol to guide mobility in the ICU.

Professional experience and wisdom have taught us that immobility is a risk factor for various adverse outcomes, such as deep vein thrombosis, joint contractures, pulmonary dysfunction, and bone demineralization to name a few. Balancing bed rest and mobility may improve both short- and long-term outcomes for our patients. Moreover, early, routine mobilization of critically ill patients is safe and reduces hospital length of stay, shortens the duration of mechanical ventilation, improves muscle strength, and functional independence. At the University of Michigan, we have turned the tides by creating a structured process to get our patients moving through the use of a standardized mobility protocol. Our protocol is simple and can easily be adapted for all patient populations by simply modifying some of the inclusion and exclusion criteria. The activities are grounded in the evidence and well thought out to prevent complications and promote mobilization. The purpose of this article was to present the science behind the development of a multidisciplinary protocol for early mobilization of critically ill patients that can be adapted to any intensive care unit patient with minor modifications.

Prevention of Catheter-Related Blood Stream Infection: Back to Basics?

BACKGROUND Central venous catheter (CVC)-related infections are a substantial problem in the intensive care unit (ICU). Our infection control team initiated the routine use of antiseptic-coated (chlorhexidine-silver sulfadiazine; Chx-SS) CVCs in our adult ICUs to reduce catheter-associated (CA) and catheter-related (CR) blood stream infection (BSI) as we implemented other educational and best practice standardization strategies. Prior randomized studies documented that the use of Chx-SS catheters reduces microbial colonization of the catheter compared with an uncoated standard (Std) CVC but does not reduce CR-BSI. We therefore implemented the routine use of uncoated Std CVCs in our surgical ICU (SICU) and examined the impact of this change. HYPOTHESIS The use of uncoated Std CVCs does not increase CR-BSI rate in an SICU. METHODS Prospective evaluation of universal use of uncoated Std CVCs, implemented November 2007 in the SICU. The incidences of CA-BSI and CR-BSI were compared during November 2006-October 2007 (universal use of Chx-SS CVCs) and November 2007-October 2008 (universal use of Std CVCs) by t-test. The definitions of the U.S. Centers for Disease Control and Prevention were used for CA-BSI and CR-BSI. Patient data were collected via a dedicated Acute Physiology and Chronic Health Evaluation (APACHE) III coordinator for the SICU. RESULTS Annual use of CVCs increased significantly in the last six years, from 3,543 (2001) to 5,799 (2006) total days. The APACHE III scores on day 1 increased from a mean of 54.4 in 2004 to 55.6 in 2008 (p = 0.0010; 95% confidence interval [CI] 1.29-5.13). The mean age of the patients was unchanged over this period, ranging from 58.2 to 59.6 years. The Chx-SS catheters were implemented in the SICU in 2002. Data regarding the specific incidence of CR-BSI were collected beginning at the end of 2005, with mandatory catheter tip cultures when CVCs were removed. Little difference was identified in the incidence of BSI between the interval with universal Chx-SS use and that with Std CVC use. (Total BSI 0.7 vs. 0.8 per 1,000 catheter days; CA-BSI 0.5 vs. 0.8 per 1,000 catheter days; CR-BSI 0.2 vs. 0 per 1,000 catheter days.) No difference was seen in the causative pathogens of CA-BSI or CR-BSI. CONCLUSION Eliminating the universal use of Chx-SS-coated CVCs in an SICU with a low background incidence of CR-BSIs did not result in an increase in the rate of CR-BSIs. This study documents the greater importance of adherence to standardization of the processes of care related to CVC placement than of coated CVC use in the reduction of CR-BSI.

Can the use of an early mobility program reduce the incidence of pressure ulcers in a surgical critical care unit

&NA;The Agency for Healthcare Research and Quality has defined pressure ulcers (PUs) an important patient safety indicator (#3). Despite the existence of evidence-based guidelines for PU prevention and treatment from the United States Department of Health and Human Services, the sustained success in reducing the development of PUs is elusive in many acute care hospitals. Purpose:The specific aim of the study was to determine whether the implementation of an early standardized process for mobility could reduce or eliminate the development of PUs in a surgical intensive care unit. Methods:Patient data were collected pre- and postimplementation of the early mobility protocol. Results:The mobility compliance for patients postimplementation was 71.30% (SD = 12.73), with a range of 25% to 100%. A &khgr;2 test for independence (with Yates continuity correction) indicated a significant association between unit-acquired PUs and the pre- and postimplementation mobility groups (&khgr;21,1051 = 6.86, P = .009). Specifically, patients in the intervention group had significantly more unit-acquired PUs than the control group. No significant differences were identified between the 2 groups. Implications/Conclusions:Despite implementation of the early mobility protocol, we did not see an improvement in the PU rate overall or with time as protocol compliance improved.

Mobilizing Patients Along the Continuum of Critical Care.

The progressive care unit implemented an evidenced-based intensive care unit mobility protocol with their chronically critically ill patient population. The labor/workload necessary to meet mobility standards was an identified barrier to implementation. Workflow redesign of patient care technicians, interdisciplinary teamwork, and creating a culture of meeting mobility standards led to the successful implementation of this protocol. Data revealed that mobility episodes increased from 1.4 at preinitiative to 4.7 at 12 months postinitiative, surpassing the goal of 3 episodes per 24 hours.

Specialty Linens and Pressure Injuries in High-Risk Patients in the Intensive Care Unit

Background The cardiovascular and surgical intensive care units had the highest unit‐acquired pressure injury rates at an institution. Patients in these units had multiple risk factors for pressure injuries. Various interventions had been used to minimize pressure injuries, with limited results. Objectives To evaluate the effect of specialty linens on the rate of pressure injuries in high‐risk patients. The specialty linen was a synthetic silklike fabric that addressed the microclimate surrounding the patient, with the purpose of minimizing friction, shear, moisture, and heat. Methods The specialty linen was tried on 24 beds in the cardiovascular intensive care unit and 20 beds in the surgical intensive care unit, including sheets, underpads, gowns, and pillow cases. Data obtained from a retrospective review of electronic health records were compared for 9 months before and 10 months after specialty linens were implemented. Results Total unit‐acquired pressure injury rates for both units combined declined from 7.7% (n = 166) before to 5.3% (n = 95) after the intervention. The intervention was associated with a significant reduction in posterior (coccyx, sacrum, back, buttock, heel, and spine) pressure injury rates, from 5.2% (n = 113) before to 2.8% (n = 51) after specialty linens were implemented (P < .001). Conclusion Addressing the microclimate, friction, and shear by using specialty linens reduces the number of posterior pressure injuries. The use of specialty linens in addition to standard techniques for preventing pressure injuries can help prevent pressure injuries from developing in high‐risk patients in intensive care units.

Postoperative Care of a Liver Transplant Recipient Using a Classification System: Type A (Stable) Versus Type B (Unstable).

Liver transplantation has become an effective and valuable option for patients with end-stage liver disease and hepatocellular carcinoma. Liver failure, an acute or chronic condition, results in impaired bile production and excretion, clotting factor production, protein synthesis, and regulation of metabolism and glucose. Some acute conditions of liver disease have the potential to recover if the liver heals on its own. However, chronic conditions, such as cirrhosis, often lead to irreversible disease and require liver transplantation. In this publication, we review the pathophysiology of liver failure, examine common conditions that ultimately lead to liver transplantation, and discuss the postoperative management of patients who are either hemodynamically stable (type A) or unstable (type B).