Jerry J. Zimmerman, MD, PhD, FCCM
Critical care provider decision-making frequently involves life-and-death choices that are impacted by multiple, interactive, complex variables. Ideally these choices reflect evidence-based practice but are as likely to reflect pathophysiologic rationale and knowledge derived from training and experience. Developing and fostering a learning healthcare environment in the intensive care unit (ICU) identifies best practice, facilitates delivery of high-value patient and family care, and promotes wellness for the community of ICU practitioners working in the high-stakes, high-stress ICU environment.
Infrastructure for developing and fostering a learning healthcare environment in the ICU is schematically represented as the house of continuous process improvement. This structure is founded on the principle of patients and families first. Oversight is provided by an informed and engaged staff of interdisciplinary critical care professionals. Essential pillars of continuous process improvement include quality, cost, delivery, and safety. Attention to the quality/cost ratio ensures high-value ICU care.
Developing and fostering a learning healthcare environment in the ICU is based on the following six principles:
1. Practicing evidence-based medicine whenever possible
The Society of Critical Care Medicine (SCCM) has recently fostered evidence-based medicine in three areas related to the practice of critical care: Choosing Wisely, ICU Liberation, and the Surviving Sepsis Campaign (SSC).
The original 2014 Choosing Wisely activities for critical care included:
1. Don’t order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dL.
3. Don’t prescribe parenteral nutrition for adequately nourished critically ill patients during the first seven days of an ICU stay.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.
These initial evidence-based guidelines were endorsed by the Critical Care Societies Collaborative (CCSC) in an effort to reduce the diagnostic and treatment waste that have been associated not only with patient financial harm, but with physical and emotional harm as well. Since publication of the original Choosing Wisely for critical care, multiple articles have been published suggesting the benefits of less oxygen, less fluid, less antibiotics, less imaging, and less immobilization in the ICU. Accordingly, the SCCM Quality and Safety Committee is conducting a systematic literature review to identify new candidates for Choosing Wisely for critical care.
The SCCM-sponsored ICU Liberation initiative provides a framework for clinical standard work for provision of usual care in the ICU. The elements of ICU Liberation are:
A. Always prioritize treatment of pain.
B. Undertake scheduled daily spontaneous breathing trials and spontaneous awaking trials.
C. Be cognizant of the choice of drug classes used for sedation.
D. Monitor for and minimize delirium.
E. Facilitate early mobilization.
F. Empower and engage families in the care plan.
. Empower and engage families in the care plan. A variety of investigations have generated evidence for the value of each of the ICU Liberation elements. In addition, two recent publications have ascertained a dose-response effect of implementation of multiple ICU Liberation elements in terms of improved ICU outcomes, including decreased ICU resource utilization and reduced mortality. While a pediatric group is analyzing data related to a pilot feasibility study of pediatric ICU Liberation, the Adult ICU Liberation Group is examining strategies to disseminate ICU Liberation.
Surviving Sepsis Campaign
The SSC is a collaborative effort between SCCM and the European Society of Intensive Care Medicine (ESICM) that began in 2002. This international quality improvement program has focused on the publication of evidence-based guidelines and iterative process improvement for rapid identification and treatment of sepsis. The previous SSC 3- and 6-hour bundles have recently been merged into an ideal state hour-1 bundle that emphasizes the earliest recognition and treatment of sepsis. It includes the following elements:
1. Measure the lactate level and remeasure if initial lactate is > 2 mmol/L.
2. Obtain blood cultures before initiating antibiotics.
3. Administer broad-spectrum antibiotics.
4. Begin rapid administration of 30 mL/kg of crystalloid for hypotension or lactate > 4 mmol/L.
5. Apply vasopressors if the patient is hypotensive during or after fluid resuscitation to maintain mean arterial pressure > 65 mm Hg
Previous data derived from implementation of a 3-hour bundle suggested further beneficial effects if the bundle were implemented in less than 3 hours. It is likely that the hour-1 bundle will undergo additional iterative improvement as evidence evolves. SCCM is also collaborating with ESICM to sponsor derivation of pediatric SSC guidelines.
2. Designing clinical standard work modules to reduce practice variation, conducting iterative plando-study-act cycles of clinical standard work, and displaying outcomes of continuous process improvement activities
Advantages of protocols for delivering ICU care have been summarized as follows: avoiding errors of omission, improving unit efficiency, decreasing cost, and maintaining a standard of care. A standardized approach to care facilitates identifying and eliminating waste, maintaining gains from rapid process improvement, communicating between providers, establishing a baseline for continuous improvement, and minimizing noise and controlling for nuisance variables when attempting to identify best practice. It has been emphasized that standardization represents the foundation for iterative process improvement and, without standardization, measurements of improvement are impossible.
Clinical standard work should be evidence-based whenever possible and consensus-derived among relevant stakeholders when evidence is not available. ICU Liberation provides an infrastructure for clinical standard work for usual care in the ICU. Other SCCM areas of clinical standard work include the Sepsis 3.0 definitions for adult sepsis and a similar ongoing initiative for pediatric sepsis. In both instances, the new definitions derive from actual patient data as well as a rigorous consensus process. Developing and updating a variety of guidelines related to ICU practice remains a key initiative of SCCM’s American College of Critical Care Medicine; these guidelines provide the most up-to-date information to inform development of local clinical standard work that reflects best practice. Ideally any clinical standard work should undergo regular plan-do-studyact cycles to iteratively improve the process toward an ideal state. Providing feedback in the form of run charts of clinically meaningful outcome data and celebrating successes encourages ongoing interest and involvement of relevant stakeholders.
3. Participating in interdisciplinary teaching and education
SCCM is the largest organization of critical care professionals. Clearly a paramount SCCM mission is development and dissemination of interdisciplinary education materials. SCCM’s Critical Care Congress highlights this activity. Multiple other teaching venues that are relevant to the ICU team include adult and pediatric review and ultrasound courses, Congress pre-courses, focused topic summits, webinars, podcasts, and a wealth of information housed on SCCM’s website. SCCM’s Fundamentals courses have flourished over the past several years and are taught around the world. They now include several specialty modules. SCCM committee involvement frequently affords members opportunities to participate in specialized education that may include development of white papers. SCCM currently supports two specialty journals, Critical Care Medicine and Pediatric Critical Care Medicine, and is currently exploring publication of an open-access online journal. Both of the traditional journals are constantly exploring innovative approaches to engage readers, particularly bringing new science related to critical care to the bedside. Increasingly SCCM members and sections are connecting in real time using Twitter, Instagram, and Facebook.
4. Demanding a culture of safety
By at least one published research account, medical error represents the third leading cause of death in the United States. Provision of intensive care is uniquely challenging because of the concurrent interactions of complex patients, complex therapies, and a complex workplace, which frequently create the perfect storm for medical errors. Alternatively, a safe ICU environment requires common purpose, multidisciplinary teamwork, standard work, focus on systems, anticipation of unintended consequences, and individual accountability. Since miscommunication is frequently a root cause of medical errors, SCCM ICU Liberation and Patient-Centered Outcomes Research Institute – ICU (PCOR-ICU) programs both stress clear communication among ICU providers, patients, and families. Because hospital-acquired infections represent a common critical illness medical error, SCCM has supported efforts to reduce central line-associated bloodstream infections, catheter-associated urinary tract infections, and ventilator-associated infections. Medication errors represent the most common type of error and account for nearly 80% of serious medical errors in the ICU. SCCM’s Clinical Pharmacy and Pharmacology Section is committed to improving the prescription, transcription, preparation, dispensation, and administration of ICU medications.
5. Supporting clinical, translational, and quality improvement research
A learning healthcare organization embraces applied clinical research and rigorous quality improvement as key aspects of identifying best practice. Research should be a standard of care for most ICUs. Multidisciplinary support of local research and quality improvement enriches the ICU environment for everyone and ultimately improves patient care. Maintaining equipoise on important critical care issues by ICU providers fosters conduct of high-quality research in the ICU and ultimately underlies an evidence basis for practice. SCCM’s PCOR-ICU collaborative identified practices to best engage ICU families in the care plan, while SCCM’s THRIVE initiative is examining how patient support groups and post-ICU clinics can moderate the burden of long-term morbidity among ICU survivors and their families.
Discovery, the Critical Care Research Network, is SCCM’s research enterprise, which is committed to enhancing all types of clinical research related to critical illness. Discovery manages pilot grants, provides detailed critique of research proposals, matches research mentors with junior investigators, meets faceto-face and virtually several times a year, and integrates SCCM research resources with researchers. Supporting validation studies for the new Sepsis 3.0 definitions and SSC guidelines are other important areas of SCCM member involvement in research. Currently SCCM is also submitting multiple research proposals related to the Biomedical Advanced Research and Development Authority’s (BARDA) request for disruptive, innovative investigations to enhance national preparedness for natural and man-made disasters.
6. Promoting wellness and resilience for all ICU providers as well as patients and families
A learning health care environment requires a healthy ICU multidisciplinary team. Burnout syndrome (BOS), characterized by emotional exhaustion, depersonalization, cynicism, and reduced personal accomplishment, threatens this workforce. Symptoms of BOS are reported by approximately 50% of ICU providers. Consequences of BOS include higher levels of job dissatisfaction; shorter job tenure; more reported medical errors; negative attitudes toward patients; patient dissatisfaction; and increased failed relationships, depression, alcohol abuse, and suicidal ideation. To address this modern-day malady, the National Academy of Medicine has emphasized the importance of provider well-being to support improved patient-clinician relationships, a high-functioning care team, and an engaged and effective workforce. As part of the CCSC, in collaboration with the American College of Chest Physicians, American Thoracic Society, and American Association of Critical-Care Nurses, SCCM supported a call for action to address BOS in the ICU in 2016. Currently the CCSC is formulating a master plan of activities that will promote ICU provider well-being and resilience in an effort to enhance patient and family outcomes and experiences.
It has been astutely noted that systems awareness and systems design, like promotion of a learning healthcare environment in the ICU, are important for healthcare professionals, but these are not enough. Ultimately the secret of best-quality, lowestcost, equitably delivered, and safe ICU care becomes love. Not just love for best practice and outcomes, but love for the patient and family as well as the multidisciplinary team.