An Interprofessional Evidence-Based Approach to Reducing Post-Intensive Care Syndrome

Critically ill patients and their families are exposed to stressful situations in the Intensive Care Unit (ICU) and may develop iatrogenic problems related to their illness, injury, ventilator, or other treatments. The sudden, unexpected hospital admission coupled with the uncertainty of prognosis exposes patients and family members to psychological consequences that can last years, a phenomenon known as Post-Intensive Care Syndrome (PICS). PICS is identified as the behavioral, cognitive, and physical impairments experienced by survivors of critical illness. Not simply confined to the patient experience, PICS-Family (PICS-F) includes symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and complicated grief experienced by family members of critically ill patients. Patients and family members with PICS symptoms may report a decreased quality of life. Healthcare professionals must consider the long-term consequences of ICU care on the mind and body of our patients and their support persons. A key strategy for mitigating PICS is alignment of the processes, people, and technology in the ICU using a multicomponent, interprofessional group of interventions known as the ABCDEF bundle (Assess, prevent, and manage pain; Both awakening and breathing trials; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). Two additional PICS mitigation strategies include ICU recovery peer support (both individually and in groups) during and following critical illness as well as ICU diaries.

As a strategy to decrease the incidence of PICS and PICS-F, the Nashville Veterans Affairs Medical Center (VAMC) medical and surgical ICUs are participating in the Society of Critical Care Medicine (SCCM) ICU Liberation and THRIVE Collaboratives, which are international quality improvement projects focused on implementation of the ABCDEF bundle and peer support/support groups, respectively. Evidence-based guidelines recommend implementation of an interprofessional team approach akin to the ABCDEF bundle (Barr et al., 2013). Furthermore, peer support provides the Veteran, family members, and support persons with an opportunity to make sense of the ICU experience and potentially ameliorate adverse psychological sequelae following critical illness while also developing a support system for the journey to recovery following critical illness. We determined that implementation of ICU diaries in tandem with peer support would be ideal in addressing the emotional needs of our Veterans and their family members. Harvey et al. (2016) report ICU diaries being associated with reduction in symptoms of depression, anxiety, and PTSD for ICU survivors. Family members of critically ill patients describe ICU diaries as a facilitator to coping and communication with ICU staff.

Using the Model for Quality Improvement Framework, we implemented all three strategies, including the ABCDEF bundle, support groups/peer support, and ICU diaries, to reduce the burden of PICS and PICS-F. ABCDEF bundle implementation began January 2016 and included A.) use of the Critical-Care Pain Observation Tool (CPOT) for the assessment of pain in nonverbal or delirious Veterans, B.) daily evaluation and completion of spontaneous awakening and breathing trials in mechanically ventilated Veterans, C.) development of a sedation and analgesia protocol to guide sedative administration with mechanically ventilated Veterans, D.) routine screening for delirium with the CAM-ICU and focusing on prevention and management by means of nonpharmacologic strategies, E.) screening daily to determine whether each critically ill Veteran can be safely engaged in an early progressive mobility protocol, and F.) family participation in rounds and Veteran care. Support groups were initiated October 2016, and include meetings where Veterans, relatives, and support persons can talk to others who have had an ICU admission and share experiences of critical illness and recovery. Group meetings are led by health professionals, chaplains, relatives, and former ICU patients. Complementary to ABCDEF bundle and peer support group implementation, we implemented ICU diaries in December 2016. Diaries are initiated for Veterans with anticipated ventilator support >48 hours, pharmacologically sedated, delirium positive, or per nursing judgement. Entries are made by members of the healthcare team, family, and friends. Entries include messages of daily status and progress, hope, empathy, and prayer. The goal of ICU diary implementation is to create a sustainable process for communication between staff and family as well as improve provider recognition of family emotion and information needs.

We have collected a number of quality improvement measures to demonstrate our interprofessional changes have resulted in improvement. Outcome and process measures of ABCDEF bundle implementation include improvements in ventilator-free days, ICU length of stay, and adherence to bundle components. Peer support and ICU diary outcome and process measures include satisfaction of Veterans, relatives, support persons, and staff; number of support group participants; and percent of ICU diaries initiated/completed with eligible Veterans. Balancing measures include qualitative reports of negative effects from ABCDEF bundle implementation, support group participation, or ICU diary use. Based on our success thus far, future directions include refinement of processes and spread of ABCDEF bundle, peer support/support groups, and ICU diaries to other Veterans Affairs Medical Centers.