Skip to main content

Table 2 Care process changes in the University Clinical Center of Republika Srpska MICU after 2 years of weekly critical care tele-education

From: Impact of weekly case-based tele-education on quality of care in a limited resource medical intensive care unit

  Before After
Central nervous system Sedation interruption, neurologic assessment left to individual physician
Thiopental primary choice for sedation
Rare use of neuromuscular blockade, and only as (prolonged) infusion
Scheduled sedation interruption, neurologic assessment at least twice a day
Propofol, midazolam primary sedative agents
More frequent use of neuromuscular blockade (ARDS, intermittent or short-term use)
Cardiovascular system Sporadic use of ultrasound to assess cardiac function
Dopamine primary vasoactive medication
Beta blocker use uncommon
Routine use of bedside ultrasound to assess cardiac function in all ICU patients
Norepinephrine primary vasoactive medication
Beta blockers frequently used for common indications
Respiratory system No structured approach to mechanical ventilation, liberation
Sporadic use of recruitment maneuvers, prone positioning
No systematic approach to prevention, management of mechanical ventilation complications
Frequent use of aminophylline
Use of open aspiration systems
Surgical tracheotomy
No use of corticosteroids in pneumonia
Lung-protective mechanical ventilation in all ICU patients
Regular use of restrictive fluid strategy, recruitment maneuvers, and prone positioning when indicated in ARDS
Ventilator liberation protocol, with separation to noninvasive ventilation when indicated
Routine use of ventilator bundle measures
Use of aminophylline restricted to narrow indications
Use of closed aspiration systems
Percutaneous tracheotomy
Use of corticosteroids in pneumonia with C-reactive protein > 150
Genitourinary system No routine fluid balance calculations or volume assessment
Liberal intravenous fluids, rare diuretic use
Intermittent renal replacement only
Daily fluid balance calculation, documentation
Dynamic assessment of volume status
Restrictive intravenous fluid intake (enteral use preferred), regular diuretic use
Establishing continuous renal replacement program
Gastrointestinal system Nutrition administration left to individual physician
Universal use of proton pump inhibitors (PPI) for stress ulcer prophylaxis
Standardized, early enteral nutrition with patient targeted needs.
H2 antagonists for stress ulcer prophylaxis (PPIs reserved for upper GI bleeding from peptic ulcer disease)
Hematologic system DVT prophylaxis with low molecular weight heparin (expensive)
Liberal red cell transfusion (Hb < 8.5)
Bone marrow biopsy not performed
DVT prophylaxis with unfractionated heparin (cost savings)
Restrictive red cell transfusion (Hb < 7)
Bone marrow biopsy performed when indicated
Infection prevention, management Limited hand hygiene practices
Frequent, long-term use of broad spectrum antibiotics
Cultures and local antimicrobial sensitivity rarely used
Regular tracking of multiple sepsis biomarkers (expensive)
Organized hand hygiene program
Early empiric antibiotic treatment with rapid de-escalation
Creation of local antibiogram to guide therapy selection
Skin and mucosa No routine skin evaluation, with frequent complications Routine skin, mucous membrane examination
Pharmacology No input from hospital pharmacist Regular pharmacist input, decreased medication administration and interactions using current guidelines, recommendations (UpToDate®)
Routine antibiotic dosing adjustment based on renal, liver function
Devices Device removal left to individual physician Daily assessment for the need, removal of devices
Rehabilitation Physical therapy consult left to individual physician Physical therapist is an integrated member of ICU team on rounds, provides early mobilization
Treatment environment Minimal, restricted family visitation Continuous efforts to deliver patient-centered care
Maximal family member engagement in patient treatment decisions, rehabilitation