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