This document summarizes a webinar for selecting topics for a national ICU collaborative initiative in 2016-17. It discusses the results of a survey where pain, agitation, and delirium (PAD) and end-of-life care were the top choices. Potential Topic 1 provides an overview of how end-of-life care could be improved across the ICU continuum. Potential Topic 2 reviews evidence that consistent pain assessment and management paired with sedation protocols can reduce length of stay and complications. The webinar participants then decided to focus on improving PAD management in 2016-17.

1. NATIONAL INITIATIVE 2016-17
TOPIC SELECTION WEBINAR
November 17, 2015

2. Canadian ICU Collaborative Faculty
Denny Laporta, MC, FRCPC
Claudio Martin, MD, FRCPC
Yoanna Skrobik, MD, FRCPC
Paule Bernier, Dt.P., M.Sc.
John Muscedere, MD, FRCPC
Cathy Mawdsley, RN, M.Sc.
Bruce Harries, Improvement Associates
Leanne Couves, Improvement Associates
Carla Williams, CPSI
Ardis Eliason, Improvement Associates

3.  ICU Faculty
 Those who expressed interest in
participating (via survey)
 Others
Welcome!
3

4. 4
Who’s Online? Qui est en ligne?
POINTER

5. What professions are represented?
Quelles professions sont représentées?
Nurse MD
Educator / Quality
Improvement
Professional
Infection
Control
Administrator /
Senior Leader
Other
POINTER
Respiratory
Therapist
Nutritionist
5

6.  Summary of Survey Results
 Context and Approach
 Potential Topic 1: End of Life Care
 Potential Topic 2: Pain, Agitation,
Delirium (PAD)
 Decision
 Next Steps
Today’s Agenda
6

7. Summary of Survey Results
7
Which topics would you rate as your top THREE choices that your ICU would be interested and committed to working on in 2016-17?
n=85
1st Choice 2nd Choice 3rd Choice
(weight = 9) (weight =3) (weight =1)
Nutrition 8 8 23 39 119
Pain, Agitation & Delirium 33 26 10 69 385
Sepsis 14 12 16 42 178
End of Life Care 24 22 13 59 295
Med Rec 2 8 8 18 50
VAP 2 8 10 20 52
Pneumothorax 0 1 1 2 4
Total Weighted
et pour lesquels elle serait prête à s'engager en 2016-17?
n=8
1st Choice 2nd Choice 3rd Choice
(weight = 9) (weight =3) (weight =1)
Nutrition 0 1 0 1 3
Pain, Agitation & Delirium 2 2 3 7 27
Sepsis 2 1 1 4 22
End of Life Care 4 3 1 8 46
Med Rec 0 1 3 4 6
VAP 0 0 0 0 0
Pneumothorax 0 0 0 0 0
Total Weighted
Veuillez indiquer quels seraient vos trois (3) sujets préférés et sur lesquels votre USI aimerait travailler

8. Q1: Comments (Potential Topics)
8

9. Q2: What issues and challenges in
your ICU keep you awake at night?
9

10. Q3: What opportunities keep you
coming back to work each day?
11/17/20
15
10Canadian ICU
Collaborative

11. POTENTIAL TOPIC 1:
END OF LIFE CARE IN THE ICU
Dr. Claudio Martin
Cathy Mawdsley

12. End of Life Care
Across the ICU Continuum
ICU Admission
ICU Trajectory
“Cure vs Care”
End of Life
Care or ICU
Discharge
Patient and Family Experience
12

13. Communicating & Understanding Patients
and Families Across the Continuum
ICU Admission
• Conversations prior
to admission
• High risk
• Frequent
readmissions
• Targeted sources
of admissions
• Initial discussions
about patient values
and wishes
ICU Trajectory
• Trigger of when
“cure changes to
care”
• Learning about the
patient values
• Separating update
meetings from the
process of Goals of
Care
• Offering treatment
plans mirroring
patient values and
wishes
• Team consensus
EOL Care or ICU
Discharge
• Standardized
protocols
• Individualizing
EOLC as per patient
values
• Higher PTS scores
after death
13

14. Accreditation Canada
• Complete and accurate information is shared with the client
and family in a timely way, in accordance with the client's
desire to be involved
• The team verifies that the client and family understand
information provided about their care
2.1. Engage patients or substitute
decision-makers in a discussion of
risks and benefits of investigations
and treatments to obtain informed
consent
14

15. Some of the evidence
Time-Limited Trials of Intensive Care for
Critically Ill Patients With Cancer
How Long Is Long Enough?
Association of Intensive Care Unit
Admission With Mortality Among Older
Patients With Pneumonia
Alignment of Do-Not-Resuscitate Status
With Patients’ Likelihood of Favorable
Neurological Survival After In-Hospital
Cardiac Arrest
15

16. Some review of evidence
 Canadian Critical Care Society Guidelines for
the Withdrawal of Life Sustaining Measures
 Withholding or Withdrawing Life Sustaining
Therapy: The Canadian Critical Care Society
Position Paper
 Choosing Wisely Canada Campaign
– Organ donation (missed opportunity = lives lost)
– Goals of care for patients with progressive and
untreatable end-stage or terminal illness
16

17. Some of the evidence
17

18. How are we doing?
18

19. How are we doing?
19

20. How are we doing?
20

21. Why this topic? Why now?
Examples of harm through poor communication:
 Mismatch between preferences and actual care
– Information and Consent
 Language of ICU Team can make things worse
• Despite best intentions – “want vs choose” (Schwarze et al., 2015)
• Science to framing discussions (Downar et al, 2010)
• ACP – interpreted differently between family and ICU team
(Leder, 2015)
 Moral distress for staff
 Post ICU Syndrome with families
• Depression and PTSD
• Influenced by coping style and patient outcome
21

22. Why not this topic?
- Scope
- Is this a patient safety issue?
- Where on the continuum do you fit?
- Emotion and value laden topic
- Resources required to change culture
and systems around communication,
treatment and consent processes
- Ethics consultation
23

23. POTENTIAL TOPIC 2:
PAIN, AGITATION AND DELIRIUM
Dr. Yoanna Skrobik

24.  Consistent pain assessment paired with pain-
assessment analgesic management improves ICU
LOS, MV duration outcomes
 Less drug and more ‘range’ adapt to individual patient
needs
 Sedation titration is key in minimizing LOS and MV
complications, and may be associated with mortality
 Sedating patients for sleep or asynchrony is
ineffective
 Delirium screening is important for patient
reassurance and management choices (mobility,
dexmedetomidine)
Review of the evidence
25

25. How are we doing?
 In ICUs across Canada systematic
assessment and management protocols vary,
as does caregiver buy-in (as low as 40%)
 There are predictable ‘winner’ combinations to
make it work
 Implementation with the collaborative allows
tangible tracking of success
26

26. Why this topic? Why now?
 Because of the experience and lessons
learned from doing it over the last 10 years
 More and more metrics to suggest that
addressing PAD also enables mobility and
sleep, the two determinants of physical and
mental health for survivors
 There are novel ways to engage families in
this patient care dimension (particularly with
delirium)
27

27.  The only reason why not is the overwhelming
amount of ‘bundles’ and evidence-driven
practice we are expected to integrate… so
perhaps a resigned view of impotence when
faced with challenge would be appropriate
Why not this topic?
28

28. DECISION

29. Raise your hand if you agree with the
following statement
“I like WebEx webinars”
Practice Question
30

30. Our ICU would be willing to commit to
working on improvement of _______ in
2016-2017
PICK ONE: Raise Hand
31

31.  Call to Action
 Enrolment Process
 First virtual Learning Session in late
January / early February
Next Steps
32

32. THANK YOU
MERCI