Abstract
Useless monitors and data overload: Cardiac-output monitors
D Wood
Intensive care medicine can do without: Human decision making
G Chapman
The Doctor won’t see you now! Why ICU could do without sending families out of the room during ward rounds
S Lambden
A brave new world: Age isn’t just a number
CS Cattlin
Useless monitors and data overload: Cardiac-output monitors
D Wood
Wexham Park Hospital, Berkshire, UK
Intensivists love measuring physiological variables, and new technologies are constantly introduced to provide more values and countless derivatives. But just because we can measure a physiological variable doesn’t mean we should, let alone manipulate it. Ever mounting evidence shows that aiming for normal or supra-normal physiology in intensive care frequently has no benefit and often results in harm.
Cardiac-output monitors are one such technology. They aim to provide a constant stream of data allowing fluid and vasopressor optimisation with ever decreasing degrees of invasiveness. In terms of numbers and accuracy, the pulmonary artery catheter is considered ‘Gold-Standard’ and was a routine part of many patients’ management until the PacMan study brought a sudden end to their use. Replacement cardiac-output monitors are slowly infiltrating the critical care unit from theatres where their use in goal-directed fluid therapy attracts a best-practice tariff. In theatres, this technique makes sense from a physiological viewpoint, and there is some evidence that it does benefit the surgical patient. In critical care, why should they provide benefit where the pulmonary artery catheter failed?
In the critically ill patient, it is becoming clear that there is an early window for fluid therapy for resuscitation in an effort to prevent deterioration and multi-organ failure. Once an inflammatory response has been established, the glycocalyx damaged fluid cascades out of the vasculature into the tissues. Increasing evidence shows that every additional millilitre of positive fluid balance harms the patients. An additional bolus may push the patient up the Starling curve, but it will only be a transient cardiovascular improvement before the fluid disperses. By the time most patients are established in the critical care unit, we are beyond the early resuscitation phase and should be actively ‘de-resuscitating’ and drying our patients with pressors to support blood pressure. In this setting, the cardiac-output monitor and the values it provide will push against us and should be ignored. We also risk missing trends that really matter under the data deluge.
We are left with a store room of expensive monitors and boxes of expensive consumables. We should return these products and invest the money in areas where evidence of benefit to patients exists and in the staffing and training to implement it – and convert that now empty store room into an extra bed!
Intensive care medicine can do without: Human decision making
G Chapman
Stoke Mandeville Hospital, Aylesbury, UK
A computer program could integrate a myriad of inputs, observations, laboratory data, examination findings, symptoms, pharmacological data and medical history and process this information every minute of every day. The most up to date medical information at its silicon fingertips, every case report, every small print interaction between two drugs, processed without fatigue, learning and tailoring its expertise and approach to an individual patient. Acting without bias, without human error, relentlessly calculating the interventions necessary to optimise outcomes.
What do humans bring to decision making in intensive care medicine? The art of medical assessment, weaving multiple, potentially subtle, inputs into a diagnosis, a need for a certain intervention, a decision. Using this approach, physicians have believed we were improving outcomes for thousands of years. In truth, it is estimated that harm was only exceeded by benefit in the late 19th or early 20th century.1,2 Before this time, there was simply belief. Belief in our own abilities, belief that experience breeds excellence: “I’ve seen a hundred cases like this before” – is this simply fixation bias? In fact, simple scoring systems are as able as physicians and senior nurses to predict subtle aspects of medicine including mortality in medical patients3 and outcomes following cardiac arrest.4
Once the diagnosis is made, the majority of conditions can be very effectively managed in a protocolised fashion, as discussed in the Cauldron in 2012.5
It must be said that it is not all plain sailing, current computer analysis of ECGs, radiographs and video monitoring for seizure activity or work of breathing would need development. But if a car can drive itself? The system does not need to achieve perfection, to improve outcomes it must simply make fewer errors than us. Given the thousands of human errors occurring in UK hospitals every year a computer could be forgiven for fancying its own odds.6
Will doctors accept being upstaged by a hyped-up data-mining chess computer? Acceptance or not, the technology is upon us, Hamilton ventilators currently advertise “set the targets, height and gender and Intelligent Adaptive Support Ventilation will do the rest”. The program “Isabel” is available via all app stores, and provides a list of differential diagnoses, on your phone, given the parameters entered.
Throughout history, human tasks have been increasingly performed by machines. As computers become ever more sophisticated, is it not logical that ever more sophisticated tasks would eventually fall to the reign of the machines?
It’s a brave new world, are you on the outside looking in?
References
The Doctor won’t see you now! Why ICU could do without sending families out of the room during ward rounds
S Lambden
Imperial College London, London, UK
“The doctors are just doing the ward round, would you mind stepping outside for a few minutes …” is a common refrain in intensive care units around the world, it is followed by the familiar dance of the clinical team sliding into the bed space, whilst the family of the patient is ushered out because for reasons that are not made clear, something is about to happen at which their presence is not welcomed.
When surveyed, families tell us that the thing that a key causes of concern is a lack of regular updates and involvement in decision making.1 And yet, we routinely exclude them from the key business episode of the day. Perhaps there are reasons for this practice, however, there is evidence that some of the concerns that relate to the practice of including families in ward rounds are unfounded:
“Ward rounds will take much longer”: Including the family in ward rounds on the Paediatric ICU (PICU) had no impact on length of ward round.2 “There is plenty of family update from the nursing staff at the bedside”: Nursing staff have reported feeling ‘stuck in the middle’ of the family – clinician interaction. The implementation of ‘open’ ward rounds in paediatric intensive care significantly reduced these experiences amongst bedside PICU nurses.2 “Questions asked by consultants of their junior trainees or other team member will give the impression that we don’t know what’s going on”: Patient satisfaction is improved when multidisciplinary team interactions are directly observed, there is no reason why families observing clinicians asking questions of the members of the team would have a different experience.3 “The presence of family members on the ward round could breach patient confidentiality”: The Italian National Committee for Bioethics (INCB) has recently stated that open visiting in the ICU is consistent with the principles of autonomy, beneficence, and non-maleficence[4]. Also, in PICU, no additional exposure to unrelated patient information was reported by families.2
In conclusion, there is evidence from the healthcare management, paediatric and adult ICU literature that suggests a more open approach to ICU ward rounds, which include family members in the key business decisions of the day may confer a number of benefits. By breaking the habit of separating the decision-making process from the people who care most for the patient, it may be possible to improve communication and satisfaction, whilst saving time and resources currently dedicated to ad hoc updates.
References
A brave new world: Age isn’t just a number
Imperial College Healthcare NHS Trust, London, UK
A wise man once wrote “The problem with aging is not that it’s one thing after another, it’s everything, all at once, all the time”1
In this time of austerity when every penny and every treatment counts, the age of rationing healthcare is upon us. To ease the strain on intensive care services, I therefore propose that once a patient’s age provides eligibility for admission to a medicine for the elderly ward (MFE), they are no longer eligible for admission to the intensive care unit (ICU).
Over 50% of the population of the UK is over 65 years of age (14% of those are over the age of 85), that’s a few million people on the brink of using our limited and exorbitantly priced intensive care resources.2
It turns out that despite our best efforts, most don’t want to spend their last moments in the space age, alien land of intensive care or even the hospital itself, with 70% of Americans wishing to die in their own homes and 80% Americans with chronic diseases stating they do not wish to die on (or even spend time in) intensive care.3
So let’s take away the dilemma, the burden on families, the prolonged intensive care admission, the airway management, the invasive lines, the inotropes and the delirium. Let’s create a radical new admission pathway where there is a fork in the patient road that comes down to one thing: age. MFE or ICU. The decision is made simple.
Human nature makes us want to fix things, and the often the hardest thing to do is nothing, and I do not propose we do nothing, we treat that which can be simply treated, we give comfort, we ease pain and we do all this with the greatest of compassion, but far from the bright lights and whirring machines of the intensive care unit.