Compassion tops the list by former Society of Critical Care Medicine president.
When R. Phillip Dellinger, MD, looked back over the distinguished career that earned him a lifetime achievement award in critical care, he urged the field forward in 10 directions.
Despite the drop in severe sepsis mortality he helped drive, the biggest advance needed now is in compassion, he said in a plenary talk here at the Society of Critical Care Medicine meeting.
“As I look back at my career spanning 35 years, I think I was an average compassion person,” said Dellinger, a past president of that society and now chief of medicine at Cooper University Health Care in Camden, N.J.
“But over the last 5 years, I have made a concentrated effort to hold more hands, to try to communicate with more patients, to try to talk with patients, even briefly about things not related to their medical illness, to communicate to them that I care for them,” he said.
“The payback for the patient is large, but the payback for the physician and the healthcare provider is also large. I think I get as much out of this as the patient.
“For those of you that are much less far along on your career path, I would urge you to hold more hands, to try to communicate with more patients, to try to understand more about your patients.”
Dellinger listed nine other ways ICUs could be doing better for patients, in addition to bringing a bigger dose of compassion:
2. Two-way communication with patients
With a poignant example of a very ill young woman who worked hard to communicate with the care team about her desire to get her ventilator tube out, Dellinger illustrated how clinicians can be compassionate and not just rely on one’s list of reflexive talking points.
3. Severe sepsis care
While the recent ProCESS and ARISE trials, testing early goal-directed therapy in severe sepsis, showed roughly 19% 90-day mortality across study arms, “we should not rest on our laurels,” Dellinger urged.
The vast majority of ICUs don’t reach anywhere near that low a rate.
“There is still a tremendous challenge ahead for us to spread this message out to smaller and intermediate hospitals about earlier identification, earlier antibiotics, and earlier fluid resuscitation,” he told attendees. “Sepsis is still a time bomb.”
4. Post-intensive care syndrome
Up to a quarter of ICU patients develop post-traumatic stress disorder after discharge, and many suffer significant impairment.
“We are making progress. We are talking about trying to get restraints off patients, about sleep cycle, about orientation, about early ambulation, about the right choice of medication for patients having agitation or delirium,” he said. “We all need to get on the bandwagon.”
5. Pre-ICU care
While more than 10,000 noncritical care providers take a course on the fundamentals of critical care each year, it’s not enough, Dellinger said. And telemedicine isn’t a solution for small emergency departments or on hospital floors at night where there isn’t critical care expertise, he added. “We do need to figure out how to bring more critical care to the bedside early in the diagnosis of critical illness.”
6. Align research with healthcare changes
With providers pulled in so many different directions, research is losing ground, Dellinger suggested. One way to boost research might be to align it with what is required for healthcare delivery, perhaps mentoring fellows in projects related to throughput, cost per case, or quality indicators.
“We cannot totally digress where we are not doing translational and basic research and pure clinical care research that may not yield fruits in our healthcare delivery, but I think it certainly will be useful and beneficial in the research mission,” he said.
7. Physical exams
Many patients get only a visual exam, with their care relying mainly on laboratory tests and other sophisticated technology to replace the physical exam.
“But how meaningful is it?” Dellinger questioned. “Is it done just strictly to satisfy the CMS attestation, or do we really think about a meaningful exam and do we look for important findings so that we can teach fellows and residents and medical students?”
8. ICU rounds
Patient safety research has shown poor teamwork is a causal factor underlying adverse incidents in the ICU, he noted. “Rounds should be very multidisciplinary.” At his center, standardization of the various steps from huddle to signout actually streamlined rounds rather than prolonging them, he said.
9. Patient safety
While progress has been made — notably by Johns Hopkins leading the way with checklists and daily goal sheets — a lot of work needs to be done, Dellinger said. He contrasted the nearly 38.8 sentinel safety events per 100 patient days in ICUs shown in a 2006 paper against the record of an industry with elaborate safety measures — the nuclear reactor industry, with three major accidents in over 15,000 reactor-years.
Even on a basic level in the ICU, the handwashing recordstands at about 10% to 74%. “We still have not been able to conquer something as simple as adequate hand hygiene, and therefore I must say we must do better in patient safety,” Dellinger urged.
10. Electronic medical record documentation
Documentation now is dominated by copy-and-pasting with often poor editing and ballooning length over a patient’s course of stay. “They [EMR progress notes] are awful and nobody seems to mind,” he said. “Sometime in the not too distant future this needs to be addressed. We must do better.”