The Intensive Care Units (ICUs) at the UVM Medical Center were busy this year caring for critically ill patients. We are now gearing up for what always promises to be a busy winter. As a tertiary (specialty) medical center and level one trauma center, our ICU cares for the sickest patients, those stricken by severe pneumonia, overwhelming infections, shock, catastrophic strokes or heart attacks, and trauma or other surgical emergencies.
Wintertime is often accompanied by an increase in our patient count related to respiratory complications of chronic illness or trauma related to winter conditions, such as motor vehicle accidents, snowmobiling, and falls during roof snow removal. Many of these patients will come from our own community, but many more will come from other centers throughout Vermont, upstate New York, and New Hampshire, where the capacity to care for such sick patients is limited.
Due to the ongoing global research efforts of academic medical centers such as our own, the field of critical care is in a perpetual state of striving to improve the outcomes of patients suffering from critical illness. For instance, many of the practices we once thought were beneficial for patients, like deep and prolonged sedation, are now recognized as being potentially harmful in their capacity to prolong ICU stay and increase complications of ICU care.
In accordance with the current standards of practice, our medical and surgical ICUs now strive for 100 percent compliance with “daily sedation interruption.” This practice involves shutting off sedative medications to allow patients to awaken at least once daily, and has been demonstrated to shorten the time that patients spend on mechanical ventilation and reduce the time that they require care in the ICU.
We now make a daily effort to keep people “comfortable but awake” when possible, and get them up an out of bed and moving on their own as soon as possible. We have also recently instituted new practices to help restore the normal sleep rhythms of our patients, in order to avoid the confusion and delirium that can result from sleep deprivation.
In an effort to limit the infectious complications of ICU care, our own Critical Care Quality Assurance committee meets monthly, in collaboration with members of the Jim Jeffords Quality Institute, to discuss new ways of improving patient safety in our ICUs. This committee closely monitors and reviews ICU-related infections, and has led major efforts to reduce the rates of these infections. For instance, blood stream infections associated with indwelling vascular catheters (IV’s) were once thought to be a “normal” and unavoidable consequence of ICU-related care. In the wake of recent efforts, the Medical ICU has now observed 450 days elapse without a single central IV catheter infection, and has had only one event in over two years, a rate of infection ten times below the average of competing academic hospitals, and well below the 10th percentile nationally (better than at least 90 percent of other hospitals).
In our next blog, I will update everyone on progress we’re making on improving communication between physicians, nurses, patients, and their families in our ICUs.
Gilman Allen, MD, is Medical Director of Adult Critical Care at the University of Vermont Medical Center. He is also an Associate Professor in the Larner College of Medicine at UVM.