ICU Aftershocks

Combating adverse effects of the ICU with NIH-funded research

by Victoria Ellwood

"Patients come into the ICU very, very sick. The primary goal of course is to save their lives … which we often do,” says Michele Balas, PhD, RN, CCRN-K, FCCM, FAAN. “But when they’re released from the hospital, some may suffer from profound physical, mental and cognitive impairment. Mentally, they may never be quite the same afterwards.”

Judith Tate, RN, PhD, concurs. “We know that anybody who’s admitted to the ICU and survives is at risk for a number of long-term consequences that frankly are not particularly good,” she said. “They may have physical problems, but they’re also at risk of psychological problems and difficulties with cognitive skills. Their brain is affected.”

Nationally, these problems plague a staggering 30 to 80 percent of adult patients treated in the ICU. At Ohio State, researchers Balas and Tate have been awarded major funding from the National Institutes of Health to help find – and implement – ways to sidestep the devastating and lingering after-effects of ICU care. As nurse researchers, they are particularly positioned to make a difference.

“Nurses are quite uniquely poised to partner with scientists, scholars and fellow clinicians to take a leading role in advancing research,” said Karen Rose, PhD, RN, FGSA, FAAN, director of the Center for Healthy Aging, Self-Management and Complex Care within the College of Nursing. “No other researchers contribute this distinct perspective. They observe first-hand what the patient experiences, their family’s concerns and what’s going on in the patient’s surroundings. All of these things contribute to the patient's well-being … and bring relevance and impact to the research.”


Michele Balas: Learning our ABCs and DEFs

Michele BalasBalas heads a collaborative research team* that recently was awarded a three-year $1.2 million grant from the National Institutes of Health/National Heart, Lung and Blood Institute (NIH/NHLBI) to conduct a study addressing the disturbing after-effects of ICU care and how best to implement solutions to it. The study, “Determinants of Implementation Success: Coordinating Ventilator, Early Ambulation and Rehabilitation Efforts in the ICU (DISCOVER – ICU),” seeks to improve the outcomes of patients admitted to ICUs in the United States.

“Each year, millions of patients treated in the ICU are at risk of experiencing delirium, often referred to as acute confusion, sometime during their hospital stay,” she explained. “In addition to delirium, they also may be plagued with a variety of other problems, such as pain, anxiety, decreased mobility, sleeplessness and social isolation.”

Causes for the profound impairments, while not completely understood, are thought to stem from extended use of ventilators, along with the use of heavy sedatives – particularly benzodiazepines – immobility, lack of sleep and a chaotic, fast-paced hospital environment.

Balas’ research stems from her observations and experience in clinical settings, and indicates that delirium is a psychiatric syndrome with direct cause. “The sicker you are in the ICU, the more likely you are to experience it," she said.

Thankfully, recent research points to some relatively straightforward steps, which when bundled together can help ward off this massive problem. A recent study involving 68 hospitals in the U.S. and Puerto Rico found evidence that a protocol recommended by the Society of Critical Care Medicine, labeled the “ABCDEF” bundle, can significantly curtail the odds of delirium.

This bundle, in a nutshell, combines several distinct and interconnected components, including awakening and breathing trials, choice of pain and sedative medications, delirium monitoring and management, early mobility and family engagement.

“Traditionally, people in the ICU are kept under pretty heavy sedation to help ease their pain; after all, who wants to remember all the things in the ICU? But they’re so heavily sedated, their brains almost shut off,” says Balas. “One of the steps in the bundle is to stop the sedation once a day and let their brain wake up. Another is to conduct breathing trials – turn off the ventilator and let the patient breathe on their own, and see how they do.”

Results from the trials using the ABCDEF bundle were impressive. “Outcomes improved in all areas tracked, and in one study the odds of a patient developing delirium were almost halved,” Balas says. Despite the solid evidence supporting the effectiveness of the bundle, though, only a fraction of hospitals involved in the study are using it as often as they should be. “Even though we know this is the best thing you can do for patients, it’s still not often getting done. There is a great opportunity for improvement.”

Balas’ current study aims to find out why. “The whole purpose of the grant and our teams’ research is to ‘discover’ how to get that evidence into everyday care,” she said. “What are the factors that make the bundle more – or less – likely to be used?”

She’s setting out to delve into the attributes that make the bundle work, including patient factors, provider factors and communication among professionals. “We want to gain insight on what makes it work, and find strategies to put it into place. I hope to uncover the most efficient way to get it implemented, and test the effectiveness of implementation in a new group of hospitals."


Judith Tate: Step-by-step return to normal

Judith TateJudith Tate is another researcher investigating ways to improve ICU care. According to Tate, “Any adult admitted to the ICU in critical condition and put on mechanical ventilation is at risk for cognitive impairment, no matter what their condition was when they came in. These issues are more prevalent with age.”

Tate and co-investigators** received a $312,000 grant from the National Institutes of Health/National Institute on Aging (NIH/NIA) to look at an intervention called PIC-UPS – Post Intensive Care Unit Problem Solving – for older adults with cognition problems following an ICU stay.

Tate says most rehabilitation services center on a “drill and practice” type of model where the patient is prescribed pre-determined exercises to help with memory. PIC-UPS, on the other hand, uses real-world tasks of the patient’s choosing, and breaks them down into smaller, achievable goals.

“As an interventionist, I can’t say what’s best for you,” she said. “But by working together, let’s find ways to solve problems, achieve stepping-stone goals, and help you overcome cognitive issues.”

Her 12-week pilot evaluates the possibility of conducting a two-year trial of the PIC-UPS intervention at Ohio State.

The interventions being studied – and touted – by both Tate and Balas signify a new way of approaching care in the ICU, a way to help patients not simply survive a critical situation, but to also come away as good, or better, than they were before.

“In the past we were always taught to just keep patients comfortable,” said Balas. “We were wrong.”

*Collaborators include Alai Tan, PhD, (Co-I) and Lorraine Mion, PhD, RN, FAAN, (Co-I) of the College of Nursing; Brenda T. Pun, DNP, RN (Co-I), Eduard E. Vasilevskis, MD, MPH, FHM (Co-I), and E. Wesley Ely, MD, MPH (consultant), of Vanderbilt University; and Lori A. Harmon, RRT, MBA (Co-I), of the Society of Critical Care Medicine.

**Co-investigators include Lorraine C. Mion, PhD, RN, FAAN, and Alai Tan, PhD, of the College of Nursing, and Jennifer Bogner, PhD, ABPP, FACRM, of the Department of Physical Medicine and Rehabilitation in the College of Medicine.