De-Escalation of Critical Care and Prevention of Iatrogenicity Through
PICU Liberation Rounding Process and a Daily Rounding Checklist
Yu Kawai MD1; Michael Nemergut MD PhD2; Yves Ouellette MD PhD1; Brenda Schiltz MD1; Gina Rohlik APRN3; Lori Neu DNP3; Scott Feigal
MSN3; Debra Rowekamp MS RN3; Britt Fetterly BSN3; Karen Fryer BSN4; Robert Kahoud MD1; Grace M Arteaga MD1
1
Division of Pediatric Critical Care, 2Department of Anesthesia and Pediatrics, 3Department of Nursing, 4Division of Anesthesia Clinical Research
Background
PICU Liberation ABCDEF Bundle was recently
implemented to:
• Standardize weaning of ICU support after clinical
stabilization
• Prevention of iatrogenicity
A: Assess, Prevent, and Manage Pain
B: Breathing Trials
C: Choice of Analgesia and Sedation
D: Delirium Assessment, Prevention, & Management
E: Early Mobility and Exercise
F: Family Engagement and Empowerment
Objectives
To implement a new bedside nurse rounding script
and a physician-led de-escalation daily rounding
checklist to:
• Improve PICU Liberation ABCDEF Bundle
compliance
• Reduce the risk for iatrogenic conditions
Methods – Data Collection
5 point Likert Scale survey related to ICU Liberation
Bundle distributed to MDs, nurses, respiratory
therapists, pharmacists, and dieticians
• 1 month prior and 2 months after the
implementation of the new rounding system
• Assessed for satisfaction with rounds
Independent observers collected data during rounds
• Assessed for frequency of PICU Liberation
ABCDEF Bundle element discussion
Mayo Clinic Children’s Center, Rochester MN
Methods - Implementation Frequency of Bundle Discussion
PICU Liberation nursing rounding script developed
and implemented (Figure 1)
• Focused on PICU Liberation elements
• Previous script organized by organ system
14-task, physician-completed de-escalation
checklist developed and implemented (Figure 1)
• All checklists completed over the first 50 days after
deployment collected
Figure 1. New Rounding System Data from the Rounding Checklist
Compliance rate for first 50 days:
Consultant Initials
PICU Daily Rounding Checklist
(last updated 1/25/18, kawai.yu@mayo.edu for questions/concerns)
_________
ROOM #: ___ ___ DATE: ___ / ___ / 18 Was Checklist
• 90.4% (322/356 total patient-days)
Already Helped
Planned Discharge/Transfer to General Floor Today? YES Addressed Modify
(if circled "YES," option to NOT complete checklist) or N/A Plan
Convert IV to PO meds
(Tolerating enteral nutrition?)
Renally dose meds
(Cr rising? Any nephrotoxic agents?)
Frequency of medical plan modification:
Initiate bowel regimen
(No bowel movement or on opioids?)
Narrow/Discontinue antibiotics
• 62 times in 14.0% (45/322) of the total checklists
(48 hrs from cultures? Treatment course?)
Initiate H2 blocker and/or PPI
(Shock, coagulopathy, resp failure, steroids, NPO, UGIB?)
Initiate prophylactic enoxaparin or heparin
completed
(Adolescents, CVL ≥7 days, immobility, trauma, obesity, malignancy, hx of DVT?)
Restart home meds
TEAM BUNDLE TO ELIMINATE DELIRIUM
Discontinue physical/chemical restraints
Familiarity
Discontinue lines/tubes/devices
Most frequently modified tasks (>75% of all):
Mobility
Consult PT/OT/PMR
Initiate sleep enhancement protocol
1. Converting IV to PO meds
Sleep
(less frequent RN assessments, grouped care activities, melatonin/trazodone)
CAPD for 0 to <18 years of age ≤8 ≥9 N/A
2. Initiating bowel regimen
Assess
CAM-ICU for ≥18 years of age - + N/A
Complete Below If CAPD ≥9 or CAM-ICU +
AT RISK BUNDLE TO ELIMINATE DELIRIUM
3. Initiating GI prophylaxis
Reduce Medication Related Risks
If WAT-1 >3 or above baseline score → manage withdrawal ≤3 >3 N/A
4. Consulting PT/OT/PMR
Use opioid/benzo sparing agents
(acetaminophen/ibuprofen/ketorolac/dexmed/clonidine/gabapentin)
Discontinue unnecessary scheduled/PRN meds
(opioids/benzos/anti-cholinergics/anti-histamines/anti-emetics, etc.)
Consult psychiatry if considering an antipsychotic agent
5. Initiating sleep enhancement protocol
Rx
Satisfaction with the Rounding Process Conclusions
PICU Liberation nursing script:
• Improved care provider satisfaction with rounds
• Increased adherence with the ABCDEF Bundle
Physician-completed daily rounding checklist:
• Achieved high compliance
• Increased timely de-escalation of care
• Minimized the risk of iatrogenic conditions