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Dome - A New Model of ICU Care Emerges

Dome December 2013

A New Model of ICU Care Emerges

Date: December 2, 2013


Nathan Maryn, a 76-year-old patient recovering from surgery to remove several soft tissue tumors, walks with the aid of his wife, Barbra, and physical therapist Jennifer Sahm (right). Studies show that getting patients—even the critically ill—up and out o
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Nathan Maryn, a 76-year-old patient recovering from surgery to remove several soft tissue tumors, walks with the aid of his wife, Barbra, and physical therapist Jennifer Sahm (right). Studies show that getting patients—even the critically ill—up and out of bed prevents muscle wasting and weakness, allowing them to recover sooner. Helping patients get physical exercise is just one way that family members are encouraged to participate in their loved one’s care through a new pilot project in Johns Hopkins Hospital’s surgical intensive care unit (SICU).

In the modern intensive care unit—the place that houses the hospital’s most critically ill patients—sophisticated machines pump, whir, calculate, beep and scan patients, spewing out reams of medical data. Meanwhile, patients and their family members anxiously await news from their doctors and nurses.

“It’s like the machines have taken over,” says Richard Dean, an electrical engineering faculty member at Morgan State University. “It’s just not a human place.” Dean became familiar with Johns Hopkins Hospital’s ICU four years ago during his wife’s yearlong battle with ovarian cancer and later, during his daughter’s treatment for the same disease.

Now a member of the Johns Hopkins Hospital Patient and Family Advisory Council, Dean says it’s easy to lose track of the big picture in such a disorienting and emotionally charged environment.

“At the end [of her life], my wife received heroic measures she wouldn’t have wanted,” he explains. He’s hopeful that a new Johns Hopkins effort he’s participated in will improve future experiences of critical care patients and their loved ones.

Led by the Armstrong Institute for Patient Safety and Quality, Project Emerge seeks to help redesign the ICU to better meet the needs of patients and their families. Building on the institution’s long-term effort to study and improve ICU care, the program exemplifies Johns Hopkins Medicine’s commitment to patient- and family-centered care, a key tenet of the organization’s five-year strategic plan.

Along with engaging patients and their loved ones in decision-making, Project Emerge aims to eliminate the most likely causes of preventable harm among the sickest and most vulnerable patients. Those range from avoidable complications, such as delirium—a syndrome marked by the onset of symptoms, like severe confusion and hallucinations—to failure to provide care consistent with the patient’s treatment goals and preferences.

“A patient treated in the ICU is at risk for over a dozen types of preventable harm and may require up to 200 preventive therapies a day. Unfortunately, studies show that patients typically only receive about half of these therapies,” says Peter Pronovost, Armstrong Institute director and JHM senior vice president for patient safety and quality.

 He says many of the devices in a modern ICU don’t talk to one another. In order for clinicians to determine how their patients are doing and if they’re receiving all the recommended treatments, they must gather data from many different machines and integrate the information.

System of Systems

“We depend too much on the heroic actions of physicians and nurses to keep patients safe,” says Adam Sapirstein, a critical care physician at The Johns Hopkins Hospital who is leading efforts to roll out Emerge in the hospital’s surgical ICU (SICU). Such actions wouldn’t be necessary if health care fully realized the potential benefits of technology, he says.

Emerge intends to create a “system of systems” that will combine and make sense of this flood of information. To do so, the project is tapping into the wisdom of a diverse team of engineers, nurses, doctors, bioethicists, and patients and family members, such as Dean—18 disciplines in all. One way the Armstrong Institute has solicited ideas is by hosting “innovation days” that allow health care and technology professionals and students to observe the ICU and to brainstorm and propose what a new and improved critical care setting would look like.

Ideas include “Dr. Siri,” a voice-prompted computer assistant to provide bedside medical guidance and calculate medications, and special headgear with an optical computer that gives instant access to a patient’s record and current status.

Benefits of Collaboration

Intensive care nurse Rhonda Wyskiel, who has participated in these brainstorming sessions, says input from every team member is valued equally. She also points out the benefits of cross-disciplinary collaboration. For instance, when engineer Alan Ravitz of the Johns Hopkins Applied Physics Lab asked what would improve her ability to deliver critical therapies while also increasing patient and family awareness of them, Wyskiel drew a clock face to describe her idea.

Now her design is central to the planned improvements. As part of a pilot program in the SICU, a “clock” will appear on a monitor in each patient’s room and on tablets for care providers. Programmed to present individual treatments, it shows when a patient should receive particular therapies and whether they have been delivered.

A computer tablet that coordinates and integrates all the data from the monitoring equipment is at the heart of this project. It reminds staff members when to do tasks as well as alerts them to situations when their patients may be at risk.

On one screen, for instance, clinicians can review a dashboard tracking each patient’s risk for experiencing preventable harms, such as delirium, harmful blood clots and ventilator-associated pneumonia. The most urgent dangers are highlighted on the tablet screen in red, while developing problems are highlighted in yellow. Areas already addressed by the medical team are listed in green.

A clinician consults the tablet by tapping on the screen to see how to reduce the risk of a particular harm. The page for ventilator-associated harms, for instance, recommends that providers drain patients’ secretions and maintain the head of their beds at a 30-degree angle.

Patients and their loved ones will have their own tablets, giving them another way to interact with the care team and to ensure that everyone is on the same page about the patient’s goals of care. The device also provides new options for how to be involved, and even participate, in care activities. For example, family members can select tasks from a menu of options, such as assisting with oral hygiene to prevent potentially life-threatening infections that pose a risk to patients on a breathing machine.

Increasing Participation

Wyskiel created the family involvement menu because of an experience she had when she was visiting her own mother in the ICU following surgical complications. “I was told I couldn’t touch her and could only be in her room for 10 minutes at a time,” she says. She hopes the app will encourage family members to get involved in their loved one’s care.

Funded by a $9.4 million grant from the Gordon and Betty Moore Foundation, the Emerge system will also integrate sensor devices, such as hand-grip strength meters and pedometers, to track a patient’s progress on important physical indicators.

This fall, the SICU at The Johns Hopkins Hospital will pilot the tablet-based system. A refined version launches in 2014 at Johns Hopkins Bayview Medical Center’s medical intensive care unit.

After further tweaks, the system will debut on the West Coast at the University of California, San Francisco Medical Center, another partner in the Moore Foundation-sponsored project.

—Shannon Swiger and Barry Rascovar

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Read more about patient- and family centered care and the strategic plan online at hopkinsmedicine.org/strategic_plan/

To see a video on patient- and family-centered care at Johns Hopkins Medicine, visit http://bit.ly/1ayDW5k.

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