Friday, October 1, 2010

ICU Rounds Report - Oct 1st, 2010

October 1st, 2010

Big Changes Coming!
You may have overheard the residents talking about the new Accreditation Council for Graduate Medical Education (ACGME) work hours announced this week, which will dramatically change the way residents work in our ICUs (and floors!) next July, 2011. Nervous hospitals grappling with the dramatic changes are asking the deadline be extended until 2012, but that is unlikely because of fears within the ACGME that if they don't act now, the federal government (and OSHA in particular) might.

What's new? The changes are primarily focused on first year residents (interns), who will be able to work shifts of only 16 hours or less (down from 30). The 80-hour week, mandatory time off between shifts and 1 day off in 7 rules remains. Senior residents can continue to work longer overnight shifts, but they are now capped at 28 (rather than 30) hours. Finally, residents must work no more than 6 nights in a row after July.

Who's doing this and why? The ACGME, which is private, non-profit agency tasked with accrediting of residency programs makes these rules. While they are optional, residencies that don't comply lose accreditation and hence, government funding. Hospitals are paid over $100,000/yr per resident by Medicare, so it's essentially mandatory. Since 1989, the ACGME has been under increasing pressure from consumer advocacy groups, OSHA and CMS to reduce medical errors by improving resident working conditions. Much debate ensured over how to do this. Finally, in July 2003 the ACGME implemented the current work hour restrictions, based on a law enacted in New York state after a previously healthy 18 year old girl died under the care of sleep deprived intern caring for 40 patients at once. Unfortunately, since the implementation of the new work hour rules in 2003, research has not shown an affect on patient outcomes, positive or negative.

There is, however, a large body of evidence that shows sleep deprivation leads to more medical mistakes and harms residents in 4 ways: motor vehicle accidents, mental health, pregnancy (!?) and needle sticks. Critics of the new rules say that these largely unproven benefits are offset by increased errors due to more frequent hand-offs. There are also concerns that residents trained under the new rules will be inadequately prepared to enter practice, having not obtained the necessary hours of patient care to achieve competency.

In the midst of the on-going controversy,  Congress commissioned a study from the Institute of Medicine to evaluate the effects of long work hours. This report, published in 2008, stated essentially that residents were working dangerously long hours with too little supervision and called for a drastic overall of the resident education, including reduced work hours, protected time for naps during long shifts and heightened supervision, including 24 hour in-house attending coverage.   The new ACGME recommendations are derived partially from that report, with the notable absences of a nap requirement (though 'strategic napping' is encouraged) and specific supervision protocols. Whether these new hour requirements are sufficient to stop the calls for reform from external forces remains to be seen. What they will do to patient care and the quality of resident education are even bigger question marks. Either way, get ready for some big changes.

More history about the dead 18 year old and some interesting further reading here.

Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety. Resi- dent duty hours: enhancing sleep, supervi- sion, and safety. Washington, DC: National Academies Press, 2008.

Nasca TJ, Day SH, Amis ES Jr. The new recommendations on duty hours from the ACGME Task Force. N Engl J Med 2010; 363(2):e3 (Web only). (
Blum AB, Raiszadeh F, Shea S, et al. US public opinion regarding proposed limits on resident physician work hours. BioMed Central. ( 1741-7015/8/33.)

PT/OT for the Intubated Patient? When should we start PT/OT? Can it make a difference?  ICU patients are known to quickly decondition, lose lean muscle mass and have prolonged rehabilitation marked by significant functional impairment. In the first study of it kind, researchers randomized a mixed ICU group to daily PT/OT in intubated patients compared to usual care (starting PT/OT when the tube is out). Both groups received protocol driven mechanical ventilation, daily SBTs, sedation holidays and glycemic control.

How did it work? First of all, it appears to be safe. One serious adverse event, in almost 500 sessions, occurred - a brief desaturation to less than 80%. Other outcomes? Patients given early PT/OT were almost twice as likely to return to independent functional statues at discharge (59 vs 35%, p=0.02), had half the delirium (median duration 2 vs 4 days p=0.02) and spent less time on the ventilator (average 21 vs 24 days, p=0.05). Sweet!

This study is exciting, but not perfect. It wasn't (couldn't!) be blinded, which introduces bias. Next, only patients with independent functional status prior to admission were included in the trial. We don't know if patients with impaired pre-ICU functional status would benefit. Many of our patients come from that group, and they are clearly the highest risk for further losing function. Finally, overall these patients were less sick (average APACHE II scores were ~20 in both arms) than many of our patients.
Schweickert WD, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized controlled trial. Lancet 2009

From Danielle
Vasopressin and Sepsis. Vasopressin is an anti-diuretic hormone analog originally approved for use during diabetes insipidus. Since then it has been tested for use as a vasoconstrictor. Vasopressin has been shown to be beneficial during septic shock. It has been noted that a relative deficiency of vasopressin occurs during sepsis. In some prospective case-controlled studies, vasopressin was noted to increase systemic vascular resistance, mean arterial pressure, and urine output. Doses are usually 0.01-0.04units/minute IV.
Landry, et. al. 1997. "Vasopressin deficiency contributes to the vasodilation of septic shock." Circulation. 95(5):1122-5.
Tsuneyoshi I. 2001. "Hemodynamic and metabolic effects of low-dose vasopressin infusions in vasodilatory septic shock." Crit Care Med . 29(3):487-93.
Malay, et. al. 1999. "Low-dose vasopressin in the treatment of vasodilatory septic shock." J Trauma. 47(4):699-703.

Leave you wanting more? Old issues are online here.

Jordan Hackworth, M.D.
Fellow, Critical Care Medicine
Department of Anesthesiology
University of Virginia

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