The Intensive Care Society 2010

Comment

Letters to the editor

Extend FAST HUG with FAITH
he mnemonic FAST HUG1 was proposed almost ve years ago by Jean-Louis Vincent as a way of assisting healthcare workers looking after critically ill patients. The mnemonic stands for: Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, Ulcer prophylaxis, and Glucose control. All the components are evidence-based and have been used the world over. Although there has not been a study of the concept of FAST HUG as a bundle for critical care, common sense would dictate that rigorously using a package of proven therapies can only enhance outcomes. However, while I embrace the concept, I have since noticed that on its own, it misses fundamental aspects of critical care, which are equally important. Often simple things like uid balance, investigation results, constipation, and other treatments are overlooked to the patients detriment. With the current medical training programme whereby sometimes very junior trainees review patients, or in very busy units, it is vital that a simple, comprehensive systematic approach to reviewing a critically ill patient is engendered. I propose a small extension to Vincents mnemonic to: FAST HUG FAITH. FAITH is a mnemonic for Fluid balance, Aperients, Investigation and results, Therapies, and Hydration.

including, dehydration, immobility, electrolyte abnormalities, neurological injuries, hypothyroidism, bowel pathology and opioid-based sedation. Aperients are commonly used to prevent or relieve constipation. Aperients fall into four groups; bulking agents (eg bre supplements); lubricants/stool softeners (eg microlax enema); gut stimulants (eg senna); and osmotic agents (eg lactulose). Constipation in critically ill patients is not a benign condition. Mostafa et al have shown that constipation can lead to failure to wean from mechanical ventilation and increase length of stay.7 One other important but yet not easily recognisable complication of constipation is abdominal pain.10-12 Judicious use of aperients may reduce the incidence of constipation and associated complications.

Investigations and results

The majority of admissions to intensive care are unplanned or emergencies. Consequently most of these critically ill patients will not have had full investigation of their primary condition prior to admission. It is incumbent upon intensivists to investigate such patients in order to institute correct management. Any tests or investigations ordered must have results reviewed and acted upon daily. Included is inspection of lines, catheters, insertion sites and wounds as potential sources of infection.13,14 A record of the duration of these lines and catheters should be kept and made easily available for daily review. The Institute of Health Improvement (IHI) in the USA in its central line bundle recommends a daily review of line necessity with prompt removal of unnecessary lines.15

Fluid balance
Fluid resuscitation is an essential component of management of critically ill patients. The amount of uid administered is dependent on the diagnosis and the patients response to it. Patients admitted with severe sepsis or septic shock require a much larger volume of uid than other conditions. Inevitably such patients rapidly develop a positive uid balance. Fluid balance has been shown to be an independent predictor of survival, especially in the rst three days of admission.2,3 These retrospective studies have shown that a negative uid balance is associated with better survival. This trend has, however, been conrmed by the SOAP study, which also found that positive uid balance was among the strongest prognostic factors for death.4 McNeils et al found that a positive uid balance in the rst 24 hours of admission was associated with the development of abdominal compartment syndrome.5 A positive uid balance in mechanically ventilated patients with ALI/ARDS has been shown to be associated with worse outcome.6 It is, therefore, an essential part of good critical care management that an accurate daily and cumulative uid balance is maintained and judiciously reviewed and an early negative (or neutral) uid balance be achieved when possible.

Therapies
A daily review of clinical progress is essential in order to assess the effectiveness of the therapies rendered. In the case of antibiotics a review of clinical progress as well as microbiological results should lead to de-escalating antibiotics.16 Severe sepsis and septic shock have high mortality and the early administration of an appropriate antibiotic is associated with improved outcome and reduced length of stay.17,18 The Surviving Sepsis Campaign guidelines (2008) recommend administration of an appropriate antibiotic within one hour of admission.14 It has been estimated that for every hour of delayed antibiotic therapy there is a mean decrease in survival of 7.6%.18 The management bundle of the Surviving Sepsis Campaign(SSC)14 recommends intensive insulin therapy, low dose corticosteroids, low tidal volume ventilation and activated protein C. It is of paramount importance that as the patient begins to recover that they should be commenced on their essential medications they were taking prior to current illness. There is a tendency for polypharmacy in critical care management. Drug interactions may occur. The intensivist should review the drug chart daily in order to scale down and rationalise the patients therapy.
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Aperients
The true incidence of constipation in critical care patients depends on the type of intensive care unit studied, but ranges from 5 to 83%.7-9 There are many causes of constipation
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Hydration
Assessment of the hydration status of critically ill patients is fraught with difculties. Often these patients are grossly oedematous but intravascularly uid depleted. In addition, some of these patients have cumulative positive uid balance. Diuretics may have been used prior to current illness leaving the patient overall uid depleted. Insensible uid loss is always difcult to estimate. This may increase with pyrexia to 2 to 2.5 mL/kg/day for every degree temperature rise above normal. Although both parenteral and enteral nutrition bags contain water, additional water may still be needed to compensate for excessive insensible loss, wound loss, diarrhoea, vomiting and diabetes insipidus. Hypernatraemia and uraemia are common signs of dehydration in the ICU patient. For the perioperative patient, the British Consensus Guidelines Group (GIFTASUP) have recently published guidelines on choice of intravenous uid to be administered.19 Addition of these ve components of critical care makes sense and a replete mnemonic FAST HUG FAITH enhances Vincents FAST HUG approach by encompassing a more comprehensive bedside review of everything happening with the critically ill patient. In addition to a sense of closeness to your patient (FAST HUG), adding FAITH brings another dimension of believing in the right things you are doing to get them back home. As is increasingly becoming obvious, it is not high technology medicine that is making the biggest positive impact on our patients, but remembering the simple, easy-todo things.

References
1. Vincent JL: Give your patient a fast hug (at least ) once a day. Crit Care Med 2005;33:1225-29. 2. Schuller D, Mitchell JP , Calandrino FS, Schuster DP. Fluid balance during pulmonary oedema. Is uid gain a marker or a cause of poor outcome? Chest 1991;100:1068-75. 3. Alsous F , Khamiees M, De Girolamo A et al. Negative uid balance predicts survival in patients with septic shock. A retrospective pilot study. Chest 2000;117:1749-54. 4. Vincent JL, Sakr Y, Sprung CL et al. Sepsis in European intensive care units: Results of the SOAP study. Clinical Investigations. Crit Care Med 2006;34:344-53. 5. McNeils, Marini C, Jurkiewicz A et al. Predictive factors associated with development of abdominal compartment syndrome in surgical intensive

care units. Arch Surg 2002;137:133-36. 6. Sakr Y, Vincent JL, Reinhart K, et al. High tidal volume and positive uid balance associated with worse outcome in outcome in acute lung injury. Chest 2005;128:3098-08. 7. Mostafa SM, Bhandari S, Ritchie G et al. Constipation and its implications in the critically ill patient. Br J Anaesth 2003,91:815-19. 8. Mostafa SM, Bhandari S, Ritchie G. Constipation and its implications in the critically ill: A national survey of United Kingdom intensive care units. Br J Anaesth 2001;87:343P . 9. Montejo JC, for the Nutritional and Metabolic Working Group of Intensive Care Medicine and Coronary Care Units. Enteral nutritionrelated gastrointestinal complications in critically ill patients; Multicentre study. Crit Care Med 1999;27:1447-53. 10. Cameron JC. Constipation related to narcotic therapy. A protocol for nurses and patients. Cancer Nurs 1992;15:372-77. 11. Held JL. Cancer care: preventing and treating constipation. Find out your role in managing this common symptom. Nursing 1995;25:26-27. 12. Manara L, Bianchetti A. The central and peripheral inuences of opioids on gastrointestinal propulsion. Ann Rev Pharmacol Toxicol 1985;25:249-73. 13. Burke JP. Infection control a problem for patient safety. NEJM 2003; 348:561-66. 14. OGrady NP , Alexander M, Dellinger P et al. Guidelines for the prevention of intravascular catheter-related infections. CDC MMWR Recomm Rep 2002;51:1-29. 15.Institute for Healthcare Improvement. Implementing the Central Line Bundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ Changes/ImplementtheCentralLineBundle.htm Accessed December 2009. 16. Dillinger RP , Levy MM, CarletJM, et al. Surviving Sepsis Campaign:International guidelines for management of severe sepsis and septic shock:2008. Intensive Care Med 2008;34:17-60. 17. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community acquired pneumonia:link between quality of care and resource utilisation. Arch Intern Med 2002;162:682-88. 18. Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34:1589-96. 19. Powell-Tuck J, Gosling P , Lobo D et al. Summary of the British Consensus Guidelines on Intravenous Fluid Therapy for Adult Surgical Patients (GIFTASUP)- for comment. JICS 2009;10:13-15.

Moses Chikungwa Consultant Anaesthetist/Intensivist,

Mid Staffordshire NHS Foundation Trust mchikungwa@yahoo.co.uk

An audit of compliance of critical care discharge summaries with NICE guidelines

or patients treated in critical care units, it is easy to assume that, having survived the acute illness, recovery will be quick and problem-free. Unfortunately, patients are often left with signicant long-term problems but it is widely accepted that these complications can be reduced with careful handover during discharge.1 Despite this, adequate follow-up is rare.2 In July 2007, NICE published Clinical Guideline 50: Acutely ill patients in hospital: recognition of and response to acute illness of adults in hospital, aiming to overcome these failings in communication and documentation.3 The guidelines advocate a formal structured handover of care...supported by a written plan to ensure continuity of care, including a summary of the critical care stay, plans for ongoing

treatment and any needs identied.3 On discharge from critical care, medication should be reviewed to ensure that all medication is still required and discontinued medication is reassessed to ensure optimal patient therapeutics.4 Physical weakness and long-term psychological distress are common complications of a prolonged admission but correct rehabilitation and follow-up is proven to reduce the impact of these problems.5 Proper and systematic summaries, therefore, must be completed to initiate correct follow-up and allow preventable problems to be pre-empted. An audit was performed in two tertiary and two district hospitals in Wales to assess the implementation of the guidelines. Data was collected from critical care discharge
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Discharge summary criteria

Case summary Diagnosis Treatment summary Ongoing therapy Nutritional plan Infection status Physical & rehab needs Psychological needs Language needs

0%

20%

40%

60%

80% Incomplete

100%

electronic format was clearly legible, easily accessible, wellorganised, expandable and gave guidance on completing each section. In comparison, the paper forms used by both UHW and YG had limited space and a more unstructured layout, providing little assistance for those completing the form. The documentation used in UHW and YG has been updated since the audit. This audit demonstrated the ability of a structured electronic discharge form to achieve consistent standards, which can improve patient safety. The full implementation of NICE Clinical Guideline 50 will ensure continuity of care and reduce patient complications.

Complete

Acknowledgement
The authors would like to thank their supervising tutor Dr. Brian Jenkins and Dr. Dave Hope for their help and support in completing this audit

Figure 1 Overall audit results.

summaries from 218 live adult discharges (average 55 per hospital) from critical care between 1st September and 30th November 2008. The results (Figure 1) demonstrate that discharge summaries have been widely implemented by the four hospitals. Though there were inconsistencies, the areas most relevant to ongoing patient care were collectively completed thoroughly, such as case summary (86%), ongoing treatment (82%) and nutritional plan (89%) but had room for improvement. Infection status (40%) and language needs (6%) were consistently poorly completed. Infection status is of particular concern as it suggests that current high prole campaigns, such as the Welsh 1,000 Lives Campaign, are not having the desired effect and may demonstrate a continued and needless risk to patient safety. The audit highlighted substantial disparities in form completion between the hospitals studied, with Singleton and Morriston Hospitals in the Abertawe Bro Morgannwg (ABM) University Health Board performing considerably better than both University Hospital of Wales (UHW) in the Cardiff and Vale University Health Board and Ysbyty Gwynedd Hospital (YG) in the Betsi Cadwaladr University Health Board. The authors believe the use of an electronic discharge summary in the ABM Trust contributed signicantly to this, as the

References
1. Metnitz P , Fieux F , Jordan B et al. Critically ill patients readmitted to intensive care units lessons to learn? Intensive Care Med 2003;29: 241-48. 2. Day V and the Department of Health Expert Group. Comprehensive Critical Care: a review of adult critical care services. 2000. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_4006585. Accessed Dec 2008. 3. National Institute for Health and Clinical Excellence. Clinical guideline 50: Acutely ill patients in hospital. Recognition of and response to acute illness in adults in hospital. NICE; London: July 2007. http://www.nice.org.uk/ nicemedia/pdf/CG50FullGuidance.pdf Accessed Oct 2008. 4. Campbell A, Bloomeld R, Noble D. An observational study of changes to long-term medication after admission to an intensive care unit. Anaesthesia 2006;61:1087-92. 5. Scragg P , Jones A, Fauvel N. Psychological problems following ICU treatment. Anaesthesia 2001;56:9-14.

Olivia Curtis, Denise Duignan, Sheena Durnin durnins@cardiff.ac.uk, William Kenyon, Rebecca Thomas, Katherine Trigg, Simon Trundle,
Medical Students, Cardiff University

Correspondence regarding: Iatrogenic anaemia in the critically ill, JICS 2009;10:279-81.

e read with interest Dr Astles survey on iatrogenic anaemia and frequency of blood testing in the intensive care unit (ICU).1 The NHS Next Stage Review2 focuses on quality at the heart of patient care in the National Health Service. The survey is a ne example of simple interventions improving quality of patient care. It reiterates that improving quality can reduce cost. In health, haematopoiesis replaces about 50 mL blood per day,3 but this is suppressed in the critically ill. Not surprisingly, almost 95% of the patients admitted to the ICU have a haemoglobin level below normal by day three.4 The factors inuencing sampling in the ICU are:5 The ease of access to arterial blood The work pattern prevalent within the unit

The belief that patients are critically ill enough to require regular investigations. The controllable variables to minimise iatrogenic anaemia in the ICU are: Reduction in sampling frequency (by education) Reduction in discarded volume. In previous research conducted in the UK, we have established the role of education in reducing unnecessary blood sampling.6 In addition, closed sampling systems, now available in the UK, have a signicant positive impact. Modifying blood sampling technique7 while using an open arterial sampling system is benecial. The survey correctly highlights that more experienced nursing staff take samples less frequently. It is important
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to avoid ritualistic practice, especially for more inexperienced staff. The intended benets are improvement in the quality of care increased patient safety reduction in workload cost saving. It is important that we continue to educate staff to achieve the above-mentioned benets.

4. Rodriguez RM, Corwin HL, Gettinger A et al. Nutritional deciencies and blunted erythropoietin response as causes of the anemia of critical illness. J Crit Care 2001;16:36-41. 5. Roberts D, Ostryzniuk P , Loewen E et al. Control of blood gas measurements in intensive care units. Lancet 337;1991:1580-82. 6. Hegde PS, Tarsey K, Blunt MC. Education reduces unnecessary diagnostic blood sampling in the intensive care unit. Crit Care 2003;7(Suppl 2):P241. 7. Hegde PS, Tarsey K, Blunt MC. A modication of the blood sampling technique in critical care to reduce blood wastage. Crit Care 2003;7 (Suppl 2):P240.

References
1. Astles, T. Iatrogenic anaemia in the critically ill: A survey of the frequency of blood testing in a teaching hospital intensive care unit. JICS 2009;10:279-81. 2. Darzi, A. The Next Stage Review. NHS, London 2009 http://www.dh.gov.uk/ en/publicationsandstatistics/publications/publicationspolicyandguidance/ DH_085825 Accessed November 2009. 3. Bhaskaran NC, Lawler PG. How much blood for a blood gas? Anaesthesia 1988;43:9:811-12.

Thejas Bhari Specialist Registrar, Alexandra Hospital, Redditch Prashant S Hegde Consultant in Anaesthesia and Intensive Care, Worcestershire Acute Hospitals NHS Trust prashant.hegde@worcsacute.nhs.uk

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