webinar series before & after slides

Copyright © 2013 American Association of Critical-Care Nurses

Anita Greenberg MA.Ed Instructional Specialist

Information Design Samples


Product: Clinical Topics Webinar Series

Company: American Association of

Critical-Care Nurses (AACN)

Monthly webinar presentation by renowned clinical specialist highlighting new evidence-based practices on clinical “hot” topic.


Selected Slide Samples: Information Design

Before & After


ECMO’s Expansion: Number of Centers and Cases

ECLS Registry Report

International Summary

Extracorporeal Life Support Organization2800 Plymouth Road

Building 300, Room 303Ann Arbor, MI 48109January, 2013

Overall Outcomes

Centers

Survived ECLSTotal Patients Survived to DC or Transfer

Neonatal

26,205Respiratory 22,145 85% 19,559 75%

4,987Cardiac 3,058 61% 2,010 40%

851ECPR 540 63% 331 39%

Pediatric

5,656Respiratory 3,692 65% 3,183 56%

6,225Cardiac 4,034 65% 3,054 49%

1,745ECPR 948 54% 708 41%

Adult

3,761Respiratory 2,400 64% 2,084 55%

2,884Cardiac 1,581 55% 1,132 39%

876ECPR 325 37% 241 28%

38,723 32,30253,190Total 73% 61%

Centers by Year

0

50

100

150

200

250

0

500

1000

1500

2000

2500

3000

3500

4000

Count 83 86 98 111 111 112 115 112 115 111 114 113 117 115 117 126 129 131 141 151 163 179 200

Cases 1644 1775 1933 1909 1879 1876 1868 1743 1720 1722 1857 1853 1905 1966 1907 2172 2335 2543 2733 3121 3111 3568 3545

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Page 1 of 26

Author’s Slide


ECMO’s Dramatic Expansion: 1990-2012

2004: Greatest Expansion

New equipment design

Indications for Adult Respiratory Failure

Centers 241%

Cases 219%

1990 2012

Redesigned Slide

Sedation-Agitation Scale (SAS)

Riker RR, et al. Crit Care Med. 1999;27:1325-1329. Brandl K, et al. Pharmacotherapy. 2001;21:431-436.

Score State Behaviors

7 Dangerous

Agitation

Pulling at ET tube, climbing over bedrail, striking at

staff, thrashing side-to-side

6 Very Agitated Does not calm despite frequent verbal reminding,

requires physical restraints

5 Agitated Anxious or mildly agitated, attempting to sit up, calms

down to verbal instructions

4 Calm and

Cooperative Calm, awakens easily, follows commands

3 Sedated Difficult to arouse, awakens to verbal stimuli or gentle

shaking but drifts off

2 Very Sedated Arouses to physical stimuli but does not communicate

or follow commands

1 Unarousable Minimal or no response to noxious stimuli, does not

communicate or follow commands

Author’s Slide

Sedation-Agitation Scale (SAS)

Riker RR, et al. Crit Care Med. 1999;27:1325-1329. Brandl K, et al. Pharmacotherapy. 2001;21:431-436.

4

5

6

7

1

2

3

Levels of Sedation

Levels of Agitation

Calm and Cooperative

Determine score by descriptors

Redesigned Slide


Daily electrode change pilot: July 2011

MPC4 and CCU

MPCU

Baseline

MPCU

Daily

Electrode

Change

%

change

CCU

Baseline

CCU

Daily

Electrode

Change

% change

Average Alarms/Bed/Day 183 97 47% ↓ 195 106 46% ↓

Average Alarms/Bed/Day

Crisis Alarms

6.4 6 6% ↓ 3 3 0%


Warning Alarms

49 26 47% ↓ 18 10 44% ↓


Advisory Alarms

113 54 52% ↓ 162 87 46% ↓


System Warning Technical

Alarms

15 10 34% ↓ 11 6 45% ↓

Author’s Slide


Daily Electrode Change Pilot Average Alarms/Bed/Day

0

50

100

195

47% 46%

183

MPCU

CCU

After

Before

97

106

Redesigned Slide


Analgosedation • Analgesic first (A-1), supplement with sedative

• Analgesia Sedation vs. Hypnotic Sedation

Strom Study Results:

• Patients receiving analgosedation had

– More days without ventilation (13.8 vs 9.6 days, P = 0.02)

– Shorter stay in ICU (HR 1.86, P = 0.03)

– Shorter stay in hospital (HR 3.57, P = 0.004)

– More agitated delirium (N = 11, 20% vs N = 4, 7%, P = 0.04)

• No differences found in

– Accidental extubations

– Need for CT or MRI

– Ventilator-associated

pneumonia

Strøm T, et al. Lancet. 2010;375:475-480.

Author’s Slide


Analgosedation Study: Analgesia Sedation vs Hypnotic Sedation

Strøm T, et al. Lancet. 2010;375:475-480.

Patients Receiving Analgosedation

Ventilator-free

ICU LOS

Hospital LOS

Agitated Delirium

4.2 days

13%

No difference: Accidental extubations, need for CT or MRI, VAP

86% chance

257% chance

Redesigned Slide

Target Level Sedation: Nursing-Implemented

2.3

5.7

14

4.8

7.5

20

0

5

10

15

20

25

Duration of MV ICU LOS Hospital LOS

Me

dia

n T

ime

(d

ays

)

Protocol n = 162

Routine n = 159

Significant patient characteristics/metrics/outcomes

Protocol Routine P value

CIVS† 66 (40) 66 (42) 0.9

Duration CIVS, hrs* 3.5 ± 4 5.6 ± 6.4 0.003

Bolus† 118 (72) 127 (80) 0.14

Reintubated† 14 (8.6) 21 (13) 0.2

Trached† 10 (6.2) 21 (13.2) 0.04

*Data presented in median; †Data presented as n (%)

CIVS: continuous intravenous infusion sedation

P = 0.13

P < 0.001

P = 0.003

Brook AD, et al. Crit Care Med. 1999;27(12):2609-2615.

Single center, prospective, trial of 332 consecutive ICU patients requiring mechanical ventilation randomized to protocolized sedation (n = 162) or routine care (n = 159) at Barnes Jewish Hospital from 8/97 to 7/98. Protocol used goal orientated sedation to target Ramsey with bolus requirements before initiation of continuous infusion and uptitration of opioids and benzodiazepines.

Original Slide


Effect of Nursing-Implemented Target-Level Sedation on Duration of Mechanical Ventilation (MV)

Median Time (Days)

14

5.7

2.3

20

7.5

4.8

0 5 10 15 20 25

Brook AD, et al. Crit Care Med. 1999;27(12):2609-2615.

Duration of MV

ICU LOS

Hospital LOS

Routine (n=159)

Protocol (n=162)

Redesigned Slide

Critical Care Pain Observation Tool

Gélinas C, et al. Am J Crit Care. 2006;15:420-427.

Original Slide


Facial Expression

Body Movements

Muscle Tension

4 Main Categories: Rate Each Category:

0 1 2

Low High

Critical-Care Pain Observation Tool (CPOT)

Compliance with

Ventilator OR Vocalization

Score Range: 0 (little/no pain) to 8 (severe pain)

Payen JF, et al. Crit Care Med. 2001;29:2258-2263.

Redesigned Slide

Impact on Delirium (from MENDS trial)

Pandharipande PP, et al. JAMA 2007; 298(22) 2644-2653.

• Double-blind RCT of dex (0.15 – 1.5 mcg/kg/hr) vs lorazepam (1-10 mg/hr)

• Titrated to sedation goal (using RASS) established by ICU team

• Dexmedetomidine resulted in more time spent within sedation goals than lorazepam (P =

0.04)Differences in 28-day mortality and delirium-free days were not significant

Original Slide


30

40

50

60

70

80

90

1 2 3 4 5 6

Impact of Dexmedetomidine vs Benzodiazepines on Delirium (MENDS Trial)

Dexmedetomidine:

70% less chance of delirium on any given day

More time spent within sedation goals

Percent of Patients Delirious

Day

Lorazepam Dexmedetomidine

Pandharipande PP, et al. JAMA. 2007;298(22):2644-2653.

Pandharipande PP, et al. Crit Care. 2010;14:R38.

Redesigned Slide


Thank You.

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