Nursing specific materials regarding IAH and ACS
Overview
Despite some of the early literature that focused on abdominal compartment syndrome and heroic interventions such as bedside decompression to "save" a dying patient, institutions that truly understand IAH/ACS recognize that impacting outcomes primarily requires careful diligent nursing care. The best way to improve outcomes is not to treat endstage ischemic organs that are already failing (i.e. ACS), but instead to prevent ACS by intervening early for IAH. However, treating IAH requires recognition in the early phase of the syndrome so that bedside care can be provided. This is clearly the realm of the patient's nurse. They are at the bedside, they recognize subtle changes and suspect something is changing and they should be empowered to measure IAP and to begin therapy within their scope of practice without the need to contact a physician so some of these simple ideas. This section will review some of the data relating to nursing empowerment. It will review how nursing empowerment it is resource effective and when applied to an entire ICU population results in better outcomes for patients and earlier discharge from the ICU - in effect saving money.
Empowering Nurses to Measure IAP in patients with suspicion for IAH/ACS does not result in over-utilization of resources.
Some "traditional" institutions still require a physician order for everything including something as simple as measuring IAP. This requires either a pre-signed standing order (good idea) for every patient admitted to the ICU who fits criteria, or a phone call to the physician (bad idea) to allow IAP monitoring. The justification often stated for the later approach is that nurses will inappropriately measure IAP in patients who do not need such monitoring and this will over-utilize resources. This is patently false:
First of all, in reviewing large multicenter epidemiology trials it is apparent that 30% to 60% of patients suffer from IAH, with a substantial number of them developing ACS and organ failure (click here for link to that epidemiology data). Therefor, institutions that infrequently measure IAP are clearly missing this syndrome and under diagnosing the problem. Classic examples would be a septic shock patient or a severe pancreatitis patient who develops organs dysfunction. Since most of these patients will develop ACS that is unrecognized if not measured, failure to measure IAP and failure to recognize it will likely have a higher impact resource utilization than occasionally measuring the pressure in patient who ends up not developing IAH.
Secondly, nursing researchers have documented very high incidence of IAH/ACS in institutions that have empowered nursing staff to selectively measure IAP. The University of Utah implemented nursing ability to selectively measure IAP in 2004. They initially measured intra-abdominal pressure in about 9% of cases and with experience over time have increased monitoring to about 15% of patients (still far less than the predicted incidence of this syndrome, but certainly not wasteful in terms of over monitoring). At the World Congress on IAH/ACS in August 2011 this institution presented data noting that utilization of WSACS assessment protocols (click for link) for monitoring combined with clinician (nursing or MD) judgment they found that 74% of all monitored patients developed IAH or ACS.[1] St. Joseph's Mercy Hospital in Ann Arbor Michigan reviewed their IAP monitoring data for 2009 and 2010. They found that 12% of admitted ICU patients fulfilled the WSACS criteria for IAP monitoring and that those patients had an 86% to 90% probability of suffering from IAH/ACS.[2] The speakers conclusions were that if a patient has 2 or more risk factors for IAH, they basically had the syndrome and that they needed to be more aggressive in detecting and measuring IAP. Most of the cases with IAH were their severe sepsis patients - the typical case was "sick and septic." Finally by standardizing a protocol for monitoring and empowering nurses to measure IAP without a phone call to the doctor they have driven compliance with IAH monitoring from 48% to 68% and continue to strive for more optimal IAP monitoring. Virginia Commonwealth University in Richmond also reported on their results following introduction of a nursing empowered IAP monitoring protocol that included standing fluid management orders in a burn unit. They found that by introducing this protocol, ACS occurrence decreased from 40% to 0%.[3] Their conclusions - "judicious use of fluids and the empowerment of ICU nurses to titrate resuscitation in patients with severe burn results in a reduction in the rate of secondary ACS."
Thirdly, numerous institutions that have protocol driven IAH monitoring (nursing empowered) combined with bedside medical therapy (most which is nursing driven) and surgical intervention only as a last resort have demonstrated better survival at lower cost. [click here for section on bedside medical interventions] [Click here for an article on the topic] These institutions utilized commercially available monitoring devices to enhance ease of use and nursing compliance - spending only $10k to $20k total per year on the devices, but reporting savings in the hundreds of thousands to millions of dollars per year in reduced surgery, surgical complications and ICU resource utilization.[4-8] [click here for section on outcomes and cost savings].
Lessons on implementing a Nurse Driven IAH monitoring protocol
Note - please contact us with any additional suggestions. This is a work in progress and insightful suggestions and ideas are welcome.
Implementing a nursing driven IAH/ACS protocol is not easy. It will require motivation and work on the part of the concept champion and it will require participation of numerous players. These are a few ideas that may help:
1. Educate yourself
Educate yourself as much as possible regarding IAH and ACS. This will allow you to respond with insight and data to anyone who doubts the importance of this syndrome in the practice of critical care. This web site is designed to assist greatly with that task and provides numerous independent links. The AACN also has a written protocol that has been updated in 2010 so it fairly up to date.
2. Create an educational presentation (use slides from this site and others) as a teaching tool. Supplement it with cases from your own ICU to provide that direct human link.
3. Become the concept champion, find individual shift champions
No change in medicine comes easily. You will need to drive this through persistence. This will include finding like minded individuals to support you on shifts that you do not normally work and to assist in any meeting you might not be able to attend.
4. Get buy in from the clinical nurse specialist / educator and the nursing director
You will need their help and support. Teach them, show them the data on outcome and resource utilization as well as the protocols that show how m any items are nursing driven so they realize this is a nursing and doctor "disease" and care won't advance without everyone participating.
5. Find physician champions
You know your doctors. Find the most progressive, open minded clinicians. Begin the discussion, provide them with some of the literature, links to educational resources, etc. Provide them with clinical cases you have seen that were or probably were IAH/ACS cases to put a face and human aspect to the concept
6. Create a check list of risk factors and criteria for beginning IAP monitoring. This can be tossed in the trash after use, but gives the staff a standard check list. Use the WSACS risk criteria to make this list (and read above to see how reliable this is for screening)
7. Create a standing order set
Make a set of order specifically requesting all newly admitted patients and all newly decompensated patients be screened for IAH risk factors. Use your own criteria or perhaps better and more defendable in terms of evidence based use the internationally developed screening criteria (click here for that document).
Create an order set that allows nursing intervention at the bedside based on the measured IAP. For example what to do at levels of 12-15, 16-20 and > 20 mm Hg. (Click here for international protocol that is not an order set). Most of the interventions are bedside and many do not require physician involvement so allowing automatic, standardized nursing involvement makes sense. More specifically an order set could contain many of the non-italicized items from below:
For any pressures over 12 Hg: All patients need pain control and sedation reassessed; proning needs to be avoided; bed position should be evaluated and optimized to lowest IAP by lowering legs, unflexing hips to expand the abdomen; any constrictive abdominal bandages need to be removed; Fluid requirements must be very closely evaluated used goal directed hemodynamic monitoring and recognizing the impact of IAP on those parameters; Avoid reflex fluid boluses, concentrate all drips; Consider NGT and rectal tube decompression; Consider enemas; Consider bowel prokinetic agents such as IV erythromycin and metoclopramide
For any pressure over 15 mm Hg: Implement all the above suggestions that are appropriate; slow enteral nutrition to trophic levels; Consider colloid infusion followed by a diuretic; Consider hemofiltration to remove excess fluid and cytokines if tolerable; Order an ultrasound of the abdomen to determine if free fluid is present; If free fluid is present contact the physician to perform paracentesis to remove that fluid; If a known mass is present such as an abscess or hematoma consider CT or US guided drainage.
For any pressure over 20 mm Hg: Implement all the above suggestions that are appropirate; Contact the physician if this has not already been done to assist with implementation of the physician level interventions above; Implement neuromuscular blockage bolus plus drip to relax entire thoracoabdominal cavity; stop enteral nutrition; Consider colonoscopic decompression if large colon obstruction is present; contact surgeon so they can plan intervention if pressure continues to rise over 25 mm Hg.
These orders should be part of the routine orders on every single admitted patient. This allows early screening and early intervention. Failure to standardize these and require nurses to call in advance of monitoring simply leads to a very high failure to implement.
8. Address any concerns that the other players might find
Example - concern of CAUTI and conflict with Foley management protocols. This is discussed in another section of this web site (click here for CAUTI and IAP discussion). There is little or no risk of CAUTI when IAP monitoring is implemented using aseptic technique, however infection control might come shut you down at the last minute. Get this out in the open early, address the issue and close this concern sooner than later. If you glance at the slide presentation below you will become aware of one known case where the goal of removing the Foley to reduce CAUTI resulted in delayed recognition of ACS and a patient death. Many more such cases exist due to a failure to balance risk and benefit to patients.
9. Educate all the staff and the doctors once buy in with the main players is achieved and an order set exists
10. Train everyone on how to monitor IAP
11. Set a start date, get those orders signed and start measuring and intervening
12. Gather clinical cases where IAP monitoring appeared to allow earlier recognition and explanation of a patients problem, how it helped in the patient care, etc and present these cases monthly to maintain momentum.
13. Review admissions for criteria to monitor, determine compliance and implement methods to educate and enhance compliance.
14. Stick with it - something will come up and cause difficulty, but work through those issues and move forward.
Teaching Materials
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Development and Implementation of a Nurse Driven Protocol for patients at risk of Intra-abdominal hypertension" - By RoseMary Lee, Clinical Nurse Specialist Homestead Hospital Florida (4.5 MB) |
References
1. Pearson, E.G., G.K. Baraghoshi, and E.J. Kimball, The identification of at risk patients in the implementation of protocolized management for intra-abdominal hypertension and abdominal compartment syndrome. Am Surg, 2011. 77(7): p. S113.
2. Posa, P., et al., Nurse-drive protocol for early detection and monitoring of intra-abdominal hypertension. Am Surg, 2011. 77(7): p. S103.
3. Whelan, J.F., et al., Nursing empowerment is an important part of a burn resuscitation protocol, resulting in decreased fluid creep. Am Surg, 2011. 77(7): p. S102
4. Cheatham, M.L. and K. Safcsak,
Is the evolving management of
intra-abdominal hypertension and abdominal compartment syndrome
improving survival? Crit Care Med, 2010.
38(2): p. 402-7.
8. Cheatham, M., K. Safcsak, and M. Sugrue, Long-term implications of Intra-abdominal hypertension and abdominal compartment syndrome: Physical, Mental and financial. Am Surg, 2011. 77(7): p. S78-S82.