University in St. Louis. I'm joined today by my mentor, John Lin, Associate Professor of Pediatric Critical Care Medicine. In a time of the COVID-19 pandemic, pediatric critical care providers may be asked to care for adults. Today, we would like to discuss tips for the pediatric intensivist to promote ICU liberation while caring for adult patients. As we know from our experiences in the pediatric ICU, communication and collaboration of the interprofessional team remain key to that success of ICU liberation. With social distancing, PPE conservation, and other efforts to minimize the spread of SARS-CoV-2, this is especially true. To highlight this, let's review the ICU liberation bundle, which includes A, assess, prevent, and manage pain. B, both spontaneous awakening and breathing trials. C, ways of analgesia and sedation. D, delirium, assessment, prevention, and management. E, early mobility and exercise. F, family engagement and empowerment. To successfully implement these components, it takes a team. This figure from Ann Donovan's publication in Critical Care Medicine in 2018, Interprofessional Care and Teamwork in the ICU, highlights many of the stakeholders in the ICU interprofessional team. John, how do you engage the ICU interprofessional team to promote ICU liberation? Ashley, thanks for starting us off and asking this important question. One of the core components that facilitates interprofessional team collaboration is daily rounds. Having simultaneous presence of core ICU bedside team members, patients, and their families during daily ICU rounds sets up an environment where each profession is able to contribute to their maximum level of training and experience. Patients are able to provide a voice to their wishes and families are able to advocate for their loved ones. This daily collaborative process sets an example for ongoing impromptu discussions that work towards achieving and further refining patient care plans and goals for the day. And what are some of the barriers to ICU liberation caused by COVID-19? And how do you overcome these barriers? In SCCM's newest journal, Critical Care Explorations, we specifically address barriers for each of the ICU liberation bundle elements and offer strategies on how to overcome them. I would direct our audience to this publication for further details. But broadly, the barriers for each of the bundle elements have two similar themes. First, we have seen restrictions in patient and ICU team member interactions imposed by a combination of coronavirus disease pathology, need for increased personal protective equipment, and disruption of the interprofessional team structure. This in turn leads to the second barrier of decreased frequency of assessments and changes in the interactions among the ICU interprofessional team that does include the patient and their family. More specifically, daily bedside rounds and the daily workflow of each ICU team member have been greatly impacted. The need to allow for social distancing, changes to family visitation policies to mitigate the risk of in-hospital viral transmission, and changes to staffing who forced ICU teams to rely on virtual presence via web-based teleconferencing platforms. While this may at times allow greater participation on rounds from people whose other responsibilities kept them from physically attending rounds, current existing technology often degrades the quality of that interaction, either from technical difficulties or a lack of ability to interpret nonverbal communication. Additionally, the need for all team members to wear face masks at all times and various levels of PPE when entering patient rooms in order to protect ourselves, each other, and our patients further alters our ability to make the immediate and personal connections with other medical team members and our patients and their families. The empathetic smile, the positive verbal and nonverbal encouragement or reassurance, and the personal touch are hidden behind face masks, face shields, and isolation gowns. This change in daily interactions and communication has led to family members being separated from their loved ones facing foreign and frightening circumstances. It has left patients feeling isolated, and at times it has left medical providers feeling disconnected from our patients. Thanks, John, for that great overview of the barriers that we're dealing with with COVID-19. Next, we'd just like to think about how we transition the care for ICU liberation from children to adults. Theatrics, we often think of adults as big children. I'd suggest in many ways, this is true regarding younger adults. John, what are some of the tools for ICU liberation, and how do you suggest we use them in adults? So, Ashley, that's a great point. The key here is to not try to learn a completely different set of assessment tools for things like pain, sedation, and delirium. Trying to learn in short order during a crisis, new tools that are adult-based to assess pain, sedation, or delirium runs the risk of distracting from what all PICU team members already know works, namely repeated patient assessment, clear communication among all team members of patient goals and changes in clinical condition, and teamwork. It's also important to understand that many pediatric-specific scoring tools have significant similarities, and in some cases, have been derived from adult-based tools. For example, when assessing pain, the RFLAC tool allows the clinician to infer pain level in someone who isn't able to verbally communicate their level of pain. It uses similar physical cues to accomplish this, same as the adult-specific CPOT and BPS pain assessment scores. When assessing sedation in a critically ill child, the RAS has been validated in children as young as two months, just as it has in adults. For those units where a sedation assessment is done using the SVS rather than the RAS, we must keep in mind that both scores assign negative values to increasing depth of sedation, or positive numbers for increasing degrees of agitation. In both systems, zero represents an awake and calm patient. Both can be used to communicate the desired level of sedation in our patients, regardless of age. Similarly, when assessing for delirium, we are ultimately assessing for cognition, awareness, and ability to interact appropriately to visual or verbal cues. Routine use of an assessment tool that asks us to be aware of delirium risk, coupled with all of the work that has been demonstrated to reduce delirium risk is key. Use of the tool and discussions of its results, not the tool itself, is critical to ensuring delirium risk. Use of the tool and discussions of its results, not the tool itself, is what keeps the ICU interprofessional team working together to identify, prevent, and treat delirium. The PS and PCAM tools used in children were derived from the adult CAM ICU delirium screen and can be considered essentially equivalent. The CAPD has been validated in patients as old as 18 years old, which for screening purposes would be an adequate trigger for delirium assessment in adults of any age as well. Using a tool that allows identification of hyperactive, hypoactive, or mixed activity delirium, regardless of which specific tool, is the most important piece. For all of these three domains, staying with the assessment tool that is already established in your own PICU is pragmatic and will be the most successful at assessing those same domains in the adult patient. The biggest difference in ICU liberation in adults compared to kids rests in the approach to extubation readiness assessment. In adults, use of paired spontaneous awakening and spontaneous breeding trials works in someone who has the capacity for concrete and executive thinking. This approach has not been proven to be safe in young children or infants, and there are concerns of unplanned extubation or line dislodgement. Instead, the extubation readiness test, or ERT, coupled with a nurse-driven sedation titration algorithm that targets a set sedation level, have been proven to be safe, effective, and predictive of earlier and successful extubation. A similar multi-professional approach can be used in the adult patient in the PICU. Here are some of the specific considerations we must remember for older adults. As you consider how to best care for critically ill adults in your PICU, it's important to establish a relationship with your adult ICU colleagues to serve as a resource when faced with comorbidities and chronic medications commonly used in adults but not seen in children. This partnership should be established between pediatric and adult colleagues for each ICU profession, physician, nursing, respiratory therapy, and pharmacy. Rehabilitation specialists can work to identify pre-existing or newly identified needs for assistive devices, such as glasses or hearing aids, that optimize patient function and interaction. Psychosocial support team members, such as Child Life, Social Work, and Chaplaincy, can also serve as a resource to develop ways to mitigate your patient's social and physical separation from families and support systems. Lastly, particularly in older adults with pre-existing comorbidities, such as dementia, delirium risk is increased. To recap, as pediatric providers caring for adult patients during the COVID-19 pandemic, we must not forget the importance of ICU liberation. We recommend incorporating many of the strategies you use for pediatric patients into the care you provide for adults. And the special considerations to remember are that adults, especially older adults, are at higher risk for delirium. Monitoring delirium closely and modifying environmental risk factors early on in the admission is crucial. And we have to work together to overcome barriers of care put in place because of the unique situation related to the COVID-19 pandemic. And we have to rely on our interprofessional team to make this work. Finally, one specific barrier we must address in the COVID-19 pandemic is PPE conservation. In our own PICU, we have found success in asking frontline staff for ideas to balance PPE use while promoting ICU liberation. Through these discussions, many of the members of the interprofessional team have taken on roles of other professionals to overcome social distancing restrictions and minimize providers entering a patient's room. You may consider encouraging your own interprofessional team to brainstorm together how we can promote liberation while overcoming the unique infection prevention barriers of COVID-19. So Ashley, this has been a nice and very rapid review of ICU liberation and then the unique characteristics that pediatric specialists will need to encounter when helping out with taking care of critically ill adults. There are numerous resources available through the SCCM ICU liberation website. And the references of the papers which we used to pull some of this data are embedded in each of the slides that you can review at your own leisure. Thanks so much for your attention. And we really appreciate the opportunity to share our passion for a holistic approach to care of the critically ill patients, whether a child or adults.

pediatric critical care

ICU liberation

COVID-19 pandemic

communication

collaboration