Thank you very much, Eric and Dr. Morales, for such wonderful presentations. And today I'm not going to talk to you about the equation of motion or how to analyze waveforms, but I'm going to talk to you what you guys can do, members of the critical care team, to the success of the patient and patient-veterinary interactions. So I'm going to talk to you about the incorporation of the critical care team. I do not have any financial disclosures at this moment. Our learning objectives for today are going to be to identify members of the critical care team and their roles, understand how members of the critical care team contribute to the success of patient and ventilator interaction, and understand the importance of the value that members of the critical care team bring to lower mortality rates. Now I took the liberty to add some of my colleagues from Columbia, just so that we can put a face to the title. And also I'm going to be referencing a lot the ICU liberation bundle, because I think that it's very important and crucial to the overall success of the patient, and it also helps with patient-ventilator interactions. So let us get started. This is just a picture of Columbia's critical care team and the medical intensive care unit, composed of many members of the ICU team, such as nurses, nurse practitioners, physicians in training, social workers, et cetera. So where do these members of the critical care team work? Well, they work in an intensive care unit, which is a specialized hospital unit dedicated to the care of patients requiring life support, and those at extremely high risk for organ failure and death. And approximately 5.7 million individuals are admitted to an ICU in the United States each year. These are some of the members of the critical care team, which I will further discuss, but we have intensivists, APPs, and physicians in training, just to name a few. So let's start with the quarterback, right, the intensivist. And I'd like to know how many intensivists are in the house, so if you can raise your hand. How many intensivists? Okay. Wow. That's a big number of you. So the intensivist, a physician with specialized training in critical care medicine, is the leader of the team and has ultimate responsibility for medical decision-making. And an extensive body of literature demonstrates that the presence of an intensivist as team leader as opposed to a physician without specialty in critical care training is associated with lower mortality rates. Now what can the intensivists do to help with patient and patient-vendor interactions work? In the morning, as we do our morning bedside rounds, right, one of the things that we can do, and this brings me to the A element of the ICU liberation bundle, is to assess, prevent, and manage pain, right? That is crucial for a patient. Why is it so important to manage pain? Well, a lot of the times when we try to do our SATs and SBTs with these patients, they end up failing because we have a rapid shallow breathing index. The patients are very, like, hyperventilating, taking very slow tidal volumes. Now could it be because of pain-related or just a simple component of anxiety? Is there any pharmacological agents that, interventions that need to be in place? So as an intensivist, that is something that we can definitely pay close attention to and better manage pain. Okay, next one will be physicians in training. This includes medical students, interns, residents, fellows, and the presence of clinicians in training is positively associated with role clarity, as well as the frequency and quality of information exchanges among ICU team members. So how many physicians in training do we have in the house? All righty, that's great. So you guys serve as an extension to the intensivist, just like APPs do as well. So you can also carry out the plan of the intensivist and make sure that it gets carried away. Next, we have our critical care nurses, very, very important role, right? It's a highly skilled nurse who provides all aspects of care for a very ill patient. He or she has close contact with the patient and the family and can often uphold the patient's wishes. The critical care nurse becomes an important part of decision-making with the patient, the family, and the care team. And greater nursing education and expertise is associated with lower mortality among ICU patients. And I cannot emphasize how important nurses play a role in the ICU care team. They're one of the first ones that suction the patient as needed. They're the first ones that a really good nurse can identify patient-venomator like the synchrony. They can identify if a patient has a cough leak, things that will trigger a higher response from other people, such as physicians, respiratory therapies, et cetera. Now this brings me to the B element of the ICU liberation bundle, which is spontaneous awakening trials and spontaneous breathing trials, right? So our nurse plays a vital role in conjunction with the respiratory therapist to start sedation interruption so that we can awake these patients and start these breathing trials to get them extubated and hopefully out of the ICU. How many nurses do we have in the house? Any nurses? All right. We do have them. Well, thank you for everything you do. Next we have our respiratory care—oh, gee, that's a good-looking guy right there—until he takes off his mask. All right, so respiratory therapists typically oversee the provision of mechanical ventilation, which is the central supportive therapy for patients experiencing respiratory failure and among the most common ICU treatments. Although the provision of mechanical ventilation is collaborative by nature, respiratory therapists possess unique expertise and experience in how to operate the ventilator. And like pharmacists, their involvement in care is associated with lower mortality in the ICU. Being a therapist, it is very crucial, and we play an important role, kind of like for checks and balances. You guys have no idea how many times we get silly requests such as, let's say, a patient that has a partially compensated respiratory acidosis, and you'll have a physician coming to you, a resident, first year, second year, asking you to change the respiratory rate from 14 to 16 when the patient is breathing at a rate of 24. So things like that, you know, we kind of tell them and explain to them, listen, this patient is actually overbreathing the vent, so that would not be the best approach. But definitely they play a crucial and vital role in the ICU critical care team. And just like part of the big element of the ICU liberation bundle, we're the ones that start the spontaneous breathing trials and put them on pressure support so that we can extubate them. By the way, where are my respiratory therapists at? All right, back in there. Thank you. Thank you for coming, guys. Eric and Ivan, we're being outnumbered, so we got to do something about this. All right, next, we have our pharmacists. Where are the pharmacists in the house? So important. You guys play such a vital role. So clinical pharmacists provide unique expertise on drugs that are the cornerstone of ICU treatment. Drug administration and dosages can be highly influential on patient outcomes, and intensivist physicians might not possess all of this information at the ready. Data demonstrates that the presence of a clinical pharmacist in the ICU is associated with lower adverse drug events and improved patient outcomes. And this brings me to the C element of the ICU liberation bundle, which is choosing sedation, sedatives versus analgesics. And what better person to suggest and come up with a plan than our clinical pharmacists? So thank you guys for what you do. You guys do a lot as a clinical pharmacist, especially in Colombia. We always have them included in our morning rounds. And you guys have no idea, just like the checks and balances that I was talking about between respiratory therapists and the orders that we get from physicians, it's the same thing with pharmacists and physician orders in terms of medication management. Next, we have our APPs, Advanced Practice Providers, which is composed of physician assistants and NPs. Do we have any PAs and NPs in the house? Wow, that's a lot of you. Thank you for coming. So a caregiver trained in licensing clinical services, he or she works in the ICU under doctor's lead, and a study suggests that such advanced practice providers, when appropriately trained in acute care, can be highly effective in helping to deliver high quality medical critical care and can be important elements of team with multiple providers, including those with medical house staff. Now, just like APP, just like physicians in training, APPs serve as an extension to the intensivist as well. And some of the things that the APPs can do, and this brings me to the D element of the ICU liberation bundle, is to assess, prevent and manage delirium, which is very important for these patients, right? As I was alluding to before, when we try to put these patients on SATs and SBTs and we see them failing, is it because they have an anxiety component? Are there any pharmacological interventions that we need to provide as a bridge to extubation? Or is it pain related? So definitely managing delirium is very important. Next, we have our physical therapist. Do we have any physical therapists in house? All right, I see you back there. Physical therapist is a caregiver who helps restore a function of the body that involves the muscles, bones, tissues or nerves. And with this help, the patient can better move around in daily life activities. And I'm going to also quickly go to the occupational therapist. Do we have any occupational therapists? No occupational therapists, okay. Which is a caregiver who helps the patient relearn life skills. Examples of these skills include grooming, feeding, dressing and just as simple as balancing a checkbook. Now, PTOT is very important and this brings me to the E element of the ICU liberation bundle, which is early mobility, right? We know that this is very important for the patients to get them strong, to get them extubated, to get them out of the ICU. So thank you guys for what you do. And now next in the ICU critical care team, we have our registered dietitians and dietitians provide unique expertise for patients' nutritional needs and must account for the problem that feeding protocols are often contingent upon other therapies. For example, when and how patients are provided nutritional support is in part determined by whether they are placed on a ventilator, their level of alertness and their immune system functioning. Therefore, dietitians must collaborate with all members of the ICU team to ensure that patients receive adequate and timely nutritional support. So this is very important. We want our patients to be strong enough to be able to pass those SBTs, right? We want them to be strong enough to be able to do PT and OT. So registered dietitians play a very important role. Do we have any dietitians here? No dietitians, okay. Our next member in the critical care team is our clinical psychologist and when available and able to join the critical care team, clinical psychologists and other behavioral health care specialists play a unique role in that they specifically address patients' psychological recovery and they provide care for patients, families and critical care providers. Particularly noteworthy is that patients who receive care by a clinical psychologist have lower rates of anxiety, depression and post-traumatic stress following admission to the ICU. Any clinical psychologists? No clinical psychologists in the house. Okay. And this is more relating to the PICU, Child Life Specialists, which are experts in child development who works with ill children. And the Child Life Specialist provides place and distraction therapy. He or she often works with other experts in the Pediatric Intensive Care Unit or PICU to improve the health and well-being of very ill children. And next in line we have the chaplain. We also have to meet our patient's spiritual needs, which is a clergy member in the hospital who talks with patients, families and staff. The chaplain provides spiritual support and may help find a clergy member of the patient's faith to better meet the patient's spiritual needs. Often the chaplain plays an important role in end-of-life care. And last but not least, we have our family members, which brings me to the F element of the ICU Liberation Bundle, which is family engagement. And in the modern ICU, family members are increasingly considered to be part of the ICU team, especially when they take on the role of surrogate decision makers for loved ones who are too ill to advocate for themselves. The practice of family participation on medical rounds has received the most attention in this area, with data suggesting that while rounds are traditionally viewed as a forum for collaboration among the clinicians, they can also be used for collaboration with family members, including information exchanges and reducing decisional conflict. And I just want to briefly say that there are many members that play a vital role as well that didn't make it into the critical care team slide, but also your unit clerks, your SLPs, environmental services, and of course your volunteers, right, that come and play music for the patients, those volunteers that come with, not rescue dogs, but therapy dogs. That's increasingly important for these patients. So I want to thank you all for what you do for the patients. It's been a rough three years, but trust me that every little effort that you guys put individually, collectively, that's how we promote and contribute towards the success of patient and patient-veterinarian interaction. Thank you so much.

critical care team

patient care

pain management

delirium

family engagement