Dangers for ICU Patients

Highly trained doctors and nurses care for seriously ill patients in intensive care units (ICUs) using cutting edge equipment and techniques. Although patients generally receive high-quality care, ICUs can be dangerous for patients due to the combination of very sick patients, invasive treatments, and the high stress environment. What are the dangers for ICU patients? What can you do to reduce your risk for yourself or a loved one?

Unsurprisingly, if you find yourself in an ICU, you may be too ill too speak up for yourself. Or you may not be able to speak due to a ventilator. Therefore, many of the suggestions below are directed at family members.

However, you may have notice about an upcoming ICU visit. For instance, you may expect to need ICU care after surgery. In this case, you can speak with your doctor and evaluate your hospital before your surgery date to learn how your hospital reduces the risk of danger for ICU patients.

Dangers for ICU patients.

This post covers things to consider when choosing a hospital, how to get the type of care you want, as well as the following dangers for ICU patients:

• Diagnostic errors.
• Medical device alarm overload.
• Delirium.
• Post-ICU syndrome.

I encourage you to also read the first post in this series, where I provide information on ICUs in general, as well as information on the following dangers for ICU patients:

• Medication errors.
• Ventilator harm.
• Injuries and infections from central vein catheters.
• Infections.
• Immobility issues.
• Communication failures

Diagnostic errors.

Diagnostic errors include missed, incorrect or delayed diagnoses. Importantly, diagnostic errors are more common in ICUs than for non-ICU patients, posing a serious danger for ICU patients.

How common are diagnostic errors in ICU patients?

Researchers evaluated autopsy-confirmed diagnostic errors in adult ICU patients, and determined that misdiagnosis in ICU patients was up to 50% more common than for non-ICU hospitalized patients. Furthermore, in the US, 50% of hospital deaths take place in ICUs or immediately following ICU stays.

• First and foremost, if a diagnosis doesn’t make sense, speak up!
• Make sure the medical team has heard all your concerns. Don’t get frustrated and give up when telling your “story”.
• Don’t assume each doctor on the team is communicating with each other. Take careful notes and share the information as needed.
• Don’t be afraid to ask for a second, or even third opinion.
• If you notice signs of an infection, tell the doctors and nurses.

Medical device alarm overload.

Importantly, medical device alarms alert staff about a change in a patient’s health status that requires attention. However, despite the critical role of alarms, they also pose serious problems when either they create similar sounds, when no one changes their default settings, and/or when no one responds.

If you’ve spent any time in an ICU room, you know about the constant beeping of alarms on medical devices. Shockingly, one hospital reported an average of 1 million alarms going off in a single week!

Moreover, the alarms do not consistently indicate danger. In fact, research indicates that 85 – 99% of device alarms do not require clinical intervention. For instance, alarms can sound when the settings are incorrect, of if the sensors are placed incorrectly.

The overwhelming number of alarms, combined with the large number of false alerts, can lead to a desensitization to alarm sounds, a condition called “alarm fatigue”.

When this occurs, nurses may ignore important alerts. Moreover, to cope with the constant alarm noises, nurses may turn the volume down, turn the alarm off, or adjust the alarm thresholds beyond what is safe. All of these actions, and inactions, can have serious, often fatal, consequences.

Unfortunately, alarm issues are common. According to The Joint Commission, failure to respond to appropriate alarm signals in a timely manner occurs every day in many hospitals in the US.

What can hospitals do?

Hospitals can take steps to reduce alarm overload and false alarms, including:

• Establishing a process for safe alarm management and response.
• Identifying the default settings and appropriate limits for each device.
• Establishing use guidelines, including identifying when alarm signals are not clinically needed.
• Setting guidelines for tailoring alarm settings for individual patients.
• Adequately inspecting, checking, and maintaining devices with alarms.
• Properly training all team members.

What can you do?

Unfortunately, if you are an ICU patient, you are likely to sick to help address this issue.

However, if your loved one is in the ICU, you can minimize the danger of missed alarms by learning:

• What monitors are in use and why.
• What the different alarms sound like for each piece of equipment.
• Which alarms are urgent and demand immediate attention.

Then, if an urgent alarm sounds, you can seek help from the nurses on duty immediately – even if you must look in the hall or at the nurse’s station.

Delirium.

Delirium, a change in the brain that causes mental confusion and emotional disruption, makes it difficult to think, remember, sleep, pay attention, and more. And it is one of the common dangers for ICU patients. In fact, delirium is common in critically ill patients, occurring in up to 80% of the sickest ICU patients. Moreover, it is a significant contributor to detrimental health changes and death in ICUs.

For instance, patients with delirium have longer hospital stays and lower 6-month survival than patients without delirium. Additionally, delirium may cause cognitive impairments that last for months or years after hospital discharge.

For instance, studies suggest that 40 – 80% of patients who survive a critical illness have cognitive impairment a year after their hospital discharge. Unsurprisingly, cognitive impairment is more common among elderly patients as well as for those who experienced prolonged ICU delirium. However, it is also common in older and younger patients who stayed in either surgical or medical ICUs.

Why do ICU patients develop delirium?

In general, you’re more likely to develop if you’re 65+ years old and/or have multiple health conditions. And surgery, which leads to an ICU stay for many patients, increases the risk.

Additionally, many ICU patients face the following risk factors for delirium:

• Sleep deprivation.
• Use of certain medications, such as sedatives, blood pressure medications, sleeping pills, and pain relievers.
• Dehydration
• Poor nutrition
• Infections, such as urinary tract infections.

Assessing patients for delirium.

Experts recommend that hospitals monitor all ICU patients with a validated delirium assessment instrument, such as the Intensive Care Delirium Screening Checklist (ICDSC) or the Confusion Assessment Method for the ICU (CAM-ICU).

Importantly, research shows that delirium was detected 55% more often when testing was performed frequently, in comparison to one assessment performed in the morning.

Can the risk of delirium be reduced?

Experts believe that addressing the common delirium risk factors for ICU patients – including electrolyte abnormalities, infection, and exposure to sedative and analgesic medications – can help prevent delirium among ICU patients. However, this might be easier said than done. For instance, pain itself can increase the risk of delirium, but so can pain medications.

What can patients do?

If you think you may end up in the ICU, talk to your doctor before your admission to an ICU. Ask if you could receive medications that can cause delirium, and if so, can any of these medications be reduced, eliminated, or substituted. Additionally, ask what steps the hospital takes to reduce the incidence of delirium among ICU patients, including regular assessments.

What can family caregivers do?

If your loved one is in the ICU, watch for signs of delirium and report any concerns to a doctor as soon as possible. Additionally, as above, ask about the use of medications that may increase the risk of delirium. And ask what strategies can be used to reduce the risk for your loved one. Finally, ask the team to perform assessments at least once a day, although several times a day is preferred.

Post-ICU syndrome

One of the dangers for ICU patients actually occurs after patients leave the ICU. Post-ICU syndrome (PICS) is a collection of physical, mental, and emotional symptoms that can present, and linger, after a patient leaves the ICU. Unfortunately, these symptoms can last for weeks, months, or even years.

What causes PICS?

Many factors cause PICS, including the use of life-sustaining equipment, sedatives, and pain medications.

Who can develop post-intensive care syndrome (PICS)?

All patients can get PICS after an ICU stay. However, older patients are most likely to experience a decline in their physical and cognitive function after discharge from an ICU.

Additionally, family members who provide care and support to ICU survivors can develop similar mental and emotional symptoms of PICS, referred to as PICS-family (PICS-F).

What kinds of symptoms do patients get?

Patients with PICS may develop new or worsening issues, including:

Brain (cognitive) symptoms:

• Decreased memory, thinking problems.
• Difficulty talking.
• Forgetfulness.
• Poor concentration.
• Trouble organizing and problem solving.

Emotional symptoms:

• Post-traumatic stress disorder (including nightmares, unwanted memories).
• Anxiety.
• Depression.
• Decreased motivation.

Physical symptoms:

• Muscle weakness.
• Fatigue.
• Decreased mobility.
• Difficulty breathing.
• Insomnia.

What kinds of symptoms can family members develop?

PICS-F symptoms in caregivers may include:

• Anxiety and/or depression.
• Feeling overwhelmed.
• Stress.
• Post-traumatic stress disorder.
• Grief.
• Changes in sleep.

How can hospitals prevent and treat PICS?

Healthcare teams can use several approaches to prevent and treat PICS, including:

• Using light or minimal sedation.
• Providing the lowest dose needed to manage pain.
• Monitoring for and managing delirium.
• Getting the patient moving as soon as possible in the ICU and continuing with physical and occupational therapy after discharge.
• Recommending lung and/or cardiovascular rehabilitation, as needed.
• Treating depression, anxiety, and post-traumatic stress disorder using a combination of medications, psychological and behavioral therapies.
• Avoiding hypoglycemia (low blood sugar levels) and hypoxemia (low oxygen levels).
• Providing follow-up counseling with a psychologist or psychiatrist for patients with emotional symptoms.
• Advising the patient to get an adequate amount of sleep and to eat healthy.

What can you do?

If your loved one is in the ICU, Cleveland Clinic recommends you follow these suggestions, while in the ICU and subsequently at home, to keep your loved one “oriented” and active:

• Talk about the current date and time and familiar people, places, and current events.
• Bring in pictures or favorite items from home.
• Keep an ICU diary to help cope with anxiety, depression, and post-traumatic stress disorder.
• Read stories aloud at the bedside.
• Participate in activities such as card games or puzzles.
• Encourage sleep during the night and activity during the day.
• Ask the healthcare team to teach you how to help with exercise and bedside care.

Additionally, I recommend you actively engage with your loved one’s medical team, including the following:

• Participate in care discussions and decisions.
• Regularly ask the team if they can lower levels of pain medications and/or sedatives, while still providing comfort.
• Notify the team if you notice signs of delusion, depression, or anxiety.
• Speak up if you think the team is not adequately addressing the physical, cognitive, and/or emotional needs of your loved one.

And if you’re a caregiver experiencing signs of PICS-F, get support from your friends, family, and/or seek help from a mental health professional.

What can you do to reduce your risk from the dangers for ICU patients?

In addition to the tips I provided above on the dangers for ICU patients, and in the corresponding blog post, consider these items as well:

Choose the “right” hospital.

Just like anything else in life, not all hospitals are the same. For instance, some hospitals have more experienced doctors and nurses, better equipment, and better safety procedures in place. The hospital you choose can impact the quality of care you receive and your outcome.

In one study, researchers examined outcomes for over 22 million hospitalized patients to help them identify which hospitals had the best outcomes. Interestingly, the study found that patients at the worst US hospitals were over 2 times more likely to die and over 10 times more likely to have medical complications than if they visited one of the best hospitals.

Therefore, it’s worth your time to evaluate any hospitals you may use, before you are admitted, so you can make a wise choice about where to receive treatment.

If you live in a rural area and therefore don’t have access to a university-associated teaching hospital, you may want to travel for treatment, or even for a 2nd opinion. Similarly, if you have a rare or a life-threatening illness, it can be worth your time to travel to a hospital with experience and expertise in your condition.

How to evaluate hospitals?

You can evaluate hospitals using Leapfrog’s Hospital Safety Grade Ratings. You can learn if a hospital has specially trained doctors to care for ICU patients under the “Hospital, Nurses and Medical Staff” tab. Additionally, you can find information on a hospital’s ability to protect patients from preventable errors, accidents, injuries and infections.

For more information, read How to Choose a Hospital.

Get the level of care you want.

If you (or your loved one) have a serious medical condition, or are facing a serious surgery, it’s important for you to consider what kinds of treatments you would and would not like. For instance, you can indicate that you don’t want care in the ICU, you don’t want to be put on a ventilator, or you don’t want to be kept alive with machinery.

Importantly, there are 4 types of documents you can use for this purpose:

• DNR (do not resuscitate order) – this order specifically covers CPR.
• PLOST – a one-page form with your desires outlined.
• Advanced directive (or living will) – a document that contains your desires regarding your values and desires related to end-of-life care if you are incapacitated and unable to speak for yourself.
• Durable power of attorney – a legal document in which you name a healthcare proxy who can make medical decisions for you if you are unable.

Below is a summary of the differences in these 4 documents. However, because this is such an important topic, I encourage you to read How to Get the Medical Care You Want for more detailed information.

Learn More…

If you or a loved one are seriously ill, I recommend you also read these posts:

• Risks for Intensive Care Unit Patients.
• Is a DNR a Good Idea for You or a Loved One?
• Pros and Cons of Hospice Care.
• The Benefits of Palliative Care.