Highly trained providers treat the sickest of the sick in intensive care units (ICUs) using high-tech equipment. We’ve all seen the news stories about COVID-19 patients receiving treatment in ICUs. Of course, it’s not just COVID patients who need ICUs. Other very ill patients who are at high risk also receive care in the ICU. Although patients receive extraordinary care that saves lives, there are risks for patients in intensive care units due to the combination of high-risk patients and the complex, high-stress environment. What are the risks? What can you do?
Note that many ICU patients cannot speak up for themselves due to the seriousness of their condition. Additionally, many ICU patients breathe with the help of ventilators, making it impossible to speak. Therefore, many of the suggestions below are directed at family members.
However, if you expect to need ICU care after surgery, you can speak with your doctor and evaluate your hospital before your surgery date to learn how your hospital reduces the risk of harm for patients in intensive care.
Who needs intensive care?
According to the National Institutes of Health (NIH), “intensive care is appropriate for patients requiring or likely to require advanced respiratory support, patients requiring support of two or more organ systems, and patients with chronic impairment of one or more organ systems who also require support for an acute reversible failure of another organ”.
Why would a doctor admit a patient to an ICU?
In general, doctors should not admit patients to the ICU if the patients are either not ill enough to need ICU care or if there is no hope of recovering to an acceptable quality of life.
The NIH recommends doctors consider these factors when determining if a patient needs ICU care:
- Severity of illness.
- Coexisting disease.
- Physiological reserve.
- Availability of suitable treatment.
- Prior response to treatment.
- Recent cardiopulmonary arrest.
- Anticipated quality of life.
- The patient’s wishes.
Importantly, the NIH recommends that age by itself should not be a barrier to admission to intensive care. However, doctors should recognize that “increasing age is associated with diminishing physiological reserve and an increasing chance of serious coexisting disease”.
Additionally, patients’ wishes regarding levels of care should be respected. For example, if a patient has an advanced directive stating he/she does not want intensive care, doctors should not admit him/her to an ICU. See below for more information on advanced directives.
How many patients receive treatment in ICUs?
According to the Society of Critical Care Medicine, more than 5 million patients in the US are admitted each year to ICUs.
What types of care do ICU patients receive?
- Intensive or invasive monitoring.
- Support of airway, breathing, and/or circulation.
- Stabilization of acute or life-threatening medical issues.
- Comprehensive management of an injury and/or illness.
- Maximization of comfort for dying patients.
What are the risks for patients in intensive care units?
Although patients in ICUs generally receive extraordinary care, there are serious risks for patients in intensive care due to the severity of illness and the types of invasive care needed.
This post covers the following risks for patients in intensive care:
- Medication errors.
- Ventilator harm.
- Injuries and infections from central vein catheters.
- Immobility issues.
- Communication failures.
Next week’s post covers tips for choosing a hospital and for getting the type of care you want, as well as these risks for patients in intensive care:
- Diagnostic errors.
- Medical device alarm overload.
- Post-ICU syndrome.
Among the common risks for patients in intensive care is medication errors, often cited as the most common type of error within hospitals. Mistakes include patients getting the wrong drug, the wrong dosage, drug overdoses, and overlooked drug interactions and allergies.
Although medication errors occur throughout all sections of hospitals, medication errors are particularly pertinent in ICUs and other critical care settings. Unsurprisingly, ICU patients are vulnerable due to illness-related weakness, a reduced ability to metabolize drugs, and the high number of medications used. Interestingly, doctors prescribe twice as many medications for ICU patients as compared to non-ICU patients.
Additionally, the dosages of most medications given in the ICU are based on the patients’ weight, which requires mathematical calculations that are often based on estimated weights. Lastly, the combination of high-risk medications, varied routes of administration, and a busy, high-pressured environment, leads to an increased risk of errors.
How dangerous are medication errors?
Medication errors can lead to patient harm, including death. Researchers found that 19% of medication errors in the ICU are life-threatening and 42% are serious enough to require additional life-sustaining treatments.
How common are medication errors in ICUs?
According to a 2008 report, medication errors in critical care are frequent, serious, and predictable. For instance, researchers found that medication errors account for 78% of serious medical errors in the ICU.
Additionally, studies found that among adult ICU patients, the rate of medication errors ranges from 1.2 to 947 errors per 1,000 patient ICU days, with a median of 106 errors per 1,000 patient ICU days. For children in the ICU, researchers found reports of 100 – 400 prescribing errors per 1,000 patients.
Sadly, some experts state that nearly all critical care patients will experience a potentially life-threatening error at some point during their stay.
What can you do?
Minimizing the risk of medication errors in the ICU must involve the doctors, nurses, and administrators of the hospital. For instance, hospitals can adopt medication standardization processes, use computerized physician order entry systems (CPOE) and bar code technology.
If you are in the ICU, it is likely impossible for you to monitor the medications you receive. However, if your loved one is in the ICU, you can reduce the risk of medication errors by following the tips in my blog Medication Errors in Hospitals – How Can You Protect Yourself?
Research your hospital.
The hospital you choose can impact your level of risk. You can look up your hospital to see how well they score for medication safety programs on The Leapfrog Group’s website.
Ventilators, also called life-support machines, pump air into patients’ airways if they cannot breathe adequately on their own.
What kinds of harm can ventilators cause?
Firstly, you can develop an infection if bacteria enter the lung through the ventilator’s tubing. Importantly, these infections can lead to dangerous cases of pneumonia.
Additionally, a ventilator can also harm your lungs, either from too much pressure or too much oxygen. Ventilator-induced lung injury (VILI) can lead to multi-system organ dysfunction, and increase mortality.
What can you do?
There is little you can do to reduce your risk of these harms. However, before agreeing to a ventilator for yourself or a loved one, you should ask your doctors about the likelihood of having to stay on a ventilator indefinitely.
Injuries and infections from central vein catheters.
The use of central vein catheters (CVCs) is common for critically ill patients. These catheters, sometimes called “central lines”, are inserted into a large, central vein. Doctors use these catheters to administer medications, insert medical devices for complex procedures, and for treatments such as dialysis.
CVC’s are meant for temporary use, and complication rates increase when lines are left in too long. Importantly, there are many risks associated with the insertion and/or use of central vein catheters, including:
- Bacterial or fungal bloodstream infections.
Central vein stenosis.
Thrombosis – the formation of a blood clot in a vein, artery, or the heart.
Can the risks be reduced?
Clearly, it’s vital that the CVC is properly inserted following guidelines. Once the CVC is in place, nursing staff play a key role. Nurses must maintain, monitor, and use these catheters, making sure to look for signs of infections, bleeding, thrombosis, and other issues. Additionally, nurses must keep the site clean and sterile.
As a patient or family caregiver, you can help reduce the risk by:
- Regularly checking the CVC site and immediately reporting any concerns to staff.
- Regularly asking your medical team when/if they can remove the CVC.
In addition to infections associated with ventilators and central vein catheters, ICU patients can also develop other dangerous infections, including urinary tract infections, sepsis, and C. diff. Moreover, many ICU-acquired infections are caused by antibiotic-resistant bacteria, which make them difficult to treat.
Studies found the rate of hospital-acquired infections is 3-5 times higher for patients who receive more than 1 week of advanced life support in an ICU as compared to hospitalized patients who don’t need ICU care. In fact, hospital-acquired infections are one of the most common and serious complications of ICU care, often caused by invasive monitoring or life support therapies.
Moreover, infections, usually hospital-acquired, are the most common cause of death for patients who survive the early period after major trauma. Additionally, infections are the most identified cause of multiple-organ dysfunction syndrome.
What can hospitals do to prevent infections?
Fortunately, hospitals have programs to reduce the risk of infections. However, the widespread use of invasive devices puts patient at risk.
To prevent infections, hospitals should follow the CDC’s list of Standard Precautions that are the minimum infection prevention practices that apply to all patient care, in all patient settings, including ICUs. Unsurprisingly, some hospitals have better policies and procedures than others.
Additionally, some hospitals have started innovative infection control measures, including bathing and nasal cleansing, and regular toothbrushing.
What can you do?
To reduce the risk for yourself or a loved one, follow these recommendations:
- Regularly ask about the removal of invasive tubing and lines, including urinary and/or central vein catheters.
- Make sure everyone, medical staff, patients, and visitors all regularly wash their hands.
- If a doctor prescribes heartburn medications and/or antibiotics, ask if they are needed and appropriate.
For more detailed tips on reducing your risk of infection, read
- How to Protect Yourself from Hospital Infections.
- Why is Sepsis so Dangerous?
- How Do You Get C. Diff Infections?
Patients in the ICU rarely get out of bed. Moreover, those on ventilators may barely move at all. This prolonged immobility can lead to bedsores, which can lead to dangerous infections. Additionally, immobility can lead to dangerous, potentially life-threatening, blood clots. Lastly, muscles get weak from lack of use, making it harder to recover.
For more information on the impact of immobility and tips to reduce risk, read:
Effective communication among healthcare staff is critical for safe and highly reliable care of ICU patients. Information must be shared in a timely manner between doctors and nurses in the ICU and with other teams. Unsurprisingly, researchers found that communication problems were more likely to occur while patients are being transferred in or out of an ICU, and when ICU staff communicate with non-ICU staff.
Importantly, any breakdown in communications can lead to patient harm. In fact, one study found that 37% of all medical errors in ICUs are caused by poor communication between nurses and doctors.
What can hospitals do?
Fortunately, hospitals can implement policies that can improve communication, including checklists, training, and formal handover processes.
What can you do?
If your loved one is in the ICU, there are a few things you can do to reduce the risk of communication errors, including:
- If your loved one is in the hospital before a transfer to an ICU, ask the doctor to communicate with the ICU staff about your loved one’s condition and requirements before the transfer.
- Ask the ICU team how they reduce communication issues.
- Stay with your loved as much as you can and participate in conversations regarding his/her condition and treatment.
- Take detailed notes during every conversation with your loved one’s doctors. If you can’t be there in person, speak to the doctor on the phone and take notes. (Note – you might need a healthcare proxy form to speak with the doctor, but in my experience, many doctors will speak to immediate family members without a proxy form.) Share these notes, as needed, with every member of the team. Don’t assume every doctor or nurse is aware of what other staff members said.
- Speak up if something doesn’t seem right!
If you or a loved one are seriously ill, I recommend you read these posts:
- ICU Staffing Requirements.
- Is a DNR a Good Idea for You or a Loved One?
- Pros and Cons of Hospice Care.
- The Benefits of Palliative Care.