Of all the seemingly pointless stuff done by junior members of the ICU medical workforce, nothing is more important than attention to the small unglamorous details in routine patient management. The person who charts the heparin and thereby prevents catastrophic thromboembolism has arguably done more to promote patient welfare than the person who replaced the knee or cannulated the aorta for bypass. As such, it is remarkable that the college has not turned their attention to these matters in a more formal fashion, eg. by asking Fellowship Exam questions about it. As with all such oversights, we can confidently expect a correction. Eventually some SAQ will ask trainees to "discuss the elements of routine supportive management in ICU" or "critically evaluate" those elements, or some such. In this event, this chapter will appear prescient. Until then, it will remain in the vastly overpopulated category of apocryphal exam-irrelevant content.
The definition of "routine elements of care"
Without any formal definition, one might produce something like "supportive and preventative care for a critically ill patient which is standard across the spectrum of presenting pathologies". Routine care in the ICU consists mainly of ensuring that the patient does not develop a complication of staying in the ICU, which is a hostile dangerous environment. As such, these routine elements are an important part of ICU quality assurance processes.
The FASTHUG concept
The origins of the FASTHUG mnemonic are attributed to JL Vincent, who published an article on this in 2005. It was basically a self-directed CME exercise (the article even begins with learning objectives) and was never intended to become canon. It was supposed to be a mental checklist, one which sounded sufficiently silly that the author himself appears to have been embarrassed of it ( "it does not need to be practiced out loud", he wrote). Four years later it caught on sufficiently that others picked it up and ran with it. Vincent and Hatton upgraded the mnemonic to FAST HUGS BID ( 2009) which included spontaneous breathing trial, bowel care, indwelling catheter removal and de-escalation of antibiotics. Chris Nickson from LITFL went on to expand it further to FAST HUGS IN BED Please, adding environmental control for delirium, a reminder to de-escalate therapies, and to finish with psychosocial support. ICN's Eamonn and Andy escalated the mnemonogeny to produce DANISH BUG FEST, which also adds skin care to the list. If one were possessed by the demons of one-upmanship, one might go one step further and take advantage of an online anagram generator to push the matter into truly absurd territory, as seen below.
|FASTHUG||FAST HUGS IN BED Please||DANISH BUG FEST||FAT STAPH FUNGI BADNESS|
Head up 30 degrees
Fluid therapy and feeding
Analgesia, antiemetics and ADT
Sedation and spontaneous breathing trial
Head up position (30 degrees) if intubated
Skin/ eye care and suctioning
Environment (e.g. temperature control, appropriate surroundings in delirium)
De-escalation (e.g. end of life issues, treatments no longer needed)
Psychosocial support (for patient, family and staff)
Head of bed 30 degrees
Feeding and Fluids
Environment (delirium avoidance)
Skin – pressure areas
T-piece (Spontaneous breathing trial)
Head up position
ADT (AAA) and other vaccines
Environment (appropriate surroundings in delirium)
Skin/ eye care
The comment thread below Nickson's article treats us to other pearls such as FAITH (Fluid balance, Aperients, Investigations and results, Therapies and Hydration), FAST HUG BABIES, FAVOURITE THUGS ( Feeding – Analgesia – Volume Status – OT/PT – Respiratory – Infection – Transfusion –
Embolic – Tubes/Drains – Heart – Ulcer – Glucose Control – Spine/Special/Statins ) and every permutation of the Latin alphabet. The Canadians have also added FASTHUG-MAIDENS to add some drug-related items. In summary, it is clear that the critical care community is fond of a structured approach to writing ward round notes.
Rationale for routine elements of care
On can make several arguments in support of protocols in general, and this protocol specifically:
- Protocols such as this mnemonic are inexpensive decision-making support instruments which limit the negative influence of human limitations ont he massive excess of information which needs to be processed and synthesised in ICU.
- Standardisation of an approach to routine care will lead to uniformity and therefore increased efficiency, which may be a time-saving measure
- Protocol-driven routine care decisions can be taken equally well by the junior members of medical staff, which empowers them (and shifts some of the workload from the seniors)
- Protocols for complicated routines are already a well-established part of practice in other fields which require attention to detail and which are intolerant of error, eg. the pre-flight checklists of pilots.
Rationale for specific elements in detail
Without degenerating into madness, one may safely focus on the original FAST HUG as the most basic version of this concept. Each component has some rationale behind it.
Feeding is obviously important. Critically ill patients will usually be unable to signal their hunger to you. To emphasise nutrition would not surprise anybody, and huge tracts of guideline shave been published to guide management of nutrition in the ICU. So as not to reinvent the wheel, it would suffice to say that it seems important to review the nutritional state of an ICU patient on a daily basis, even if to say "yep, we're still fasting them". This can be taken to an extreme, eg, in this article by Zepeda et al (2015) there's a whole dietary FASTHUG, dedicated to nutrition (where the T stands for "trace elements" for example). Huge complicated diagrams and decisionmaking pathways infest that article. It is unclear whether this level of complexity has any significant benefit, as compared to less structured approaches.
Analgesia requires daily re-assessment because of the complacent tendency to leave infusions running, and because a calm (comatose) patient is easier to look after from a nursing perspective. On the other hand, unrelieved pain in the ICU is (among other things) inhumane. Most ICU patients experience pain they later describe as "severe" (Puntillo, 1990) and this is something we should probably consider. The general rule (Jacobi et al, 2002) is to have an adequate minimum of pharmacologial analgesia, which should be multimodal and subject to daily adjustment.
Sedation is similar in that it may be required for a period, but needs to be thought about regularly to determine whether it is still required, or whether it would be appropriate the change the drugs. Epidemiologic studies demonstrate that inappropriate sedation in ICU is common, and is associated with significant healthcare costs (Devlin, 2008). The incidence was between 2.8% and 44% for over-sedation and between 2% and 31% for under-sedation (Jackson et al, 2009), obviously very variable because nobody seems to agree as to how they should measure sedation. When asked afterwards, ICU patients report having had a strong desire to be less awake (Ethier et al, 2011); being aware of their ICU stay is obviously fairly traumatic for them because up to 14% of them end up satisfying the old DSM-IV criteria for PTSD (Cuthbertson et al, 2004).
Thromboprophylaxis is something which could be rather embarrassing when forgotten about, particularly in an audience with a coroner. Depending on which massively bloated society guidelines you follow, either all or most ICU patients should have some combination of mechanical and pharmacological thromboprophylaxis. If no prophylaxis is indicated because of some specific reason, this reason should be documented on a daily basis purely from a medicolegal ass-covering perspective, as evidence that it was a reasoned decision rather than neglect.
Head up 30 degrees is an interesting matter to include in the FASTHUG mnemonic, as it has persisted in the evolving proliferation of FASHUGlike mnemonics in spite of the relatively low level of support for it. It dates back to studies from the early 1990s which associated supine posture with aspiration. For example, Torres et al (1992) were able to demonstrate that the supine patients aspirated about five times more technetium-labeled sulfur colloid into their bronchi than the semirecumbent ones. However, thus far this finding has not translated into any data supporting the commonly believed factoid that head elevation prevents VAP. Niël-Weise et al (2011) performed a meta analysis (of a whole three trials, 337 patients) and concluded that there was not enough evidence to recommend head-up position with a straight face, but that "experts prefer this position in ventilated patients". Others (eg. Mabasa et al, 2011) recognised the whim of experts as the wrong reason to routinely do anything, and have simply replaced the "H" in HUG with "hypoactive or hyperactive delirium" which does have some scientific foundation. This of course is all thrown out the window when the patienthas raised ICP, and is therefore in need of head elevation for ICP management reasons.
Ulcer prophylaxis is moaned about ("lifesaving pantoprazole", they complain) but is in fact vitally important, given the high rate of stress ulceration in critically ill patients. There is an entire chapter dedicated to this matter because it had come up recently in Question 10 from the first paper of 2018. Without repeating much of the material, it will suffice to say that PPIs are indicated in at-risk patient in ICU who are intolerant of enteral feeding, and who are otherwise at risk of gastrointestinal bleeding. This strategy probably does not affect mortality, and there is a lack of consensus about which agents are best (though right now PPIs appear to be the frontrunners).
Glucose control is something which in JL Vincent's 2005 paper would have meant "tight glycaemic control", a'la Greet Van De Berghe et al (2001). These days, since the NICE-SUGAR people have so thoroughly buried this practice, the "G" in the mnemonic persists as a reminder to pay attention to the BSL. A Brazilian study (Magnan et al, 2009) had been able to demonstrate an improvement in their relatively broad glycaemic control targets (i.e. fewer patients ended up hyperglycaemic). Hyperglycaemia in the ICU is a well-known source of badness which has attracted college examiner attention (eg. Question 23 from the first paper of 2005 and Question 7 from the first paper of 2002), therefore earning itself a whole dedicated chapter on glycaemic control. Without repeating that material, it will suuffice to summarise here that hyperglycaemia is associated with increased mortality, worsens prognosis in several groups of patients (trauma, severe head injury, subarachnoid haemorrhage, myocardial infarction, sepsis, stroke) and has well-recognised proinflammatory effects (and conversely insulin has some anti-inflammatory effects). Additionally, as a sugary mass of slow-moving syrup, the hyperglycaemic patient is famously susceptible to infection. In summary, hyperglycaemia = badness.
Arguments against "routine" protocols
After being confronted with pages upon pages of treatment algorithms and fifty-point daily ward round checklists, the pragmatic intensivist may respond with a paroxysm of vulgar profanity. With the use of mouth soap, one may render their counter-argument to the following main points:
- No protocol could encompass the entire spectrum of decisionmaking possibilities.
- Widespread acceptance of protocols and checklists may lead to the mindless application of such protocols in patients where it is plainly inappropriate, because junior staff are "empowered" to chart heparin and fluids for everybody
- Protocols and checklists are only as thorough as they are cumbersome, i.e. the increased workload in implementing the checklist is the tradeoff for standardisation and care uniformity, and thus the more standard and uniform your care the longer you spend filling out checklists. This seems counterproductive for an instrument which was designed to improve efficiency.
- Development of protocols risks the development of audit practices where adherence to the protocol is used as a performance indicator, i.e. something divorsed from patient care outcomes (eg. the use of adherence to Surviving Sepsis guidelines to determine the effectiveness of sepsis management)
- Of the individual FASTHUG components, few are well-supported by high level evidence
- The evidence in support for the protocol as a bundle is not very robust (see below).
- Among major problems with determining whether such checklists are valid or appropriate is the issue that there are no systematic comprehensive guidelines to the development of such checklists (Hales et al, 2007).
- It is a widely acknowledged fact that in the ICU there are many different ways to do something, and bundled measures which aim to reduce diversity in favour of increasing "efficiency" could result in the impoverishment of our practice by eradicating interesting or novel approaches.
Evidence to support protocolised supportive care algorithms
This practice is acceptable, i.e. ICU staff seem to tolerrate it fairly well. Cetofanti et al (2014) found that their ward round checklists were completed for 93% of the rounds, and the discussions which took place around this were viewed favourably by all (i.e. interprofessional communication and education was thought to have improved). This mixed methods study interviewed about 56 clinical staff to determine their opinions and reactions to the introduction of a daily goal checklist.
FASTHUG may decrease VAP rates. Papadimos et al (2008) found the introduction of FASTHUG produced a decrease from 19.3/1000 ventilator-days to 7.3/1000 ventilator-days. However, at the same time as introducing FASTHUG, these guys also got an intensivist-led team to look after their surgical ICU (which, presumably, was prior to this a lawless wasteland ruled by surgical warlords).
Care bundles in general are viewed as something positive by the critical care community (Horner et al, 2012), which is a tendency towarrds greater organisation and a decrease in the ineffficient variations in care (though it may lead us to embrace abominations such as the early Surviving Sepsis).
It needs to be mentioned in a concluding statement of some sort that though this is a widespread practice, none have looked at what effect it is having, assuming that it must be positive.