1. Introduction
Patients with severe trauma require intensive care unit (ICU) treatment for various complex injuries. However, the intricate nature of the treatment process in trauma care creates an environment prone to medical errors, often referred to as a "perfect storm." Such errors can arise from various factors, including unstable vital signs, incomplete patient histories, and insufficient information. In addition, trauma surgeons face the challenge of making time-critical decisions while simultaneously managing complex teams and collaborating with many disciplines [
1]. When managing severely injured patients, trauma surgeons usually play a dual role as both surgical specialists and critical care providers, taking charge of all treatment processes. Therefore, trauma surgeons need to possess the necessary qualifications and capabilities in surgical critical care to manage their patients in the ICU. Moreover, ensuring a seamless continuity of management within the same quality of surgical service contributes to improved outcomes [
2]. Furthermore, it is crucial for trauma surgeons to minimize medical errors and provide high-quality critical care, in addition to performing resuscitation in the trauma bay and conducting surgical procedures in the operating room.
Many studies have underscored the significance of appropriate physician staffing and the use of protocols, clinical practice guidelines, and checklists to improve clinical outcomes in modern ICUs [
3,
4,
5]. In particular, some studies showed that the implementation of checklists for organized critical care in ICUs led to improved patients' outcomes [
6,
7]. In our trauma ICU (TICU), we recently adopted the Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed Elevation, Ulcer Prophylaxis, Glycemic Control, Spontaneous Breathing Trial, Bowel Regimen, Indwelling Catheter Removal, and De-escalation of antibiotics (FAST HUGS BID) checklist, which is easily remembered by simple mnemonics. This checklist was initially introduced as "FAST HUG" by Vincent in 2005 and later updated to "FAST HUGS BID" by Vincent III and Hatton in 2009 [
8,
9]. The FAST HUGS BID is a multidisciplinary protocol and checklist that includes essential and evolving components of evidence-based critical care.
In this study, we hypothesized that the implementation of the FAST HUGS BID checklist in the TICU could reduce in-hospital mortality and length of stay (LOS) in the ICU and hospital. Accordingly, we compared clinical outcomes before and after the implementation of the FAST HUGS BID checklist in our TICU. Furthermore, we performed a detailed analysis to assess the effectiveness of each checklist component before and after its implementation.
4. Discussion
In this study, we observed that the implementation of the FAST HUGS BID checklist improved the clinical outcomes of trauma patients in the ICU. Although patients with after-FD were characterized by higher severity of injuries, as indicated by a greater ISS, they exhibited lower rates of in-hospital mortality and complications, shorter ICU and hospital LOS, and reduced duration of invasive mechanical ventilation. Furthermore, multivariate logistic and linear regression analyses revealed that the implementation of the FAST HUGS BID checklist was an independent factor associated with shorter LOS in the TICU and hospital and lower in-hospital mortality.
The assertion that the implementation of the FAST HUGS BID checklist substantially affects the TICU population is well-supported by the following evidence. First, the implementation of the checklist resulted in a decrease in medical errors due to its concise and easily memorable format, which included the fundamental components of care involving all members of the trauma team. Second, the trauma team was able to make a care plan for each day and assess its completion using the checklist during daily ICU rounds. Several studies have endorsed our approach. For example, Stahl et al. showed that a structured checklist could reduce medical errors in the management of trauma patients [
6], Barcellos et al. reported a reduction in the duration of mechanical ventilation and ICU stay with the implementation of a checklist [
10], and Pronovost et al. revealed a decrease in the rate of catheter-related bloodstream infections through checklist utilization [
11]. Additionally, some studies demonstrated a reduction in the rate of ventilator-associated pneumonia (VAP) following the use of a checklist [
12,
13], and Haynes et al. documented a decrease in mortality and complications following the implementation of a checklist during surgery [
14,
15].
Our literature review indicates a scarcity of comparative studies evaluating the impact of the FAST HUG or its updated version since its initial proposal by Vincent [
8,
9]. Those studies have primarily focused on comparing outcomes of specific diseases or individual components, such as VAP reduction. In contrast, in this study, we selected indicators that could assess the effect of each element within the FAST HUGS BID, collected data, and compared their applications. In addition, we specifically compared LOS in the ICU and hospital and in-hospital mortality using the Kaplan-Meier curve, which are considered quality indicators for critical care treatment. Furthermore, we employed multivariate logistic regression analysis to demonstrate the association between the application of the FAST HUGS BID and other relevant factors. Our findings indicate that the application of the FAST HUGS BID, along with other factors, has a significant impact on clinical outcomes.
F for Feeding. Many studies have reported that malnutrition or weight loss increases complications and worsens outcomes in severely ill patients [
16]. Li et al. found that early enteral feeding in patients with trauma in the ICU was associated with lower mortality and shorter hospital LOS [
10]. Additionally, Ortiz-Reyes et al. suggested that compared to delayed enteral nutrition, early enteral nutrition improved clinical outcomes in mechanically ventilated patients [
17]. Moreover, many studies have demonstrated that early enteral nutrition is associated with lower mortality, shorter LOS, and improved clinical outcomes in mechanically ventilated patients, especially in trauma patients [
18]. These findings align with the results observed in our study, where the after-FD group exhibited a shorter time to initiate enteral nutrition. It is worth noting that feeding represents one of the most important advantages of the FAST HUGS BID, considering that patients with sepsis or trauma may require nearly double the amount of energy during the acute phase [
19].
A for Analgesia. Pain can affect a patient's psychological and physiological recovery, and adequate pain relief is an integral part of effective intensive care management. Critically ill patients commonly experience pain because of not only their underlying illness but also routine procedures, such as turning, suctioning, and dressing changes [
20]. After applying the FAST HUGS BID checklist at our center, we observed a decrease in the use of narcotic analgesics and an increase in the utilization of nefopam. Despite maintaining a pain scale of three points in both groups, pain was effectively managed without excessive use of narcotic analgesics, which has been considered a positive effect [
21,
22,
23]. In light of such emerging evidence, it can be argued that the elimination of disadvantages associated with the misuse and abuse of narcotic analgesics should be prioritized over the concerns about the potential side effects arising from the increased use of nefopam.
S for Sedation. Although the after-FD period exhibited a higher rate of dexmedetomidine and propofol usage and a lower rate of benzodiazepine usage, there were similar sedation levels in both periods; this was evidenced by Richmond Agitation-Sedation Scale scores consistently falling within the target range throughout this study. Previous studies have shown that dexmedetomidine or propofol offers advantages (e.g., reduced ventilation days and LOS in the ICU) over benzodiazepines in sedating critically ill patients [
24,
25]. It may be difficult and controversial to conclude that the use of dexmedetomidine or propofol instead of benzodiazepines directly affects survival in critically ill patients [
24]. However, based on the findings of our study, it can be inferred that reducing benzodiazepine usage while increasing the utilization of dexmedetomidine or propofol contributed to a decrease in ventilation days and LOS in the ICU, as well as overall mortality. It is worth noting that a recent meta-analysis by Ng et al. reported the effectiveness of dexmedetomidine in reducing the incidence of delirium or agitation in the ICU [
26]. However, because of the retrospective nature, there was a limitation in comparing the occurrence of delirium between the before and after periods in this study.
T for Thromboembolic Prophylaxis. According to the recently published American Association for the Surgery of Trauma and the American College of Surgeons Committee on Trauma clinical guidelines, patients with severe trauma face a high risk of venous thromboembolism, and prioritizing prophylaxis is crucial in preventing potentially lethal complications [
27]. Indeed, appropriate thromboembolic prophylaxis for critically ill patients with severe trauma who are unable to move or walk is an important factor in achieving favorable outcomes [
27]. In this study, we confirmed that thromboembolic prophylaxis was more actively administered after the implementation of the FAST HUGS BID approach, and there were a higher utilization rate of low molecular weight heparin and enoxaparin and a shorter time to the initial administration of enoxaparin in the after-FD period. It can be inferred that these factors contribute to improved clinical outcomes.
H for Head-of-Bed Elevation. Since the 1990s, head-of-bed elevation has been reported to reduce the incidence of gastroesophageal reflux and VAP in ventilated patients [
28]. A recent systematic review indicated that head-of-bed elevation to 30°–60° resulted in a reduced occurrence of VAP (with an absolute risk reduction of 25.7%) compared with supine (0°-10°) positioning. However, the analysis did not reveal any improvement in other outcomes, including microbiologically proven VAP, length of ICU and hospital stay, or duration of mechanical ventilation [
29]. There are various opinions regarding the optimal degree of head-of-bed elevation (30°–60°), but it is unclear which degree is most effective in reducing VAP [
30]. After the implementation of the FAST HUGS BID checklist, we uniformly applied an elevation of 30° in all patients, except for those with cerebrospinal fluid leakage due to unstable spinal cord injury or skull base fracture before fixation. We kept the angle for head-of-bed elevation at 30° in the TICU because we observed an increase in incidents of unplanned tube removal (e.g., endotracheal tube, central venous catheter, and chest tube) when the elevation exceeded 30°. Furthermore, we witnessed an increase in pressure sores resulting from back maceration, primarily caused by the patient sliding down the bed. Moreover, we verified that after-FD patients had a shorter time to initiate head-of-bed elevation, and the incidence of pneumonia was significantly reduced. While other elements were also affected, it can be inferred that the uniform and systematic implementation of head-of-bed elevation contributed to the reduction in the incidence of VAP.
U for Ulcer Prevention. Before 2020, routine prophylaxis against stress ulcers in the ICU was not well justified, and the advantages and disadvantages of stress ulcer prevention were not clearly verified [
31,
32]. However, a recent review paper published in 2022 concluded that prophylaxis should be considered for critically ill patients with risk factors for stress ulcers. Nonetheless, frequent reassessment and de-escalation of therapy are required when patients have a lower risk of bleeding [
33]. In our study, we observed a lower rate of utilization of ulcer medication, including proton pump inhibitors, among after-FD patients. This phenomenon can be attributed to the selective use of medications and the de-escalation of stress ulcer prevention therapy through regular re-evaluation in the TICU following the implementation of the FAST HUGS BID checklist.
G for Glucose Control. A recent systematic review highlighted that intensive glucose control is related to an increased risk of severe hypoglycemic events, but it also leads to reduced ICU LOS, sepsis, and mortality [
34]. In this study, blood glucose levels were within the optimal range in both the before-FD and after-FD groups. However, the average blood sugar level was lower in the after-FD group than in the before-FD group, suggesting that blood sugar was controlled more efficiently in the after-FD group. Although this study had limitations in directly confirming whether better-controlled blood glucose levels were associated with reduced ICU and hospital LOS, sepsis incidence, or mortality, it can be inferred that these factors might have indirectly influenced clinical outcomes.
S for Spontaneous Breathing Trial. A randomized controlled trial published in 2008 demonstrated a significant reduction in ventilation days, ICU and hospital LOS, and mortality when spontaneous awakening and breathing trials were implemented daily [
35]. Additionally, Robertson et al. showed that the implementation of a daily spontaneous breathing trial protocol resulted in improved extubation rates [
36]. In this study, we observed that the after-FD group had a shorter time to extubation but a higher rate of unplanned intubation. Herein, we need to interpret with caution that the before-FD group exhibited an unusually lower rate (0.9%) of unplanned intubation. Since the rate was exceptionally low compared to the optimal range for failed extubation (5%–10%) [
37], these findings suggest paradoxically that the absence of daily spontaneous awakening or breathing trials before the implementation of the checklist might have contributed to prolonged ventilator care.
B for Bowel Regimen. Diarrhea is common in ICU and has been found to be associated with increased mortality rates and prolonged ICU and hospital LOS [
38]. In this study, we observed a decrease in the incidence of diarrhea events in the after-FD group. It can be inferred that the ICU staff checked for the presence and frequency of diarrhea daily, changed the feeding solution and diet, or prescribed symptom-relieving medications more aggressively following the checklist's implementation. These efforts, either directly or indirectly, might have contributed to the decrease in ICU and hospital LOS, as well as the mortality rate, among patients in the after-FD group.
I for In Indwelling Catheter Removal. Central venous and urinary catheters are necessary for massive transfusion, drug administration, total parenteral nutrition, and close monitoring of critically ill patients in the ICU. However, the risk of infection associated with these catheters is a critical concern. Therefore, many studies, including recent systematic reviews, have underscored the importance of promptly removing unnecessary central venous and urinary catheters to prevent catheter-associated infections [
39,
40,
41,
42]. In our study, we found that the indwelling periods of the central and urinary catheters significantly decreased after-FD. This observation indicates that the condition of the catheter was checked more closely, and unnecessary catheters were removed earlier in each round after the implementation of the checklist. Consequently, these efforts might have reduced the LOS in the ICU and hospital and improved mortality.
D for Drug De-escalation of Antibiotics. Empirical antibiotic therapy is widely employed in the ICU due to the high prevalence of infections, and appropriate antimicrobial therapy is crucial for critically ill patients. However, caution must be exercised as it may cause the development of drug-resistant organisms. Consequently, Masterton emphasized the importance of antibiotic de-escalation and discontinuation at the earliest possible time [
43]. A recent systematic review demonstrated that antibiotic de-escalation therapy can be both safe and effective for most infections [
44]. Consistently, our study also showed a significant decrease in the number of antibiotics used, particularly restricted antimicrobials typically reserved for drug-resistant organisms, and a shorter duration of antibiotic use after-FD. These results suggest that antibiotic utilization was managed more closely and effectively after the checklist's implementation.
To the best of our knowledge, this study is the first to evaluate the effectiveness of the implementation of the ICU round checklist, FAST HUGS BID, in severe trauma patients. Notably, our study differs from previous studies in that we analyzed each component of the checklist separately to identify potential improvements following its implementation. In addition, this study has several strengths, including the quantitative assessment of how much the checklist contributed to reducing ICU and hospital LOS and improving in-hospital mortality through the construction of a multivariable logistic regression model with adjustment for various confounding factors. However, this study has limitations owing to its retrospective observational nature. Regarding the evaluation of performance and outcome improvement, various factors other than the checklist's introduction might have influenced the results. Additionally, the presence of a time gap between the before- and after-FD periods might have introduced a limitation in terms of conducting a fair comparison. The difference in group sizes might have increased the possibility of selection bias. Moreover, because the study was conducted at a single center exclusively for patients with trauma, the generalizability of our results to other ICU settings may be limited.
Author Contributions
Conceptualization: Seo D, Jung K. Data curation: Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang BH, Song S, Kim S, Jung K. Formal analysis: Seo D, Moon J, Kwon J, Huh Y, Kang BH, Jung K. Investigation: Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang BH, Song S, Kim S, Jung K. Methodology: Seo D, Jung K. Supervision: Jung K. Validation: Seo D, Jung K. Visualization: Seo D, Heo I, Jung K. Writing - original draft: Seo D, Heo I, Jung K. Writing - review & editing: Seo D, Heo I, Moon J, Kwon J, Huh Y, Kang BH, Song S, Kim S, Jung K.