Many authors have written about the need to treat patients closer to their beds, in order to observe them more as distinct people. The FAST HUG mnemonic, which consists of a checklist, was suggested as an idea to be employed everyday, by professionals dealing with patients who are critically ill. Minding these questions and motivated by an idea of follow patients' treatment closer, we have put into practice the instrument developed by Jean-Louis Vincent, evaluating the seven most important procedures in critically ill patients, and performed the FAST HUG. This checklist consists of seven items to be evaluated: Feeding, Analgesia, Sedation, Thromboembolic prophylaxis, Head-of-bed elevation, stress Ulcer prevention, and Glucose control. Knowing that the pressure ulcer is one of the challenges faced by ICU nurses, related to patients' need to stay at rest, to be under rigorous control or more complex therapy, it was decided to create the eighth item on the checklist: S, for skin. It stands for skin treatment, with the techniques used in the unit (Braden Scale), monitoring and evaluating closer skin integrity, and allowing nurses to calculate the scoring average of the Braden Scale, and greater incidence of ulcer in interned patients.
To expose the shortcomings found during the FAST HUG application, and to show results obtained with the eighth item of the FAST HUG mnemonic: S – Skin.
A descriptive study, based on institutional data, was carried out in the adult ICU of a private hospital. It was performed from 2 to 27 June 2008, except on weekends. Three hundred and twenty-three patients were involved. The checklist was carried out during the afternoons by the head nurse, or the assistant nurse of the unit. In order to do this job, a spreadsheet was elaborated to control data, updated every week. This spreadsheet provided graphics for a more objective control of the results obtained. The idea was exposed to the team, during a training program, and so we started the activities.
Results and discussion
For 20 days of the checklist, 323 patients were evaluated for the eight items. The real shortcomings most frequently found were related to thromboembolic prophylaxis (85%) and glucose control (90%). These shortcomings were immediately evaluated and, depending on this analysis, this item would go on or not, according to the patient's clinical situation. The shortcomings found were tracked just as they were detected, and their cause would be discussed in a multidisciplinary group, and a solution was found. If the item was not observed, it would be written down but not treated as a real shortcoming. The changes in medial prescription were done immediately. In cases where the patient did not show a favorable situation for the utilization of thromboembolic prophylaxis (bleeding, presurgical, among others), it would be treated as a nonreal shortcoming. The same was done for glucose control. We realized that after 4 weeks using this instrument there was a small reduction of shortcomings in glucose control (Figure 1), and a discrete raise in thromboembolic prophylaxis (Figure 2). From this point we reviewed the checklist, in order to provide a field to write down real shortcomings, so that they are given more relevance and treatment, since the patients' clinical situation deserves different treatments that do not interfere in the unit's quality of service. The inclusion of skin evaluation through the Braden Scale was an opportunity to follow patients' skin, by means of risk evaluation to develop wounds, providing data on the daily scoring average of the Braden Scale and the spot where these wounds were more frequent. An average Braden score of 13.65 (Figure 3) was verified, and it was also seen that the greater incidence of pressure ulcer was in the sacral region (44.75%) (Figure 4).
It can be concluded that FAST HUG, in addition to being a tool to evaluate assisting quality and to assure patients that their needs will be fulfilled while they remain in the ICU, may be considered a boost to overcome new challenges. Along with the checklist, a reduction of shortcomings found in glucose control was observed and a rigorous multidisciplinary evaluation of patients with contraindications to the use of prophylaxis of TEV. Also, we could see a greater attention of the multidisciplinary team to the results provided by the evaluation of skin wound risk, since they offer a significant prognostic value.