AACN Advanced Critical Care:
Symposium: Geriatric Issues in Critical Care
Use of Protocols in Older Intensive Care Unit Patients: Is Standardization Appropriate?
Casey, Colleen M. PhD, ANP-BC, CNS, CCRN; Balas, Michele C. RN, PhD, CRNP, CCRN
Section Editor(s): Hedges, Christine Symposium Editor
Colleen M. Casey is Assistant Professor/Nurse Practitioner, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, L-475, Portland, OR 97239 (email@example.com).
Michele C. Balas is Assistant Professor, University of Nebraska Medical Center, Omaha.
Increasing numbers of older adults are cared for in intensive care units (ICUs) across the country. These patients are disproportionately impacted by illnesses such as sepsis, ventilator-associated pneumonia, and infections. Their care and course of recovery are complicated by myriad factors, including their often-indistinct presentation of illness and issues related to pharmacotherapy. Increasingly, clinical practice guidelines are being used to facilitate the care of patients with select illnesses and presentations. However, these guidelines, protocols, or bundles, as they are known, generally have not been studied in an older population. This article describes the ventilator-associated pneumonia and sepsis bundles relative to the older critical care patient. Although an exhaustive discussion of every intervention within each bundle as it relates to older ICU patients is beyond the scope of this article, selected bundle parameters are presented, with examples of special considerations for the older ICU patient.
Patients aged 65 years and older comprise more than one-half of all intensive care unit (ICU) admissions; are at greater risk for nosocomial infection, sepsis, and subsequent mortality than younger patients; and have an increased chance of becoming chronically critically ill, defined as patients who require continued ICU care ranging from weeks to months.1–4 The need for intensive care was recently found to confer an increased risk of both disability and mortality after discharge for Medicare beneficiaries, mostly attributable to those older adults who required mechanical ventilation.5,6 Severity of illness, functional status, age-related physiologic changes, and prolonged mechanical ventilation, but not necessarily age alone, have all been implicated as factors contributing to the often-undesirable outcomes experienced by older adults.5,7–12
Protocols, clinical practice guidelines (CPGs), or “bundles,” as they are sometimes called, are used ubiquitously in the critical care environment to address multiple aspects of care and to guide treatment of many conditions, including those involving glucose control, sedation and weaning parameters, and, most well-known, sepsis and pneumonia management.13–17 The Society of Critical Care Medicine describes bundles as “a group of therapies for a given disease that, when implemented together, may result in better outcomes than if implemented individually.”18 These protocols are derived either at the institutional or unit level or more globally by expert panels or various professional practice organizations, such as the Society of Critical Care Medicine, the American Association of Critical-Care Nurses, the Infectious Diseases Society of America, or the American Thoracic Society.
Furthermore, national and international efforts by groups, such as the Institute for Healthcare Improvement (IHI), aim to evaluate outcome measures across hospitals, states, and countries by attempting to standardize these protocols and the collection of related data on such critical care illnesses as ventilator-associated pneumonia (VAP), central catheter–associated bloodstream infection, hyperglycemia, and sepsis. Despite the aim of these protocols to deliver standardized treatment plans, many of them leave room for clinical interpretation based on individual patient characteristics.
Limited study on the use of protocols specifically in older ICU patients has shown a higher 28-day survival rate in older adults after implementation of a sepsis bundle, for example.19 However, research has not addressed whether to customize some of these ICU CPGs based on considerations specific to older ICU patients (eg, age-related physical changes, altered drug metabolism), which may be because older adults, until very recently, were frequently excluded or underrepresented in ICU clinical trials and observational studies.4 Should older adults be treated with the traditional approaches outlined by various protocols? Or, should their treatment be tailored differently on the basis of their comorbidities, physiologic and functional ability, or illness severity?
Discussing every CPG commonly used by ICU teams is beyond the scope of this article. Because pneumonia and sepsis disproportionately affect older adults, both relative to younger patients and compared to other conditions, this article will discuss aspects of these 2 protocols as they relate to the older ICU patient.3–6,20,21
General Concerns Related to the Older ICU Patient
Beyond discussion of any particular protocol, it is imperative to recognize that before any protocol can be initiated, appropriate assessment and diagnosis must occur. In the older patient, this diagnostic piece can be elusive. Older adults often present to clinics or emergency departments when they are critically ill, often with acute neurologic symptoms as the most distinct and obvious physical findings. These changes in level of consciousness or cognition often do not represent a primary neurologic diagnosis, but rather can mask an infection, electrolyte imbalance, or drug toxicity.22
Atypical presentation in older adults generally represents a change in their immunologic functioning. Changes in cell- and humoral-mediated immunity accompany aging, as do alterations in the traditional physiologic barriers of skin and mucosa; these factors can lead to a weakening of an older adult's immune defenses against infection. Protein malnutrition, common in older patients, is associated with a decrease in lymphoid tissue and resultant decline in T-cell function.9 Many of these changes result in the absence of signs that are normally considered hallmarks of infection—fever, chills, and other constitutional symptoms. In fact, the typical signs of pneumonia—fever, cough, and sputum production—can be absent in the older adult, with only 33% to 60% of older patients presenting with a fever.22 Instead, older patients with either sepsis or pneumonia may present with acute confusion, tachypnea, and tachycardia.23 For older adults living with chronic illness, an exacerbation of a preexisting condition (diabetes, emphysema) may precede any other signs of an infection. Because of this often-subclinical presentation of pneumonia and various other illnesses in older adults, treatment can be delayed, likely contributing to worse outcomes for this population.24 As a result, indistinct clinical presentations in the older adult make pneumonia difficult to diagnose, so a high index of suspicion is required in this population.25 Furthermore, older patients may improve more slowly than younger patients, with delays in radiographic resolution common.26
The use of pharmacotherapy is implicit in critical care and a mainstay of virtually any ICU protocol. The use of medications in older adults in the ICU becomes complicated because of (1) altered pharmacokinetics secondary to normal age-related organ system changes (including changes in body composition); (2) multiple and sometimes severe illnesses; and (3) the introduction of multiple-drug therapy, sometimes with conflicting mechanisms of action. Adverse drug reactions (ADRs) account for 16% of hospital admissions and 50% of all medication-related deaths.27,28 These occurrences are 7 times more common in older adults than in younger people, with age shown as an independent risk factor for ADR.9
To account for some of these pharmacokinetic differences, equations such as the Cockcroft-Gault formula have been developed to help practitioners better assess an older patient's kidney function.29 However, even this formula cannot be used without recognition of some limitations. Although the Cockcroft-Gault formula has been used for healthy older adults, concern exists for its use among ill older adults, especially those who are critically ill. Several other factors often accompany hospitalization and can influence the renal clearance of drugs; they are as important as age-related changes and, importantly, are not represented in the formula. These factors include (but are not limited to) hydration, cardiac output, and intrinsic renal disease.30
Moreover, some medications commonly used by older adults have shown varying effects relative to particular diseases. For example, one study suggests that angiotensin-converting enzyme inhibitors lower the risk of pneumonia in some older adults, whereas proton pump inhibitors may actually increase this risk.31 Older adults are particularly susceptible to ADRs caused by antimicrobials, with gastrointestinal and central nervous system effects the most common.32 As with other medications used by older adults, the ICU team often must consider renally dosing antibiotics. However, this clinical decision must be weighed with the risk that reduced antibacterial dosages could result in resistant strains. In addition, properties of various antimicrobials must be considered, such as avoiding those antibacterials that act as strong or moderate inhibitors of cytochrome P450 enzymes, because many drugs commonly taken for chronic disease in the older population are metabolized via the cytochrome P450 enzyme pathway.22
Overall, clinicians must remember several physiologic changes that influence drug absorption, distribution, metabolism, and excretion in the older ICU patient. Older adults have reduced protein binding, which can lead to higher levels of active free drug consideration.33 Highly protein-bound drugs, such as warfarin, oral hypoglycemics, digitalis, and aspirin, present an increased risk of toxicity.33 Because total fat content increases with age, lipid-soluble drugs such as propofol and benzodiazepines can have a prolonged half-life in older patients.8 Moreover, commonly used drugs such as narcotics can exacerbate the age-related changes of decreased gastric motility and urinary retention.
Clearly, balancing all of these considerations, when caring for a critically ill older adult, requires keen assessment, diagnostic reasoning skills, and some baseline knowledge of age-related pharmacokinetics and pharmacodynamic principles. Drawing upon the expertise of consultant pharmacists can help to inform medication choices, in terms of choice of agent, dosages, and mode of administration. Furthermore, accessing and using resources (such as the adaptation of the Beers34 criteria to the inpatient setting by Bonk and colleagues35) that have studied some of these medication issues can help to identify inappropriate medication usage in hospitalized older adults.34–36 While not specific to the ICU setting, the Bonk study found that the 7 most commonly prescribed Beers medications used for older hospitalized patients included diphenhydramine (20%), promethazine (10%), amiodarone (7%), meperidine (5%), clonidine (5%), ketorolac (5%), and diazepam (5%).35
The National Hospital Discharge Survey data show that pneumonia hospital discharge rates for the population older than 65 years are nearly 6 times those of younger cohorts, at a rate of 189/10 000 compared with 33/10 000 in 45- to 64-year-olds.37 Classifications of pneumonia include community-acquired pneumonia, hospital-acquired pneumonia, and VAP, with VAP one of the leading causes of nosocomial infection in ICUs.38,39 Factors such as prolonged mechanical ventilation, oversedation, lack of ventilator weaning, aspiration, supine positioning, and poor oral health have all been recognized as contributing to VAP.40 Some of these factors disproportionately burden older adults (eg, aspiration and poor oral health), with aspiration pneumonitis, one of the leading causes of rehospitalization among Medicare beneficiaries.41–43
Because of the high morbidity and mortality across all age groups with hospital-acquired pneumonia, several guidelines have been published by the Centers for Disease Control and Prevention in the past 30 years. In 1994, the Centers for Disease Control and Prevention addressed concerns related to VAP for the first time with the most recent recommendations published in 2004.14 Ventilator-associated pneumonia is defined as nosocomial pneumonia in a patient on mechanical ventilatory support (either by endotracheal tube or by tracheostomy) for 48 or more hours.14 The IHI prioritized the prevention of VAP as part of its 100,000 Lives Campaign, beginning in 2004, a nationwide initiative to significantly reduce morbidity and mortality in American health care that transformed into the 5 Million Lives Campaign between 2006 and 2008.44
Central to the VAP bundle, as the protocol is known, are several key interventions including elevation of the head of the bed, daily “sedation vacations” and assessments of readiness to extubate, peptic ulcer disease prophylaxis, deep venous thrombosis (DVT) prophylaxis, and frequent oral care with chlorhexidine.14 Additional organizations have since added supplemental evidence-based guidelines including continuous aspiration of subglottic secretions and discontinuation of routine changes to ventilator circuits.40,45 Overall, literature supporting these practices does not specifically include studies examining these interventions in older adults, for either proven benefit or side effects. Even the Specifications Manual for National Hospital Quality Measures—ICU, a product of The Joint Commission addressing VAP, peptic ulcer disease, and DVT measures as a uniform set of national hospital quality measures for ICUs, does not address age specifically relative to its recommendations.46
A great deal of literature supports the use of these interventions, either individually or as a bundle, in decreasing VAP.47–51 More recently, there has been some criticism that a lack of methodologic rigor across studies precludes conclusions about whether the VAP bundle is medically effective or cost-effective, but institutions and facilities continue to prioritize efforts around VAP reduction.52,53 In the process of implementing these interventions for their presumed benefit, additional consideration by ICU providers about the potential hazards these interventions can pose to certain older ICU patients is warranted (see Table 1). For example, the importance of patient positioning relative to VAP stems from literature suggesting that supine positioning can increase the risk of aspirating gastric contents, with semirecumbent positioning protecting against this type of aspiration, thus mitigating this risk factor of VAP.54 However, head of bed greater than 30° (the minimum recommended in the VAP bundle) could actually compromise older adults' skin integrity by increasing friction and sheer, for example.55 The Joint Commission's recommendations do elaborate that the degree of head-of-bed elevation should be consistent with the patient's clinical condition, but do not explicitly describe any relationship between age, skin integrity, and the potential risks associated with head-of-bed elevation greater than 30°.46
Table 1: Select Stra...Image Tools
Several VAP bundle interventions involve medication prophylaxis, which underscores the importance of evaluating the risks and benefits of any medication relative to an older adult's clinical condition, renal function, allergies, and other medications. For example, the importance of peptic ulcer prophylaxis, especially in patients with respiratory failure or abnormal coagulation, has been demonstrated and is common practice in many ICUs, based on patient risk factors.56,57 However, newer research is calling this common practice into question, with various studies showing that histamine type 2 (H2) antagonists, sucralfate, and proton pump inhibitors can be associated with an increased risk of pneumonias, thought to result from the neutralization of stomach acid, which provides a natural barrier to pathogens attempting to pass from the gastrointestinal tract to the respiratory tract.45,58–60 Furthermore, in the older adult, H2 antagonists, cimetidine in particular, have been associated with central nervous system complications, thrombocytopenia, and drug interactions.36,61 Similarly, the repeated administration of low-molecular-weight heparin as part of the recommended DVT prophylaxis can present risks to older patients with impaired renal function, by leading to an accumulation effect with an increased risk of bleeding.30,62 Consequently, the American College of Chest Physicians, in its DVT recommendations, has explicitly advised that for patients with renal impairment, particularly older adults, agent selection, dose adjustment, and drug level or anticoagulant monitoring be individualized to the patient.63
Sepsis Incidence and Outcomes in Older Patients
Sepsis is a complex syndrome that is defined by the presence of both infection and a systemic inflammatory response.64 Affecting nearly 700 000 people annually in the United States alone, sepsis is one of the leading causes of death and disability in the ICU.65–69 The number of severe sepsis cases is expected to grow by 1.5% per year because of the high incidence of the condition in older patients and the disproportionate increase of the older US population.70 These trends are of significant concern considering that the average cost per case of severe sepsis is estimated at $22100, with annual total costs of $16.7 billion nationally.70
Chronologic age is an important risk factor for the development and outcome of severe sepsis. Martin et al20 reported that older adults (≥65 years of age) accounted for 12% of the US population and 64.9% of all sepsis cases (relative risk 13.1 compared with younger patients; 95% confidence interval, 12.6–13.6).20 In their study, case fatality rates increased linearly by age, with age an independent predictor of mortality.20 Older sepsis patients not only die earlier during hospitalization, but survivors are more likely to be discharged to a non–acute health care facility for rehabilitation.20
The disparity that exists between older and younger patients with sepsis, in terms of incidence and outcomes, is likely multifactorial. Early recognition of sepsis in older adults may be hampered because they often do not exhibit typical, or expected, manifestations of the systemic inflammatory response syndrome.23 One study of septic patients found that older adults (>75 years) were more likely to present with tachypnea and mental status changes than were younger patients, whereas fever, tachycardia, and hypoxemia were less common among older patients.71 However, another study found tachycardia to be a presenting symptom in both sepsis and pneumonia.23 Age-related changes in the immune system contribute, in part, to differences in the type and source of infection when comparing younger and older septic patients.72 Older patients with sepsis are more likely to experience gram-negative infections than younger patients, particularly in the respiratory and genitourinary systems.20 Finally, the comparatively higher rates of institutionalization, comorbidities, functional status disability, malnutrition, and hospitalization likely affect the incidence, course, and outcomes of sepsis in older adults.23,73
Development of Sepsis Bundles
In 2003, critical care and infectious disease experts representing 11 international organizations (including the American Association of Critical-Care Nurses) developed management guidelines for severe sepsis and septic shock.74 This international effort, better known as the Surviving Sepsis Campaign (SSC), was aimed at increasing awareness and improving outcomes in severe sepsis; the IHI also adopted the SSC campaign as one of its quality improvement initiatives. One of the most recognized and used ICU bundles, the SSC: International Guidelines for Management of Severe Sepsis and Septic Shock, was most recently updated in 2008.15
The Severe Sepsis Bundles (available at http://www.survivingsepsis.org/Bundles/Pages/default.aspx) are a summary of the evidence-based recommendations in the 2008 SSC guidelines.15 The 2 bundles, Sepsis Resuscitation and Sepsis Management (see Tables 2 and 3), were developed to outline the timing, sequence, and goals in the care of septic patients, all to achieve a 25% reduction in mortality due to severe sepsis or septic shock. Although hospitals are encouraged to customize the protocols to meet their institutional needs, the SSC strongly suggests that major changes are not made because, as they believe, the elements represent the best strategies to improve care and can allow for comparison of processes and outcomes across institutions.
Application of Sepsis Bundles in Older Patients
Although the most current SSC guidelines explicitly discuss pediatric considerations in severe sepsis, the applicability and effectiveness of these guidelines in older adults are not specifically addressed. Considering that the incidence of sepsis among individuals older than 85 years is 100 times greater than the incidence among individuals aged 5 to 14 years, it has been suggested that these guidelines should absolutely be used by all clinicians caring for older adults.70 Some experts have even noted that some of the SSC guideline therapies actually provide larger absolute risk reductions for older adults, when compared with younger patients.73 In this population of older adults, assessment of preadmission functional status and quality of life are essential points to consider when laying out treatment options.
Several interactive factors make the initial recognition, diagnosis, and treatment of sepsis in older adults more challenging than in younger patients. The vital signs of an older adult with sepsis may be altered not only because of the syndrome's pathophysiology, but also because of the presence of comorbid conditions and related medications. For example, heart rate and blood pressure changes in response to inflammation or sepsis may not occur as expected, in part because of medications that many older patients take for preload, afterload, inotropic support, and/or contractility (eg, β-blockers, vasodilators). Providers must quickly ascertain what medications a patient takes and how it can influence the patient's presentation. They must also keep in mind common age-related phenomena, such as tachycardia being less well tolerated in older adults and hypoxemia compounding any preexistent diastolic dysfunction, which is common in older adults.9,12
Initially, it may be difficult to obtain vascular access and timely and adequate samples of blood, urine, and sputum from older adults who are frail, confused, malnourished, or dehydrated prior to hospital admission.73 Older adults who are exposed to instrumentation (ie, Foley catheter and central venous catheters) and institutionalization prior to hospital admission present clinicians with further diagnostic and treatment challenges.23,73
In older adults admitted from long-term care facilities, preadmission lines and tubes must be documented, cultured, and removed as soon as feasible to optimize source control. A thorough skin and wound assessment is also needed to identify potential hidden sources of infection (eg, decubitus ulcers). Any delay in source and organism identification can delay prompt administration of antibiotics, which is crucial to an older adult with sepsis.75 Additional history must also be elicited to determine whether the older adult recently received antibiotics for other infections or was exposed to others with severe or resistant infections, particularly if they are admitted from a facility.
Advanced age is not a contraindication to protocolized resuscitation. Liberal amounts of fluid may be needed when resuscitating older adults with sepsis because of the underlying pathophysiology of this syndrome.23 Because many older adults have preexisting cardiac dysfunction, chronic renal insufficiency, hypoproteinemia, and reduced muscle mass, care must be taken, though, to avoid fluid overload.12,76 Generally speaking, adequate preload must be maintained, and higher hemodynamic pressures may be necessary to maintain cardiac output.12 Although there may be a tendency to slow the rate or decrease the amount of intravenous fluid in older adults because of a fear of congestive heart failure, fluid challenge techniques should be the same as those used in younger adults, albeit with a heightened vigilance for complications in the older septic patient. As per the SSC 2008 guidelines, fluid challenges should occur as long as they are associated with hemodynamic improvement and be reduced if cardiac filling pressures increase without concurrent hemodynamic improvement.15
Other recommendations as part of the SSC bundles target the need to support multiple organ systems, including mechanical ventilation, glucose control, the use of recombinant human activated protein C (rhAPC), administration of blood products, use of steroids, and renal replacement therapy.15 Optimal ventilator strategies specific to older adults have not yet been thoroughly studied, and some research has found that fluid resuscitation leading to a positive fluid balance can actually prolong mechanical ventilation in older surgical patients.76,77 Debate has also ensued over appropriate glycemic guidelines in the general septic population; even less specific direction exists for older septic patients whose self-regulation of glucose declines with age and who may be more susceptible to both hypo- and hyperglycemia.9,16,17,78,79
Advanced chronologic age is not a contraindication to rhAPC use.23 A planned subgroup analysis of the Recombinant Human Activated Protein C Worldwide Evaluation of Severe Sepsis (PROWESS) study (designed to test the safety and efficacy of rhAPC) found that patients aged 75 years and older benefited from rhAPC administration, with a 15.5% reduction in the absolute risk of death by 28 days, with this survival benefit extending to 2 years.80,81 The current SSC guidelines suggest the use of rhAPC in all adult patients with sepsis-induced organ dysfunction who are at high risk of death (typically Acute Physiology and Chronic Health Evaluation II [APACHE II] ≥25 or multiple organ failure), provided there are no contraindications, including active bleeding or high risk of bleeding and assured administration time of 96 hours of rhAPC.15 The fact that many older adults are on anticoagulant or antiplatelet therapy for various indications increases their risk of bleeding relative to younger adults.76
Older patients with sepsis may require transfusion of packed red blood cells because chronic anemia is common among community-dwelling older adults, and acute infection may drive counts lower.23 Because older adults were frequently excluded from prior studies of transfusions in the ICU, the optimal transfusion threshold in this population has yet to be determined.23,73 Once the older adult patient is adequately resuscitated, the SSC currently recommends that red blood cell transfusion occur when hemoglobin decreases to less than 7.0 g/dL and maintained at a target hemoglobin of 7.0 to 9.0 g/dL (70–90 g/L) in adults, provided there are no contraindications such as myocardial ischemia, severe hypoxemia, acute hemorrhage, cyanotic heart disease, or lactic acidosis.15
Comprehensive Approach to Caring for Older ICU Patients
Standardization within the ICU setting offers the potential to improve patient care, improve patient outcomes by reducing ICU/hospital length of stay, and potentially decrease health care expenditures, regardless of age.82 In addition to protocols that have been “bundled” around particular illnesses, such as VAP, sepsis, and catheter-associated infections, more general checklists that cover a range of organ systems, processes, and typical orders have also taken hold in ICUs either formally or informally.83–86
These checklists, intended to be used by ICU providers to cover the basic daily goals for all ICU patients, are particularly appropriate for older ICU patients. None of the interventions are complicated in and of themselves, nor does completion of them ensure a good outcome. These checklists are not meant to be exhaustive, to be applied to every patient at all times, or to override common sense that would tailor care in an alternate manner.84 However, daily goal checklists are well-suited to the heterogeneity of the older ICU population because they draw regular, frequent attention across the ICU care team to the details of care so important to this group of patients (see Table 4).
Table 4: Summary of ...Image Tools
For example, Vincent's FAST HUG mnemonic stands for Feeding, Analgesia, Sedation, Thromboembolic prevention, Head of bed, stress Ulcer prophylaxis, and Glucose control.84 In fact, many elements of the FAST HUG checklist are addressed by components of the VAP and sepsis bundles. One of Vincent's intents for the checklist was that it not only be used for discussion in rounds, but also be adopted as a mental checklist for all staff members (nurses, physicians, physical therapists, respiratory therapists, nutritionists, pharmacists) to remember the essential aspects of patient care.84
One of the newest checklists, the ABCDE bundle, specifically targets delirium and weakness, 2 of the greatest threats to the older ICU patient.87 The ABCDE bundle represents awakening and breathing coordination, delirium monitoring, and exercise/early mobility.13,88–90 Bundle components are evidence-based and represent the opportunity to standardize communication, improve interdisciplinary care, reduce mortality and morbidity, and improve cognitive and functional outcomes.87
These daily checklists are part of a movement in the ICU environment toward more comprehensive, multidisciplinary care designed to promote better outcomes among older hospitalized patients.91
In general, protocols developed for use in the ICU setting represent the best available evidence for health care teams to use in their care of critically ill patients. These protocols, while imperfect, offer a solid framework from which to deliver care that reflects best practice, even if that practice later changes on the basis of new evidence (as has been the case most recently with glucose control).16,17 Nurse practitioners and clinical nurse specialists will continue to play key roles in helping to implement and enact CPGs, bringing evidence-based care to the bedside.75 Clearly, a need exists for more critical care research, especially involving protocols, that specifically studies, or at the very least includes, the older ICU patient.4 Also lacking is robust translational research that accommodates the real setting of the ICU and comparative effectiveness research that can prioritize what interventions are most feasible and effective for use across multiple settings and institutions.
The use of the VAP and sepsis bundles in the older ICU patient population is appropriate provided the clinical decisions made using each guideline take into consideration the many clinical variables and sometimes competing goals of care in older adults (fluid resuscitation vs fluid overload). These types of clinical decisions are best suited to working in interdisciplinary teams, promoting discussion of the various risks and benefits, and relying upon daily goal checklists to foster and structure productive communication. This balancing act, tailoring care based on objective data, patient history, and clinical nuance and expertise, is what can make geriatric critical care even more stimulating and demanding for ICU clinicians.
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bundle; critical care/intensive care; geriatric; protocol; sepsis; ventilator-associated pneumonia
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