(397) A Unit Under Pressure: Proactive Bioethics in the TSICU

Introduction: Ethics, a valuable ICU resource is often deployed once conflict is present, late into a prolonged stay or when power struggles have already become entrenched. Ethic models to date face several obstacles: delay in consultation, perception of bioethics, and lack of sustainable change. Our model proposes a proactive, preventive approach to ethics consultation.

Methods: We present a prospective quality improvement project conducted between August 2023 and January 2024 in a 22-bed adult TSICU at an academic, ACS level 1 trauma center and transplant center. A full-time senior clinical ethicist was embedded into the multi-disciplinary team, joining weekday bedside rounds. She identified potential conflict, performed focused preventative intervention following general targeted screening, served as a resource for staff, and provided structured debriefing. Using the Banner Ethics Screening Tool (BEST) all patients were screened without regard to age, race, diagnosis, or other exclusions. BEST specifically assesses presence of appropriate code status, a completed MPOA document or identified statutory surrogate, a short- and long-term care plan and conflict. The primary outcome investigated was length of ICU stay.

Results: 229 patients were screened and those deemed high risk were followed closely by the ethicist. This resulted in 829 days saved in the ICU, with the greatest impact seen for 10 specific DRG's. Ethics consultation helped identify care pathways/priorities, foster goals of care discussions, address complex surrogacy issues, and provided consistent support for patients and families over time.

Conclusions: The TSICU patient population is particularly vulnerable, facing complex medical and ethical challenges that are unintentionally compounded by moral distress, gaps in scheduling and delays in ethics consultation. Integrating an ethicist into the daily routine, helped anticipate and mitigate ethical issues and foster an environment of preemptive care rather than reactive crisis management. The BEST tool was associated with a significant reduction in length of stay, which could be used in the future to help lower acuity units prioritize ethics resources. This pilot demonstrates the profound impact a single ethicist can have on a high acuity units culture, communication and length of stay.