ICU care improves with intensivists, initiatives
Use of restraints minimized
When quality improvement leaders at the M.D. Anderson Cancer Center at the University of Texas in Houston decided to improve patient safety in the intensive care unit (ICU), they found that some necessary changes could be done at little cost, while others needed a huge budget. But the overall quality improvement project yields lessons for any hospital, they say.
M.D. Anderson is a well-known cancer center, with 518 beds, including an ICU with 42 beds and a staff of 160. In 2001, the ICU experienced 1,467 admissions, 9,183 patient days, and an average daily census of 28 patients. In 2000, the hospital’s office of performance improvement decided to target the ICU for a study of process improvement. The office is made up of the departments of quality improvement and the academy for performance improvement, both focused on promoting continuous quality improvement in patient care, research, clinical education, and cancer prevention.
The ICU was a natural target for the office’s process improvement efforts, says Sherry Martin, MD, associate vice president for process improvement in the department of quality improvement. She tells Hospital Peer Review that patient care in an ICU is inherently costly and unsafe, noting that the Washington, DC-based Leapfrog Group reported in November 2000 that approximately 500,000 patients die in ICUs each year. "A new critical care unit was built at M.D. Anderson in 1999, so that provided the opportunity to create a new environment in the ICU that would ensure safer practices at lower costs," she says. "With the Leapfrog report drawing attention to the issue, we saw an opportunity to improve our ICU care."
Intensivists added, restraints minimized
The quality improvement staff teamed up with representatives from the ICU to conduct an extensive analysis of the ICU’s operations and patient outcomes. The team was led by Thomas Feeley, MD, division head of anesthesia and critical care, and Lee Parmley, MD, ad-interim chair of critical care at the hospital. The team devised a multipronged approach to improving operations in the unit. The first step was to rename the ICU. It is now known as the critical care unit (CCU). These are the other changes implemented recently:
• Use of intensivists. The hospital changed the CCU’s physician model so that medical care is provided by or in conjunction with intensivists, physicians devoted exclusively to management of critically ill patients. The six intensivists are physicians who are board-certified in anesthesiology, surgery, or internal medicine and have subspecialty training and board certification in critical care medicine. "This system replaced a prior staffing model in which CCU patients were managed by the primary admitting service with assistance from consultants when requested," Martin says.
The new physician group provides two intensivists each week, Parmley says. One group covers medical patients, and the other covers surgical patients. Each attending conducts rounds on his or her respective patients with a multidisciplinary team composed of critical care fellows, anesthesiology residents, medical students, and one or more critical care nurse practitioners or physician assistants, a dietitian, pharmacist, social worker, respiratory therapist, and charge nurse. The team participates in a presentation of each patient and, together with the intensivist, develops the day’s treatment plan.
"A physician representative remains present in the CCU 24 hours a day, and the intensivist is available to the CCU nursing staff and in-house physician 24 hours a day and can be at the bedside in less than 30 minutes if called," Parmley says.
• Nurse management. To provide nursing leadership 24 hours a day, the hospital established three additional nurse management positions in the CCU. In addition, two clinical nurse specialists were added to provide sophisticated clinical management support to the nursing staff. Continuous quality management was a key goal for the team, so they reconfigured positions to provide data management and financial functions and improve communication.
"Minimizing cost was also a goal of the team," Martin says. "Therefore, after studying the personnel cost data, [team members] determined that elimination of agency nurses and float pool would not only improve the quality of care but would save money. The team implemented aggressive hiring techniques to maintain the core staff levels."
• Team building. The hospital hired a consultant to help the CCU team create a mission statement and conduct team-building sessions. The sessions were directed by the nurse leadership and focused on establishing consistent policies and procedures.
• Pain management. The team paid special attention to pain management in the CCU because it is such a priority for critically ill patients. The team audited charts for documentation of pain scale scores and found only 76% compliance with policies requiring pain assessment on every admission and every two hours thereafter. When the team investigated, it found that nurses often attempted to assess pain but found the standard pain scales useless when patients were unable to verbalize their pain levels. Further investigation of pain management literature revealed that a nurse’s estimation can correlate closely with a patient’s reported pain level.
"So the team modified the procedure to allow nurses to use criteria-based estimation when the patient is unable to respond," Martin says.
• Patient satisfaction. The quality improvement team considered patient satisfaction an important indicator of quality in the CCU, so it developed an assessment tool. The survey tool contains questions about the adequacy of information given by the physicians and staff, pain management, courteousness of the physicians and nurses, visiting hours, and cleanliness of the waiting area. A volunteer gives the survey to a family member once a week, and a quality team member in the CCU tallies the results.
With the survey results, staff are able to intervene with problems while the patient is still in the CCU, Martin says.
• Restraints. Restraint use is common in any CCU to prevent patients from extubating themselves or interfering with monitoring devices, but the quality improvement team wanted to ensure that restraints were used judiciously and as little as possible. The team collected data for three months examining the duration of restraint, type of restraint, reason for restraint, and correlation to self-extubations. The analysis helped the CCU develop new standards for restraints that minimized their use, and after the implementation of the new system, all restrained CCU patients were audited for three months.
• Nosocomial infections. The incidence of ventilator-related pneumonia from December 1999 to July 2000 was 5.8 per 1,000 vent days in the CCU, which was on the high end of the national averages, Martin says. The quality improvement team saw an opportunity for improvement and found that, within 48 hours of hospital admission, the oropharynx of the CCU patient changed from mostly gram-positive organisms (normal mouth flora) to predominately gram-negative organisms, many of which are pathogens. Therefore, the team focused on better oral care. They added a dental oncologist and respiratory therapist to the team, with the goal of developing a standard procedure for oral care with respect to technique, products, and frequency. The team developed a comprehensive policy on oral care and taught the nursing staff and respiratory therapists.
• Antibiotic-impregnated catheters. Central venous catheters are integral to the treatment of critically ill patients, but they are the leading cause of primary bloodstream infection. To reduce the rate of infections, the quality improvement team introduced the use of central venous catheters impregnated with minocycline and rifampin.
• Medication errors. Medications for critically ill patients typically are numerous and complicated, increasing the risk of error. Most patients are seen by several physician specialists, resulting in a multitude of medication orders. Quite often, Martin says, the CCU staff was not sure if certain medication orders needed to be continued, discontinued, altered, or whether there was any conflict among the multiple orders.
"The team established a new procedure in which physician order forms are pre-printed each Monday with the patient’s medications," she says. "The intensivists and the primary team jointly review the medications and reorder only those that are required, thereby discontinuing some medications more rapidly. In addition, the team identified the most high-risk medications and developed protocols for their administration."
Positive outcomes, but at a cost
Martin says the quality improvement team’s work yielded substantial improvements in the CCU. Mortality in the CCU decreased from 22% in 1998 to 15.5% in 2001. The average length of stay decreased 18%, from 5.5 days to 4.5 days. She also says the improvements, especially the new staffing models, led to more content employees and decreased personnel turnover rates. The average turnover per month was 3% in 2000, but it decreased by 63% to 1.12% in 2001.
Pain-assessment documentation increased 49% over a three-month audit period. The patients’ family satisfaction surveys yielded mostly high scores for the CCU, but they also highlighted problems such as dissatisfaction with the waiting areas. The quality improvement team initiated the purchase of new furniture for the waiting areas and worked with the housekeeping staff to increase cleaning rounds, especially on weekends.
Restraint usage decreased 46% over a six-month period without increasing self-extubations. The introduction of antibiotic-impregnated catheters decreased catheter-related infections 96.6% for medical patients and 69.9% for surgical patients. The Monday review of medication orders results in an average reduction of about 9% of the drug orders, which staff say results in fewer side effects, errors, and drug interactions.
There were some significant cost savings as a result of the quality improvements, mostly related to the elimination of agency nurses, but the overall project was quite expensive, Martin says.
The addition of intensivists to the CCU costs the hospital in the neighborhood of $1 million a year, she says.
"A lot of people will look at this and say, Oh sure, M.D. Anderson can do it because they have the money,’" Martin says. "And that is true for some of these improvements. But when you look at the changes that led to some real improvements, most of what we’ve done could be done on a shoestring budget."
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