Rapid Adoption Network approach yields successful collaboration
Participating facilities report saving lives and money
As a growing number of quality initiatives have shown, quick change can be effective change, and that certainly appears to be the case with VHA Inc.'s Rapid Adoption Networks (RAN) collaborative addressing bloodstream infections, sepsis, and ventilator-associated pneumonia. The New Jersey and Pennsylvania hospitals that participated have saved more than $2.5 million and an estimated 29 lives, according to Irving, TX-based VHA.
"Rapid adoption slaps you in the face," says Sue Radick, RN, BSN, BPN, CRRN, patient safety/quality specialist at Abington (PA) Memorial Hospital. "Anyone who works on improvement projects knows that often we do not see outcomes for years." With this approach, she notes, you invest the time upfront, see the outcomes, and "everyone is happy."
What VHA did, she explains, was the following: "First they brought us in as group, sat us down, helped us to perform a gap assessment, and from there they helped us develop a blueprint for QI. We also had access to blueprints of other organizations who participated."
"You bang out the details in one fell swoop, and then you have rapid implementation," adds Suzanne Hendrick, RN, nurse director, critical care at the Crozer-Chester Medical Center in Upland, PA. "Several groups took it on, and they all came back and talked about successes and failures."
Different approaches
Although they both participated in the same collaborative, the two facilities were at different stages of change and faced different barriers. "For a while, there had been organizational recognition that we needed to do something about sepsis," says Radick. "There was a high mortality rate, but no consistent practice that addressed best clinical outcomes."
On the other hand, says Hendrick, "We were already part of the IHI 'Transformation of the ICU' project in 2004 focusing on putting in place the ventilator bundle, and we continued trying to build new protocols and methods to make sure we did not have any ventilator-associated pneumonias [VAPs]."
"The huge gap we faced was that there was no road map for care providers to follow no 'cheat sheet,' per se, on what you needed to do and what gave patients their best chance for survival," notes Radick. The solution to this problem, she says, "ultimately became our sepsis guidelines," which focused on such goals as early identification, aggressive fluids resuscitation, prompt administration of appropriate antibiotics, early involvement of specialists, and prompt transfer to critical care. (The entire guidelines can be found, below.)
"During our first meeting, they had several different infections that we should focus on, and even though we had been working on this and had a good foundation on VAPs, the body of evidence and practices change every day, so we incorporated new things and built on others," notes Hendrick.
One of the barriers that was identified was the weaning protocol, says Evelyn Easter, RN, clinical manager, critical care. "We did not have total buy-in from the intensivist staff, respiratory therapy, and nursing; we did not feel they worked collaboratively, and we did not have a solid weaning protocol driven by respiratory therapy which was what we wanted," she explains. "We did not want to have to wait for a doctor to say 'It's OK to extubate.'"
"We had recommendations from the CDC [Centers for Disease Control and Prevention] and other evidence-based data, but through participation in the collaborative we got to discuss common barriers and fixes with others face-to-face conversations with your peers on how they do it in other institutions," says Charleen Faucette, MT, director, infection prevention.
The staff ended up employing a progress note that the respiratory therapy department designed. "There's a signature line for RT, the nurse, and the physician or mid-level provider," Easter explains.
Education also was critical at Abington, says Pat Sorrentino, RN, CEN, clinical leader in the ED where the initiative started. "We educated 360 people," she reports. "We started by discussing what sepsis is; we brought on five educators because we are a large department. We had to educate staff on central line insertion."
In addition to the formal education sessions, Sorrentino says she put items in her monthly newsletter. "We do monthly reviews on charts and send out notification to the staff even if they're doing well," she adds. "We keep it going in unit councils, talking almost every month about how we're doing and it's now a yearly clinical competency, so we keep it alive." The department also changed its computer templates so they captured fluid volume and vital signs. "This heightened physician awareness of every bit of fluid volume we gave to the patients," Sorrentino explains.
It's also important to constantly monitor progress and correct compliance issues, says Easter. "We identified the fact that some staff were not being compliant in actually doing the sedation 'vacation,' and spontaneous awakening trials," she reports. "Some protocols were being interpreted instead of sticking to them."
How was the issue addressed? "We started meeting with staff, rounding in the morning with respiratory therapy and talking with nurses, asking why they were not compliant, what the problems were, and stressing that this was something that needed to happen," says Easter.
"With the rounding, the managers of respiratory therapy and nursing came in early, so it was performed with the night staff since many of the decisions were made in the night," adds Hendricks. "A lot of times rounding takes place during the day, even though the process may not involve the day staff."
Getting staff on board
At Abington, says Radick, Richard S. Eisenstaedt, MD, chair of the department of medicine, played a critical role in getting staff on board. "He went to the ED physician leaders and told them he needed a multi-disciplined team," she recalls. "They felt compassionate enough about it that they were willing to go the extra mile; they even came in on their days off."
In the beginning, she says, the ED physicians met every week, then every two weeks, and then monthly, along with critical care physicians, an infectious diseases doctor, two nurse leaders, and Radick herself. "If we had not gotten their buy-in it would have collapsed," she asserts, adding that whenever it looked like the team "hit a wall," the VHA folks came in and helped.
"Suzanne and I have open communication with the nursing staff," says Easter. "Any time there is a new initiative, we are very cognizant that we need to explain why we're doing what we're doing and make them part of the change process."
Critical care nurses, she continues, "are pretty smart people; they understand the ramifications of having people extubated early, getting them out of bed, and moving them along the continuum of care."
In addition, says Easter, "We always have key players talk to the staff, and we have very open relationships with quality and respiratory therapy; we're not afraid to identify problems."
Can't argue with results
Radick says her facility has exceeded its goals. "The literature says that overall sepsis mortality is between 33% and 50%," she shares. "We determined our baseline was around 40%, and we had hoped to decrease ours by 25% by the third-quarter of following the implementation guidelines."
As it turned out, she says, the first-quarter rate was 41%, but education had not been completed. "Early in the second quarter we went down to 28%, which was huge," Radick notes. Later on, she says, the figure went back up again, into the high 30s. "We saw through our monitoring that we were doing good work, and determined a better indicator was not to use hospitalwide data, but data based on what was in the ED," Radick says. Using that standard, she says, six quarters post-guideline, "we are at 83% survival, 17% mortality, and that's huge." The staff, she says, are now comfortable with the guidelines.
"Our last RAN was on the weaning protocol, which was built and implemented within three or four months, although we've been tweaking it since then," reports Hendrick.
"Our last VAP in a med/surg ICU was May 2007 41 months ago," notes Faucette.
The role of the quality manager
Mary Lou Lafreniere, CPHQ, RHIA, MBA, interim director, patient safety & quality at Chester, shares her thoughts on the role a quality manager should play in this and other QI initiatives. "In most of our projects, the quality manager usually works in a consultative way, as the unit managers really know what's happening on the front end," she says. "We try not to be intrusive, but rather act as a support person. If any barriers present themselves, we can help break those barriers down."
In addition, she says, "We integrate all PI activities into our monthly patient safety and quality committee meetings, and that information flows up to the board through a joint conference. There really is a sense of importance to the organization, and this group is very proud of what they've been able to do and accomplish."
"Our role is kind of like a gatekeeper, for lack of a better term," adds Radick. "We helped with the project management piece."
"They helped us with process mapping, and they kept us on task," says Sorrentino. "They also asked about things we hadn't thought about."
"We're kind of like a change agent," Radick adds, "And we reel them back in when they get off track. I also make sure everyone maintains a professional, courteous manner."
Another key to the project's success, she continues, is accountability. "VHA contacted me and my colleagues on a regular basis for updates; I felt I was accountable to them because they gave us our tools," she says. "There were even times when we would have preferred to postpone a scheduled conference, but they said no; they expected to hear from us. They were relentless." Because she has so many competing priorities, she adds, she might have let part of this initiative go had she not had those constant reminders.
"You have to get the right people at the table to begin with," adds Sorrentino. "Think about who should be at the table, get them to buy in, make sure they are able to work as a team, and employ diligence and perseverance. Keep your eye on the prize; you can't let it go."
Sepsis Guidelines for the Emergency Trauma Center
PURPOSE: To provide guidelines for the identification, evaluation, and management of patients who present to the Emergency Trauma Center (ETC) with severe sepsis or septic shock.
I. Patient Identification and Initial Management
- Patients ≥18 years of age with suspected diagnosis of sepsis will be prioritized for prompt physician evaluation and activation of Sepsis Guidelines if indicated.
- Triage nurse or triage team leader identifies appropriate patients with suspected sepsis and informs Charge Nurse for prompt bed placement and appropriate allocation of resources.
- When patients are identified during bedside triage or physician evaluation, notification of the primary nurse will occur for prompt response to orders. Primary nurse will inform Charge Nurse when additional resources required.
- Determine source or potential source of infection.
- Determine if source will require specialty consultation.
- Prioritize medical management and stabilization with intravenous (IV) fluids and prompt antibiotic administration.
- Core temperature < 96.8 or > 100.4
- Heart rate > 90 beats/minute
- Respiratory rate > 20 breaths/minute
- White blood cell count < 4000 or > 12,000 or > 10% bands
- Prompt ETC physician evaluation and/or re-evaluation
- Vital sign reassessment every 15 minutes.
- Repeated 500 ml NSS boluses up to 2-3 liters (or 30 ml/kg) until SBP > 90 mm Hg or MAP > 65 mm Hg or at the discretion of the treating ETC physician.
* In order to identify patients earlier in the sepsis continuum, only one of the traditional four SIRS criteria is required.
II. Activation of Sepsis Guidelines
- The ETC physician will activate the Sepsis Guidelines when there is inadequate response to fluid resuscitation and SBP remains < 90 mm HG or MAP < 65 mm HG
- ETC physician may activate the Sepsis Guidelines at any time prior to the fluid resuscitation based on their clinical judgment.
- ETC physician may choose not to activate the Sepsis Guidelines for select patients whose BP remains < 90mm Hg if the patient's clinical condition is stable and there are no other clinical features consistent with evolving shock.
- ETC physician will inform the Administrative Associate (AA) to STAT Call:
- Critical Care Bed Coordinator for bed assignment.
- Critical Care Resident
- Lenfest ICU bed - call cell phone:
- #7107 (weekdays)
- #7626 (nights and weekends)
- All other ICU beds or no bed assigned – contact Toll Daylighter/Moonlighter at:
- #7155 (day, nights, weekends)
- Critical Care Medicine Attending Physician
- ETC physician will inform Administrative Associate (AA) to:
- STAT call Surgery or Subspecialist for consultation.
- Contact Critical Care Bed Coordinator for bed assignment.
- When admitted under surgery or subspecialty service, the appropriate admitting resident will be notified to place orders for the ICU admission.
- After 30 minutes, if an admitting service is not determined, the ETC physician will contact the service he or she feels would be most appropriate for admission.
- If that service is not in agreement with admission to their service, the ETC physician will contact an alternate service to discuss.
- If the alternate service is not in agreement with admission to their service, they will contact the original service to discuss the case.
- If a joint decision between those services cannot be determined within 30 minutes, the ETC physician will determine the appropriate admitting service.
III. Roles and Responsibilities
- Triage Nurse
- Identify appropriate patients with suspected infection using above criteria.
- Prioritize bed assignment and notification of the ETC Charge Nurse for room assignment.
- Prompt evaluation of all patients with an infection or suspected infection meeting above criteria.
- Initiate medical management and stabilization.
- Initiate Sepsis Guidelines if patient does not respond to initial fluid resuscitation.
- Insert central line if inadequate peripheral access (adequate access will allow a 500ml fluid bolus to be administered within 15-20 minutes).
- Antibiotics should be ordered and initiated within one hour, based on enclosed guidelines or following consultation with infectious disease specialist.
- Emergent management will also include continued fluid resuscitation.
- ETC physician may choose to monitor central venous pressure, continuing aggressive fluid resuscitation if the CVP <10 and systolic BP <90 (or MAP <65).
- Alternatively, aggressive fluid management in hypotensive patients may continue without the need for CVP monitoring.
- In most patients with septic shock, neither the initiation of pressor therapy or concerns of volume overload would preclude continuing with an additional 2-3 liters of intravenous fluids.
- If a pressor is required, norepinephrine or dopamine would be the preferred pressor.
- Patients with drug allergy to one of the recommended antibiotics;
- Patients with suspected meningeal or CNS infection;
- Patients at risk for opportunistic or otherwise unusual infection by virtue of immunosuppression, recent travel, occupational or environmental exposure or any other confounding or atypical clinical features;
- Activate Sepsis Guidelines in ED PulseCheck and contact consultant services.
- Document in clinical record the time urgent consults are placed and corresponding response times.
- Re-page consults if no response occurs within 10 minutes.
- Advise ETC physician of any response delays.
- Direct consults to ETC Physician.
- Document in ED PulseCheck when ICU resident presents to emergency department (resident is responsible for informing AA of their arrival).
- Prompt response for patient assessment and completion of sepsis order sets.
- Establish two separate adequate IV access sites (adequate access will allow a 500ml fluid bolus to be administered within 15-20 minutes).
- Obtain and send labs: CBC/Diff/Platelets, CMP, PT/PTT, and lactate level (preferably without tourniquet).
- Obtain two sets of blood cultures from two separate sites prior to antibiotic administration and accurately document time and site of blood draw via ED PulseCheck Templates.
- One set may be obtained at time of IV placement after the site is prepped with Chlorahexidine Gluconate (CHG) scrub for 30 seconds.
- Do not flush catheter prior to drawing specimen.
- Assist with prompt patient placement to room for physician evaluation.
- Access ED PulseCheck to assure prompt room assignment is placed by the bed coordinator.
- Communicate with Patient Flow Center to prioritize bed assignment when indicated.
- Facilitate admission process.
- Notify primary nurse when bed ready.
- Contact Daylighter/Moonlighter at cell phone #7155 for disposition questions.
- Evaluate patient in the ETC within 30 minutes of Sepsis Guideline activation.
- Notify the AA of their arrival in the ETC.
- Prioritize critical care bed assignment.
- Enter room assignment into the ED PulseCheck system.
- Communicate bed availability or plan of action with ETC Charge Nurse.
- Goal from bed request to patient transfer is 90 minutes.
Source: Abington Memorial Hospital.
As a growing number of quality initiatives have shown, quick change can be effective change, and that certainly appears to be the case with VHA Inc.'sYou have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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