Maryland ICUs collaborate to revamp care processes
Center is recognized for patient safety strategies
How would you like to reduce ventilator-associated pneumonia at your organization’s intensive care unit (ICU) by 19%, and decrease bloodstream infections by 36%, in only eight months? Those are the impressive results achieved by hospitals participating in the Maryland Patient Safety Center’s ICU Safety Culture Collaborative.
The group received the National Quality Forum and Joint Commission on Accreditation of Healthcare Organizations’ 2005 John M. Eisenberg Patient Safety and Quality Award for national/regional innovation in patient safety, for strategies that have dramatically improved care in the ICUs of Maryland hospitals.
Thirty-eight Maryland ICU teams committed to a goal of reducing ventilator-acquired pneumonia, improving care processes for medication administration, and reducing central line-associated bloodstream infections.
"There is a lot of motivation and energy around improving ICU care processes and outcomes. The center has leveraged that energy and pulled together 30 hospitals to work on specific safety objectives," says Debbie Christian, MSc, BSN, the center’s director of patient safety interventions. In early 2006, the center will launch an Emergency Care Safety Culture Collaborative.
The hospitals came together at three points during the year, with multidisciplinary teams including quality managers, risk managers, nurses, respiratory therapists, pharmacists, and physicians, each with a physician leader and an executive sponsor.
During these workshops, the teams exchanged ideas and reported on tangible improvements achieved at their own organizations. In addition, teams participated in conference calls, performed weekly rounds to identify safety issues, and gave skills training to staff.
"Organizations are reporting to us that the resources needed to address many safety issues identified by teams during safety rounds are often inexpensive, usually costing only a couple hundred dollars. But the impact is great, with visible changes," says Christian.
"Multidisciplinary rounding has improved the quality of work life. Now nurses aren’t afraid to ask doctors questions, and pharmacists are part of the team."
Here are some unique aspects of the center’s Safety Culture Initiative:
• Real-time data are used.
Most of the data used by the Center are collected "live" in real time, rather than retrospectively, which typically is what hospitals use to identify problem areas, says William F. Minogue, MD, FACP, director of the Maryland Patient Safety Center.
"By looking at the data real-time, you can determine whether the small-scale improvements are actually doing what you expect," he says. "The take-home message is that the data are collected to determine how to improve care."
In addition, data collection is incorporated into the care process so that data are collected and used in the course of daily work, Minogue adds.
"The benefit of the real-time data is that you can intervene for the patient that is there right now," says Margaret Toth, MD, chief quality officer of the Delmarva Foundation and leadership council member at the center. "With retrospective data, there is nothing we can do once the patient has left without the care that they need."
For example, specific practices can make ventilator-associated pneumonia less likely, such as raising the head of the patient’s bed and giving medications to prevent blood clots.
"By rounding on all patients, we can see in real time how we are doing. Did 100% of our patients get 100% of what they needed today?" asks Toth. "And if not, what can we do right now today, to make sure that tomorrow we do better?"
• The teams work collaboratively.
When it comes to patient safety, competition shouldn’t exist, says Toth. "Our hospitals, which are competitors, have demonstrated that they are working cooperatively and sharing safety information, which is pretty extraordinary," she says.
The teams found that they were coping with similar challenges, such as getting patients weaned off ventilators in a timely and appropriate manner. "Our hospitals were really struggling with this," says Christian. "When we started talking with the clinicians about it, a number of them did not have a protocol in place to address it."
The center asked several of the ICU teams to form a work group to review existing protocols and find one that worked for them. "We ended up with a few hospitals testing the protocol the work group liked best. That caught on, and now 20 ICU teams are using this protocol," says Christian. "By working on the same issue, each contributed their unique skills."
• A daily goal is set for each day, with input from caregivers.
In the past, clear-cut goals for each patient fell through the cracks in the busy ICU setting, says Toth. To address this, the teams began doing multidisciplinary rounding with daily goals for each patient, such as for a heart failure patient to lose an additional three pounds of water weight.
"If towards the end of the day, they see that the patient gained a pound of water instead, the care team has a clear marker for immediately looking into what is preventing the patient from progressing and making changes that are needed as quickly as possible," says Toth.
At Carroll Hospital Center in Westminster, MD, caregivers ask the question "What do we need to do to move this patient closer to leaving the critical care unit?" during daily rounds.
"Patients’ critical care presentation and illness can be so complex that a simple intervention may slip through," says Kimberly Lau, RN, performance improvement coordinator. "Someone may have overlooked the need to order prophylaxis for peptic ulcer, or anticoagulation for DVT prophylaxis, which prevent complications."
Since daily rounds have been implemented, the percentage of patients with the head of the bed raised at a 30 degree angle, which prevents ventilator-associated pneumonia, has increased, says Lau. "The overall length of stay and the length of time patients spend on ventilators have both gone down," she adds.
[For more information, contact:
- Kimberly Lau, RN, Performance Improvement, Carroll Hospital Center, 200 Memorial Ave, Westminster, MD 21157. Telephone: (410) 871-6903. E-mail: [email protected].
- Debbie Christian, MSc, BSN, Director, Patient Safety Interventions, Maryland Patient Safety Center, 7240 Parkway Drive, Suite 400, Hanover, MD 21076. Telephone: (410) 712-7448. Fax: (410) 712-7401. E-mail: [email protected].
- William F. Minogue, MD, FACP, Director, 6820 Deerpath Road, Elkridge, Maryland 21075-6234. Telephone: (410) 540-9210. Fax: 410-540-9139. E-mail: [email protected].
- Margaret Toth, MD, Chief Quality Officer, Delmarva Foundation, 7240 Parkway Drive, Suite 400, Hanover, MD 21076. Telephone: (410) 712-7456. E-mail: [email protected].]
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