ICU Interventions to Improve Care

Why This Talk?

Quality improvement is rewarding Change culture Reasons for reluctance
Dont believe the data Bundles are not necessary Do not want to be told how to practice medicine Inconvenient Too much time Too many mandates and protocols already Will be used to punish physicians if not incorporated

ICU Bundles
A "bundle" is a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually.
www.ihi.org.

ICU Checklist / Goal Sheet

Checklists serve as a daily reminder to a set tasks or processes that improve the delivery of care but are not necessarily linked or bundled together

Why bundles and checklists?

Ensures best medicine is applied with complete consistency The consistent application of established best practices leads to improved outcomes and decreased complications Accountability

ICU Interventions
Ventilator Bundle Central Line Bundle Sepsis Bundle* Multidisciplinary rounds Daily Checklist / Goal sheet Glucose Control* Sedation/analgesia Delirium

Ventilator Bundle
Elevation of the Head of the Bed Daily interruption of sedation and assessment of readiness to wean Peptic Ulcer Disease Prophylaxis Deep Venous Thrombosis Prophylaxis Daily Oral Care with Chlorhexidine

Results of Implementation
After institution of ventilator bundle VAP rates decreased from 2.7 - 8.2 per 1000 MV days to 0.0 - 3.3 per 1000 MV days. Benefis Medical Center

Ventilator Bundle Tips

Daily interruption of sedation protocol Coordinate interruption of sedation with weaning protocol Use of validated sedation scale Incorporate other ICU staff Use visual cues Standardized order sets Checklists / multidisciplinary rounds

Central Line Bundle

Appropriate hand hygiene Chlorhexidine skin prep Maximal barriers for central line insertion Subclavian vein placement is preferred site Review lines daily and remove unnecessary catheters
MMWR 2002;51(No. RR-10):1-36

Improvement
1500 ICU months and 300,000 catheter-days during the sustainability period were reported Mean rate of catheter-related bloodstream infections
Baseline; 7.7 per 1000 catheter-days 16-18 months; 1.4 per 1000 catheter-days 34-36 months; 1.1 per 1000 catheter-days
N Engl J Med 2006; 355:2725 BMJ 2010 Feb 4; 340:c309

Tips
Rigorous staff education Central line checklist Keep all necessary equipment in an easily accessible cart Empower nursing to enforce use of a central line checklist Include daily review of line as part of multidisciplinary rounds and daily goals sheet Easy to find record of date and time of placement

Central Line Checklist

Prevention of Catheter Infections

Antiseptic- or antibiotic-impregnated CVC Anti-infective lock Chlorhexidine-impregnated sponge dressing

Sedation and Analgesia

Protocol-directed sedation Use of validated sedation scale Bolus doses of benzodiazepines instead of a continuous infusion Sedatives with a short duration of action Daily interruption of sedation (DIS) also referred to as spontaneous awakening trials

Daily Interruption of Sedation Benefits

Decrease ventilator days Decrease LOS ICU and Hospital Decrease complication, i.e. VAP Decreased medication complications Decreased delirium Decreased cost of care

Barriers and Tips

Barriers
Lack of nursing acceptance Time constraints Perceived patient safety Long-term psychological sequelae

Tips
Education Involve nursing and support staff in development of protocols Success breeds success

No sedation
A Protocol of No Sedation For Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Trial
Strom T, Martinussen T, Toft P Lancet. 2010;375:475-480

140 mechanically ventilated adult patients randomized in an unblinded manner to receive either no sedation or sedation Patients in both groups received intravenous morphine as needed for analgesia No sedation had significantly more days without ventilation (13.8 days vs 9.6 days), shorter stay in the intensive care unit and in the hospital Agitated delirium and haloperidol use were more frequent in the no sedation group

Early ICU Mobility

Decreases time on ventilator Decreases LOS ICU Decreases LOS hospital Decreased delirium Decreased use of benzodiazepines and narcotics Improves functional ability at time of discharge Improved feeling of wellbeing (standardized questionnaires) Safe: no difference in complications

Data
Early activity is feasible and safe in respiratory failure patients Crit Care Med 2007;35:139 Early exercise in critically ill patients enhance short-term functional recovery Crit Care Med 2009; 37:2499 Early intensive care unit mobility therapy in the treatment of acute respiratory failure Crit Care Med 2008; 36:2238 Needham DM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010; 91:536-542 Early intensive care unit mobility therapy in the treatment of acute respiratory failure Critical Care Med 2008, 36: 2238 Early physiotherapy in the intensive care unit Respir Med 2005; 99:1096

Early Intensive Care Unit Mobility Therapy in the Treatment of Acute Respiratory Failure
Statistically more likely to have physical therapy, have therapy initiated in ICU, and have more PT sessions First out of bed; usual care 11.3 days vs protocol 5 days (p=0.001) Decreased ICU LOS; 8.1 days vs 7.6 days. (p =0.084) Decreased hospital LOS 17 days vs 14.9 days (p = 0.048) Hospital costs: Usual care Protocol Team salaries $6805 $7309 Cost per PT $44,302 $41,142 Proportion of protocol patients at each level Level 1; 26.7% Level 2; 7.3% Level 3; 10.9% Level 4; 55.1% Crit Care Med 2008; Vol 36:p 2238

Therapy Protocol
Crit Care Med 2008; Vol 36:p 2238

Mobility Tips
Protocol for sedation with daily interruption of the sedation Develop safety-related guidelines regarding when patients were considered eligible for mobility and who determines eligibility Coordination between the nurse, respiratory therapy, and therapist Appropriate staffing of therapists Consider early physiatrist consults for patients with anticipated prolonged ICU stays

Delirium
Risk factors
Patient: old age, alcoholism, impaired hearing, impaired vision, HTN, depression, smoking, baseline cognitive impairment Critical illness: acidosis, anemia, sepsis/fever, hypotension Preventable: Medication, sleep disturbance, immobilization

Delirium
Assessment of delirium in the ICU
Intensive care delirium screening checklist (ICDSC) Confusion assessment method for the ICU (CAM-ICU)

Minimizing risk factors where possible Sedation protocols and sedation holds

Delerium
Sedation and analgesia medication Sleep deprivation Immobilization

Delerium and sedation in the intensive care unit: Survey of behaviours and attitudes of 1384 healthcare professionals

71% use sedation protocol 76% written policy on spontaneous awakening trial (SATs) 44% practice SATs on more than half of days 59% screen for delirium 33% use a specific screening tool
Crit Care Med 2009; 37:825

Foley Catheters
Remove foley catheter as soon as possible Securement device Reminder systems may reduce catheterassociated urinary infections (CAUTIs)
52% decrease in the rate of CAUTIs and a 37% reduction in the mean duration of catheterization
Clin Infect Dis. 2010;51:550-560

Multidisciplinary Rounds
Coordinate care between all care givers Discuss plans and required staff to implement plans Discuss bundles and checklists Culture change Saves providers time Save on multiple pages Incorporates the family into the team.

Multidisciplinary Rounds
Physician (team leader) Nurse Respiratory therapy Pharmacy Representative physical therapy, occupational therapy, speech therapy, and rehab coordinator Dietician Social worker / discharge planner Palliative care coordinator Individual designated to document

Rounds Tips
Multiple models Implement slowly Consider adding family when ready Considerate of time

Checklist / Goal Sheet

Checklist: reminder to evaluate a limited number of specific medical interventions, preventative measures, bundles and processes to improve consistency of care Goal sheet: outlines the goals of the medical therapy defined by the multispecialty team to be completed that day

Daily Checklist / Goal Sheet

Decrease errors of omission, create reliable and reproducible evaluations, improve quality standards and use of best practices Facilitate communication Integrate the multiple other bundles and care processes required in the ICU

Checklist / Goal Sheet

Room to improve
Barriers Relapses Need for repetitive education
Staff Doctors

Everyone needs to buy-in

Starting the Process

Identify and prioritize the projects Create a multidisciplinary team Enlist all stakeholders to identify the potential barriers, opportunities, and resources for the project and help find appropriate solutions Prepare the project and build support Create data collection and reporting system to provide accurate baseline data and document improvement. Introduce strategies to change clinician behavior and create the change that will produce improvement Continue to reevaluate and change as necessary

Starting the Process

Champions Continuous education Direct feedback on success Change in culture

HELP
Institute for Healthcare Improvement
WWW.IHI.ORG

Society of Critical Care Medicine Paragon Qualitity Improvement

WWW.SCCM.ORG