Overview

A community hospital dramatically improved the quality and safety of care for ICU patients using an evidence-based collaborative improvement model.

Issue: Despite the good intentions of care teams, evidence-based practices associated with improved patient outcomes are not universally followed in health care delivery. [1] Interventions to improve patient safety outcomes in the intensive care unit (ICU) have been successfully demonstrated in academic settings. [2] However, developing patient safety practices that can be successfully replicated in diverse community settings remains a challenge. The ICU—which accounts for up to one-third of total hospital costs—is an ideal place to initiate patient safety improvement efforts. ICU patients are at greater risk for health care–associated infections because they undergo intensive treatments while having a limited ability to defend themselves from errors. Patients receiving mechanical ventilation, for example, are susceptible to developing ventilator-associated pneumonia, a complication that is associated with higher death rates, longer ICU and hospital stays, and increased costs estimated at $40,000 per case. [3]

Objective and Intervention: To improve the effectiveness and safety of patient care in its ICU, the Porter Valparaiso Hospital Campus ICU joined the Transformation of the Intensive Care Unit (TICU) national collaborative sponsored by VHA Inc. (Specific clinical goals are described below, under Measures.)

Organizations: The Porter Valparaiso Hospital Campus is a 300-plus-bed community hospital located in Valparaiso, Indiana. Community physicians admit and are responsible for the care of patients in the hospital's 13-bed, medical-surgical ICU and eight-bed cardiac care unit. VHA, Inc., formerly Voluntary Hospitals of America, is a health care cooperative based in Irving, Texas, that serves not-for-profit organizations across the United States. The TICU collaborative grew out of the Idealized Design of the ICU initiative jointly sponsored by VHA and the Boston-based Institute for Health Care Improvement.

Date of Implementation: In November 2003, Porter joined more than 50 hospitals participating in the TICU collaborative.

Target Population: The intervention targets critically ill patients in the ICU.

Key Measures: The TICU collaborative goal is for 90 percent of patients on mechanical ventilation to receive the "ventilator bundle"—care processes that research shows improve outcomes. [4] The care processes are:

• weaning assessment to determine if ventilator use can be discontinued,
• ensuring appropriate sedation so that patients follow commands at least once per day,
• elevating the head of the bed by at least 30 degrees to prevent gastric juices from being aspirated into the lungs, and
• providing prophylaxis for peptic ulcers and deep venous thrombosis.

Porter also set a goal of achieving tight serum glucose control (80–110 mg/dl) among ICU patients, which research shows reduces complications, mortality, and length of stay. [5]

Process of Change: The Porter critical care division manager, critical care educator, and a physician leader attended TICU-sponsored educational sessions led by quality improvement experts at Johns Hopkins Medical Institutions and Hartford Hospital. The team prepared for change by identifying potential barriers and planning how to overcome them. For example, physician "buy-in" was promoted through educational presentations at medical staff meetings and regular articles in a monthly physician newsletter. The team started with a goal of improving bed elevation compliance. Signs were posted above every patient bed and clinicians were encouraged to check bed elevation upon entering rooms. After demonstrating success, the team turned to what can be a difficult change for many institutions: achieving tight glucose control. Nurses made suggestions on ways to improve adherence to the glucose protocol and were given progressively more autonomy to manage the protocol over time.

In addition to improving "ventilator bundle" care processes (see Measures, above), a program of regular oral care was initiated to reduce the risk of bacteria migrating through the ventilator from a patient's mouth to the respiratory tract and causing pneumonia. The success of these initiatives encouraged staff to improve infection control measures for reducing nosocomial infections associated with central intravenous lines. This included use of a cart stocked with the standardized supplies needed for maximum barrier precautions and other changes such as the use of antibiotic-coated catheters. Frequent hand washing and the use of hand sanitizer were promoted during a mandatory education day, and signs encouraging compliance by clinicians and family members were posted at the entrance to every patient room. Process and outcomes data were collected using a Web-based application that produces ICU performance reports for feedback to nursing and medical staff.

Results: Performance on "ventilator bundle" measures improved from a low of 20 percent adherence on weaning assessment before the intervention to 100 percent adherence across all five measures after six months. Tight glucose control was achieved for three of five ICU patients in the month after implementing the glucose protocol from less than one of five patients. At the same time, hypoglycemic episodes were nearly cut in half. Ventilator-associated pneumonia and catheter-related bloodstream infections were eliminated in the ICU for five and nine months, respectively. Antibiotic-resistant infections (MRSA/VRE) were reduced by 50 percent. There have been no new cases of renal failure among ICU patients since the glucose protocol was implemented. The ICU mortality rate decreased from more than 20 percent to 7 percent (see figure), and the average ICU length of stay declined by one day after the intervention.

Lessons Learned: "While we've always had a focus on quality and safety," says Terri Gingerich, R.N., critical care educator at Porter, the TICU collaborative provided a framework for evidence-based improvement that "enabled us to pull our assets together" for transformational change. Collaborative learning allows an institution to identify promising approaches in others' experiences and "modify them to fit your own house," Gingerich says. "Not everything that works in one institution works in another." Although flexible in its implementation, Porter is uncompromising in basing process changes on proven evidence—an approach the team found critical to establishing credibility with physicians. Nurses now respectfully question physicians if a patient is not being treated according to an evidence-based protocol and keep copies of research studies close at hand in case a physician should question the evidence.

Gingerich attributes the ICU's fast pace of change to the decision to tackle one of the most difficult problems—glucose control—early on. Observable improvements in wound healing and survival were dramatic compared with prior experience, creating momentum for ICU staff to take the initiative in making further changes. Strategies for change often were simple, such as placing visual cues in strategic locations and enlisting as many people as possible to check for compliance. Any nurse passing a patient room who noticed a bed was not properly elevated, for example, would stop and correct it. Bringing ICU staff and physicians together to work on improvement created a heightened sense of teamwork and respect in the Porter ICU. "Physicians never miss an opportunity to praise staff" for their contributions and everyone is treated as an equal part of the care team, according to Gingerich. The ability to make a difference in improving patient care has "reignited" the spirits of ICU nurses, she adds.

While conventional wisdom has been that nosocomial infections are an unavoidable side effect of critical care, this attitude no longer prevails at Porter. Nurses now take personal responsibility for the safety of every patient and are empowered to stop those violating infection control practices. The attitude is, "we are going to do all we can to protect our patients," Gingerich says. After a high-risk patient developed ventilator-associated pneumonia, for example, the team reviewed the case to see if anything could have been done differently to prevent a similar occurrence. As word of the ICU team's success spread through the hospital, others have wanted to share in the success. As a result, ICU staff vacancies have been eliminated, similar improvements are being implemented in the cardiac care unit, and the hospital is exploring how to bring comparable changes to other units.

Implications: Hospitals need a flexible structure for quality improvement that balances validity and feasibility so that they can apply evidence-based practices in the local setting, according to Peter Pronovost, M.D., Ph.D., associate professor of anesthesiology and critical care medicine at Johns Hopkins University and medical director for TICU. Although labor-intensive to collect, outcomes data are valuable as they can demonstrate results to the care team and hospital management, says Lisa Schilling, R.N., director of the TICU collaborative for the VHA. The ability to apply best practices in community settings challenges the assumption that high-quality care can be found only in large academic centers. "There isn't an institution in the country that doesn't have the ability to make the changes we did," says Gingerich. "We've shown that you can get the same standard of care in your own community" as in the best institutions. Johns Hopkins researchers estimate that these kinds of ICU best practices reduce costs and could prevent thousands of deaths each year if applied nationwide. [6][7]

Related Results: Among all ICUs participating in the second year of the VHA TICU collaborative, ventilator-associated pneumonias declined by 41 percent, ICU patient mortality by 18 percent, and average length of stay by 11 percent, according to an Oct. 8, 2004, presentation by Schilling at the TICU national meeting in Philadelphia. These results follow previously reported improvements among hospitals participating in the first year of the collaborative. [8] Nineteen ICUs participating in a new VHA sepsis care improvement initiative have reduced patient mortality by 69 percent and average ICU length of stay by 36 percent after one year.

For Further Information: Contact Terri Gingerich, R.N., critical care educator for Porter, at tgingerich@portermemorial.org and Lisa Schilling, R.N., director of the VHA Transformation of the ICU national collaborative, at lschilli@vha.com.

References
1. P. J. Pronovost et al. (2004) Interventions to reduce mortality among patients treated in intensive care units. J. Crit. Care 19, 158–64.
2. S. M. Berenholtz et al. (2004) Eliminating catheter-related bloodstream infections in the intensive care unit. Crit. Care Med. 32, 2014–20.
3. K. M. Vande Voorde and A. C. France. (2002) Proactive error prevention in the intensive care unit. Crit. Care Nurs. Clin. North Am. North Am. 14, 347–58; Centers for Disease Control and Prevention. (2004) Guidelines for Preventing Health-Care–Associated Pneumonia.
4. S. M. Berenholtz et al. (2004) Improving care for the ventilated patient. Jt. Comm. J. Qual. Saf. 30, 195–204.
5. G. van den Berghe et al. (2001) Intensive insulin therapy in the critically ill patients. N. Engl. J. Med. 345, 1359–67.
6. P. J. Pronovost et al. (2004) Interventions to reduce mortality among patients treated in intensive care units. J. Crit. Care 19, 158–64.
7. S. M. Berenholtz et al. (2004) Eliminating catheter-related bloodstream infections in the intensive care unit. Crit. Care Med. 32, 2014–20.
8. P. J. Pronovost et al. (2004) Improving sepsis care in the intensive care unit: An evidence-based approach. VHA Research Series.

This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.