Improving Outcomes in the ICU: Experience at Exeter Hospital

1. Improving Outcomes in the ICU:Experience at Exeter Hospital Richard D. Hollister, MD Director, ICU Chairman, ICU Best Practices Committee Department of Pulmonary/Critical Care Medicine

8. Do checklists and other forms of disciplined, systematic care work in the ICU?

9. Evidence-Based Examples Checklists for Central line insertion Checklists to prevent ventilator-associated pneumonia Mandatory intensivist consultation for ICU level patients Protocols to treat Septic Shock Protocols to manage hyperglycemia Multidisciplinary ICU rounds

12. ICU leadership structure ICU nurse manager: Anne Steele, RN Physician Directors: Paul Deranian, MD; Alan Gladstone, MD; Richard Hollister, MD; David London, MD; Mark Reiner, MD Administrative Liaisons: Anne Marie Bularzik, VP, CNE; Barbara Hughes, DNP, RN, VP System Quality Clinical leaders: Carol Allard, RN; Kellie Cosgrove, RN; Melissa Keith, RN; Cathy Hackett, RN; Lisa Kennedy, RN, Margaret Rosset, RN Nurse educators: Carol Frock, RN (ICU); Chris Bone, RN (PCU); Melissa Pollard, RN

13. ICU leadership and direction Monthly Critical Care committee meeting represented by Intensivists, IM, Anesthesia, Cardiology, Hospitalist, nursing, administration, RN educators, pharmacy, Infection control. Monthly ICU Best Practice committee: establish and implement protocols that reflect evidence-based means to optimize outcomes

15. What constitutes ICU �Best Practices?� Initiation of rapid response teams Tight glucose control Prevention of ventilator associated pneumonia Prevention of catheter-related blood-stream infections Intensivist-led ICU/Mandatory consultation Multidisciplinary rounding approach Protocols for treatment of severe sepsis/septic shock

16. Exeter Hospital ICU pre-2007 Prior to 2007, our ICU model was �Open� Any EH medical staff physician could admit to the ICU without intensivist oversight Intensivists were on site but only called in at the sole discretion of the staff physician Problems with orchestrating care: multiple consultants, providers not always immediately available at the bed side. �Nobody coordinating all of the patient�s care� Problems with failure to rescue: intensivists called in late, after pt �crashed� or after organ failure in advanced stages.

17. 2007 - Intensivist led ICU Mandatory phone call to the intensivist for all ICU admissions Intensivists lead the care on all ventilated patients and on all but the most stable ICU level patients The intensivist reviews the ICU census every day and reserves the right to become involved/orchestrate the care of any ICU level patient at any time.

18. Buy-In Focus on research/data: Ideas don�t take flight unless there is a sound basis in evidence Pronovost JAMA 2000 Meta-analysis of Intensivist-led care in the ICU Leap-Frog group Society of Critical Care Medicine Measure outcomes

19. Buy-In

20. Buy-In Medical Division Meeting Surgical Division Meeting Hospitalist Group Meeting Exeter Hospital Quarterly Staff Business Meeting Medical Executive Committee Cardiology Group Meeting

21. Buy-In

23. Multidisciplinary Rounds in the ICU: Who participates? Intensivist Patient�s nurse for the day ICU clinical leader Respiratory therapy PhD clinical Pharmacist Nutrition Social Work Palliative care

24. Multidisciplinary Rounds in the ICU: Nuts and Bolts Data is collated by nursing including 24 hour events, vital signs, I/O�s, iv infusions, line and endotracheal tube insertion dates, tube feed rates, skin integrity, lab data, culture data, ventilator data and abg�s. The data is read off to the entire team while the intensivist documents in his note Respiratory therapy confirms vent settings PhD pharmacist recites all medications and dosages in front of team based on EMR.

27. Multidisciplinary Rounds in the ICU: Generating a daily plan Sedation and vent changes are made in real time while team is present (very important for vent weaning) Nutrition recommendations are made in the proper clinical context and account for nursing, physician and patient perspectives Questions are encouraged and answered. Medication dosing adjustments are made according to pharmacist�s input in real time reducing possibility of dosing errors or failing to dose drugs in therapeutic range. Social issues are communicated to the whole team allowing for one unified message to reach patients and their families during the day. Major therapeutic goals for the day are shared amongst all team members

28. Quantifying ICU outcomes Ventilated patient Mortality Catheter-related blood stream infections Ventilator associated pneumonia Measuring Severity of Illness Reporting Illness-adjusted Outcomes

29. Ventilator-associated pneumonia: What Works? REMOVAL OF THE ENDOTRACHEAL TUBE Hand washing between pt contacts Elevate the HOB Scheduled drainage of condensate from ventilator circuits (we use heated wire circuits that prevent condensation build-up) Continuous subglottic suctioning Maintenance of adequate cuff pressure in the ETT

30. Ventilator-associated pneumonia �It�s hard to get VAP if you are not intubated� Daily sedation vacation Daily spontaneous breathing trial once FiO2 below 50% and PEEP of 5 or less All intubated patients are managed by board-certified intensivists Stress ulcer prophylaxis Tight blood glucose control that is protocol driven

31. Nursing Care of the Ventilated Patient Mouth care with special kits every 4 hours. Keeping the head of the bed > 30 degrees (when possible)�track and trend. Stress ulcer disease prophylaxis�track and trend. Deep vein thrombosis prophylaxis�track and trend. Daily sedation vacations�track and trend.

32. Exeter Hospital: Ventilator Associated Pneumonia

33. Catheter-related bloodstream infections �You can�t get a line infection if you don�t have a line� Daily nursing and physician examination of line site Daily assessment of line necessity: Can we take it out? Use of PICC lines when appropriate when access needed only for TPN, antibiotics or lab draws Infection control places reminder notes in progress note section of chart asking physicians to document why line remains in place (outside of the ICU) Experienced operators insert the vast majority of central lines: Board certified Intensivists, General and Vascular surgeons Tight blood glucose control that is protocol driven

34. Catheter-related bloodstream infections Arrow antimicrobial triple lumen catheter kits that contain Chlorhexidine prep Full sterile barrier All other triple lumen catheter kits have been removed from patient care areas (OR, ER, ICU). We use only one kit type.

36. Nursing Care of the Patient with a Central Line Change dressing every 6 days or as needed Daily assessment of need for central line in multidisciplinary rounds Survey on central line insertions (hand washing prior to procedure, use of sterile gown, gloves, and large drape, mask, cap, chlorhexadine prep, and site used)�tracking and monitoring.

38. Exeter Hospital: Catheter related blood stream infections

40. APACHE: What is it? A rigorously validated set of equations that predict the likelihood of ICU mortality and ICU length of stay based on numerous physiologic and clinical parameters that are easily identified and quantified.

41. APACHE IV Data derived from 104 ICUs 45 hospitals Over 100,000 patients

42. Components of APACHE IV Acute Physiology Score (max points) Pulse: 17 Mean BP: 18 Respiratory Rate: 18 PaO2 or A-aDO2: 15/14 Hematocrit: 3 WBC: 19 Creatinine: 7 UOP: 15 BUN: 12 Sodium: 4 Albumin: 11 Bilirubin: 18 Glucose: 8 Glasgow Coma Score Age Chronic Health Conditions ICU admission Data Admitting Diagnosis

43. Goals for FY 2008: In Progress Implement Induced Hypothermia protocol for cardiac arrest APACHE IV Scoring (Continue) Severe Sepsis/Septic shock protocol Roll out Multidisciplinary Rounds to the Progressive Care Unit

44. How do we continue to change?How do we continue to adapt?