Collaborative Quality and Safety Initiatives within the SICU

1. Collaborative Quality and Safety Initiatives within the SICU Devin Carr, MSN, RN, RRT, ACNS-BC, NEA-BC Administrative Director Surgery and Trauma Patient Care Center

2. Acknowledgements Addison K. May, MD, FACS, FCCM Professor of Surgery and Anesthesiology Director, Surgical Critical Care Program Director, Surgical Critical Care and Acute Care Surgery Fellowship Division of Trauma and Surgical Critical Care MDSCC Leadership Team Surgery and Trauma PCC Board

3. Surgery/Trauma PCC Strategic Plan Why we exist Mission The Surgery and Trauma Patient Care Center supports the mission of Vanderbilt University Medical Center in meeting the healthcare needs of our community. We are dedicated to the highest standards in patient care, education, and research. What we want to be Vision The Surgery and Trauma Patient Care Center will be a national leader in quality, service, value, and employee engagement by creating an environment that inspires, motivates and rewards our staff. What we must achieve to be successful Goals

4. Pillar Objectives

7. 9T3 patient volume 6 beds closed due to staffing Travelers added • 2010: ~1240 admissions to the ICU designated beds

8. SICU Snapshot - 2010 • 1240 admissions to the ICU designated beds • Average admissions per year 2005 – 2010 = 1244

9. MDSCC ‘s Systematic Approaches To Assuring Quality and Safety • Efforts categorized by: • Structure, methodology, support • Management and disease specific processes • Management guidelines and protocols • Computerized order-sets and monitoring • Compliance monitoring • Communication and handovers • health care teams • physician teams • Families

10. Surgical Critical Care Practice Model • Multidisciplinary Surgical Critical Care Service • Collaborative care model • Dedicated ICU team availability • Consultation policy for all patients • Evidence based “best-practice” guidelines • Aggressive PI and QA program • Database and severity scoring for “real-time” analysis of outcomes and changes

11. Specialized Supporting Personnel • Dedicated Clinical PharmD • Nutritionist • Process Coordinator/Quality Consultant (Surgical Critical Care Platform) • Dedicated Respiratory Therapy Team • Procedure Support Nurses

12. Management responsibility and rationale • Primary team maintains ultimate authority and responsibility • Primary team – long standing patient relationship • Best understanding of specialty specific physiology • Ultimate liability • MDSCC team responsible for order entry • Reduces diffused lines of communication, multiple order entry, medication errors, and facilitates single plan of care • > 95% of pt management occurs without friction • Markedly determined by quality and volume of high level communication of pathophysiology and management goals

13. The MDSCC model • SICU team: • MDSCC faculty • Critical Care fellow • 2 mid-level residents • 3 interns • 8 ACNPs • Nursing, PharmD, Respiratory, Nutrition • Daily rounds: • 7:30 – 10:00am daily (except Friday – 9:00) • Mid-levels and fellow present 6:30 – 7:30 am for primary team communication

14. SCC Steering Committee Beauchamp, Sandberg, Abumrad, Jones, Miller, May (Chair) , Parmley, Guy, Carr, Financial Admin. Medical Directors Forum Institutional Critical Care Committee MDSCC oversight and reporting structure MDSCC Leadership A. May – Chair L. Weavind, M. Dortch D. Meyer, A. Stanieski, Lead NP Dept. Surgery M&M MDSCC A. May – Chair All faculty ACNP Nursing Leadership PharmD Process Coordinator Respiratory Therapy 9N/S Medical Director Chair - Medical Directors/ICCC SICU M&M B. Collier - Chair fellows, faculty, nursing, Pharm D, Proc. Coord. SICU PI/QA B. Collier – Chair faculty, nursing, PharmD, fellows, ACNP, Inf Contr SICU ACNP Group Lead ACNP + ACNP group Lisa Weavind - MD Liaison Education Director Surgical RRT John Barwise – Med Director Barbara Gray – Proc Coord. CC Tower ACNP Assist. Director

15. Nursing education Ancillary education Resident education Attending education • Informatics Systems • T Anders, C Kleymeer • Computer order sets • Links • Web pages MDSCC PI & QA Program Model Medical Director – Addison May PCC Administrator –Devin Carr PI/QA Executive Committee • Physician members • P Pandharipande • L Weavind • Nursing members • R Benoit – Educator • Staff RN • Others • M Dortch Pharmacist • M Travis Infection control • ACNP representative Committee Chair – Bryan Collier PI Coordinator – B Gray SICU nurse manager – D Meyer Nursing & Ancillary Staff Resident & Attending Staff Database Reports Nursing & Ancillary Staff Input Resident & Attending Staff Input PI initatives Management Guidelines Protocols Order Sets

16. MDSCC Efforts:Management and disease specific processes • Maintenance of euglycemia • Sedation guidelines • VAP initiatives • Antibiotic Stewardship • Central line initiatives • Skin breakdown initiatives • Inadvertent extubation initiatives • Hand hygiene initiative • SICU common order-sets • Protocol compliance monitoring • Bedside surgical procedure processes • Transfusion guidelines

17. Guidelines, Policies, and Procedureshttp://staging.mc.vanderbilt.edu/surgery/trauma/mdscc.htm

18. Glycemic Control

19. SICU Euglycemia WIZ VGR

21. Sedation

22. Implementing goal directed sedation

23. Implementing goal directed sedation therapy588 pts, 1735 audit days, 86% ventilated, 86% vasopressors, mean APACHE II 16

24. Infection reduction and prevention

25. Reduction of nosocomial ICU infections

26. Ventilator Bundle (2002-present) All critically ill patients received stress ulcer prophylaxis and deep venous thrombosis prophylaxis

27. Ventilator Dashboard (July 2007-present)

28. Implementation of a Real-Time Compliance Dashboard Helps Reduce SICU Ventilator-Associated Pneumonia with the Ventilator Bundle Victor Zaydfudim MD, Lesly A. Dossett MD MPH, John M. Starmer MD, Patrick G. Arbogast PhD, Irene D. Feurer PhD, Wayne A. Ray PhD, Addison K. May MD, C. Wright Pinson MBA MD. Supported by the National Research Service Award T32 HS 013833 from the Agency of Healthcare Research and Quality, US Department of Health and Human Services

29. Individual Parameter Compliance

30. Complete Parameter Compliance Average improvement 6% per month

31. SICU VAP Rates Expected

32. SICU NHSN INFECTION RATES

33. ProtocolCompliance Tool • Allows monitoring of procedures across units • Tool utilized by nursing personnel to ensure 100% compliance • Enhances recognition that practices alter infection rates

34. What results do these efforts achieve VUMC - SICU BSI RATES1999 - 2001 Multidisciplinary Critical Care in the SICU

35. Directed efforts to improve line access and maintenance • 4 / 2010: • “Scrub the hub” • Blood culture guidelines • Since recent initiatives • 440 days without CLA-BSI • 97 days x 1 • 38 days x 1

36. Methods to reduce bacterial resistance • Infection prevention in the ICU • Antibiotic stewardship programs • Appropriate antibiotic use Indication for, breadth of, length of exposure • Antibiotic class issues • Antibiotic rotation • Outbreak management

37. VUMC TICU & SICUEBM Guideline & Protocols • AB Stewardship Protocols • AB Rotation • AB De-escalation • AB Prophylaxis • Peri-operative prophylaxis • ICP Monitor • Traumatic Orthopedic Fractures • Penetrating Abdominal Trauma • Craniofacial Trauma • Dx/Rx of pneumonia • Bronchoscopy/Quantitative BAL • Dx/Rx of sepsis • Rx fungal infections • Hand Hygiene Program • Transfusion guidelines • Intensive Insulin Protocol • Skin breakdown risk assessment protocol • Critical Care Nutrition Guidelines • VAP Bundle • Head of bed elevation • Oral hygiene • Daily spontaneous breathing screening and trials • ICU Sedation/Analgesia – RASS Scale • Stress Ulcer/DVT Prevention • Central line insertion & management • Lung protective ventilator protocol

38. MDSCC Efforts:Communication and handovers • Bedside nurse inclusion in rounds • Standardize communication, reduce errors • Daily goals and charge nurse rounding • Ensure consistent communication of plan of care • Procedure support nurse • Standardize processes, scheduling with team • Family rounds and open visitation • SICU team cell phones – faculty/fellow, charge nurse, intern • Electronic MR log – team notification of patient transfer • Computerized warning for orders outside of ICU • SICU time out • Full consultation for all SICU patients

39. Bedside RN Rounds Presentation Sheet • Tmax • BP • HR/Pulse • Neurological Status • Sedation (RASS/CAM) • Pain Mgt • IV Fluids • Insulin Protocol • I&O • Braden Score • 24H Nursing Issues

40. Components of procedural safety

41. Procedural “timeout” and checklists

42. Standardization of post-op handover Process Personnel Format - SBAR

43. Rationale for the use of ACNP in the SICU • to achieve mandatory MDSCC consultation within the SICU • to enhance utilization of and compliance with numerous management guidelines, protocols, and policies • to achieve enhanced throughput • to achieve enhanced family communication • to enhance continuity of care

44. Roles of the SICU - ACNPs: • Manage 4-8 patients in the SICU not currently being covered by MDSCC team • Round on these patients with MDSCC attending 7:00 to 7:30 to assist with throughput • At bedside for arrival of all daytime admissions (~through peak hours of 3-6pm) • initial screening of patients for full team involvement • initial order entry on these patients • Assist with procedures • Develop a system for evaluation of support needs/placement of patients in the ICU > 7 days • Enhance family communication • Assist with PMG development and implementation

45. MDSCC / SICU ACNP Model

46. Thank-you!