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

“A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day…Remarkably, the nurses and doctors were observed to make an error in just one percent of these actions—but that still amounted to an average of two errors a day with every patient”

The Boeing Model 299: First tested in flight October 30, Later known as the B-17 Flying Fortress. “The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion…[The pilot] had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as one newspaper put it, ‘too much airplane to fly.”

The pilot was not “experienced enough” The pilot was not “vigilant enough” The pilot needed “more education” The airplane was “too complex to fly” The airplane was “doomed to failure” Why did the 299 crash?

“They came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing and taxiing…With checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident.”

Do checklists and other forms of disciplined, systematic care work in the ICU? Yes!

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

How have we implemented changes in ICU care at Exeter Hospital?

ICU is not a place. ICU is a SYSTEM OF CARE.

ICU leadership structure ICU nurse manager: Anne Steele, RN ICU nurse manager: Anne Steele, RN Physician Directors: Paul Deranian, MD; Alan Gladstone, MD; Richard Hollister, MD; David London, MD; Mark Reiner, MD 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 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 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 Nurse educators: Carol Frock, RN (ICU); Chris Bone, RN (PCU); Melissa Pollard, RN

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

Exeter Hospital Quality Committee Critical Care committee Physician ICU directors Staff RNs & Clinical leaders Pharmacy RN educators Administration Infection control ICU Best Practices Committee Medical staff members Surgical staff members Administration Nursing leadership

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

Exeter Hospital ICU pre-2007 Prior to 2007, our ICU model was “Open” Prior to 2007, our ICU model was “Open” Any EH medical staff physician could admit to the ICU without intensivist oversight 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 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 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. Problems with failure to rescue: intensivists called in late, after pt “crashed” or after organ failure in advanced stages.

Intensivist led ICU Mandatory phone call to the intensivist for all ICU admissions 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 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. 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.

Buy-In Focus on research/data: Ideas don’t take flight unless there is a sound basis in evidence 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 Pronovost JAMA 2000 Meta-analysis of Intensivist-led care in the ICU Leap-Frog group Leap-Frog group Society of Critical Care Medicine Society of Critical Care Medicine Measure outcomes Measure outcomes

Buy-In Communicate

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

Buy-In Take every opportunity, formal and informal, to explain to the medical/surgical staff why these initiatives are important

Multidisciplinary Rounds “I not only use the brains that I have but all that I can borrow.” -Woodrow Wilson

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

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. 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 The data is read off to the entire team while the intensivist documents in his note Respiratory therapy confirms vent settings Respiratory therapy confirms vent settings PhD pharmacist recites all medications and dosages in front of team based on EMR. PhD pharmacist recites all medications and dosages in front of team based on EMR.

Robyn Fortney, LICSW Vickie Irwin, RD Kristen LeBoeuf, RN Paul Deranian, MD Intensivist Lindsay Brooks, Pharm. D. Jennifer Devaney, RN Carol Allard, RN Clinical Leader David Hill, RT Rick Hollister, MD Intensivist Not pictured: Patrick Clary, MD Palliative Care

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) 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 Nutrition recommendations are made in the proper clinical context and account for nursing, physician and patient perspectives Questions are encouraged and answered. 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. 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. 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 Major therapeutic goals for the day are shared amongst all team members

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

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

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

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

Exeter Hospital: Ventilator Associated Pneumonia ZERO ventilator associated pneumonias in over 400 patient vent- days

Catheter-related bloodstream infections “You can’t get a line infection if you don’t have a line” “You can’t get a line infection if you don’t have a line” Daily nursing and physician examination of line site Daily nursing and physician examination of line site Daily assessment of line necessity: Can we take it out? 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 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) 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 Experienced operators insert the vast majority of central lines: Board certified Intensivists, General and Vascular surgeons Tight blood glucose control that is protocol driven Tight blood glucose control that is protocol driven

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

Nursing Care of the Patient with a Central Line Change dressing every 6 days or as needed Change dressing every 6 days or as needed Daily assessment of need for central line in multidisciplinary rounds 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. 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.

Exeter Hospital: Catheter related blood stream infections ZERO line infections in over 800 patient line-days

APACHE IV Acute Physiology And Chronic Health Evaluation Quantifying severity of illness and predicting mortality in the ICU

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. 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.

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

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

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

“In command and out of control” * How do we continue to change? How do we continue to adapt? *originally attributed to management guru, Kevin Kelly “The first thing I told our staff is that we Would be in command and out of control…By that I mean that the Overall guidance and the intent were provided by me and the senior leadership, but the forces in the field wouldn’t depend on intricate orders coming from the top. They were to use their own initiative and be innovative as they went forward.”