Collaborative Quality and Safety Initiatives within the SICU

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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

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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

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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
People Service Quality Growth/Finance Innovation
We will provide a caring, respectful, and encouraging work environment that supports ongoing professional development opportunities and meaningful recognition for all employees. We continuously improve how we serve others. We provide evidence-based, patient/family-centered care that is safe, timely, effective, efficient, and equitable. We will manage our resources efficiently and wisely. We will develop new approaches to improve care, to enhance patient, family, and staff education, and to facilitate teamwork and collaboration.
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Pillar Objectives
People Service Quality Finance/ Growth Innovation
Turnover 12.5 or less New hire retention 67.5 or higher after 18 months Community survey action plans updated quarterly with progress toward goals measured, documented, and communicated to work group Participation in future community surveys greater than 85 Overall quality of care 95th percentile or percent excellent increase by 3 per quarter Overall teamwork between doctors, providers, nurses, and staff 95th percentile or percent excellent increase by 3 per quarter Patient engagement 95th percentile or percent excellent increase by 3 per quarter Solicit internal customer feedback, establish baseline performance, identify improvement opportunities, and establish targets Standardized Infection Ratio 1.11 Adverse Events 7.67/1000 patient days Hand hygiene compliance 100 Develop and implement standardized process for handover communication Establish baseline performance Identify opportunities for improvements and establish targets Identify publication opportunities and provide support for developing ideas and manuscripts Manage our staffing within budget Reduce inappropriate increases in LOS by 10 (ie, delays in discharge) Reduce supply charges Eliminate waste Decrease lost charges Create a process for capturing innovative staff ideas Develop a process for assessing the effectiveness of and implementing innovative ideas across the PCC Recognize innovative best practices
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9T3 patient volume
6 beds closed due to staffing
Travelers added

• 2010 1240 admissions to the ICU designated beds

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SICU Snapshot - 2010

• 1240 admissions to the ICU designated beds
• Average admissions per year 2005 2010 1244

2010 2005 through 2010
Mean APACHE II 16.3 16.3
Mean APACHE II Predicted Mortality 25.0 24.8
Mean UHC Predicted Mortality 10.8 9.4
Actual in hospital mortality 9.1 8.3
APACHE II gt 20 29.5 28.7
Mean length of stay 4.46 days 4.76 days
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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

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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

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Specialized Supporting Personnel

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

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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
• gt 95 of pt management occurs without friction
• Markedly determined by quality and volume of high
  level communication of pathophysiology and
  management goals

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The MDSCC model

• SICU team
• MDSCC faculty
• Critical Care fellow
• 2 mid-level residents
• 3 interns
• 8 ACNPs
• Nursing, PharmD, Respiratory, Nutrition
• Daily rounds
• 730 1000am daily (except Friday 900)
• Mid-levels and fellow present 630 730 am for
  primary team communication

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MDSCC oversight and reporting structure
Institutional Critical Care Committee
SCC Steering Committee Beauchamp, Sandberg,
Abumrad, Jones, Miller, May (Chair) , Parmley,
Guy, Carr, Financial Admin.
Medical Directors Forum
MDSCC Leadership A. May Chair L. Weavind, M.
Dortch D. Meyer, A. Stanieski, Lead NP
Dept. Surgery MM
MDSCC A. May Chair All faculty
ACNP Nursing Leadership PharmD
Process Coordinator Respiratory
Therapy 9N/S Medical
Director Chair - Medical
Directors/ICCC
SICU MM 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
CC Tower ACNP Assist. Director
Surgical RRT John Barwise Med Director Barbara
Gray Proc Coord.
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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 Orde
r Sets
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MDSCC EffortsManagement 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

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Guidelines, Policies, and Procedureshttp//stagin
g.mc.vanderbilt.edu/surgery/trauma/mdscc.htm
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Glycemic Control
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SICU Euglycemia WIZ VGR
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Comparison of manual to computerized protocol results Comparison of manual to computerized protocol results Comparison of manual to computerized protocol results Comparison of manual to computerized protocol results Comparison of manual to computerized protocol results
Manual n 309, Computerized n 243, p
Total glucose values Total glucose values 11,175 10,003
Median glucose values per patient Median glucose values per patient 18 12 0.27
Glucose values in target range (80110 mg/dL) Glucose values in target range (80110 mg/dL) 34.0 41.8 lt0.001
hyperglycemic glucose levels (gt150 mg/dL) hyperglycemic glucose levels (gt150 mg/dL) 15.1 12.8 lt0.001
Time to goal, h Time to goal, h 15 12 0.23
patients reaching target range in 12 h patients reaching target range in 12 h 62.1 69.1 0.47
Mean glucose value (mg/dL) Mean glucose value (mg/dL) 120 116 lt0.001
hypoglycemic episodes hypoglycemic episodes 0.54 0.23 lt0.001
patients with 1 hypoglycemic event patients with 1 hypoglycemic event 11 7.8 0.25
patients with gt2 hypoglycemic events patients with gt2 hypoglycemic events 4.2 1.2 0.04
Hypoglycemic glucose lt 40 mg/dl JPEN. 2008 3218-27. JPEN. 2008 3218-27. JPEN. 2008 3218-27. JPEN. 2008 3218-27.
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Sedation
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Implementing goal directed sedation
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Implementing goal directed sedation therapy588
pts, 1735 audit days, 86 ventilated, 86
vasopressors, mean APACHE II 16
Age (Mean SD) 58 14 yr
Alert (RASS 0 to -1) 62 (1,075/1735)
Sedated (RASS -2 to -3) 25 (435/1735)
Heavily sedated (RASS -4, -5) 9 (142/1735)
Agitated (RASS gt0) 5 (83/1735)
Ever delirium (CAM-ICU positive) 122/144 (85)
of values at target RASS 78.7
over sedated (gt1 from ordered) 10.3
under sedated (gt -1 from ordered) 4.7
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Infection reduction and prevention
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Reduction of nosocomial ICU infections
VAP BSI UTI
Daily spontaneous breathing assessment/trial Guideline for full barrier sterile precautions Foley care guidelines
Targeted sedation On-line checklist and compliance monitoring Foley removal protocol and screening
HOB Antibiotic coated catheters
Oral/dental hygeine Chlorhexidine prep
Hypopharyngeal suctioning Chorhexidine BiopatchTM
Stress ulcer prophylaxis Daily documentation of continued indication
On-line compliance monitoring
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Ventilator Bundle (2002-present)
Parameter Team approach
1 Spontaneous Breathing Trials RTs
2 Richmond Agitation Sedation Scale MDs and RNs
3 Head of bed elevation RNs
4 Oral care RNs
5 Dental hygiene RNs
6 Hypopharyngeal suctioning RNs
All critically ill patients received stress ulcer
prophylaxis and deep venous thrombosis prophylaxis
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Ventilator Dashboard (July 2007-present)
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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
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Individual Parameter Compliance
Parameter Aug 07 Oct 07 Nov 07 Jan 08 Feb 08 Apr 08 May 08 Jul 08
SBT 86 (75-97) 91 (87-94) 93 (92-95) 97 (95-100)
RASS 85 (82-89) 88 (82-94) 93 (88-99) 98 (97-98)
HOB 92 (89-95) 92 (87-97) 96 (93-100) 98 (97-99)
Swab 84 (78-90) 87 (86-88) 94 (88-100) 98 (97-98)
Teeth 95 (94-97) 95 (92-98) 99 (97-100) 99 (99-100)
HySx 73 (53-92) 76 (65-87) 92 (83-100) 95 (94-96)
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Complete Parameter Compliance
Average improvement 6 per month
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Demographic and Clinical Covariates
January 2005-June 2007 August 2007- July 2008 p
Age (years) 58.8 16.5 59.7 16.1 0.82
BMI (kg/m2) 28.3 7.2 32.0 8.7 0.05
APACHE II 17.8 5.1 22.0 5.6 lt0.01
Ventilator days prior to VAP 7 (5.5-10.5) 9 (5-20) 0.28
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SICU VAP Rates
Expected
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SICU NHSN INFECTION RATES
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ProtocolCompliance Tool

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

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What results do these efforts achieve
VUMC - SICU BSI RATES1999 - 2001
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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

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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

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VUMC TICU SICUEBM Guideline Protocols

• 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

• 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

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MDSCC EffortsCommunication 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

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Bedside RN Rounds Presentation Sheet

• Tmax
• BP
• HR/Pulse
• Neurological Status
• Sedation (RASS/CAM)
• Pain Mgt
• IV Fluids
• Insulin Protocol
• IO
• Braden Score
• 24H Nursing Issues

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Components of procedural safety
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Procedural timeout and checklists
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Standardization of post-op handover

• Process
• Personnel
• Format - SBAR

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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

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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 700
  to 730 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 gt 7 days
• Enhance family communication
• Assist with PMG development and implementation

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MDSCC / SICU ACNP Model
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Thank-you!