Transcript Document 7164144

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
June 10, 2011
1
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
2
Surgery/Trauma PCC
Strategic Plan
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.
Why we
exist
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.
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
evidencebased,
patient/famil
y-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.
What we must
achieve to be
successful
Pillar Objectives
People




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%
Service




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
Quality




•
Standardized Infection
Ratio ≤ 1.11
Adverse Events ≤
7.67/1000 patient days
Hand hygiene compliance
100%
Develop and implement
standardized process for
handover communication
o Establish baseline
performance
o Identify opportunities
for improvements and
establish targets
Identify publication
opportunities and provide
support for developing
ideas and manuscripts
Finance/
Growth



Manage our
staffing within
budget
Reduce
inappropriate
increases in LOS
by 10% (ie, delays
in discharge)
Reduce supply
charges
o Eliminate
waste
o Decrease lost
charges
Innovation



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
9T3 patient volume
95
90
85
80
75
70
65
60 66
% bed occupancy
6 beds closed due to
staffing
86 87
70
72
90
87
85 86
89
81
72
75 76
68
70
68
82 83 82
82
78
74
91
89
Travelers added
• 2010: ~1240 admissions to the ICU designated beds
SICU Snapshot - 2010

1240 admissions to the ICU designated beds

Average admissions per year 2005 – 2010 = 1244
2010
2005 through 2010
16.3
16.3
Mean APACHE II Predicted Mortality
25.0%
24.8%
Mean UHC Predicted Mortality
10.8%
9.4%
9.1%
8.3%
% APACHE II > 20
29.5%
28.7%
Mean length of stay
4.46 days
4.76 days
Mean APACHE II
Actual in hospital mortality
MDSCC ‘s Systematic Approaches To Assuring
Quality and Safety

Efforts categorized by:
1.
Structure, methodology, support
2.
Management and disease specific processes
–
–
–
3.
Management guidelines and protocols
Computerized order-sets and monitoring
Compliance monitoring
Communication and handovers
–
–
–
health care teams
physician teams
Families
9
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
Specialized Supporting Personnel

Dedicated Clinical PharmD

Nutritionist

Process Coordinator/Quality Consultant (Surgical
Critical Care Platform)

Dedicated Respiratory Therapy Team

Procedure Support Nurses
11
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
12
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
13
MDSCC oversight and reporting structure
SCC Steering Committee
Medical
Directors
Forum
Beauchamp, Sandberg, Abumrad, Jones,
Miller, May (Chair) , Parmley, Guy,
Carr, Financial Admin.
Dept. Surgery M&M
Institutional
Critical Care
Committee
MDSCC Leadership
A. May – Chair
L. Weavind, M. Dortch
D. Meyer, A. Stanieski, Lead NP
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
SICU PI/QA
SICU ACNP Group
B. Collier - Chair
fellows, faculty, nursing,
Pharm D, Proc. Coord.
B. Collier – Chair
Lead ACNP + ACNP group
faculty, nursing, PharmD,
Lisa Weavind - MD Liaison
fellows, ACNP, Inf Contr
Education Director
Surgical RRT
John Barwise – Med Director
Barbara Gray – Proc Coord.
CC Tower
ACNP Assist.
Director
14
MDSCC PI & QA Program Model
Medical Director – Addison May
PCC Administrator –Devin Carr
PI/QA Executive Committee
Committee Chair – Bryan Collier
PI Coordinator – B Gray
SICU nurse manager – D Meyer
Physician members
•P Pandharipande
•L Weavind
Nursing members
R Benoit – Educator
Staff RN
Others
•M Dortch Pharmacist
•M Travis Infection control
• ACNP representative
Nursing education
Ancillary education
Resident education
Attending education
Resident & Attending Staff Input
Nursing & Ancillary Staff Input
Database Reports
Nursing & Ancillary Staff
Resident & Attending Staff
Informatics Systems
T Anders, C Kleymeer
PI initatives
Management Guidelines
Protocols
Order Sets
• Computer order sets
• Links
• Web pages
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
16
Guidelines, Policies, and Procedures
http://staging.mc.vanderbilt.edu/surgery/trauma/mdscc.htm
17
GLYCEMIC CONTROL
18
SICU Euglycemia WIZ VGR
Comparison of manual to computerized protocol results
Manual
n 309,
Computerized
n 243,
11,175
10,003
18
12
0.27
Glucose values in target range (80–110 mg/dL)
34.0
41.8
<0.001
% hyperglycemic glucose levels (>150 mg/dL)
15.1
12.8
<0.001
15
12
0.23
% patients reaching target range in 12 h
62.1
69.1
0.47
Mean glucose value (mg/dL)‡
120
116
<0.001
% hypoglycemic episodes
0.54
0.23
<0.001
% patients with 1 hypoglycemic event
11
7.8
0.25
% patients with >2 hypoglycemic events
4.2
1.2
0.04
Total glucose values
Median glucose values per patient
Time to goal, h
Hypoglycemic = glucose < 40 mg/dl
p
JPEN. 2008; 32:18-27.
SEDATION
21
Implementing goal directed sedation
Implementing goal directed sedation therapy
588 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 >0)
5% (83/1735)
Ever delirium (CAM-ICU positive)
122/144 (85%)
% of values at target RASS
78.7%
% over sedated (>+1 from ordered)
10.3%
% under sedated (> -1 from ordered)
4.7%
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
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
Ventilator Dashboard (July 2007-present)
Implementation of a Real-Time Compliance
Dashboard Helps Reduce SICU VentilatorAssociated 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
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)
Complete Parameter Compliance
Average improvement 6% per month
SICU VAP Rates
Expected
SICU NHSN INFECTION RATES
33
MC 2705 (Rev. 06/04)
Vanderbilt University Medical Center
Monroe Carell Jr.
OR
atVanderbilt
Nursing Checklist:
Central Venous Catheter Insertion
Protocol
Compliance Tool
NOTE: Please use either black or blue ink to complete this form.
CCU
BICU
MR #:
/
Date:
Type of catheter:
Double lumen
Triple lumen
Introducer
Swan-Ganz
Vascath
Time start
(1st needle stick):
Insertion Site:
Internal Jugular
Subclavian
Femoral
Other (specify):
List all sites where insertion was attempted.
RIJ
LIJ
RSC
LSC
MICU
PCCU
Side:
Right
Left
RF
:
LF
Mask
NSICU
Other
Time end
(catheter secured):
Yes
No
Didn’t ask
Yes
No
Didn’t ask
Yes
No *
Didn’t ask
(5) central lines experience?
How many different needle sticks did the patient receive (number of skin breaks)?
1
2
3
4
5
6+
Unknown
Was the sterile field maintained throughout the entire procedure?
Yes
Pre-insertion skin prep (check any used):
Alcohol
Betadine (povidone-iodine)
Other (specify):
Follow-up CXR:
Ordered
CXR findings (check all that apply):
No pneumothorax
Catheter in good position
Bio-occlusive
Nurse
Patient tolerated the procedure well?
Complications?
None
Attending
Nurse Practitioner
No
Pre-existing infection
Pneumothorax (describe action taken):
Catheter position adjusted (describe):
Dressing applied by:
Gauze
Other (specify):
Proceduralist
Yes
Placement unsuccessful
Other (specify):
No
Allows monitoring of procedures
across units

Tool utilized by nursing personnel
to ensure 100% compliance
Full body drape
Not ordered (specify reason):
Type of dressing:

Other (specify):
Sterile towels
Chlorhexidine
:
Check if:
Consent obtained
Pt/Family teaching done
Guidewire exchange
Describe the level of training of the person who actually inserted the line?
Medical Student
Intern (PGY-1)
Resident (PGY-2+)
Fellow
Describe the circumstances under which this line was placed:
Non-emergent
Emergent (life-threatening or code situation)
SICU
Please use military time
(i.e. 1:00 pm is 13:00)
/
Indications for use:
Pressors
Hemodynamic monit.
Fluids/blood products
Frequent lab draws
The provider inserting this line:
a. Handed-off his/her pager before the procedure?
b. Washed hands immediately prior to procedure?
c. Has previously placed at least five (5) central lines?
* If “No”, was this procedure supervised by someone with least five
Yes
No
Didn’t ask
Barrier precautions (check any used):
Sterile gloves
Sterile gown
TICU
NICU
Comments:
Other (describe):
Please file page 2 in patients chart and return top form to the designated location in the ICU.
Signature: ______________________________________________ Date: _________________

Enhances recognition that
practices alter infection rates
What results do these efforts achieve
VUMC - SICU BSI RATES
1999 - 2001
10.00
8.00
6.00
4.00
2.00
0.00
BSI Rate
NNIS
1999
2000
2001
5.76
5.31
6.65
5.31
8.07
5.31
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
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
VUMC TICU & SICU
EBM Guideline & Protocols

AB Stewardship Protocols
—
Hand Hygiene Program

AB Rotation
—
Transfusion guidelines
AB De-escalation
—
Intensive Insulin Protocol



AB Prophylaxis
—
Skin breakdown risk assessment
protocol

Peri-operative prophylaxis

ICP Monitor

Traumatic Orthopedic Fractures

Penetrating Abdominal Trauma
—
Head of bed elevation

Craniofacial Trauma
—
Oral hygiene
—
—
Dx/Rx of pneumonia

Dx/Rx of sepsis

Rx fungal infections
VAP Bundle
—
Bronchoscopy/Quantitative BAL

Critical Care Nutrition Guidelines
—
—
Daily spontaneous breathing screening
and trials
—
ICU Sedation/Analgesia – RASS Scale
—
Stress Ulcer/DVT Prevention
Central line insertion & management
Lung protective ventilator protocol
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
Components of procedural safety
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
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
MDSCC / SICU ACNP Model
46
Thank-you!