June 10, 2011 1

Collaborative Quality and Safety Initiatives within the SICU

Devin Carr, MSN, RN, RRT, ACNS-BC, NEA-BCAdministrative Director

Surgery and Trauma Patient Care Center

Acknowledgements

Addison K. May, MD, FACS, FCCMProfessor 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

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.

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.

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.

Goals

Vision

Mission

Surgery/Trauma PCCStrategic Plan Why we

exist

What we want to be

What we must achieve to be successful

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 communicationo Establish baseline

performance o 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

o Eliminate wasteo 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

9T3 patient volume

6668

70

7470

7886 87

72

82

68

89

82 83 82

7275 76

91

81

9087 85 86

89

6065707580859095

% bed occupancy

Travelers added

6 beds closed due to staffing

• 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

20102005 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 > 20 29.5% 28.7%

Mean length of stay4.46 days

4.76 days

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MDSCC ‘s Systematic Approaches To Assuring Quality and Safety

Efforts categorized by:1. Structure, methodology, support

2. Management and disease specific processes– Management guidelines and protocols– Computerized order-sets and monitoring– Compliance monitoring

3. Communication and handovers– health care teams– physician teams – Families

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

> 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

Institutional Critical Care Committee

MDSCC oversight and reporting structure

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SICU M&MB. Collier - Chair

fellows, faculty, nursing, Pharm D, Proc. Coord.

SICU PI/QAB. Collier – Chair

faculty, nursing, PharmD,

fellows, ACNP, Inf Contr

SICU ACNP GroupLead ACNP + ACNP group

Lisa Weavind - MD Liaison

Education Director

MDSCC LeadershipA. May – Chair

L. Weavind, M. DortchD. Meyer, A. Stanieski, Lead NP

SCC Steering CommitteeBeauchamp, Sandberg, Abumrad, Jones,

Miller, May (Chair) , Parmley, Guy, Carr, Financial Admin.

Medical Directors

Forum

MDSCC A. May – Chair All faculty ACNP Nursing Leadership

PharmD Process Coordinator Respiratory Therapy 9N/S Medical Director Chair - Medical Directors/ICCC

CC TowerACNP Assist.

Director

Dept. Surgery M&M

Surgical RRTJohn Barwise – Med DirectorBarbara Gray – Proc Coord.

MDSCC PI & QA Program Model

Committee Chair – Bryan Collier

PI Coordinator – B GraySICU nurse manager – D Meyer

Physician members•P Pandharipande

•L Weavind Nursing members

R Benoit – EducatorStaff RNOthers

•M Dortch Pharmacist•M Travis Infection control

• ACNP representative

PI/QA Executive Committee

Database Reports

Nursing &

Ancillary Staff Input

Resident & Att

ending Staff Input

PI initativesManagement Guidelines

ProtocolsOrder Sets

Nursing & Ancillary StaffResident & Attending Staff

Nursing education

Ancillary education

Resident education

Attending education

Informatics Systems T Anders, C Kleymeer

• Computer order sets• Links

• Web pages

Medical Director – Addison MayPCC Administrator –Devin Carr

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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

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

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GLYCEMIC CONTROL

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SICU Euglycemia WIZ VGR

Comparison of manual to computerized protocol results

Manualn 309,

Computerizedn 243,

p

Total glucose values 11,175 10,003

Median glucose values per patient 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

Time to goal, h 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

Hypoglycemic = glucose < 40 mg/dl JPEN. 2008; 32:18-27.

SEDATION

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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 sedationOn-line checklist and compliance

monitoring

Foley removal protocol and

screening

HOBAntibiotic 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 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

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)

Individual Parameter Compliance

Complete Parameter Compliance

Average improvement 6% per month

SICU VAP Rates

Expected

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SICU NHSN INFECTION RATES

LF

Time end (catheter secured):

MR #:

Check if:

Femoral

Internal Jugular

/ / Date:

Type of catheter:

Triple lumen Introducer Swan-Ganz

Insertion Site:

Subclavian

Other (specify):

Pt/Family teaching done Consent obtained

Pre-insertion skin prep (check any used): Alcohol Betadine (povidone-iodine) Chlorhexidine Other (specify):

Describe the circumstances under which this line was placed: Non-emergent Emergent (life-threatening or code situation)

Please file page 2 in patients chart and return top form to the designated location in the ICU.

List all sites where insertion was attempted. Other (specify):

: Time start (1st needle stick): :

How many different needle sticks did the patient receive (number of skin breaks)? 1 Unknown

The provider inserting this line:

* If “No”, was this procedure supervised by someone with least five (5) central lines experience? Yes No Didn’t ask

Yes No

Please use military time (i.e. 1:00 pm is 13:00)

a. Handed-off his/her pager before the procedure? Yes No b. Washed hands immediately prior to procedure? Yes No *

Didn’t ask Didn’t ask Didn’t ask c. Has previously placed at least five (5) central lines?

Describe the level of training of the person who actually inserted the line? Medical Student Intern (PGY-1) Resident (PGY-2+) Fellow Attending

Barrier precautions (check any used): Sterile gloves Sterile gown Mask Sterile towels Full body drape

Side: Right Left

2 3 4 5 6+

Follow-up CXR: Ordered Not ordered (specify reason):

CXR findings (check all that apply): No pneumothorax Pneumothorax (describe action taken): Catheter in good position Catheter position adjusted (describe):

Type of dressing: Bio-occlusive Gauze Other (specify):

Patient tolerated the procedure well? Yes No

Was the sterile field maintained throughout the entire procedure? Yes No

Complications? None Other (describe):

Dressing applied by: Nurse Proceduralist Other (specify):

Nursing Checklist: Central Venous Catheter Insertion

Vanderbilt University Medical Center

RIJ LIJ RSC LSC RF

Guidewire exchange

Placement unsuccessful

MC 2705 (Rev. 06/04)

NOTE: Please use either black or blue ink to complete this form.

Comments:

Vascath

Signature: ______________________________________________ Date: _________________

Indications for use: Pressors Hemodynamic monit. Fluids/blood products Frequent lab draws

Pre-existing infection

Nurse Practitioner

Double lumen

atVanderbilt

Monroe Carell Jr. OR

CCU MICU SICU BICU PCCU NICU

NSICU TICU Other

ProtocolCompliance Tool

Allows monitoring of procedures across units

Tool utilized by nursing personnel to ensure 100% compliance

Enhances recognition that practices alter infection rates

Multidisciplinary Critical Care in the SICU 35

0.00

2.00

4.00

6.00

8.00

10.00

BSI Rate 5.76 6.65 8.07

NNIS 5.31 5.31 5.31

1999 2000 2001

VUMC - SICU BSI RATES1999 - 2001

What results do these efforts achieve

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 & 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

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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

Tmax

BP HR/Pulse Neurological Status

Sedation (RASS/CAM)

Pain Mgt IV Fluids Insulin Protocol I&O Braden Score 24H Nursing Issues

Bedside RN Rounds Presentation Sheet

Components of procedural safety

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

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

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MDSCC / SICU ACNP Model

Thank-you!