Originally published in the December 2003 issue of Critical Connections,
Volume 2, Number 6.

Two intensive care units (ICUs) at Hartford Hospital have reported such positive results from the Transformation of the ICU (TICU) program that the hospital’s three other ICUs have joined the initiative.

“The project has helped instill a culture of safety and has improved overall quality of care,” says Al Herzog, MD, vice president of medical affairs at Hartford Hospital in Hartford, Connecticut. “The project originally started in two ICUs but we expanded it. We are so pleased that now all five of our ICUs have become involved.”

Eighteen months ago, Hartford Hospital enrolled the medical and surgical ICU teams in the TICU project. The goals of the TICU project, a national collaborative involving 25 hospitals, are to improve the quality and safety of ICU care, while optimizing patient care, reducing costs and increasing workforce satisfaction. The initiative uses evidence-based practices and innovative approaches to managing care to help ICUs meet a variety of clinical, financial and operational challenges. The TICU program is an outgrowth of a pilot project co-sponsored by the Institute for Healthcare Improvement (IHI) and VHA Inc., a national network of 2,200 community-owned healthcare organizations and affiliated physicians.

“The outcomes in the surgical ICU have been remarkable since we began the TICU program,” says Eric D. Dobkin, MD, senior associate director of surgical critical care and Hartford’s surgical ICU director. “Our mortality rate during the time period has dropped by almost 25%. We have also seen a dramatic decrease in the percentage of patients who stay longer than seven days — from 20% to 15%. We have decreased our length of stay by more than one day without any change in admission pattern or in readmission rate.”

Outcomes were also dramatic in the medical unit. “Our mortality has been creeping down from 21% over the last two years to 19%,” says Eric T. Shore, MD, director of the medical ICU at Hartford Hospital. “Our length of stay dropped from 5.3 days to 4.2 days — almost a 20% decrease. In addition, patient throughput increased by 17% — over 100 patients, compared with the previous year. Using the same 12 beds, with a shortened length of stay, we are able to get more patients in.”

Hartford Hospital is an 814-bed facility with a long and rich history in critical care. The hospital has had a multidisciplinary team directed by an intensivist in its surgical ICU for almost 15 years, as well as one of the nation’s oldest accredited surgical critical care fellowships. Hartford’s five ICUs contain 58 beds and operate in a modified-intensivist private practice setting, with intensivist coverage provided 24 hours a day, seven days a week.

Al Herzog, MD

“Before implementing these changes, we believed that we provided excellent care but thought that we could be better. What we were lacking was a framework to help us move to the next level of care,” explains Dr. Dobkin. “We liked the TICU project for a variety of reasons. We especially liked the program’s focus on results. The project required us to measure what we did and offered a simple Web-based tool to enter data. This system provides real-time results, which allows for rapid feedback. The power of results cannot be underestimated.”

Dr. Dobkin also praises the TICU faculty and mandatory inclusion of senior leadership. “We thought this was extremely valuable because physicians and nurses often run into barriers at the administrative level. The VHA’s requirement that senior administration be involved as a participating team member ensured that this was going to be a quality endeavor,” he says.

Dr. Shore agrees: “Hartford Hospital’s senior leaders understand and have bought into the TICU project. Most importantly, they are supporting it financially. The ICU transformation has spanned a greater range of people than any other single Hartford Hospital performance improvement (PI) project because senior administrators come to our meetings and know the entire team.”

The TICU faculty included such SCCM leaders as Peter Pronovost, MD, PhD, FCCM and Thomas Rainey, MD, FCCM, Laura Adams, a leader in improving healthcare quality and service, along with experts in the fields of nursing, workforce, end-of-life care, financial issues, and program management.

As vice president of medical affairs, Dr. Herzog is the VHA liaison. He notes that institutional change has to be driven both from the bottom up and the top down. “I recommend administrators at other hospitals seriously consider TICU,” he says. “This is one of the best things we can do to improve ICU care. This helped us instill cultural safety and that spilled over into other areas.”

All three agree that the biggest challenge TICU faces is winning employee confidence and enthusiasm. “There was resistance until we started showing results,” notes Dr. Dobkin. “Now they are committed. And I can’t say enough about the ICU staff, residents, fellows and attendings who have worked so hard to improve the safety and quality of care that we provide our patients.”

Dr. Shore advises building a core team of dedicated people who are committed to using evidence-based principles to raise the level of care in the unit.

“One of our biggest initiatives was implementing what we call the ‘short-term goal form,’ based on the experience of Dr. Pronovost at Johns Hopkins,” explains Dr. Dobkin. “Essentially this is a plan for the day for each patient, based on a cockpit checklist system. It is a series of approximately 25 questions we ask about each patient each morning. It covers everything from physiologic findings to communications issues and safety concerns. If the answer to any of the questions is negative, then that requires a plan for that negative implication. Since its initiation, the nursing staff and residents have improved from knowing only 50% of their patient’s goals for the day, to over 95%. More than 90% of the goals are completed for each patient within 24 hours. Other initiatives have included family participation on rounds, a family voicemail system, tight glucose control, and medication error prevention.”

Hartford Hospital’s surgical ICU is a 12-bed unit with an intensivist-directed team model providing multidisciplinary care. Their eight-member TICU multidisciplinary team comprises several nurses and nurse managers, a social worker, a respiratory care therapist, and a nurse practitioner. The medical ICU is a 12-bed unit staffed by 42 registered nurses, eight intensivists, five advanced practice nurses, University of Connecticut medical students, and house staff.

Editor's note: The Society is seeking similar success stories about implementing the multidisciplinary team model by its members. Because implementing the model is often a challenging task, sharing your experience may help other intensivists overcome similar obstacles to the ones you faced. Your experience will also help SCCM highlight the fact that the multidisciplinary team model can work in any setting and that the intensivist can work effectively with other healthcare providers.

These stories will be collected and published by SCCM as a resource to its members and other healthcare practitioners.