Message from the President
Move Your Team Ahead as You Move Your Patients Up and Out of the ICU
Judith Jacobi, PharmD, BCPS, FCCM
Critical Care Pharmacist, Dept. of Pharmacy
Methodist Hospital/Clarian Health Partners
Indianapolis, Indiana, USA
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A population-based retrospective study from Pennsylvania showed that the best patient outcomes (lowest odds for death) were associated with high-intensity intensivist staffing (mandatory intensivist consult or primary intensivist management) and a multiprofessional team. The study included acute care hospitals with medical intensive care units (ICUs).(1) However, the next best outcomes (compared to hospitals without multiprofessional teams) were reported in hospitals with a multiprofessional team but no intensivist or only an optional intensivist consult. Daily team rounds were independently associated with a 16% reduction in the odds of death. While there may be other hospital factors that explain the differences observed (best-practice implementation by the team, pharmacist-initiated reduction in adverse drug events, or improved communication), the benefits of daily rounds by a multiprofessional team are apparent.
Have you thought about areas of your ICU that could be improved? A cohesive group with effective communication, focused on ICU patients and their outcomes, is the basis for enhanced quality improvement. Do you have all the necessary members on your team? Practitioners may want to get involved but are afraid to ask. Others may be constrained by staffing limitations and other duties. Critical care team leaders must present a business case to the appropriate administrators to secure the necessary team members.
Once your team is assembled, where do you start? How can you prepare your team to maximize the chance for success? How can you achieve the type of success reported by some of our Society of Critical Care Medicine (SCCM) members?
I have highlighted several self-reported success stories from SCCM members who have reduced ventilator days. Multiple factors can prolong ventilator days, so there are multiple potential solutions – from changing sedation strategies to preventing pneumonia and facilitating early mobilization. I hope these reports inspire you to initiate projects in this important performance improvement area and to share your success stories with others.
Presbyterian Hospital
Presbyterian Hospital in Charlotte, North Carolina, was committed to achieving a 10-hour reduction in mechanical ventilation hours, while also achieving better staff communication and a reduction in nursing turnover. After an extensive survey and data analysis, the team hypothesized that patients were being oversedated and identified areas for improvement. The team collaborated to develop an SBARQ round sheet to provide continuity and structure. Members also established an official rounding start time and an educational program about the new processes, focused on ventilator and sedation/analgesia bundles. In the first three months, the team reduced ventilator hours by an average of 4.6 hours, and only one case of ventilator-associated pneumonia (VAP) was reported in 871 days. Patient and safety satisfaction surveys reported improvements in overall quality of care, teamwork, communication with families, and pain assessment. ICU vacancies dropped from 12% to zero.(2)
Achieving effective team performance requires great effort. A Delphi assessment methodology categorizes the key knowledge, skills and attitude components for team competency training in communication, task management, situational awareness, decision-making and leadership.(3) The authors suggest using the identified competencies in a one-day training program for team members.
Team training processes have been adapted from the airline industry, where crew resource management training methods have focused on team communication, error recognition and processes to prevent error. Crew training methods focus on changing attitudes and behaviors about safety and hone techniques for identifying error risk factors.(4) Checklists and procedures must be developed, and participants must be encouraged to get involved in the decision-making process. They must be taught to question problematic decisions while carrying out operational plans. A variety of external groups are available to provide team training courses, including the Society’s Paragon Critical Care Quality Implementation Program. The Agency for Healthcare Research and Quality has also developed its TeamSTEPPS program, which provides a variety of tools for team training.(5)
Organizational and administrative commitment to change must be obtained to adequately support the development and activities of the team. Formal team training requires time away from the work area, and ongoing initiatives must be part of the recognized work process. External requirements for quality measurement and improved outcomes are increasing and an important component of the package used to convey this message to administrators. The Society has additional suggestions in the Talking Money with Administrators toolkit,(6) which gives practical examples and outlines the steps needed to make a business case for change.
Methodist Hospital
The medical ICU team at Methodist Hospital in Houston, Texas, was committed to increasing extubations by 50% following successful spontaneous breathing trials (SBTs), with the aim of decreasing ventilator length of stay. Through efforts led by the respiratory therapists, the team redefined the SBT program over two years. Adjustments included scheduling earlier SBT times so they would not interfere with rounds, creating an SBT progress note, and recording results in a database. The team overcame resistance by providing educational programs and refining criteria for eligibility. The unit decreased the mean ventilator length of stay from 144 hours to 96 hours – a 33% decrease – and is setting out to duplicate the process in all of the hospital’s ICUs.(7)
Another crucial component is the team leader and/or champion. Some hospitals have many natural leaders, but most need ongoing development and training. The project champion must have passion and time to devote to the program. Change must be sustained through regular data reporting, periodic celebration of positive results or renewed focus when program results need improvement. Team re-training is an anticipated requirement as the ICU staff turns over or as enthusiasm wanes. The SCCM Paragon coaches provide the type of ongoing leadership and team training needed for rapid achievement of results.
A recent report illustrates the full impact of a critical care team initiative that resulted in significant improvements in patient outcome while involving every member of the ICU team. Needham and colleagues developed a program for progressive mobility of stable medical ICU patients.(8) The team included nurses, pharmacists, respiratory therapists and physicians, as well as physical and occupational therapists and a physiatrist. Part of the project involved changing sedation approaches; sedative agents were used as needed rather than by infusion. Nurses allowed patients to remain more awake and coordinated activities with the therapists to progressively increase patient mobility. Although the highest level of mobility include walking while on mechanical ventilation via an endotracheal tube, the majority of patients were only able to sit at the edge of the bed. Still, patients recovered more quickly and with less deconditioning and delirium. The team’s coordinated efforts to achieve this illustrate high-level team communication and cooperation.
While this intervention is not appropriate for all ICU patients, it clearly embodies the ultimate success of the ICU team by facilitating patients’ recovery in a way that augments their return to functionality in an outpatient setting.
Start Today
Whether your team is ready to strive for such an ambitious project, or is looking for a more basic intervention, is not important. What is important is that the initiative begins soon. If you are a clinician who is not sure where to start, you should speak with your team colleagues, get support for the idea among your critical care committees, and collect some preliminary data. Get help from colleagues through the Critical Care Forum discussion groups available at www.MySCCM.org and expand your knowledge at www.LearnICU.org. Take the message to your supervisors and don’t be dissuaded by a slow initial response; be persistent and proactive in seeking support from other ICU practitioners as you build your project team. You will have the opportunity to develop a meaningful project and improve process and outcomes. Remember: if your patients are not getting better every day, they are getting worse. Move your team forward and your patients will get ahead.
References:
1.Kim MM, et al. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010; 170:369-376.
2. Crutchfield C, Wheeler J. Commit. Transform. Improve: Presbyterian Hospital in Charlotte, North Carolina. Poster presented at: Society of Critical Care Medicine’s 39th Critical Care Congress; January 9-13, 2010; Miami, FL.
3. Clay-Williams R, et al. Determination of health-care teamwork training competencies: a Delphi study. Int J Qual Healthcare. 2009; 21:433-440.
4. Despins LA. Patient safety and collaboration of the intensive care unit team. Am J Crit Care. 2009; 29:85-91.
5. TeamSTEPPS Curriculum Tools and Materials. Agency for Healthcare Research and Quality website. http://teamstepps.ahrq.gov/abouttoolsmaterials.htm. Accessed June 15, 2010.
6. Taking Money with Administrators: A Guide for ICU Clinicians Who Want to Change the System. Des Plaines, IL: Society of Critical Care Medicine, 2004. Purchase at: http://sccmams2.sccm.org/Purchase/ProductDetail.aspx?Product_code=COST. Accessed June 15, 2010.
7. Hargett K. Commit. Transform. Improve: Methodist Hospital in Houston, Texas. Poster presented at: Society of Critical Care Medicine’s 39th Critical Care Congress; January 9-13, 2010; Miami, FL.
8. Needham DM, et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010; 91:536-542.
