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The Challenge of the ICU

Joe Cantlupe, for HealthLeaders Media, May 13, 2011
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Not all healthcare facilities are successful, however, and some are struggling with reducing bloodstream infections. CLABSIs continue to occur, especially in outpatient hemodialysis centers and inpatient wards. For the most part, meticulous insertion and care of the central line by members of a clinical care team are essential, according to the CDC.

Fewer cases of sepsis would result with the prevention of CLABSIs.

For Hartford (CT) Hospital, an 819-bed facility, successful work against bloodstream infections begins with team meetings. As many as two dozen specialists, physicians, and nurses meet as the bloodstream infection steering group to evaluate changes in each unit to determine how they are doing and, more specifically, what might have gone wrong, if it did: Why was the rate of bloodstream infections up in this unit?

There are meetings not only in each department, but each unit. Those huddles are held, and reports are forwarded to ICU department heads. Each unit that becomes involved in clinical care rounds on a daily basis, where checklists, a “balanced scorecard of needs,” are used to examine each aspect of care, says Jamie Roche, MD, vice president of patient safety and quality at Hartford.

Hartford Hospital officials began to evaluate workflow practices to improve efforts against bloodstream infections after studying patient falls in the facility. “One would think these are two radically different areas,” says Roche, “but the lessons learned and what we are experiencing increases our ability within the organization to enhance performance improvement methodologies.”

The hospital leadership and line staff also examined the work of hospitals that implemented improvements in thwarting bloodstream infections, such as the University of Massachusetts Medical Center in Worcester. “We benchmark what they have done, looked at their successes, look at this from a process improvement standpoint,” says Roche. “Let’s look at the process and let’s try to take the variability out of it and make it sustainable.”

In January 2010, the hospital launched a bloodstream infection steering committee to evaluate its work and make improvements, says Jack Ross, MD, director of epidemiology and infectious diseases at Hartford Hospital. “We got the stakeholders at the table, the infection control people, the people who write the computer software that generate reports for us and the medical directors,” Ross says. “We looked at each other and said, ‘Let’s take the variability out of what we do for a new, improved process and make this sustainable.’”

Specifically, they worked to improve communication among staff members. “We start with huddles for every single time there is a bloodstream infection,” he says, referring to meetings of team members, which can include more than 12 people. “We get the unit team that cared for that [patient],” Ross says. “We look at the chart from the time that patient came through the door until the infection occurred. We do our homework ahead of time and then sit down and see what is the opportunity for improvement.”

Checklists have become an important function among clinicians at Hartford Hospital to begin the process of evaluating BSIs, Ross says. Using the checklists along with electronic systems ensures accurate tracking, he adds. In addition, educational programs for providers and patients are ongoing.

The hospital’s patient safety action group meets every morning and has launched a weekly newsletter that highlights the actions of the hospital as a priority issue in reducing infections, Roche says. Specific care initiatives were undertaken along with the planning changes, Roche says, such as a Scrub the Hub campaign, which emphasized cleaning the caps on the ends of catheters.

The changes implemented by the hospital system resulted in BSI reductions, Roche says. In 2008, the hospital reported 48 BSIs, which “amounted to four per month, for the last 10 months,” Roche said. In February, there was just one reported.

Roche says the system’s efforts yielded the changes “due to a combination of measures” that were undertaken, not simply one direct cause. “No one element can be singled out in the prevention process for bloodstream infections,” Roche says.

Success Key No. 4: Improving care with intensivists

Fewer than 15% of the nation’s hospitals have full-time intensivists, but research shows that using intensivists can save thousands of lives per year. There is a projected increase in demand, especially with a large aging population in this country.

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2 comments on "The Challenge of the ICU"


Nick King (5/16/2011 at 11:40 AM)
The article briefly mentions telemedicine but it is worth expounding on. One of the more promising high technology approaches to improving ICU care is the use of tele-ICUs. This technology has been shown to have clinical benefits for patients and cost-saving benefits for hospitals and insurers. By staffing specially-trained critical care doctors and nurses in a command center to monitor and care for patients in multiple and remote hospital units, tele-ICUs can also absorb the expected increase in ICU demand at a time when there is a shortage of critical care cluinicians. Command centers can be licensed to monitor up to 500 adult ICU beds. Recent research on tele-ICUs is worth a read: http://bit.ly/fuVdO3

Scott Arnold, PT (5/13/2011 at 2:14 PM)
I would like to add to the above items the impact early ICU patient mobility programs are having on reducing ICU length of stay and improving quality of life of ICU survivors including vent-dependent patients. Physical and occupational therapists have partnered with intensivists and nursing staffs at our hospital to get ICU patients moving as soon as possible. Evidence-based literature shows the safety and cost-savings associated with this practice change. Scott Arnold PT, Mayo Clinic Hospital, Jacksonville, FL