The Challenge of the ICU
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In the late 1990s, St. Joseph Hospital in Orange, CA, began considering intensivists “by recognizing early on that we needed 24-hour attention to the patient,” says Raymond Casciari, MD, chief medical officer for the 392-staffed-bed hospital.
Mary Ann Vincent, RN, BSN, MBA, vice president of performance improvement at St. Joseph Hospital, says intensivists have played a major role in overall reduced infections and illness in patient care. With new procedures, the hospital has not reported a single incidence of VAP in 47 months. Moreover, there was a 75% reduction in CLABSIs in the ICU in 2010. Only two infections were reported in a 12-month period, and none for five months in a row. Overall mortality rates for sepsis decreased from 26.5% to 19.29% in one year.
In 2009, there were eight CLABSIs in the ICU and in 2010 there were only two CLABSIs, a 75% reduction. Before intensivists were used in the program, in 2006, there were 21 CLABSIs in the ICU, Vincent says. “The intensivists have annual quality and safety performance goals and reducing infections happens to be one of them,” she adds.
“It’s a whole new perspective on what they are bringing to the hospital,” Casciari says of the intensivists.
Much of that perspective is reflected in the hospital having 24/7 care provided by intensivists in the ICU, Vincent says. It has been crucial for the hospital to attain positive changes in patient care, she says.
“Since the intensivists are on site 24/7 and lead the ICU multidisciplinary rounds twice daily seven days per week, they review the checklist for [catheters], and continued use of ventilators,” Vincent says. “They are there to ask the question ‘Does the patient still need this?’ and if not they write the appropriate order,” Vincent adds. “It is their presence in the ICU and their collaboration with the ICU staff that serves to support the improvement and sustainment of results. How does this differ from a surgeon following the patient in the ICU? The surgeon likely only makes rounds once per day and is not in the unit 24/7.”
At the hospital, intensivists also have taken on a leadership role in working with other physicians and patients to determine if patients are suitable for palliative care. Developing palliative care programs in ICUs is growing in importance not only for patient and family care, but also for the economic potential of the ICU, Casciari says.
While it is an extremely sensitive issue, it is also a practical one, Casciari and other experts say. While there may be patients who are gravely ill remaining in ICUs, they can be provided better end-of-life care in palliative settings.
The Dartmouth Atlas Project, in an evaluation of ICUs and patient care, notes that there is “growing concern about the way chronic illness is managed in the United States, and about the possibility that some chronically ill and dying Americans might be receiving too much care.”
Communication is important for whatever change evolves in the ICU, and intensivists are important elements to facilitate that change, Casciari says. “If you can prevent sepsis, on one hand, and in other cases have people die with dignity—that’s the mission of the hospital,” he says.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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