Dedicated Trauma ICU Cuts Infection Rates

Two changes affecting trauma care at a Florida hospital cost nothing to make, but saved the hospital more than $100,000 in costs over nine months.

When a clinician presents hospital administration data showing that its ICU isn't performing as well as the ICU 30 miles up the road, leadership can react one of two ways: by taking offense, or by making changes.

Robyn Farrington, RN, trauma program manager at Broward Health Medical Center in Fort Lauderdale, FL, took the second option when she saw the results of a study in the Journal of Trauma and Acute Care Surgery showing that trauma patients at her mixed ICU had worse outcomes than ones admitted to a dedicated trauma ICU (TICU) at Delray Medical Center in nearby Delray Beach.

Trauma patients are defined by the hospital as "those suffering from an injury so severe that it could cause death if not attended to within the first 60 minutes."

"An individual could very easily have been almost offended, because we were doing it so long a certain way thinking we were doing a great job," says Farrington. "You have to look at the results objectively and just know that what's there is only there in an effort to improve patient care."

Improving patient care was what Marko Bukur, MD, an attending trauma physician at both hospitals, set out to do when he decided to study the differences in trauma patient outcomes between the two ICUs. His own observations, based on working in both units, led him to hypothesize that outcomes would be better in the dedicated TICU.

He says that care at the dedicated unit was more cohesive, had more organized nurse involvement during rounds, and relied less on consultants than the mixed ICU. "I've seen things always ran smoother at the dedicated trauma unit."

'Striking Differences' Between ICU Types
So Bukur and his co-authors conducted a retrospective review of the ICUs that are both Level I trauma centers and covered by a single group of surgical intensivists. The researchers examined outcomes for 3,833 patients over five years.

"There were pretty striking differences in the amount of ICU complications that occurred," Bukur says. Specifically, the researchers found:

• Overall complications were significantly higher in trauma patients admitted to the mixed ICU (27.5% vs. 17%)
• Failure to rescue was higher in trauma patients admitted to the mixed ICU (3.7% vs. 1.8%)
• Trauma patients admitted to the dedicated TICU had significantly lower chances of developing post-injury complications
• Overall mortality was lower among patients in the TICU

"It's the same physicians providing care," Bukur says. It was "just the infrastructure in place at the [dedicated trauma] ICU that was likely accounting for the vast majority of the difference."

Two Major Changes

When Farrington saw the study results, she knew they had to act. "We made some fundamental changes within our ICU," she says.

Specifically, two major changes were made. Both took only about two months to implement and cost nothing, but already have improved patient outcomes since they were implemented almost a year ago.

First, the placement of trauma beds was changed simply by reassigning where on the unit trauma patient beds were located.

Previously, "trauma patients could really be scattered anywhere within those 24 beds," Farrington says. Now, the higher number beds—about 8 to 12 of them—are designated for trauma patients, so that all trauma patients are geographically near each other on the unit.

The other big change was assigning a core group of ICU nurses to work as dedicated trauma nurses. "The nurse manager engaged the staff to determine those nurses who really wanted to work the trauma patients," Farrington says.

As a result, trauma patients are now cohorted together and cared for by a dedicated nursing staff, creating a "closed" unit without physically closing it off, putting up walls, or doing any construction.

Some flexibility remains. The number of trauma patients might fluctuate, and the designated trauma beds might sometimes get some overflow, but for the most part, those beds are for trauma patients. The nurses also participate in daily rounds at certain times of day using a designated trauma checklist.

Nursing Leaders Supported Changes
In addition to reassigning the beds, the nurse manager reached out to the nursing staff to determine who would be part of the new trauma team, and to ensure that they had their Trauma Nursing Core Course (TNCC) certifications up to date and current. After that, it was simply a matter of creating new schedules.

Farrington credits the nurse manager for taking the lead and making these changes.

"It was very easy to implement; the key was the buy-in of the nursing leadership team in the ICU," she says.

Importantly, no one was assigned the trauma nurse role against his or her will; instead the nurse manager put out the call to her staff, and willing nurses volunteered.

"We have a good core that stepped up and said, this is something we want to do," Farrington says. "There has to be a willingness to do it, as well" as having the knowledge and skill base of trauma nurses.

Results
The changes have resulted in cost reductions and patient outcome improvements within the ICU, Farrington says. She later said via email that since its inception in August 2014, the changes have so far led to the following improvements:

• Decreased length-of-stays have led to a savings of just over $100,000
• Fewer pneumonias: Prior to implementation there were nine or ten cases per quarter. In the final quarter 2014, there were four cases; and in the first quarter of 2015, there has been only one case of pneumonia
• Fewer CLABSIs: Four CLABSIs were documented in the eight months before the change went live; for the past nine months, just one CLABSI has been reported within in the trauma population

"The more than you do something, the more likely you'll excel at it," Bukur says of the dedicated trauma nurses.

"This is free," Farrington says. "A couple months with no real investment, other than time and energy."