To help assess pain, the patient must be awake, so if, for example, a patient whose breathing is ventilator-assisted does not have a significant brain injury, respiratory therapists will give them a trial of breathing on their own, says Kaups.
"We have decreased use of benzodiazepines significantly, so our sedation medications are less likely to cause delirium, and we also have changed vent days, which have gradually decreased as has our length of stay," she says.
Mobility and exercise ASAP
Mobility and exercise is also extremely important in improving outcomes and cutting ICU length of stay, says Kaups.
"Even if they have rib fractures and pulmonary contusions, we're going to have them sit up—there's no reason they can't with help and have them get up and walk," she says, noting that even someone who is completely healthy will lose 10% of their muscle strength each day they spend in bed.
"If we don't, they'll see significant amounts of muscle mass loss," she says. "And the more we get people up and moving, the better they do from a delirium standpoint."
As part of rebuilding the pain medication order sets, Baptist's electronic medical record for ICU patients was modified to make sedation goals more prominent for nurses, as well as modifying care protocols to provide nurses and therapists cohesive and coherent guidelines about getting people out of beds, says Wright.
Emphasis on collaboration
Because so many clinicians interact with ICU patients, teamwork and a cohesive strategy to change protocols is paramount.
Wright says 45–50 people were involved in the collaborative. Over the course of its participation, Baptist reduced hospital length of stay by about a day, increased overall likelihood of survival by 15%, and reduced the time when patients were in a coma by a similarly dramatic amount, Wright says.
He was most surprised by the increase in survival rate, but says the incorporation of daily multidisciplinary rounds checking on patients "to the point of being boring—every patient, every day—is what it takes," he says.
Wright says that more than 200 nurses had to be trained in a common language and order sets, working together with a core team of physical, occupational, and respiratory therapists.
Philip Betbeze is the senior leadership editor at HealthLeaders.