Initiative cuts ventilator days by 50%, improves care
Initiative cuts ventilator days by 50%, improves care
Six Sigma initiative focuses on best practices
A Six Sigma initiative to improve care for ventilator patients has decreased ventilators days by more than 50% at St. Anthony's Hospital in St. Petersburg, FL.
"Our goal was to reduce ventilator days but by doing that, we also reduced the total length of stay for patients in the hospital and decreased ventilator-acquired pneumonia and infections," says Debbie Ulrich, RN, case manager in the hospital's intensive care unit and cardiovascular intensive care unit.
St. Anthony's is part of BayCare Health System, which includes nine not-for-profit hospitals in the Tampa Bay, FL, area. The health system rolled out a Six Sigma initiative in March 2005 and hired 12 dedicated team members to become Black Belts and assigned each an improvement project, says Angi Jennings, Six Sigma Black Belt, who led the clinical team through the project.
"We looked at the cost per case for the ventilator patient population and looked at our outcomes, such as mortality rates, infection rates, and readmission rates. We took a practical problem of patients being on ventilator days too long and made it a statistical problem. We then took the statistical problem and went back to the team to put together practical solutions to improve the problem," Jennings says.
Jennings put together a multidisciplinary team with representatives from every discipline that provides care for ventilator patients. The team included representatives from nursing, respiratory therapy, case management, pharmacy, physical therapy, infection control, pastoral care, and nutrition, along with a representative from senior management at the hospital.
The team conducted a retrospective analysis of ventilator patient data and determined that the hospital exceeded its targeted time for patients to be on a ventilator 30% of the time.
Following Six Sigma methodology, the team determined that five major variables contributed to the problem. They involve: standardization, hospital-driven initiatives, physician-driven initiatives, information system documentation and support, and team member education and training.
Using the data from the analysis and best practices for care of ventilator patients, the team developed a set of weaning criteria and a uniform weaning protocol for all ventilator patients.
They established multidisciplinary rounds each day for every ventilator patient and developed a daily rounding sheet, an accountability tool that is used during rounds every day on every ventilator patient.
The team created a biweekly dashboard that shows how many days patients were on the ventilator and developed a process so that the ventilator team is notified daily which patients in the hospital are on the ventilator instead of having to call each nursing unit to find out.
The team starts each day with ventilator rounds on every patient in the hospital who is on a ventilator, Ulrich says. If the physician who admitted a patient is in the hospital, he or she participates in the daily rounds.
"We discuss how the patient came onto the vent, their situation prior to coming to the hospital, and the clinical aspect of patient care, with each department giving input," Ulrich says.
As the team conducts rounds together, each team member fills out the daily rounding sheet showing where the patient is on the plan of care and signs it.
The team starts early in the process to look at family support and discharge planning, bringing in social services as necessary.
"We start by looking at how long the patient has been on the ventilator. We determine if the patient is weanable by talking to the pulmonologist and the respiratory therapist. If it's going to be difficult, we start early on to get consent from the family or the patient to do a tracheotomy, which makes weaning easier and helps prevent infections," Ulrich says.
If the patient is going to be on a ventilator long term, the team considers a GI consultation to see if the patient would benefit from a PEG tube for feeding and discusses potential alternative care options, such as an acute rehabilitation hospital.
Team approach
The team's daily protocol includes infection control measures, looking at how long the lines have been in, determining when they need to be changed, and getting bacterial cultures done quickly.
"We look at nutrition, whether the patient can tolerate having tube feeding started. All different departments are involved. The team approach means that patients are getting what they need both nutritionally and clinically in order to be ready for weaning earlier," Ulrich says.
When a patient is weaned, Ulrich consults with the physician to make sure the patient still meets ICU criteria when he or she is off the ventilator. Patients may need to remain in the ICU because they have other conditions or need certain medications, she says.
The case manager's role is as critical to the success of the initiative as nursing and respiratory therapy, particularly in the cases of long-term ventilator patients whose families face a lot of decisions about future care, Jennings points out.
"[Ulrich's] early intervention in discharge planning from the time of intubation has allowed the team to focus on long-term care facility placement and has allowed the family and the clinicians to deal with end-of-life issues sooner," Jennings says.
Ulrich works closely with the hospital's social worker to ensure that the patient can be safely discharged to home or to another level of care.
"The physicians and the family members often don't realize what resources are in the community. We help them determine whether hospice or palliative care is needed and what facilities take tracheotomy patients and which take ventilator patients," Ulrich says.
She refers patients without funding to the social worker, who assists in applying for Medicaid funding.
"The physicians are realizing the value of the team. They are coming to us sooner rather than later asking what is available for the family after discharge and what they need in order to accomplish it," Ulrich says.
The same physicians who work with Ulrich when they have ventilator patients are calling on case managers in other parts of the hospitals for help in coordinating care and discharge planning, she says.
"It has given case management a lot more important role for physicians. They don't just see us as someone to call when a patient needs a nursing home. They know that we are able to help in so many ways to coordinate patient care," she says.
Six Sigma methodology begins with assembling a team, then clearly defining the defect to be corrected, in this case counting the number of ventilator days, Jennings says.
The team gathered 37 clinical and nonclinical variables, including the age of the patient, the principal diagnosis, type of sedation, daily blood gas readings, type of pain medication, and daily chest X-ray results. They also looked at on which day physical therapy and nutrition consults occurred, and which pulmonologist was treating the patient.
The team pulled the variables on 427 ventilator patients who were hospitalized during 2004 by manual chart review and electronic medical records.
"We brainstormed and asked the team members individually and as a group why they thought the patients were on the ventilators too long," Jennings says.
The team found lack of communication among the treatment team was the biggest barrier to getting patients off ventilators in a timely manner, Jennings says.
"Each discipline was doing their job and charting it, but there was no interdisciplinary communication. One department was doing something on the pathway that might interfere or add additional days to what another department was doing," Jennings says.
The team decided to create standards for each of the seven departments to follow.
For instance, standard weaning criteria varied among the disciplines. The team set out the steps to get patients off the ventilators as quickly as possible, beginning at the moment someone is intubated.
The hospital's pulmonologists took the lead in developing an updated weaning protocol so that all a physician has to do is order weaning and the team understands what should occur. They set out the criteria that needed to be met for the process of weaning the patient to begin and created the daily rounding sheet for each discipline to fill out.
At the same time, the hospital adopted the 100,000 Lives criteria, which provides best practices for avoiding ventilator-acquired pneumonia, giving the team additional improvements that were driven by the hospital.
These include criteria such as elevating the head of the bed by 30% and regular daily vacations from sedation.
"We made these criteria a component of the rounding sheet to hard-wire the process," Jennings explains.
As part of the Six Sigma process, the respiratory therapists had to demonstrate their competency in areas such as emergency intubating and extubating in front of the medical director.
In the past, the physicians wanted to be present before a patient was intubated or extubated.
"It was important that our team gain the confidence of the physicians so that patients could be moved to a lower level of care in a timely fashion," Jennings says.
At the completion of the project, the team conducted nursing inservices on pain management, sedation information, and other clinical best practices, and each of the seven departments involved in the project conducted "lunch-and-learn" sessions with the rest of the clinical staff.
During the last phase, the control phase, the Black Belt relinquishes the process to the clinical staff and charts the results for 12 months to make sure the process is working.
Ten months later, the team has been under its target for ventilator days every month.
"The hospital has made a cultural change, and the gains during the Six Sigma project have been sustained," Jennings says.
A Six Sigma initiative to improve care for ventilator patients has decreased ventilators days by more than 50% at St. Anthony's Hospital in St. Petersburg, FL.Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.