Informal interventions clear ICU logjam
Informal interventions clear ICU logjam
Doctors heed chart notes, LOS drops 36%
Eighteen months ago, staff at Our Lady of the Lake Regional Medical Center in Baton Rouge, LA, realized that the open admission policy in the adult intensive care units (ICU) needed to be revised.
A random survey revealed that nearly 40% of the patients had conditions more appropriate to regular medical-surgical nursing units, intermediate long-term care, or their own homes. That’s why patients who needed care often had to wait.
Since Our Lady of the Lake offers all services except obstetrics and transplants, both specialists and primary care physicians admit patients to the medical ICU beds. Analysis of the reasons for ICU placement, revealed many instances of observation. In other cases, families resisted the idea of moving their loved ones to more suitable settings and doctors acquiesced.
"We needed to do something because the winter onslaught of flu and pneumonia was coming," says Rose Marie Patin, BSN, RN, MA, divisional nursing director of Cardiology/Critical Care.
On the strength of their survey findings, Patin and a multidisciplinary team launched a highly creative intervention that increased ICU admissions by 33% within 12 months. She credits administrative support as the chief contributor to their success. Other elements include:
• partnership with a group of pulmonary disease specialists who provided medical leadership;
• rapid-cycle improvement techniques and ventilator protocols learned through the Boston-based Institute for Healthcare Improvement.
Relying on influence rather than authority, the improvement team initiated daily rounds of the four ICUs (12 medical beds, 12 surgical beds, 10 coronary care beds for heart surgery patients, and 10 cardiac care beds for medically treated heart patients). The improvement goal was to reduce average length of stay from 4.5 days to 3.4 days.
Besides Patin, team members included an ICU nurse as the team leader, a pulmonologist, a pharmacist, and a dietitian.
Patin explains that all the patients were under the care of private physicians, which meant that the team had no authorization to write on their charts. "So we found a politically correct alternative," she says. They affixed salmon-colored self-adhesive notes. The first messages were introductory: "Dear doctor, we wish to notify you that we are rounding in ICU." Then the tone shifted to "May we suggest?" offering ideas for alternative handling of intravenous (IV) medications and ventilators.
Physician responses ran the gamut from tearing up the notes and tossing them into the waste basket to presenting the team with detailed rationales outlining why their patients were in ICU. "Mostly they fell right in with our efforts," Patin says. "Many of our suggestions were taken, and patients began to move out of the unit faster." Length-of-stay samples from December 1998 to April 27, 1999, averaged 2.9 days, a 36% reduction. In the few instances where inappropriate practices came to light, the hospital’s medical administrators discussed the cases with the attending physicians.
As the team tracked the time and place of ICU admission, they found transfers from regular nursing units and the emergency room. The attending physicians would authorize placement by phone during nighttime or early morning hours. "When the doctors came in the next morning, they might find that the patient didn’t need to be there," Patin says. "Then we had to get the patient a regular bed, which could take hours."
ICUs are really for nursing care, she explains. "The primary candidate is a person with a life-threatening condition who could not survive without the intensive care. But it had gotten way beyond the original use."
Subsequent policy changes and practice guidelines led to a 30% increase in medical intensive care unit admissions. (See graph, p. 106.) Changes and guidelines included:
• protocols for ventilator weaning, insulin management, and potassium replacement;
• timely administration of medications enabled by more extensive mixing and preparation of IV solutions in the pharmacy;
• guidelines for maximum time between ICU admission and visit by the attending physician. For example, if the emergency room physician admits a patient to ICU, then the attending physician visits the patient within 10 to 12 hours;
• triage procedures for respiratory services.
The team continues to round daily, working on remaining issues. The following improvements are in progress:
1. Training of new respiratory therapy professionals. The pulmonary disease specialists who worked with the improvement initiative from the inception donated their compensation to a fund for staff seeking to earn respiratory therapy credentials. The hospital also is exploring federal grants to train additional therapists.
2. Collaboration with pastoral care staff to assist patients and families with decisions about end-of-life care. Patin explains that this service will help with unexpected crises that sometimes loom before physicians have time to discuss such options. The existing support group helps families establish do-not-resuscitate directives and move patients from ICU to intermediate care where visitation policies are more liberal. (For further information on end-of-life care, see QI/TQM, September 1999, p. 106.)
3. Review of computer software packages that help physicians assess potential outcomes of ICU placement. "We’re trying to convince the medical staff that critical care should not be viewed as a distinct service but as a part of other services, such as medical or surgical," Patin says.
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