Intensive-care units are scary places; bad things can happen to good people there.
But if you can't avoid it, you want to wake up in an ICU that monitors quality and works continuously to improve patient outcomes. Someplace like Phoebe Putney Memorial Hospital in Albany, Ga.
The ICU staff at 418-bed Phoebe Putney has worked for the past two years on a program to get people well faster as part of the Breakthrough Series, sponsored by the Institute for Healthcare Improvement, a quality improvement think tank. The Boston-based institute promotes small, incremental outcomes improvements through workshops.
Its Breakthrough Series aims to advance clinical outcomes by encouraging small teams of doctors, nurses and support staff to improve care by tight collaboration. At a recent conference in St. Louis, 633 participants and visitors from more than 100 hospitals around the country talked about improving ICU care by innovating at the hospital level.
At Phoebe Putney, a Breakthrough team of 12 people established a goal of reducing ICU length of stay by 25% for patients with acute respiratory failure who were on ventilators. At the same time, the team wanted to improve quality outcomes and reduce costs.
The stakes are large for a hospital like Phoebe Putney. The facility admitted 17,864 patients in 1996, of whom 2,734, or 15%, spent some time in the ICU. A hugely disproportionate share of any hospital's costs are incurred caring for ICU patients; if fewer resources were expended in the ICU, the institution as a whole would reap huge savings.
The Phoebe Putney team members started by analyzing how they took care of the ICU population and by posing some questions. Was the process standardized? Not very. Were there measurable ways to improve? Yes. How would they know a change was an improvement? By keeping track of a baseline and by maintaining a control group that didn't participate in the new protocols.
The team measured the following for its study: length of stay in the hospital and the ICU; ventilator days and hours; retrospective chart review of DRG 475 (acute respiratory failure on a ventilator); morbidity, including reintubations, nosocomial infections, stress ulcers, deep venous thrombosis and pulmonary emboli; mortality; readmissions to the ICU or hospital; and costs.
The team, led by William Brock, medical director of the critical-care unit, and Allison Mulholland, assistant vice president for critical care, worked out a structure of teamwork and joint responsibility that focused all participants on the goals at hand.
They wrote protocols for enteral feeding, weaning patients off the ventilator, sedation, insulin use and optimal drug utilization. They monitored patients very closely so they could respond quickly when conditions worsened. When conditions improved or patients were weaned, they were moved to a more appropriate level of care.
One innovation that paid off in spades was multidisciplinary rounds in the three ICUs at 8 a.m. every day. The rounds team included a respiratory therapist, a dietitian, a triage nurse, an infection control person, a pastor, a case management nurse, the ICU director and Brock. Nicknamed the "nerd herd," the team would see 30 patients in less than an hour.
The group learned to do "quick rounds" in which the bedside nurse gives a 30-second summary of the patient's condition. The team can quickly detect problems that need extra attention.
Protocols, typically, need to be sold to nurses and especially to physicians. Some physicians resist protocols, labeling them "cookbook medicine." They see them as an intrusion between them and their patients, and they don't want to cede that much control to nurses.
But Brock is a passionate believer in clinical protocols. All told, 16 new protocols were introduced to standardize the care of the ICU patient, ranging from ventilator and oxygen weaning to nutritional support and potassium replacement.
One key decision was to make protocol use optional for attending physicians. Those who didn't wish to participate in the team-generated protocols could treat patients as they saw fit. But their resources and outcomes were still measured by the Breakthrough Series team.
The team compared the results from all patients during the study period (including protocol patients and nonprotocol) against baseline numbers collected before the study began.
Here are some of the results:
* Median hospital length of stay for acute respiratory failure requiring mechanical ventilation was 10 days for the study period, 11 days for the baseline group.
* Median ICU length of stay for the same diagnosis was five days for the study period, 7.5 days for the baseline.
* Patients in the study period group spent a median of three days on the ventilator vs. 5.5 days for the baseline.
* In the study period, mortality was 28%, compared with 36% for the baseline.
* There were no reintubations, no nosocomial pneumonias, no evident DVTs or pulmonary emboli, and no symptomatic stress ulcers.
These results would justify the quality improvement protocols on clinical merits alone. But when costs are considered, the savings are remarkable. Median hospital charges for the study period were $28,346; for the baseline they were $36,325. Pharmacy charges were notably higher for the nonprotocol patients.
The hospital estimates the annualized savings just from this change in treatment for this group of patients to be $800,000 to $1 million.