Interventions to promote compliance with evidence-based guidelines were often simple, such as posting reminders above the beds of ventilated patients about keeping the bed elevated at 30 degrees, posting signs at the entrance to patient rooms to encourage handwashing, and using wall marks or monitoring systems to indicate variance with 30-degree bed elevation.
Results. For 19 ICUs participating in the first round of the initiative, compliance to the seven best-practice process goals or standards described above improved from a range of 45 percent to 92 percent at baseline, to 70 percent to 97 percent after one year, and to 92 percent to 100 percent in the second year (Figure 9). Outcome improvements included:
- a 29 percent decrease in ventilator-associated pneumonia rates among first round participants (from 7.5 to 5.3 cases per 1,000 ventilator days) (Figure 10), with several ICUs completely eliminating ventilator-associated pneumonia for six months or longer; and
- a 15 percent reduction in average length of stay among ICUs in the first round (from 4.0 to 3.4 days) (Figure 10).
Many institutions documented decreased cost per admission, increased patient and family satisfaction, reduced contract nursing and nursing turnover rates, and fewer delayed ICU admissions, diverted patients, and cancelled surgery cases.
The impact of preventing ventilator-associated pneumonia among ICU patients can be substantial: Hartford Hospital estimated annual savings of $700,000 from reduced lengths of stay in its two participating 12-bed ICUs (VHA 2003).
Lessons learned. TICU demonstrates that an evidence-based improvement methodology can be applied in diverse settings from small community hospitals to large academic centers. While conventional wisdom has held that health care–associated infections are an unavoidable side effect of critical care, the experience of TICU participants "has expanded the limits of the possible," said Lisa Schilling, R.N., director of the TICU collaborative for VHA, Inc. Traditionally, hospitals might have been happy to reach the 25th percentile performance benchmark compared with the national average. Now there is evidence that shows it is possible to eliminate health care–associated infections of this type. And when infections do occur, the team has the tools to review the case and see what can be done to prevent future occurrences.
Measuring performance in aggregate for a bundle of care measures that relate to a common disease provides "a more robust picture of quality than any single measure," noted Sean Berenholtz, M.D., and colleagues at the Johns Hopkins Medical Institutions (2004b). While many institutions may perform well on particular care processes, few do so in providing all the evidence-based therapies for a condition. The bundled approach highlights the need for consistently providing all the care that is likely to produce better patient outcomes.
Bringing ICU staff and physicians together to work on improvement creates a heightened sense of teamwork and mutual respect, with everyone taking responsibility for the safety of every patient, said Schilling. At the Porter Valparaiso Hospital Campus, for example, if respiratory therapists or nurses see that a ventilated patient's bed is not properly elevated, they stop to correct it, regardless of whether the patient is their charge, said Terri Gingerich, R.N., critical care educator for Porter. Nurses have been empowered to respectfully question physicians if a patient is not being treated according to an evidence-based protocol. After nurses gained experience with the glucose protocol, they made suggestions for improving adherence and were given progressively more autonomy to manage the protocol over time.
Participating ICUs have found that basing process changes on evidence is critical to establishing credibility with physicians. To gain physician buy-in at Porter—where any community physician may admit patients to the ICU—a physician champion presents information on the ventilator project at medical staff meetings. Articles on the initiative regularly appear in newsletters for the hospital's admitting physicians. ICU nurses also keep copies of relevant research studies close at hand in case physicians are not familiar with the evidence, according to Gingerich.
Collecting both process and outcomes data is labor-intensive but worthwhile as it validates the clinical success factors for the team while making the business case for the institution—both critical factors to the sustainability of improvement, Schilling says. Demonstrating successful outcomes also builds momentum for further improvement. "Once [nursing staff] know that something will make a difference to help patients, they will do anything to achieve it," said Gingerich. Hospital managers who have seen the results have been motivated to spread similar improvement methods among all their ICUs.
The improved teamwork and communication also improves nursing staff morale. Typically, the work nurses do at the bedside is not always appreciated. Now, according to Schilling, the nursing staff can show the value of this work in three ways: providing better care for patients, making physicians' jobs easier, and saving lives and money. The ability to make a difference in improving patient care has reinvigorated nurses working at participating ICUs, such as Porter. This helps prevent employee burnout in an often stressful working environment. Some institutions involved in the initiative now have waitlists of nurses who want to work in the ICU.
Replication and related results. The "ventilator bundle" of evidence-based practices is one of six high-impact interventions promoted by the Institute for Healthcare Improvement (IHI) as part of its 100,000 Lives Campaign (Berwick et al. 2006). Between July 2002 and January 2004, 35 ICUs participating in an IHI collaboration reduced the incidence of ventilator-associated pneumonia by an average of 44.5 percent; outcome improvement was proportionate to the degree of adherence to ventilator bundle processes. These ICUs found that the use of multidisciplinary teams and daily goals (Case Study 6) were critical to implementation. Study authors concluded that: "The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability" (Resar et al. 2005).
VHA is building on the success of TICU with a new sepsis care improvement initiative (Pronovost and Berenholtz 2004). In the first year of the program, 19 participating ICUs have improved performance on a bundle of eight evidence-based processes of care, from a range of 36–77 percent compliance before the intervention to 62–91 percent compliance after one year, resulting in a 69 percent reduction in patient mortality and a 36 percent decrease in average ICU length of stay (Schilling 2004).
Implications. The ability to apply best practices in community settings challenges the assumption that high-quality care can be found only in large academic centers. “There isn't an institution in the country that doesn't have the ability to make the changes we did,” said Terri Gingerich, R.N., critical care educator at Porter, which cut its mortality rate by two-thirds through participation in TICU. Collaborative learning allows an institution to identify promising approaches and "modify them to fit your own house," Gingerich said.
In the current environment, which is characterized by a shortage of skilled nurses, hospitals are learning that it just as important to retain experienced staff as to recruit new employees (Chan et al. 2004). Enlisting nursing staff as equal partners with physicians in improving patient safety—such as by setting expectations that nurses can speak up for safety—sends a strong signal about the value of both nursing and patient safety in a hospital. This connection suggests that doing the right thing for patient safety can produce contingent benefits like improving quality of work life and reducing burnout and turnover among nursing staff (Gifford et al. 2002).
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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.