Dr. Emmel B. Golden, Jr., Intensive Care Unit Medical Director
Dr. Roy Fox, Intensivist
Dr. Michael Wilons, Intensivist
Mary Ann Northern, RN, BA, Performance Improvement Specialist Suzanne Porteous, RN, System Quality and Accreditation
Jan Padgett, RN, Manager of Intensive Care Unit
Kathy Duncan, RN, Director of Critical Care
Larry Hopper, RRT, Director of Respiratory Care
Lynne Lancaster, RN, Infection Control Practitioner
Kathy Leake, RN, Nursing Staff Development
Joy Lindsey, RN, Case Manager
Angela Link, PharmD, Clinical Pharmacist
Medhat Elsabawy, PharmD, Clinical Pharmacist
Kathy Nunnikhoven, RD, Dietitian
Melanie Polzin, Intensive Care Unit Head Nurse
Paul Spreckelmeyer, Speech Pathologist
Cleolyn Young, Physical Therapist

• Ventilator Bundle Compliance
• Central Line Bundle Compliance
• Average Mechanical Ventilator Days
• Rate of Ventilator-Associated Pneumonia
• Rate of Catheter-Related Blood Stream Infections
• Average Length of Stay in the Intensive Care Unit
• Mortality Rate

• Marked beds for head of bed (HOB) elevation at 30 degrees (a component of the Ventilator Bundle)
• Developed and implemented a Patient Daily Goals Sheet that was incorporated into the ICU Patient Plan of Care
• Developed Pre-Extubation/Readiness to Wean Worksheet
• Implemented intensivist coverage on nights and weekends in our open ICU
• Implemented morning multidisciplinary rounds led by ICU Medical Director with full team
• Implemented evening rounds with intensivist, float charge nurse, and respiratory therapist
• Incorporated goal sheet into rounds
• Implemented morning bed flow huddles with ICU, CVICU, PACU, ED, Bed Express, and house supervisor and expanded to afternoon huddle
• Assigned Clinical Pharmacists to ICU and initiated clinical pharmacy rounds
• Initiated palliative care consults during multidisciplinary rounding (pallative care nurse participates in rounds)
• Implemented the Ventilator Bundle, consisting of five evidence-based practices: HOB elevation >30 degrees; deep venous thrombosis prophylaxis; peptic ulcer prophylaxis; daily sedation holds; daily assessment of readiness to extubate
• Implemented Central Line Bundle, including five components: hand hygiene; maximal barrier precautions; CloraPrep skin antisepsis; appropriate site care; no routine replacement
• Addressed appropriate utilization of lines during multidisciplinary rounds
• Developed nursing checklist for central line insertion based on Center for Disease Control (CDC) recommendations
• Focused on hand hygiene with staff and family; installed alcohol hand antiseptic dispensers for staff and family use
• Standardized line carts, packaged maximum barrier supplies, implemented new central line dressing kits
• Implemented new Sage oral care products and revised oral care protocol
• Incorporated Speech Pathology consults for swallowing evaluations into Pre-Extubation Worksheet and addressed in multidisciplinary rounds
• Initiated screening/intervention by Clinical Pharmacy for appropriate use of analgesics in sedation patients, and pain management physician participates in multidisciplinary rounds
• Revised and implemented neurological check sheet and initiated change of shift neuro checks to verify findings with oncoming nurse
• Implemented change of shift alarm checks
• Provided data feedback of process and outcome measures to staff and physicians
• Provided email to staff to facilitate communication and education
• Reported monthly on IHI IMPACT Critical Care Collaborative to senior leadership
• Conducted IMPACT Extravaganza for ICU and hospital-wide staff to promote performance improvement initiative, enhance collaboration, and celebrate our success
• Conducted monthly chart review utilizing ICU Trigger Tool to determine type and incidence of adverse events
• Conducted IHI IMPACT Safety Surveys
• Developed family educational storyboards for waiting room on ICU equipment, handwashing, and isolation
• Developed and implemented Family ICU Orientation Packet (welcome letter, visiting times, hospital map, local conveniences, educational pamphlets, prayer booklet, ICU manager’s business card)
• Conducted family satisfaction surveys
• Implemented voicemail updates for families in all 38 ICU rooms
• Implemented ICU transition visits for 24 hours after transfer out of ICU (ICU float charge nurse assesses and intervenes as indicated)
• Implemented Medical Response Team: pre-ICU intervention and stabilization to prevent clinical deterioration or arrest
• Intensivist, ICU float charge nurse and respiratory therapist responses to calls to assess patients on other units

By implementing best practices, including care bundles, and creating an ICU culture of collaboration and improvement, Baptist Memorial Hospital-Memphis has achieved a reduction in ventilator associated pneumonia and catheter related blood stream infections, and a steady decline in ICU length of stay. The foundation that helped change the culture was commitment by the institution to improvement, support of our ICU Medical Director, and participation in the IHI IMPACT Critical Care Settings Collaborative.

Lessons Learned

• Conduct small tests of change
• Systematic incremental change makes a big impact!
• Educate and constantly communicate with the staff
• Design ICU processes to prevent harm and ensure a safe ICU
• Create independent redundancies to ensure compliance with critical processes
• Develop a culture of collaboration
• Reduce complexity in all processes.
• Involve the staff — this is key to improvement
• “It’s about the patient”
• Share your ideas and work
• Celebrate your success — have an “IMPACT Extravaganza”

Mary Ann Northern, RN, Performance Improvement Specialist
Baptist Memorial Hospital-Memphis
maryann.northern@bmhcc.org