Tracy Sklar, RD, Vice President Quality and Service, Catholic Healthcare West
Dan Ferguson, MD, Vice President Medical Operations, Catholic Healthcare West
Janet Holdych, PharmD, CPHQ, Care Management Specialist, Catholic Healthcare West
Faith Holzman, Loss Prevention Specialist, Catholic Healthcare West
Dan Ross, PharmD, Director of Pharmacy Integration, Catholic Healthcare West
Mary Carol Todd, RN, Vice President Medical Management, Catholic Healthcare West
Milton Louie, MD, Physician, Glendale Memorial Hospital
Peter Murphy, MD, Chief of Staff, Mercy San Juan Hospital
Julie Boone, RN, ICU Nurse Manager, Sequoia Hospital
Curtis Chow, RN, ICU Nurse, St. Elizabeth Community Hospital
Camille Clark, RN, ICU Nurse Manager, Dominican Hospital
Colleen Dawkins, RN, ICU Nurse, Sequoia Hospital
Delia Delangel, RT, Director Respiratory Care, San Gabriel Valley Medical Center
Jacquie DeMellow, RN, ICU Clinical Nurse Specialist, St. Joseph Medical Center, Stockton
Philip Fracica, MD, Medical Director, St. Joseph’s Hospital, Phoenix        
Marilou Lacson, ICU Nurse, San Gabriel Valley Medical Center
Gina Mitchell, RN, ICU Clinical Nurse Manager, St. Joseph’s Hospital, Phoenix
Glenn Robbins, RPh, Medical Staff Clinical Pharmacist, Dominican Hospital
Dana Roesler, RN, Critical Care Manager, St. Bernardine Medical Center
Pamella Sullivan, ICU Nurse, Sequoia Hospital
Lee Vanderpool, Vice President, Dominican Hospital
Patty White, RN, Chief Operating Officer, St. Joseph’s Hospital, Phoenix
Don Wiley, President, St. Joseph Medical Center, Stockton
Kathy Yeates, RN, ICU Clinical Educator, Mercy General Hospital

• Ventilator 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
• Percent of Patients in the Intensive Care Unit Greater Than Seven Days
• Rate of Adverse Events per Intensive Care Unit Day

• Convened Critical Care Collaborative Kick-Off Meeting in February 2004.  All 23 participating Teams were in attendance.  Agenda included:  key learnings from the IHI Critical Care Collaborative, presented by Dr. Thomas Rainey and Dr. Roger Resar; “Move the Dot: Impacting Mortality”, presented by Dr. Roger Resar; review of facility baseline data; panel discussion and sharing of experience with 3 CHW facilities that participated in the IHI Critical Care Collaborative (Dominican Hospital, Sequoia Hospital and Mercy Medical Center, Redding); overview of the CHW Critical Care Collaborative goals, tools and resources; presentation on developing Aims, Measures and Tests of Change.
• Developed and distributed Toolkit to all Teams (order sets, protocols, daily goal sheets, etc.)
• Developed report template for monthly team reporting of tests of change completed and results
• Convened monthly collaborative-wide conference calls team check-in, discussion and education
• Posted monthly reports of CHWConnect (system-wide web site)
• Presented status reports to CHW Quality Board
• Held educational teleconferences on "What Do Families Need?  Improving the Interaction", July 2004 and "Bringing the Family Into the Plan of Care", August 2004
• Convened Summer Learning Session in August 2004 where all 23 participating Teams presented their progress to date (Aims, Measures, Tests of Change)

Facility Specific Changes:

• Implemented multidisciplinary rounding at all sites
• Implemented Patient Daily Goal Sheet at all sites that was incorporated into the ICU Plan of Care at many facilities
• Implemented Ventilator Bundle facility-wide
  • Head of bed (HOB) elevation > 30 degrees
  • Deep venous thrombosis (DVT) prophylaxis
  • Peptic ulcer disease (PUD) prophylaxis
  • Daily sedation vacations
  • Assessment of readiness of wean
  • Oral care
• Implemented Central Line Bundle at many facilities
  • Hand hygiene
  • Barrier precautions
  • Skin antisepsis
  • Appropriate site care
• Implemented Ventilator Weaning Protocols at many facilities
• Implemented Glucose Management Protocols at many facilities
• Implemented Medical Emergency Team (MET) at several facilities
• Developed and implemented education storyboards for staff
• Developed and implemented family orientation to the ICU packet
• Completed Safety Attitudes Survey and results shared with staff

By utilizing the IHI Model for Spread Improvement and following the IHI Breakthrough Series Collaboration Model, our hospitals have achieved significant results in 4 months!  Best science and best practices have been implemented at the participating facilities resulting in the following improvements:

• Reduction in our ventilator associated pneumonia rate from 7.7 to 3.7 (NNIS definition)
• Reduction in our catheter related blood stream infection rate from 4.2 to 2.3 (NNIS definition)
• Improved compliance with all components of the ventilator bundle from 5.5 percent to 81 percent Reduction in ICU average length of stay from 7.8 days to 4.2 days
• Reduction in percentage of patients in the ICU greater than 7 days from 12.7 percent to 11 percent

Lessons Learned:

• Having a facility participate in the IHI Critical Care Collaborative was essential to provide support, resources and guidance needed to initiate and help coach Teams.
• Providing strong hospital leadership support and hospital quality management support for facilitation and data assistance at each facility is essential
• Educating Teams on the Rapid Cycle Performance Improvement model is essential and extra support is needed for facilities not experienced with small tests of change
• Communicating with all teams and team members on a frequent basis is necessary to keep then engaged in the process
• Monthly conferences are valuable for Teams to share experiences and seek advice and/or guidance
• Changing the culture of the intensive care unit is challenging but required for success
• Participating in the CHW Critical Care Collaborative improved the collaboration and teamwork among clinical and ancillary departments working together to provide care to the intensive care unit patient

Janet Holdych, PharmD, CPHQ
Care Management Specialist
Catholic Healthcare West
jholdych2@chw.edu

[Storyboard presentation at IHI's National Forum, December 2004]