Decreasing Harm to Patients by Standardizing Care

Northeast Health
Troy, New York, USA


The Northeast Health team is a participant in IHI's Learning and Innovation Community on Improving Outcomes for High-Risk and Critically Ill Patients.

  • Directors of Critical Care Units: Karen Henchey, Nancy Kapp
  • Staff Nurses: Shirley DeCamp, Becky Foggo, Connie Simpson, Christy McCormick, Linda Lewis, Jamie Wyman, Janice Peak
  • Respiratory Therapists: Marie Stark, Michael Riley, James Eastwood
  • Pharmacist: Tamara Wanchisen
  • Clinical Nurse Specialist: Marty Desmond
  • Patient Care Technician: Adam Simon



Decrease harm to patients in Albany Memorial Hospital (AMH) and Samaritan Hospital (SH), two Northeast Health hospitals, by doing the following:

  • Maintain 100 percent Ventilator Bundle compliance and the gain of having no ventilator-associated pneumonia since June 2006
  • Sustain 100 percent Central Line Bundle compliance and have no central line blood stream related infections for 365 days from the last central line infection
  • Achieve and maintain a Rapid Response Team call rate of 25 calls per 1,000 discharges by October 2008


  • To achieve good elevation of the head of the bed the staff suggested using blue painter’s tape on the wall to visualize 30 degrees. Once the staff had a good visual cue, compliance improved.
  • Added head of the bed elevation to the ventilatory check sheet, making the respiratory department an important part of the process.
  • Tested and included the bundle elements during multidisciplinary rounds and on goal sheets.
  • Tested and implemented a ventilation liberation order set which hastened removal of ventilation assistance.
  • A central line protection kit was developed by staff. Multiple tests were done with different versions of the kit. The final kit had approval of physicians and staff. Use of the kit was spread to all units in both facilities.
  • The Rapid Response Team was tested on one unit at Albany Memorial Hospital, then spread to other units within the hospital and then to Samaritan Hospital. The Team included a hospitalist, respiratory therapist, and supervisor with critical care experience. 
  • The composition for the Rapid Response Team was changed at Samaritan to take into account the different patient populations, such as behavioral health. A critical care nurse was added to the Team at this campus. Staff developed a rapid response kit that included frequently used supplies. The kit was to brought to all calls to the Team, thus saving time upon arrival to the unit.





Summary of Results / Lessons Learned / Next Steps

Lessons Learned:

  • A physician champion for implementation of change is important. The medical director of the unit provided education to the physicians by a letter and personally when needed.
  • Staff involvement in developing process change is necessary for successful buy-in.
  • Senior leader support to break down barriers, have active interest in the project, and recognize staff are all important in achieving the aims. The senior team received weekly reports on the progress. They helped overcome barriers such as resistant behavior among physicians and the approval process for IV sedation orders through the Forms Committee. The senior team recognized the critical care team at each hospital by giving the team the ACE award that includes public recognition and a monetary gift.
  • The choice of patient for testing changes to a process will impact the test. This was learned from a failed test using intermittent sedation on a patient with alcohol withdrawal.
  • To be successful a process may need to be adjusted to meet the local culture or patient population, such as with Rapid Response Teams at a facility that has behavioral health patients.
  • Create an education packet for new physicians and staff. Central Line Bundle compliance has, for the most part, been sustained at 100 percent. The times it has been below that goal were due to new physicians not being aware of the bundle content.
  • Feedback results to front-line staff so they can see the aggregate results of their efforts to implement changes.
  • Keep the focus small to begin with, then expand.

Contact Information
Susan Vitolins
Northeast Health

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