​University of Rochester Medical Center
Rochester, New York, USA

Team

The team from University of Rochester Medical Center is a participant in IHI’s Improving Outcomes for High-Risk and Critically Ill Patients Learning and Innovation Community. 

Michael Apostolakos, MD, Director, Adult Critical Care
David Kaufman, MD, Medical Director, Surgical Intensive Care Unit
Nicole Stassen, MD, Trauma/Burn Intensive Care Unit
Mary Wicks, RN, MPA, Associate Critical Care Director of Nursing
Barry Evans, RN, Critical Care Clinical Nurse Specialist
Kate Ireland, RN, MSN, Nurse Manager, Medical Intensive Care Unit
Joan Romano, RN, Nurse Manager, Surgical Intensive Care Unit
Thomas Rossborough, RN, Nurse Manager, Burn Trauma Intensive Care Unit
Larry Stalica, RN, Nurse Manager, Cardiovascular Intensive Care Unit

Aim

The team’s overarching goal was to achieve a 20 percent reduction in length of stay across all adult intensive care units (ICUs) by:

• Achieving and sustaining a reduction in ventilator-associated pneumonia (VAP) to less than 1 VAP per 1,000 ventilator days before December 2009 by attaining greater than 95 percent compliance with daily sedation interruption and patient mobility
• Reducing complications from central lines by 90 percent before December 2009 by implementing the Central Line Insertion Bundle and a Central Line Maintenance Bundle, and mandating data collection on all ICUs to track compliance

Measures

Changes

Bundle Elements:

Ventilator Bundle [*Modified from IHI's Ventilator Bundle]

1. Head of the bed at 30 degrees
2. Deep Vein Thrombosis (DVT) Prophylaxis
3. Peptic Ulcer Disease (PUD) Prophylaxis
4. Daily Sedation Interruption
5. Daily Assessment to Wean
6. Mobility
7. Oral Care

1. Handwashing
2. Sterile Drape on Patient
3. Full Barrier Precautions (Gown, Glove, Head Cover, Face Mask)
4. Skin Prep Dried Appropriate Amount of Time
5. Patient Consent Addressed
6. Universal Precaution Protocol Form Completed
7. Time-Out Signed

1. Dressing Intact
2. Dated/Timed/Initialed
3. Dressing Changed in Past 7 Days
4. IV Tubing with Date/Time/Initials
5. IV Tubing Changed Every 96 Hours per Protocol
6. Unused Lumens Have Clave Device
7. All Stopcocks Have Dead-End Sterile Caps

• Sedation Flags: Removable colored sedation interruption flags were placed on the patients’ flow sheets at 8AM and 8PM to serve as a prompt for nurses to assess their patients for sedation interruption and turn off drips if appropriate.
• Mobility Algorithm: We developed and implemented a progressive mobility algorithm for Levels I-IV. The algorithm incorporates criteria and interventions for progressing patients, from bed rest (Level I) through independent ambulation (Level IV).
• Daily Leadership Rounds: Nursing leadership rounded twice each day to communicate with each nurse about their patients’ sedation status and to discuss and plan for mobilizing the patients each day. This also provided the opportunity to assess the patients and determine if they could be advanced through the algorithm to a higher level of activity.
• Central Line Slider Board: A polystyrene board containing the Central Line Insertion Bundle components was permanently mounted on the procedure cart as a prompt for physicians and nurses regarding the appropriate process for line insertions. Once all criteria were met, a slider tab was moved from red to green indicating a go-ahead for the procedure. Appropriate documentation forms were also kept in a pocket file on the side of the cart for easy access.
• Weekly Audits: Weekly audits are conducted to track compliance with Central Line Insertion and Maintenance Bundles and audit tools were developed that contained bundle elements. Safety nurses increased audits from monthly to weekly to determine compliance with both bundles.
• Balanced Scorecards: Scorecards using the “red,” “green,” and “amber” stoplight concept are displayed each month to allow staff to track compliance. The scorecards contain monthly progress graphs in addition to historic graphs for each bundle initiative. This has increased awareness of our care practices and has improved compliance rates.

Results

Summary of Results / Lessons Learned / Next Steps

Results:

• Decreased ALOSMV by 1.2 days/month and ALOS by 1.58 days/month
• Mobility compliance increased 73.4 percent and average monthly sedation days decreased 60 percent
• Ventilator Bundle compliance increased 24.8 percent while the VAP rate went from 1.428 VAPs/1,000 ventilator days in 2007 to 1.99 VAPs/1,000 ventilator days in 2008. We implemented x-ray rounds to increase our effectiveness in VAP diagnosis and noted an increase from the previous year. It is likely that our current method is more accurate than in the past. 
• CRBSI rate decreased from 13.1/1,000 central line days to 5.52/1,000 central line days. 
• The Central Line Maintenance Bundle is a relatively new initiative and our first measure of compliance was 33.3 percent. We initiated a Central Line Dressing Change Nurse Pilot and have subsequently increased bundle compliance to 52.3 percent.
• Our monthly ICU mortality rate averages between 17 to 24 percent. We have not achieved a reduction in this measure throughout our participation in the IHI Community due to the high severity of illness of our patients. 

• Developing nurse and physician champions is vital. The support of our medical director, associate director of clinical nursing, and administration leadership along with staff involvement is a key factor to our success.
• The best tests of change are small. They enhance nursing and physician buy-in and simplify management and analysis of outcomes.
• Implementing and achieving a successful mobility initiative was the key to overcoming non-compliance with the Ventilator Bundle process. The rationale behind mobility is that daily sedation interruption must occur before patients can be mobilized.
• Overcoming barriers to mobility involved the following: using sedation flags on flow sheets to prompt sedation interruption, implementing daily leadership rounding to assist staff in evaluating patients for appropriate sedation interruption, and collaborating time and resources needed to mobilize patients.
• Education is the cornerstone of success and helps overcome barriers. We conducted educational retreat days to educate more than 400 nurses, physicians, and support staff on all of the safety initiatives and bundles incorporated into patient care in the ICUs.
• Tracking, trending, and reporting results to staff are vital so they can visualize results of their work. Balanced scorecards are valuable to recognize success and target areas for improvement.