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Service Delivery Innovation Profile

Daily, Multidisciplinary Rounds and Evidence-Based Best Practices Decrease Nosocomial Infections and Costs in the Intensive Care Unit


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Snapshot

Summary

The combination of multidisciplinary, physician-led rounds and a set of evidence-based best practices (known as "bundles") decreased nosocomial infection rates and costs in the intensive care unit.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of infection rates and costs.
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Developing Organizations

Baptist Memorial Hospital, Southaven, MS
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Use By Other Organizations

Other organizations participating in the IHI IMPACT initiative have also implemented this program.

Date First Implemented

2002
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Patient Population

Vulnerable Populations > Intensive care unit patientsend pp

Problem Addressed

Nosocomial infections in intensive care units (ICUs) are a major, costly, and preventable problem.
  • A major problem: Each year, more than 5 million patients are admitted to ICUs in the United States, with 10 percent of these patients dying. One of the major causes of ICU deaths is nosocomial infections, which occur in 10 percent of ICU patients. Urinary tract infections (UTIs), ventilator-associated pneumonia, and central line bloodstream infections are the main sources of nosocomial infections in the ICU.
  • But largely preventable: Research has shown that quality improvement initiatives can significantly reduce nosocomial infections, leading to fewer deaths and lower costs.1

What They Did

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Description of the Innovative Activity

The 28-bed medical-surgical ICU at Baptist Memorial Hospital implemented a systematic approach for reducing nosocomial infections. The initiative consisted of multidisciplinary, physician-led rounds and implementation of a "bundle" of evidence-based best practices, as outlined below:
  • Physician-led multidisciplinary rounds, with a focus on culture change and team decisionmaking: Intensivists under contract with the hospital lead ICU patient rounds with a multidisciplinary team consisting of the intensivist, patient’s staff nurse, ICU charge nurse, pharmacist, dietitian, respiratory therapist, case manager, social worker, physical therapist, and palliative care nurse. The team sets daily goals for each patient using a daily goals sheet that also includes the evidence-based bundles (see details on these bundles below). Teams use a "trigger-tools" list to define adverse events in the ICU. During these daily rounds, the intensivist emphasizes the importance of changing the culture to focus on patient safety and also encourages each team member to be a proactive part of the team by sharing their input and ideas on how to redesign processes to reduce infections. This encouragement is reinforced by the "one-voice concept," which stresses that each person attending rounds is considered to be equally important to the team.
  • Daily "flow" meeting to assess bed availability: A multidisciplinary team meets twice a day for 20 minutes (once at 9 a.m. and again at 4 p.m.) to assess the facility’s bed availability, prioritize interventions, review historical data, and make goals for the day to facilitate the bed flow process. The administrative house supervisor leads the meeting, which also includes a representative from case management, social services, environmental services, and nursing representatives from all units and admissions. This communication between key individuals assists team decisionmaking on ICU patients.
  • Implementation of a set of evidence-based best practices (known as "bundles") for reducing ventilator infections, central-line infections, and UTIs:
    • Ventilator bundle: The ventilator bundle consists of the following: elevate the head of the bed to 30 degrees, administer peptic ulcer disease prophylaxis, administer deep venous thrombosis prophylaxis, provide mouth care every 2 hours, provide a "sedation vacation" every 24 hours, and conduct repeated evaluations of the patient's readiness to be weaned from the ventilator.
    • Central line bundle: The central line bundle consists of the following: use standard hand disinfection before any procedure; use mask, sterile gown, sterile gloves, and cap for all procedures; prepare the site with chlorhexidine stick; use a full sterile drape; and dress the site with kit, Biopatch, and medicated disc.
    • UTI bundle: The UTI bundle consists of the following: regularly assess the continued need for a catheter; use sterile technique at insertion; provide perineal care on a daily basis and after every bowel movement; keep the drainage bag lower than patient's bladder at all times, including during transport; secure all catheters; and use silver-coated catheter in select cases.

Context of the Innovation

Baptist Memorial Hospital is a 339-bed acute care facility located in Southaven, MS. The facility has a 28-bed medical-surgical ICU unit. Beginning in October 2002, the hospital participated in an ICU collaborative that was part of the Institute for Healthcare Improvement (IHI) IMPACT initiative to address ICU nosocomial infections.

Did It Work?

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Results

A pre- and post-implementation comparison shows that this intervention significantly reduced infections and costs in the ICU:
  • Reduced infection rates: Infection rates for ventilator-associated pneumonia declined by more than 50 percent, from 7.5 to 3.2 per 1,000 ventilator days. Bloodstream infections declined by 47 percent, from 5.9 to 3.1 per 1,000 line days. UTIs fell more modestly, by roughly 37 percent, from 3.8 to 2.4 per 1,000 catheter days.
  • Lower costs: Total costs per ICU episode fell by 12.7 percent, from $3,406 in fiscal year 2002 to $2,973 in fiscal year 2003.
  • Evaluating impact on mortality rates: Although no data are currently available, hospital staff are currently assessing the impact of the program on ICU mortality.

Evidence Rating (What is this?)

Moderate: The evidence consists of a pre- and post-implementation comparison of infection rates and costs.

How They Did It

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Planning and Development Process

The key planning and development steps include the following:
  • Obtaining administrative support for, and identifying key physicians and staff to attend, the IHI collaborative and educational sessions.
  • Forming a multidisciplinary team to evaluate the existing process and develop a plan for implementing the evidence-based bundles.
  • Obtaining buy-in from the intensivists and from physicians who admitted patients to the ICU (who had to give permission to the team to round on their patients and make suggestions).
  • Training relevant personnel: Although most training occurred "on the job" during the daily multidisciplinary rounds, the concept of the bundles was incorporated into orientation for new nurses and also became a required competency for all ICU staff. In addition, physicians who were project leaders educated their peers during department meetings.

Resources Used and Skills Needed

  • Staffing: The intervention relies on existing staff, requiring no new staffing resources.
  • Costs: The costs for this program are minimal.
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Funding Sources

The program was funded internally.end fs

Tools and Other Resources

Institute for Healthcare Improvement. Ventilator bundle checklist. Available at: http://www.ihi.org/knowledge/Pages/Tools/VentilatorBundleChecklist.aspx

Adoption Considerations

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Getting Started with This Innovation

  • Review the evidence, as it is critical to be familiar with the literature and Centers for Disease Control and Prevention recommendations in this area.
  • Elicit internal suggestions. Staff can offer valuable recommendations related to developing and implementing the ventilator, central line, and UTI bundles.
  • Promote an organizational culture that supports rapid cycle process development and testing. Educating key physicians and staff on the IHI rapid cycle improvement process can help in achieving this culture change.

Sustaining This Innovation

  • Use multidisciplinary teams to enhance communication, which is critical to successful implementation.
  • Continually evaluate the impact of the program, including on mortality.
  • Provide frontline feedback to the individuals involved.
  • Recognize and celebrate successes on individual units; personalize these celebrations by sharing the experiences of real patients.

Use By Other Organizations

Other organizations participating in the IHI IMPACT initiative have also implemented this program.

Additional Considerations

  • A systematic approach through collaboration with the IHI's IMPACT initiative contributed to significant improvements in the ICU setting.
  • Use of bundles can promote the delivery of evidence-based care.

More Information

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Contact the Innovator

Manoj Jain, MD
6027 Walnut Grove Suite 312
Memphis, TN 38120
Phone: (901) 240-2602
E-mail: MKJAIN@aol.com

Innovator Disclosures

Dr. Jain has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Guidelines for prevention of nosocomial pneumonia. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 1997;46(RR-1):1-79. [PubMed]

O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention (CDC). MMWR Recomm Rep. 2002;1(RR10):1-26. [PubMed]

Wong ES. Guideline for prevention of catheter-associated urinary tract infection. Am J Infect Control. 1983;11(1):28-36. [PubMed]

Saint S, Elmore JG, Sullivan SD, et al. The efficacy of silver alloy-coated urinary catheters in preventing urinary tract infection: a meta-analysis. Am J Med. 1998;105(3):236-41. [PubMed]

Footnotes

1 Jain M, Miller L, Belt D, et al. Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006;15(4):235-9. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: July 21, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: July 17, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 12, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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