Daily Intensive Care Unit Team Communication Enhances Provider Understanding of Care Goals, Reduces Length of Stay

Problem Addressed

• Complex, life-threatening conditions: ICU patients tend to have life-threatening problems and complex care needs that require a combination of many treatments and services in order to achieve timely recovery and discharge.¹
• Multiple caregivers create communication challenges: As with most academic medical centers, the care of ICU patients at Johns Hopkins is the responsibility of many providers, including attending physicians and fellows, anesthesia and surgery residents, nurse practitioners, nurses, and pharmacists. The greater the number of providers involved, the greater the likelihood of poor communication.
• Lack of understanding of daily goals: ICU providers set daily goals for patients to prompt needed care and hasten recovery. However, some providers on the care team did not understand or were not aware of these goals: Prior to 2001, surveys conducted at Johns Hopkins Hospital revealed that only 1 in 10 ICU nurses and residents understood the daily goals for their patients.¹ Furthermore, providers did not outline specific, actionable tasks that would lead to goal achievement.
• Impact of poor communication: Lack of communication among providers about daily care goals can extend the patient’s length of ICU stay, thereby delaying recovery, increasing clinical risk and generating higher health care costs. Caregivers can also become frustrated by communication failures, leading to higher staff turnover rates in the ICU, where experience and staff continuity are especially important.¹

Description of the Innovative Activity

• Daily patient rounds by ICU care team: The ICU care team—which includes the attending physician and/or fellow, anesthesia and surgery residents, a nurse practitioner, a nurse, and a pharmacist—visits each ICU patient every day for 20 to 25 minutes as part of patient rounds.
• Guided discussion using daily goals form: During the daily visit, the team develops a plan of care for the day, delineating specific care goals, work tasks and task responsibility, and plan for patient evaluation. The providers use a daily goals form to guide this discussion; the form then serves as a central repository for all relevant information about the patient's care plan. Elements of the daily goals form include the following:
  • Clinical status: Information related to the patient’s clinical status is documented, including pulmonary/ventilator issues; cardiac rhythm/hemodynamics; volume status; neurological function; pain management/sedation; gastrointestinal, nutrition, and bowel regimen; laboratory results; results of cultures; drug levels; and patient safety risks. The care team lists parameters for when nurses/residents should call the attending physician. The providers also confirm that an advance directive is in place.
  • Daily care goals: The care team frames its discussion around what needs to be done for the patient to be discharged from the ICU. The form prompts the team to consider and document daily care goals, including mobilization goals, nutritional goals, and goals related to removing central lines/catheters, assessing readiness for extubation, and elevating the head of the bed. The care team also lists issues to be addressed, including pain management; social, emotional, and/or spiritual issues; skin care issues; and code status issues. Finally, the patient's greatest safety risks and strategies for risk reduction are identified.
  • Work steps: The providers outline the work steps (with associated responsible parties) that need to occur to expedite ICU discharge. These include tests and procedures; ordering of specialist consultations; discontinuation of central lines or other catheters/tubes; medication changes, including whether any medications can be discontinued; and updates provided to the attending physician and the family.
• Ongoing form review: Once completed, the form is signed by the fellow or attending physician and given to the patient's nurse, who ensures that the form remains at the patient's bedside. All providers involved in the care of the patient (including physicians, nurses, respiratory therapists, and pharmacists) review the daily goals and initial the form three times a day.
• As-needed updates to the care plan during the day: Team members update the care plan during the day if the patient's care goals change.
• Family communication: Caregivers use the form as a tool to facilitate communication with families by referencing the form when describing clinical status, the plan of care, and the daily care goals.

References/Related Articles

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Results

• Reduced LOS: Mean ICU length of stay decreased by 50 percent from 2.2 days in June 2001 (pre-implementation) to 1.1 days by February 2002 (post-implementation). Mean ICU length of stay has been maintained at approximately 1 day. Program developers speculate that the adoption of the daily goals form contributed to length of stay reductions by prompting reductions in catheter-related complications and ventilator-associated pneumonia among ICU patients. However, the adoption of concurrent quality improvement efforts (including strategies to improve ventilator care and reduce catheter-related infections) likely contributed to the reduction as well.
• Additional capacity/revenue-generating potential: The decline in LOS created sufficient additional capacity in the ICU to admit 670 additional patients each year. Given estimated revenue per new admission of $13,000, the generation of additional capacity contributes an incremental $8.7 million to annual hospital revenues.
• Better communication and understanding of goals: At baseline, less than 10 percent of residents and nurses understood the goals of care for the day; 8 weeks after implementation, more than 95 percent of nurses and residents understood these goals. Anecdotally, caregivers reported that the form was easy to use and that it served as a useful tool for clarifying work goals among providers. Residents and nurses reported that it improved communication and patient care, and made them feel like a more active part of the patient care team.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Form development: The daily goals form was developed by Dr. Provonost, ICU residents and ICU nurses rounding in the ICU by using rapid cycle improvement techniques.
• Pilot testing: The form was pilot-tested in May and June of 2001.
• Implementation: Full rollout of the intervention began in July 2001. Its impact on LOS was evaluated from July 2001 through June 2002. Numerous modifications were made during the pilot test (most during the first week of use). For example, caregivers found it necessary to add questions about long-term care goals, including palliative care. 
• Form modification: Minor changes to the form have occurred since the first week; minor changes are only made if there is major consensus among staff on the ICU that the item is necessary for daily review. Since the form is used locally and not part of the patient's permanent record, it does not need approval by senior leadership.

Resources Used and Skills Needed

• Staffing: Existing staff members developed the form. No training was needed, as the program and form are generally self-explanatory.
• Costs: Costs are minimal and include staff time required for form development.

Funding Sources

Johns Hopkins Hospital

Tools and Other Resources

Getting Started with This Innovation

• Start with the existing form and then modify it: Although potential adopters can use the Johns Hopkins form as a starting point, the form should be modified to meet the institution's particular needs, with input provided by physicians and ICU staff.
• Discuss the option to make the form a part of the patient’s medical record: The form need not be made a part of the official medical record. ICU physicians and staff should discuss the risks and benefits of making the form a part of the medical record. Potential risks include (1) as the form evolves, each change would have to undergo a review by hospital management; and (2) because an official medical record form must be assigned to a single discipline (e.g., nursing), making it a permanent record might hinder involvement of clinicians from multiple disciplines.
• Consider testing on a subset of patients: Adopters can test this innovation on a small scale by working with a group of providers to develop and test the program in one hospital ICU or even for a subset of ICU patients.

Sustaining This Innovation

• Continually update the form: The form can and should be modified frequently after initial development. Providers can meet periodically to discuss practical issues related to the form and its use, including whether it is addressing current needs sufficiently and any changes necessary to improve functionality.
• Consider expanding the concept to other units: Because poor communication among providers and inconsistent understanding of care goals are problems that are not confined to the ICU, adopters may want to expand this program to other care units in the hospital. However, in each case, the providers involved would have to agree to the use of the form as a structure for communication and modify its content to meet their needs.
• Emphasize enhanced communication, not the form: Facilitating communication is the cornerstone of this program, not the specific statements or content of the form.

Additional Considerations and Lessons

Use By Other Organizations