SummaryTexas Health Presbyterian Hospital Dallas has critical care physician specialists (intensivists) available to patients in the hospital medical and surgical intensive care units 24 hours a day. The program has been in the medical intensive care unit since 2008 but expanded into the surgical intensive care unit in January 2013. Since program implementation, the medical intensive care unit had a 2-year period without a ventilator-associated pneumonia; the central line infection rate is below the national average, medical intensive care unit readmissions have declined, blood glucose control has improved 80 percent, and the medical intensive care unit length of stay has been decreased by 2 days. The facility has collaborated with physicians to establish Accountable Clinical Management Committees, which oversee quality, strategy, finance, and operations of the medical intensive care unit and surgical intensive care unit using the intensivists as physician leaders. All members of the team are accountable for patient outcomes.
See the Description section for new information about expanded use of intensivists in the surgical intensive care unit and updates in protocols, the Results section for updated data on rates of infection and compliance, the Planning and Development section for additional steps regarding training and use of electronic health records, and the Resources section for updates on staff and resource expansion (updated April 2013).Moderate: The evidence consists of before-and-after comparisons incidence of ventilator-associated pneumonia, central line infections, and hospital-acquired pressure ulcers; testing rates; provision of pain management education; and ICU readmissions.
Developing OrganizationsTexas Health Presbyterian Hospital Dallas
Date First Implemented2008
2008 for the medical intensive care unit; 2013 for the surgical intensive care unit
Vulnerable Populations > Intensive care unit patients
Problem AddressedVentilator-associated pneumonia (VAP), central line infections, and pressure ulcers are serious, costly, and preventable problems that commonly occur in hospital medical–surgical intensive care units (ICUs), leading to longer length of stay (LOS) and higher mortality and costs. Although use of intensivists (physicians who specialize in critical care medicine), evidence-based protocols for critical care, and daily goals worksheets can improve outcomes, many hospitals do not implement these initiatives consistently or in a coordinated fashion.
- Common, costly, and deadly problems in the ICU: Common, costly and deadly problems in the medical–surgical ICU that can be prevented with careful management include VAP, central line–associated bloodstream infections (CLABI), and pressure ulcers.
- Ventilator-associated pneumonia: VAP, which accounts for up to 28 percent of all acquired infections in medical–surgical ICUs,1 is associated with high mortality rates (30 to 50 percent), increased LOS (by an average of 13 days), and higher costs (between $30,000 and $60,000 per episode).2
- Central line infections: Approximately 80,000 ICU patients get CLABIs each year, with additional patients in other hospital units suffering from them as well. CLABIs claim 32,000 to 50,000 lives each year.3
- Pressure ulcers: On a given day, more than 15 percent of hospitalized patients have a pressure ulcer, while between 7 and 10 percent of patients develop a pressure ulcer sometime during their stay.4
- Unrealized benefits of intensivist-directed care and standardized communication: Mortality rates in ICUs where care is provided by an attending physician average 14.4 percent, compared with 6 percent in ICUs where intensivists provide care. The Society of Critical Care Medicine estimates that more than 160,000 lives could be saved each year if intensivist-led multidisciplinary care teams oversaw all ICU care.5 Part of the problem in ICUs without intensivists relates to poor communication among providers about daily care goals, which can extend the patient's ICU stay, thereby delaying recovery, increasing clinical risk, and raising costs. Standardizing communication among intensivists and other ICU providers and outlining specific tasks related to daily care goals can help prevent complications that delay recovery and discharge.6
Description of the Innovative ActivityTexas Health Presbyterian Hospital Dallas has intensivists available to patients in the hospital's medical and surgical ICUs 24 hours a day, seven days a week; intensivists lead daily multidisciplinary rounds on every patient to set goals and evaluate medications and therapy, with all care and goals being based on evidence-based guidelines. Key elements of the program include the following:
- Round-the-clock intensivists: Eight intensivist physicians and seven intensivist extenders, consisting of two physician assistants and five nurse practitioners (accredited by the Society of Critical Care Medicine for completing the Fundamentals of Critical Care Support course), provide coverage for critical care patients 24 hours a day, 7 days a week. All of the intensivists are certified as Fellows of the College of Chest Physicians (FCCP). Each day, two intensivists are available in each medical and surgical ICU from 8 a.m. until 5 p.m. After 5 p.m., an extender covers each medical and surgical ICU until morning, with intensivist physicians on call if needed and available within 30 minutes.
- Multidisciplinary rounds: Intensivists lead multidisciplinary rounds 7 days a week. Participants include medical residents, critical care nurses, advanced practice nurses, a pharmacist, a respiratory therapist, a registered dietitian, a case manager, a chaplain, and the psychiatric liaison nurse. The intensivists provide a snapshot of each patient's status and review the medical plan, the critical care nurse presents the nursing plan of care, and all participants engage in the general discussion about the care steps needed to ensure continued progress from a clinical perspective.
- Daily goals form: The daily goals are established based on individual patient needs and cover areas such as patient mobilization, pain management, skin care, ventilator weaning, core measures, and family needs/issues. The goals are documented in the intensivist's progress note in the electronic health record to ensure that all members of the health care team have access to the plan of care.
- Medication review: During the rounds, the pharmacist reviews each patient's medication list and laboratory results and makes recommendations and adjustments to the patient's antibiotics and other medications. The pharmacist also makes recommendations and provides education to nurses regarding sedation adjustments needed to facilitate ventilator weaning.
- Guideline-based care and goal setting: Daily goals and care are based on specific "bundles" of protocols, as outlined below:
- Ventilator bundle: The hospital uses the Institute for Healthcare Improvement's (IHI) ventilator "bundle" (a set of proven best practices) for mechanically ventilated patients. The bundle includes the following: elevating the head of the bed 30 degrees (tape on the wall indicates proper placement), titrating sedation according to a sedation scale, providing a daily sedation "vacation" and weaning assessment, relieving gastrointestinal bleed prophylaxis, providing deep vein thrombosis prophylaxis, controlling pain, providing oral care every 6 hours (prompts for nurses are included on the hospital's medication, administration record), and providing a nutrition and physical therapy consultation. In addition, the hospital replaced the standard endotracheal tubes (traditionally used everywhere but in the operating room, where tube use is temporary) with a better model that can reduce the rate of ventilator-associated pneumonia. Ventilator weaning assessments are a continuous process, resulting in patients being weaned and extubated throughout a 24-hour period.
- Central line bundle: The hospital uses the IHI's central line bundle, which includes specified protocols for hand hygiene, full barrier precautions (caregivers must wear sterile gloves, gown, and mask, and the patient must be completely draped with a sterile sheet), use of chlorhexidine as an antiseptic, appropriate catheter site selection and postplacement care, and a daily review of line necessity to ensure prompt removal of unnecessary lines. Specific procedures address inserting, accessing, and removing catheters; drawing blood; changing needle-less infection caps and dressings; removing catheters; and administering continuous and intermittent infusions and intravenous medications. An April 2013 update indicates that an alcohol-soaked intravenous cap system was purchased to prevent central line infections.
- Skin care protocol: The hospital uses an internal protocol based on evidence for turning patients and conducting skin evaluations. Critical care nurses evaluate patients for pressure ulcers each shift. "Turning clocks" (pictures of clocks depicting the times when patients should be turned) are posted in each room to prompt nurses to turn patients at appropriate intervals. Chlorhexidine cleaning cloths have been implemented as a routine preoperative practice and bath basins are no longer used for bathing. Hand hygiene is a standard practice, with staff encouraged to stop any staff member who is not adhering to the rules. A "scrub the hub" project was conducted in fall 2010 to ensure that the central line infection rate remains low. This project is ongoing and is now part of the ICU culture.
- Foley catheter protocol: A medical staff–approved protocol was implemented to reduce Foley catheter–associated urinary tract infections (CAUTI). The CAUTI protocol requires the Foley catheter to be removed within 48 hours unless there is a valid medical reason to continue it. The protocol allows the nurse to assess the continued need for the Foley catheter every 12 hours and remove the catheter if it is no longer justified, which in some cases results in foley catheters being in place for fewer than 48 hours.
- Sepsis treatment: A formal sepsis protocol was implemented in May 2011. All patients suspected of having systematic inflammatory response syndrome (SIRS) or sepsis have a lactic acid, central venous blood gas, and blood cultures drawn in fewer than 6 hours. Each patient receives antibiotics "STAT" when ordered. A central venous pressure (CVP) sliding scale protocol has been developed so that patients can receive normal saline fluids based on the CVP results. The intensivists or the medical ICU charge nurse assesses any patients in the ED suspected of having SIRS or sepsis to start early goal-directed therapy as soon as possible. An April 2013 update indicates that the sepsis protocol was updated based on the 2012 recommendations from the Society of Critical Care Medicine.
- Glycemic control protocol: A glycemic control protocol was implemented in May 2011. This protocol requires point-of-care blood glucose testing within an hour of arrival to the medical ICU. If blood glucose is greater than 200 mg/dL, the nurses are authorized to initiate a glycemic control sliding scale. The sliding scale may be either intravenous insulin and/or subcutaneous insulin to maintain blood glucose ranges between 80 and 180 mg/dL.
- Sedation and daily weaning protocol: In April 2013, a new sedation and daily weaning protocol was implemented to include more analgesia and fewer sedating medications, allowing for quicker weans and extubations.
- Confusion Assessment Method for the ICU (CAM-ICU) delirium protocol: In April 2013, a new delirium protocol was implemented and all nursing and respiratory staff were trained to assess for delirium during every shift using the CAM-ICU delirium screening tool.
- Other measures to improve patient care: The team has implemented several measures to improve patient care. The hospital also purchased the ResQPod, which is designed to improve cardiac output during codes and decrease mortality.
- Screening: All patients admitted to the ICU are screened for methicillin-resistant Staphylococcus aureus (MRSA) on admission.
- Communication: SBAR (Situation, Background, Assessment, and Recommendation) communication methodology was initiated to reduce variation in practice and reduce the chance of errors. The ED and the medical ICU implemented the TeamSTEPPS program in March 2012, which has enhanced communication, promoted teamwork, and improved patient outcomes; in January 2012, the medical ICU implemented open visitation for families to promote better communication between caregivers and families.
- New medication administration process: In fall 2011, the hospital implemented a new medication administration process that requires the patient's identification bracelet and medication to be scanned and compared with the medication administration record in the electronic health record which has reduced medical errors.
- Standardized patient/family education and communication: Patient and family education at the time of admission has been standardized to include pain assessment, smoking cessation, fall prevention, a campus map, TV instructions, and general patient safety tips. The team developed a satisfaction survey for use with patients and families. In April 2013, a clinical nurse manager rounding program was implemented that allows families and patients to be heard by middle management.
- Streamlined admissions: The medical and surgical ICU admission packet has been revised and the admission process has been streamlined to reduce redundancy and save time.
- Monitoring: The team developed a concurrent monitoring system that allows problems and processes to be addressed as they are identified. This process is led by a clinical nurse specialist.
Context of the InnovationTexas Health Presbyterian Hospital Dallas is a private, not-for-profit teaching hospital licensed for 866 beds, with 550 of these beds being full each day on average; the hospital handles 75,000 emergency department (ED) visits annually. The hospital has two ICUs consisting of one 24-bed medical–surgical ICU and one 24-bed surgical ICU, which treats the cardiothoracic and neurological patient populations. Gary Weinstein, MD, FCCP, a pulmonologist and the hospital's medical director of critical care medicine, had been discussing the idea of using intensivists to improve critical care outcomes with hospital leaders for several years, encouraging them to be the first in the Dallas area to embrace this model of care. Hospital leaders ultimately agreed, because they saw the program as a way to improve quality of care by reducing hospital-acquired infections, pressure ulcers, and LOS in the medical–surgical ICUs.
ResultsInformation provided in April 2013 indicates that VAP, pressure ulcer rates, ICU LOS, and ICU readmissions have remained low, medication errors have decreased, pain management education has increased, and patient and family satisfaction has increased.
Moderate: The evidence consists of before-and-after comparisons incidence of ventilator-associated pneumonia, central line infections, and hospital-acquired pressure ulcers; testing rates; provision of pain management education; and ICU readmissions.
- Decline in VAP rate: The facility was VAP free from 2010 to 2012; in 51 months of the program, there were only 2 months in which the facility was below 90 percent compliance with the bundle.
- Decline in CLABI rate: The CLABI remains below the National Healthcare Safety Network (NHSN) 25th percentile.
- Decline in pressure ulcer rate: Between 2010 and 2012 only .0038 percent of patients developed hospital-acquired pressure ulcers, a decline from pre-2008 levels. Information provided in April 2013 indicates that hospital-acquired pressure ulcers have declined to the point of no longer needing to be tracked.
- Decline in number of ICU readmissions: The number of ICU readmissions within 48 hours of transfer declined from 20 in 2009 to only 2 in 2010.
- Low ICU length of stay: The medical ICU LOS has been reduced by 2 days since the inception of the program in 2008. The ICU LOS averages between 2 and 3.1 days. Readmission to the medical or surgical ICU within 24 hours is monitored to ensure that patients are not transferred too quickly.
- Increases in testing: According to information provided in April 2013, the tight blood glucose control program has been successful; in only 13 months out of 51 months fewer than 90 percent of patients' blood glucose levels were not within the 80-to-180 range.
- Decline in medication errors: Information provided in April 2013 indicates that medication errors have declined since the hospital started using the barcode system. In 2012, the barcode system was expanded to include blood products.
- Increase in pain management education: Patient pain management education has increased from 82 to 92 percent of all patients/families admitted to the ICU.
- Improved sepsis bundle compliance: Sepsis bundle compliance was 100 percent for 48 of the 51 months, according to an April 2013 update. The sepsis mortality rate for patients while in the ICU was 30 percent, which is better than the national average.
- Anecdotal reports of improved patient and family satisfaction: The open visitation policy has improved patient and family satisfaction.
- Cost savings: Information provided in April 2013 indicate that, in 2012, the program saved the facility more than $300,000 by preventing patients who did not meet ICU admission criteria from being admitted to the ICU.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Obtaining leadership buy-in: The executive committee of the hospital's medical board approved the concept of the intensivist program in 2008. Subsequently, the idea was presented to the whole medical board, which also gave its approval. The program was expanded in 2013.
- Obtaining consulting assistance: The hospital hired a critical care consulting company (CriticalMed of Washington, DC) to help establish the program. A team from the company met with the hospital's medical and nursing leaders, pharmacists, and others to design an appropriate program and determine barriers to adoption. The consultants also developed a projected budget and pro forma financial statement to guide staffing needs, which helped hospital leaders understand the program's capital requirements.
- Hiring new staff members: The Southwest Pulmonary Group of Dallas hired the two intensivists and four extenders to fill the staffing needs outlined above.
- Developing rounding template: Based on discussions with colleagues at other institutions, Dr. Weinstein developed a template to guide discussion during multidisciplinary rounds. The template includes a list of items to review for each patient daily.
- Training staff: ICU, respiratory therapy, and ED staff received training on the content and implementation of the protocols, including the ventilator bundle, the central line bundle, and the skin care protocol. The hospital had been educating staff about evidence-based practices since 2002, so this step represented a natural continuation of those efforts. In 2010, the intensivists presented a continuing education offering for the staff titled Critical Care Update and have also championed the development of becoming a facility that teaches Fundamental Critical Care Support to staff and the greater Dallas-Fort Worth area.
- Expansion to surgical ICU: Information provided in April 2013 indicates that the program was expanded into the surgical ICU starting in January 2013. Training meetings, brainstorming sessions, and one-on-one discussions with surgeons and their extenders were held to help smooth the transition. The teams comprise members from hospital leadership, the intensivists group, and unit staff. All staff members will be accountable for patient satisfaction and patient outcomes.
- Evolution of electronic health record: Information provided in April 2013 indicates that the electronic health record (EHR) continues to evolve and provide staff with readily available protocols, guidelines, and resources at the point of care. Texas Health Resources has 14 facilities using the EHR. It has helped the team develop care bundles that are easy to use and helps the team comply with care bundle components.
- Evolution of staff training: Professional growth of the staff has become a major focus. A Fundamentals of Critical Care course is now being offered three times a year; it has improved the standard of practice for physicians, nurses, and respiratory therapists. Nursing staff are working toward critical care certification as well as advanced degrees. An April 2013 update indicates that the nursing orientation program was reformatted to include mentors and has been expanded from 14 months to a 2-year program. In addition, general medical/surgical nurses across the hospital as well as ED and ICU nurses have been educated about the early signs and symptoms of SIRS, and sepsis education is part of the formal nurse residency program at the hospital.
- Continuous improvement: Daily multidisciplinary rounds have evolved, with various methods tried for rounding. The team is using a designated room with computers to access the electronic health record while maintaining patient confidentiality. Other improvement efforts are under way with regard to alcohol/drug withdrawal protocols and early mobilization of ventilated patients.
Resources Used and Skills Needed
- Staffing: The program required the hiring of two additional intensivist physicians (five were already on staff) and four additional intensivist extenders were added. In addition, a critical care clinical nurse specialist is dedicated to the concurrent monitoring and rounding in the two ICUs to ensure compliance with the measures. The team has added five additional certified nurses. Team members dedicate approximately 140 person-hours each week to daily rounds.
- Costs: Data on total program costs are unavailable; the primary costs consist of salary and benefits for new critical care staff members, consultant fees, membership fees for participation in the IHI collaborative, and the purchase of new endotracheal tubes (Kimberly-Clark MicroCuff); 10 dedicated laptop computers used during rounds; extra oral care products placed at the bedside; 10 ScvO2 (central venous oximetry probe) monitors; and special beds with mattresses that reduce the potential for skin breakdown. New technology purchases included a glide scope to assist with difficult intubations and a vein finder device to assist with difficult line placements.
Funding SourcesTexas Health Presbyterian Hospital Dallas
Tools and Other ResourcesIndividuals may obtain a copy of the hospital's rounding template by contacting the program developer.
A tool for preventing central line infections is available from the Institute for Healthcare Improvement at http://www.ihi.org/knowledge/Pages/Tools
Information about implementing the IHI's central line bundle is available at http://www.ihi.org/knowledge/Pages/Changes/ImplementtheCentralLineBundle.aspx.
In addition, the following articles and guidelines were used in the development of this intensivist initiative:
ICU family conferences:
- Coffin SE, Klompas M, Classen D, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S31-40. [PubMed]
Daily goals checklists:
- Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences. Chest. 2008;134(4):835-43. [PubMed]
Catheter/central line infections:
- Halm MA. Daily goals worksheets and other checklists: are our critical care units safer? Amer J Crit Care. 2008;17(6):577-80. [PubMed]
- Khorfan F. Daily goals checklist-a goal-directed method to eliminate nosocomial infection in the intensive care unit. J Healthc Qual. 2008;30(6):13-7. [PubMed]
- Lo E, Nicolle L, Classen D, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S41-50. [PubMed]
- Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29:S22-30. [PubMed]
- The Joint Commission. Hand-Off Communication: Steps to Success. 2008 Joint Commission Resources.
Getting Started with This Innovation
- Know the evidence: The program should incorporate evidence-based research and practices that have been shown to improve critical care patient outcomes.
- Conduct cost analysis: Conducting a detailed analysis ensures that hospital leaders understand the costs of adopting the program.
- Obtain staff buy-in: All involved staff must support the program and be willing to change care processes to adhere to best practices. First-line staff must be involved and strong hospital leaders must be supportive and open to new ideas and expansion.
- Go "low tech": Using small, simple tactics, such as "turn clocks" to designate when a patient should be turned and tape on the wall to mark proper bed elevation, can be very effective in promoting change in care processes.
- Ensure thorough training: All relevant staff should be trained on the rationale for and implementation of the program, including care protocols. Share "why, how, who, what, when, and where" information with all team members, including departments that support bedside care. Train new staff on the program as they join the organization. Training is essential for the program's success.
- Monitor and stay engaged: Concurrent monitoring is essential for ongoing, daily improvements. Stay engaged and open to new ideas and practices as well as guidelines from professional organizations.
Sustaining This Innovation
- Be patient: Allow time for changes to be accepted but continue to press for adoption by emphasizing the program's potential impact on quality of care.
- Monitor compliance: Monitor compliance with protocols to determine if the new processes are being adopted fully and are producing good outcomes.
- Track data: Because obtaining data on processes and outcomes can be difficult, adequate time must be committed to this task.
- Explore new ideas: Program adopters should continually explore new ideas to enhance the program and produce improved patient outcomes.
Contact the InnovatorPhyllis McCorstin, MSN, RN, Clinical Nurse Specialist, APN, CCNS, CCRN
Critical Care Services
Texas Health Presbyterian Hospital of Dallas
Office: (214) 345-5014
Pager: (214) 759-3353
Gary L. Weinstein, MD, FCCP
8220 Walnut Hill Lane, Suite 408
Dallas, TX 75231
Innovator DisclosuresMs. McCorstin and Dr. Weinstein have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesHuang W, Wann S, Lin S, et al. Catheter-associated urinary tract infections in intensive care units can be reduced by prompting physicians to remove unnecessary catheters. Infect Control Hosp Epidemiol. 2004;25(11):974-8. [PubMed]
Jain P, Parada J, David A, et al. Overuse of the indwelling urinary tract catheter in hospitalized medical patients. Arch Intern Med. 1995;155:1425-29. [PubMed]
Scott RD II. The direct medical costs of health care-associated infection in U.S. hospitals and the benefits of prevention. Available at: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Coffin SE, Klompas M, Classen D, et al. Strategies to prevent ventilator-associated pneumonia in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S31-40. [PubMed]
Halm MA. Daily goals worksheets and other checklists: are our critical care units safer? Am J Crit Care. 2008;17(6):577-80. [PubMed]
Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(Suppl 1):S22-30. [PubMed]
Texas Health Dallas's New Intensivist Program Puts Critical-Care Specialists in the ICU - All the Time. Reuters. 6 Feb 2009. Available at: http://www.reuters.com/article/2009/02/06/idUS180282+06-Feb-2009+PRN20090206.
1 HAI Watch. Ventilator associated infections. Available at: http://en.haiwatch.com/VAP.aspx.
Courtney BA, Ruppman JB, Cooper HM. Save our skin: initiative cuts pressure ulcer incidence in half. Nurs Manage.
5 Society of Critical Care Medicine. Critical care statistics in the United States 2012.
Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71-5. [PubMed]
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Original publication: March 03, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 05, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 08, 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.