Intensive Care Units Participating in Hospital Collaborative Implement Multiple Improvement Strategies, Leading to Fewer Deaths and Lower Costs

Service Delivery Innovation Profile

Intensive Care Units Participating in Hospital Collaborative Implement Multiple Improvement Strategies, Leading to Fewer Deaths and Lower Costs

Snapshot

Summary

The Michigan Health & Hospital Association's Keystone: ICU project incorporates the use of evidence-based interventions to reduce bloodstream infections and ventilator-associated pneumonia, the Comprehensive Unit-based Safety Program to improve safety culture, and robust measurement and feedback. In an initial study funded by the Agency for Healthcare Research and Quality, 103 participating intensive care units implemented the model and reduced bloodstream infections by up to 66 percent to a median of zero. The program improved the culture of safety among participating intensive care units and saved an estimated 1,800 lives, 140,000 hospital days, and at least $270 million over a 5-year period.

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of safety culture survey results and catheter-related bloodstream infections, along with a predictive model that estimated the number of lives, dollars, and hospital days saved over a 5-year period.

Use By Other Organizations

AHRQ is now funding an opportunity for each state, the District of Columbia, and Puerto Rico to collaborate with the Michigan Health & Hospital Association Keystone Center, The Johns Hopkins Quality and Safety Research Group, and the Health Research & Educational Trust to implement the program.

Date First Implemented

2003

Problem Addressed

Intensive care unit (ICU) patients have life-threatening problems and complex care needs that require a combination of many treatments and services to achieve timely recovery and discharge.n addition, they are susceptible to preventable complications, such as ventilator-associated pneumonia, deep vein thrombosis, and catheter-associated bloodstream infections, which lead to suboptimal clinical outcomes and prolonged length of stay (LOS). Tools to improve communication and checklists to guide adherence to evidence-based interventions are known to improve outcomes for ICU patients, yet many hospitals have not adopted these initiatives.

  • Numerous preventable complications: ICU patients are at high risk of numerous preventable clinical complications. For example, ventilator-associated pneumonia is the second most common hospital-associated infection (after urinary tract infections) and has been shown to increase LOS, costs, and mortality.Many cases of ventilator-associated pneumonia are likely preventable. As another example, central venous catheters cause an estimated 80,000 catheter-associated bloodstream infections in ICUs each year, leading to as many as 28,000 deaths among ICU patients. These infections are largely preventable, as demonstrated in the Michigan Keystone: ICU study.
  • Inconsistent adoption of programs that can help: Many initiatives exist that can improve communication and enhance patient monitoring and treatment in the ICU, leading to lower morbidity and mortality (e.g., by preventing bloodstream infections and ventilator-associated complications). Many ICUs, however, have not implemented these programs, or have done so in an inconsistent, uncoordinated fashion.

Description of the Innovative Activity

Each participating ICU has an improvement team that leads the implementation of multiple initiatives designed to improve care, including a comprehensive unit-based safety program to enhance the culture of patient safety and tools to expedite the translation of evidence into practice. These tools can help speed adoption of evidence-based processes and proven interventions to reduce catheter-associated bloodstream infections and complications associated with mechanical ventilation; and improve clinician-to-clinician communication via a daily goals sheet. Collaborative participants, which include 120 ICUs at 76 hospitals, also use a variety of mechanisms to share ideas and best practices with one another. Key elements of the initiative include the following:

  • ICU improvement teams: Each participating ICU forms an improvement team that includes a senior hospital executive, an ICU director, an ICU nurse manager, a critical care physician, a critical care nurse, and a department administrator.
  • Comprehensive unit-based safety program (CUSP): Each ICU implements a CUSP, a five-step process developed at Johns Hopkins Hospital to improve the culture of safety within a unit. The five steps include education about patient safety improvement and systems redesign; identification of defects; partnerships between senior executives and frontline staff to prioritize initiatives and secure adequate resources; and selection and implementation of a process improvement initiative. The culture of safety and teamwork is measured annually using the Safety Attitudes Questionnaire.
  • Evidence-based processes to reduce catheter-related bloodstream infections: Each ICU implements five evidence-based procedures recommended by the U.S. Centers for Disease Control and Prevention (CDC), including hand washing, use of full-barrier precautions during central venous catheter insertion, use of chlorhexidine to clean the skin, avoiding the femoral site whenever possible, and removing unnecessary catheters. To facilitate implementation, each ICU creates a central line cart with necessary supplies; uses a checklist to ensure adherence to infection-control practices; authorizes clinicians to stop colleagues if practices are not being followed; makes catheter removal a routine part of discussion during daily rounds; and provides feedback to teams regarding infection rates.
  • Proven interventions to reduce complications associated with mechanical ventilation: Each ICU adopts interventions proven to reduce ventilator-associated complications, including the following: elevation of the head of the bed to at least 30 degrees; provision of appropriate (nonexcessive) sedation so that patients remain sufficiently alert to respond to simple commands; provision of stress ulcer prophylaxis medication and deep vein thrombosis prophylaxis (through medication and/or mechanical devices); and daily assessment of readiness for extubation.
  • Tools and tactics: Examples of tools and tactics to help teams address challenges include:
    • ICU daily goals sheet: Providers use a daily sheet to enhance communication during rounds. The form prompts clinicians to evaluate and document the patient's current status, design a care plan, outline daily tasks to be completed (including by whom), and specify a plan for communicating with the patient, family, and other caregivers.
    • Central line checklist: Clinicians use a central line checklist to reduce central line–associated infections. It includes key steps before, during, and after the procedure and stresses the need to document any deviations from the checklist.
    • Optimization of ICU physician staffing: Each ICU optimizes intensivist physician staffing to ensure appropriate care coordination. This process typically involves either hiring additional intensivists or redistributing existing physician resources to ensure appropriate ICU staffing by physicians with critical care knowledge and experience.
    • Ongoing education, support, and sharing of best practices: Hospital teams participate in an annual 1.5-day conference with the Michigan Health & Hospital Association Keystone Center and Johns Hopkins staff, and participate in periodic conference calls to share best practices and receive coaching. Keystone Center staff also periodically visit participating sites to provide guidance and support. Participating sites also have access to a Web site with tools, reference documents, blinded participant data, and a bulletin board to facilitate communication and the sharing of ideas.

Context of the Innovation

The Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality, a nonprofit division of the Michigan Health & Hospital Association Foundation, is a collaboration of hospitals and national experts who study evidence and facilitate implementation of best practices at the bedside, with the goal of improving patient safety. The Keystone Center and patient safety experts at the Quality and Safety Research Group from the Johns Hopkins School of Medicine developed the Keystone: ICU project to focus on implementing initiatives to improve quality and patient safety in the ICU. The model was based on previous work done at Johns Hopkins Hospital, a 1,015 bed tertiary care facility that is part of the Johns Hopkins Health System. As noted, nearly 120 ICUs in 76 Michigan hospitals participate in the project. Similar programs have been developed by the Keystone Center for stroke, hospital-associated infections, surgical care, organ/tissue donation, obstetrics, and emergency care.

Results

The program improved the culture of safety among participating ICUs and prevented a significant number of catheter-associated bloodstream infections, leading to more than 1,800 lives saved, more than 140,000 hospital days avoided, and at least $270 million in savings over a 5-year period.

  • Improvements in culture of safety : An analysis of scores from 99 participating ICUs completing the Safety Attitudes Questionnaire found that the percentage of ICUs that had at least 60 percent consensus on the presence of good teamwork increased from 17 percent in 2004 to 46 percent in 2005.
  • Fewer catheter-associated bloodstream infections : A prospective cohort study of 103 participating ICUs found that the median rate of catheter-associated bloodstream infections per 1,000 catheter-days fell from 2.7 at baseline to zero at 3 months after implementation; the mean rate per 1,000 catheter-days fell from 7.7 at baseline to 1.4 by 16 to 18 months after implementation; and the incidence of infections per 1,000 catheter days fell from 0.62 right after implementation to 0.34 16 to 18 months later.
  • Fewer deaths and hospital days, lower costs: A Johns Hopkins predictive model estimates that the program saved more than 1,800 lives, avoided more than 140,700 hospital days, and reduced costs by at least $271 million over a 5-year period (March 2004 to March 2009).

Evidence Rating

Moderate: The evidence consists of pre- and post-implementation comparisons of safety culture survey results and catheter-related bloodstream infections, along with a predictive model that estimated the number of lives, dollars, and hospital days saved over a 5-year period.

Planning and Development Process

  • Training: Team leaders received training on topics related to patient safety, the particular interventions supported by the project, and implementation methods and strategies. Training occurred in biweekly telephone conference calls, periodic coaching sessions offered by project research staff, and statewide meetings held twice each year. Team leaders disseminated the information they learned in these sessions to their colleagues. Particular emphasis was placed on the importance of rigorous measurement, the value of centralized data collection and analysis, and local accountability for adaptation and implementation.

Resources Used and Skills Needed

  • Staffing: The program typically requires no new staff, as existing staff incorporate it into their daily routines. Over time, however, many participating organizations decided to dedicate one staff member to oversee Keystone activities as a way to support the in-house team. The critical care physician and critical care nurse serving on the ICU improvement team are required to devote 20 percent of their time to the project. All team members participate in biannual conferences and monthly conference calls.
  • Costs: Participating hospitals estimate that their total expenditures to train staff, implement the interventions, and participate in conference calls and workshops ran approximately $120,000 per year in the first 2 years. This estimate includes the value of staff time spent on the program.

Funding Sources

The Keystone: ICU project was funded from September 30, 2003, to September 30, 2005, by an Agency for Healthcare Research and Quality (AHRQ) grant (#1UC1HS14246). Participating hospitals also provided in-kind contributions to the project.

In 2008, AHRQ awarded a 3-year, $3 million contract to the Health Research & Educational Trust to coordinate a 10-state project to reduce central line–associated bloodstream infections in hospital ICUs by replicating the work done in Michigan, with particular emphasis on expanding the collaborative model to include quality improvement organizations and state health departments, and to enhance and disseminate the CUSP. As part of this project, the Health Research & Educational Trust will collaborate with the Johns Hopkins University Quality and Safety Research Group and the Keystone Center for Patient Safety & Quality. In 2009, AHRQ modified the 2008 Health Research & Educational Trust contract to expand the CUSP/central line–associated bloodstream infections project to all 50 states, the District of Columbia, and Puerto Rico.,

Tools and Resources

Information and training modules for the national collaborative CUSP/central line–associated bloodstream infections project are available at: http://www.ahrq.gov/cusp

Getting Started with This Innovation

  • Ensure strong leadership: Executive and physician leaders are critical to program success. Executive leaders need to fully engage with the team by attending meetings, providing organizational resources for data collection, and assisting in resolving cross-departmental issues that may impede the provision of safe care.
  • Ensure accurate data: To ensure that clinicians believe in the validity of the data, it should be linked to the interventions and grounded in the evidence. The data should also provide enough information to determine if change has occurred without being overly burdensome. Data collection should be rigorous and based on standard definitions, with quality checks built into the process to guard against erroneous or missing data.

Use By Other Organizations

AHRQ is now funding an opportunity for each state, the District of Columbia, and Puerto Rico to collaborate with the Michigan Health & Hospital Association Keystone Center, The Johns Hopkins Quality and Safety Research Group, and the Health Research & Educational Trust to implement the program.

Lessons Learned

Based on the success of the program in Michigan, the U.S. Congressional Committee on Oversight and Government Reform has urged the other 49 states to implement similar programs; the committee estimates that more than 15,000 lives and more than $1 billion could be saved each year if all states implemented the Keystone: ICU program.


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Sam R. Watson, MSA
Senior Vice President Patient Safety and Quality
Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality
6215 West St. Joseph
Lansing, MI 48917
Phone: (517) 323-3443
E-mail: swatson@mha.org

Chris Goeschel, ScD RN MPA MPAS
Quality and Safety Research Group Director
Patient Safety and Quality Initiatives & Manager, Operations
Johns Hopkins School of Medicine
Clinical Instructor, The Johns Hopkins School of Nursing
Adjunct Faculty, The Johns Hopkins Bloomberg School of Public Health
1909 Thames Street 1st Floor
Baltimore, MD 21231
Phone: (410) 955-0034; (443) 710-1819
E-mail: cgoesch1@jhmi.edu



Innovator Disclosures

Mr. Watson and Dr. Goeschel have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Michigan Health & Hospital Association Web site. Available at: http://new.mha.org/mha/index.htm

Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-21. [PubMed]

Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32. [PubMed]

Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec. 2005;20(2):14-6, 18, 20 passim. [PubMed]

Footnotes

  1. 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]

  2. Centers for Disease Control and Prevention. Healthcare–Associated Infections: Ventilator-Associated Pneumonia [Web site]. Available at: http://www.cdc.gov/HAI/vap/vap.html.

  3. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32. [PubMed]

  4. Pronovost PJ, Berenholtz SM, Goeschel C, et al. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23(2):207-21. [PubMed]

  5. Information provided by Sam Watson.

  6. Michigan Health & Hospital Center. MHA Keystone: ICU [Web site]. Available at: http://mhakeystonecenter.org/.

  7. Agency for Healthcare Research and Quality. Fiscal Year 2009 Budget at a Glance. May 2009. Available at:http://www.ahrq.gov/cpi/about/mission/budget/2009/fy09glance.html.

  8. Agency for Healthcare Research and Quality. Fiscal Year 2010 Online Performance Index.

  9. MHA Keystone Center for Patient Safety and Quality. 2008 Annual Report. Available at:  http://www.mha.org/keystone_center/documents/08_keystone_annual_report.pdf.

Funding Sources

Agency for Healthcare Research and Quality
Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality

Developers

Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality, Johns Hopkins University Quality & Safety Research Group

Comments

By Editorial Team on
Readers may be interested in an article entiled "Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study" published in the British Medical Journal February 4, 2010. The purpose of the study was to determine whether reduced rates of catheter related bloodstream infections achieved in intensive care units participating in the initial Keystone ICU project continued 36 months after program implementation. Results revealed that "reduced rates of catheter related bloodstream infection achieved in the initial 18 month post-implementation period were sustained for an additional 18 months as participating intensive care units integrated the intervention into practice." The article is available at http://www.bmj.com/cgi/content/full/bmj.c309.
Original Publication: 10/14/09

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 08/13/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 09/18/13

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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