Thursday, September 11, 2014

Critical Care at GBMC: No Longer Relying on Hard Work and Good Intentions Alone

On January 1 of this year, GBMC began a new era in critical care. We have always had excellent physicians and nurses caring for our sickest patients in our ICU’s, but our care delivery model – the system our people worked in – was not state of the art. 

All of that is now in the past. Under the leadership of David Vitberg MD, all ICU patients are now covered by a new, high-intensity, hospital-based team.  From inception, this new team significantly increased the level of oversight and availability for our sickest patients by extending attending physician in-house coverage from 8-10 hours (on average) to sixteen hours per day.  Also from inception, the team took ownership of all surgical intensive care unit patients. Prior to this, the attending surgeon was responsible for the minute to minute changes often required in the SICU while continuing to do his or her other work in the office or in the operating room unless a consultation request was made.  Now, the GBMC surgeons that fill the SICU with patients and the dedicated nurses that staff this unit have an equally dedicated group of intensivist physicians that attend to this high acuity patient population around the clock. This is what you would want if the patient were your loved one.

During the past six months, six new physicians were recruited to the division – four of which split time between the intensive care units and the new pulmonary practice – Pulmonary Medicine at GBMC.  In addition, three supplemental attending physicians were recruited to provide extra coverage as needed.  Supporting these ten physicians, two physician assistants were hired and now provide coverage seven days per week between 0700 to 1900 hours.

The 7 full time members of the physician critical care/pulmonary group are:

As of September 1st, all of the members of this new team are on board. But much progress has already been made to improve the quality and safety of Critical Care Medicine at GBMC.  An overriding principle in developing this new division was to elevate the delivery of Critical Care Medicine and build an environment and group of clinicians that would deliver this care in a safe, efficient, evidence-based, and compassionate manner that would defy the ‘low intensity’ label typically attributed to a community intensive care unit.  The following key initiatives highlight the division’s dedication to rapidly creating a safer and more cutting edge critical care system at GBMC.

1. Therapeutic Hypothermia for heart attack patients
Therapeutic hypothermia after return of spontaneous circulation in survivors of cardiac arrest has been shown to improve neurologic outcomes.  Between 2002-2004 many local hospitals around the beltway developed and started using therapeutic hypothermia protocols.  GBMC created an order set for this therapy but did not design a robust system to use it.  Within weeks of launching our new Critical Care program in January, an updated therapeutic hypothermia protocol was written and equipment required to delivery this therapy was acquired (Arctic Sun Temperature Management System).  The policy and procedures for cooling patients was updated to reflect best evidence, and cutting edge technology like BIS monitoring (Bispectral Index continuous processed EEG) was incorporated into the protocol. to limit potential awareness under paralysis and improve patient safety, and the related Neuromuscular Blockade policy was overhauled and fully updated. This modality is now available for use on patients who will benefit from it.

2. Critical Care Infusions: Improving patient safety and standardizing care delivery
Realizing the risk associated with different physicians ordering the same titrateable medications in different ways (and the confusion this created for our nurses), Dr. Vitberg and his team identified every titrateable infusion commonly used in all critical care areas and standardized all five fields required to order these medications.  The ‘Medication Guideline – Critical Care Adult Titrateable Infusion’ policy was approved by the Medical Board in May.  Our MIS/IT staff is completing an update in Meditech which mirrors this paper policy.  This will undoubtedly lead to more appropriate utilization of these high-risk medications, increased standardization in our practice of critical care medicine, and provide a safer experience for our patients. 

3. The ICU Transfer Checklist: Ensuring no missed hand-offs and reinforcing direct attending to attending physician communication
One of the highest risk times during a patient’s hospitalization is the time at which they transfer out of the intensive care units to lower levels of care.  To ensure that the handoff to the receiving physician happens reliably, the new group created an ICU Transfer Checklist.  A patient cannot be moved out of the unit or transferred to another facility without the sending critical care attending talking to the receiving medical attending or surgeon, the residents giving sign-out to each other (when they are involved in patient care), and the nurses giving sign-out to each other.  Since the checklist was implemented, our Team has achieved a near 100% compliance with hand-offs over the past few months.
4. Creating standard work and  organizing critical care interventions to improve patient outcomes
Many interventions in critical care are time sensitive. Implementation of protocol-based care empowers nurse and respiratory therapists to begin therapy quickly for critically ill patients and engages all members of the critical care team.  Implementation of evidence-based protocols, many of which contain bundled care items recommended by organizations like the Institute for Healthcare Improvement, improve care reliability and patient outcomes.

5. CHARMS Committee: Taking a closer look at how we screen for and treat sepsis
The CHARMS Committee (Community Hospital Action plan to Reduce Mortality from Sepsis) was organized in June 2014.  The committee is made up of MICU and SICU nurses, ED physicians and nurses, intensivists, residents, and a faculty physician representative from the Department of Medicine charged with quality improvement.  The focus of the committee is to review every aspect of sepsis care at GBMC, decompartmentalize the delivery of sepsis care across all patient care areas (i.e. ED to ICU to floor), ensure evidence-based best practices are being utilized, and improve clinical outcomes for these patients.
Goals of the CHARMS committee include:

• Develop a house-wide screening tool for sepsis (build on the existing screening tool already utilized in our ED)
• Update all sepsis order sets to reflect best practice, evidence-based medicine
• Ensure sepsis treatments are ordered and delivered in consistent fashion across all patient care areas (decompartmentalization of care: EMS-ED-ICU-floor-discharge)
• Develop a standard approach to determining need for central venous access
• Meet regularly to monitor clinical outcomes via review of data from Crimson

6. Code / Rapid Response Committee (RRT): Improving our response to emergencies around the GBMC campus
The division has worked hand in hand with the Code / RRT Committee to improve our response to cardiac arrests and rapid responses on the GBMC campus.  A recurring problem at code responses has been overcrowding.  In July, code team huddles were launched.  Every day at 0745 hours, all members of the code team meet in Unit 57, hand-off badges which indicate pre-assigned roles in a code response, and receive 5-10 minutes of educational ‘pearls’ from the ICU attending physician regarding resuscitation.  The names of the code team members are recorded on a dedicated board in the center of Unit 57.  This board contains educational material which reminds team members of their responsibilities at a code response, the educational ‘pearls’ for the day are posted, and any important announcements like QA/QI initiatives or equipment issues can be posted.  As ‘badged’ code team members arrive at the patient’s side, they replace initial responders that have started the resuscitation.  Security personnel and the admission coordinators have been trained to limit responders at the bedside to only those that are wearing a code badge.

7. Limited Bedside Ultrasonography: a core feature of any cutting-edge ICU
Limited bedside ultrasonography has evolved into an extension of the physical examination for critically ill patients.  All critical care fellowships now teach this skill to improve patient assessment, for procedural guidance, and to help guide resuscitation.  Ultrasound is typically used to rapidly answer binary questions in the ICU setting: is a pneumothorax present or absent?  Is there cardiac activity?  Is there free fluid in the abdomen? Is the vena cava empty or full?  Ultrasound must be used whenever possible to guide needles during invasive procedures.
So, you can see what happens when a new leader grasps the concept that hard work and good intentions by themselves are not enough to move closer to flawless care. It takes a team to design better systems and then carry them out! I am absolutely amazed at what Dr. Vitberg and his Team have done in a very short period of time. I can’t wait to see the improved health outcomes and care experience along with the reduced waste and greater joy that adding them to our existing team of outstanding nurses and other clinicians will bring.

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