U N C H E A L T H C A R E S Y S T E M U N C H E A L T H C A R E The Impact of a Daily Goals Tool in the ICU: More than a Checklist May 24, 2016 Our Vision To be the Nation's leading public academic health care system. Leading. Teaching. Caring.
U N C H E A L T H C A R E Acknowledgements NSICU CICU • Sharmila Soares, CN IV • Cristie Dangerfield, Nurse • Christa Williams, Nurse Manager Manager • Brooke Mclaughlin, CN IV • Megan Brissie, Nurse • Carrie Neal, CN IV Project Management Team Practitioner • Jonathan Cicci, Pharmacist • Sean Miller • Helen Nester, Nurse • Kamal Henderson, • Emelin Tan Practitioner Physician Fellow • Julie Farmer • Lissy Olivencia- • Josh Roark, Physician • Riane Hoffman Simmons, Nurse Resident • Todd Hardy Practitioner • Jason Katz, Medical • Sarah Biancaniello, Director Respiratory Therapist • Kelly Sullivan, Pharmacist IHQI • Emily Durr, Pharmacist • Tina Schade Willis • Marin Darsie, Physician SICU • Laura Brown Fellow • Maureen Heck, Nurse • Rhonda Cadena, Manager Physician Attending • Sean Montgomery, Medical • Dedrick Jordan, Medical Director Director • Shell Brownstein, Physician Attending 1
U N C H E A L T H C A R E Project Aims Improve team performance and patient outcomes via a team-driven Daily Goals Tool in the Neurosciences ICU at UNC. Objectives o Implement standardized rounding communication workflows within the ICU o Promote adherence to ICU-specific QI Improve Care Delivery initiatives o Achieve 80% utilization rate of the Daily Goals Tool by July 2016 o Reduce hospital-associated complications and Improve Clinical Outcomes preventable patient harms 2
U N C H E A L T H C A R E Medical Errors Reported as Number 3 Cause of U.S. Deaths • New BMJ report estimates number of deaths attributable to medical errors is more than double estimated by “To Err is Human” in 1999 (250K vs 100K) • Communication failures and human factors errors remain leading root causes of sentinel events and preventable medical errors Martin A Makary, and Michael Daniel BMJ 2016;353:bmj.i2139 3
U N C H E A L T H C A R E Multiple Factors Threaten NSICU Team Communication >1300 alarms / Data overload 12 hr shift 3 documentation systems High-Risk Environment Avg Noise 55dBA Multiple handoffs (Eq. to low TV) Transitional staff Peak Noise 95dBA Rotating learners (Eq. to chainsaw) Priorities Vary Between Providers MD/APP RN Pharmacist Resp Therapist • Catheter/line removal • • • Patient mobilization Antibiotic stewardship Lung protective • Family meeting • Delirium screening • Adherence to VTE & ventilation • Sedation wean • • Falls prevention GI prophylaxis Ventilator wean screen • Nutrition • Pressure ulcer • Trach/Peg decision prevention 4
U N C H E A L T H C A R E Why Should We Use Daily Goals Tools? Daily goals tools foster a culture of collaboration, improve team coordination and communication, and facilitate individualized, goal-directed patient care. Daily goals tools improve outcomes and promote adherence to interventions known to decrease morbidity and mortality. Reduce hospital- Decrease errors Reduce Decrease associated “ICU Inertia” of omission length-of-stay complications 5
U N C H E A L T H C A R E Common Elements of Daily Goals Tools Standardized Team Centric Workflow • Every Daily Goals Tool must be tailored to the unit and team • One size does not fit all Checklists & • Most effective in conjunction Accountability Bundles with well-defined improvement protocols Daily Goals Tool Single Platform for Clear Roles & Multiple QI Initiatives Responsibilities 6
The Success of Daily Goals Tools Depends Upon Much More Than T icking Boxes: “Not Just A nother Piece of Paper” U N C H E A L T H C A R E 7
U N C H E A L T H C A R E Daily Consistency Needed for Quality & Safety Focus Areas NSICU Staff Survey: % “Always Discussed” on Rounds 100.0% • Staff report key quality and safety 90.0% 80.0% issues not addressed on daily basis 70.0% • All should be at 100% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 9
Team Communication Critical for Optimal Outcomes U N C H E A L T H C A R E Case Studies in the NSICU Patient Issue Impact • Patient developed pneumonia • Patient required tracheostomy but was 52 y.o. woman with during delay not medically stable ruptured brain • Trach decision by family not obtained • LOS increased aneurysm by time patient stable, delaying trach by 5 days • Gastric tube placement recommended • Patient developed severe 69 y.o. man w/ due to poor swallowing mechanism hypoglycemia large stroke • Night prior to G-tube placement, tube feeds held but insulin dose not adjusted 10
Daily Goals Tool is a Single Streamlined Platform for U N C H E A L T H C A R E Multiple QI Initiatives NSICU Daily Goals Tool Improvement Initiatives National ICU Liberation Initiative: Bundle Improvement Collaborative A: Assess, prevent & manage pain B: Both spontaneous awakening & spontaneous breathing trials C: Choice of analgesia & sedation D: Delirium E: Early mobility F: Family engagement Institutional Patient Harms Reduction initiative Carolina Value (CAPP rounds, reduce LOS, improve transfers) TeamSTEPPS (effective team communication) Unit-Specific Early mobilization protocol CAUTI prevention VAP prevention Event reduction (falls & unplanned extubations) Delirium prevention VTE prevention Decrease length-of-stay Ventilation liberation Code status awareness Hypoglycemia prevention 11
U N C H E A L T H C A R E Daily Goals Tool Used Across 24 Hour Cycle • Night RN fills out new sheet for Nursing Report • (May be used for RN shift Overnight handoff) • RN gives Nurse Report • NP reviews assessment AM and plan for each system Rounds • RN fills out daily goals tool and recaps • RN and MD sign • NP/resident and RN review goals PM • Pertinent updates discussed w/ Check-In attending/fellow at evening sign-out Designed for compatibility w/ other NSICU communication workflows: • CAPP rounds • RN rounds reporting tool • RN – RN shift handoff • MD/APP – MD/APP shift handoff 12
Multiple Iterative Revisions Necessary for Implementation U N C H E A L T H C A R E (4 months) P: RN recaps goals. Efficient Flow D: RN documents and recaps goals. Only RN and attending sign. Standardized Closed-Loop Work Communication S: Significantly less P: Attending/fellow recaps redundant. Reliable inclusion daily goals. of RN. Closed-loop communication faster. Easy to Use D: Attending/fellow recaps P: APP/residents perform goals. RN documents. All A: Continue to evaluate recap of daily goals. team members sign. opportunities for improving efficiency. D: APP/resident verbally S: Moderately redundant. recaps goals after Inclusion of RN variable. assessment/plan. RN Lacking closed-loop documents. All team communication. members sign. A: RN recaps goals. S: Redundant. Inclusion of RN variable. Lacking closed- loop communication. Inefficient. A: Attending/fellow recaps goals. Challenges o Increased length of rounds o Variation across attendings/fellows o PM daily goals review inconsistent 13
Significant Reduction in Catheter-Associated U N C H E A L T H C A R E Urinary Tract Infections CAUTI Rate Per 1000 Foley Catheter Days 18 16 14 12 10 8 6 Median 4 • NSICU historically unit with 2 highest rate of CAUTI in UNC 0 Goal Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Healthcare System • NSICU achieved >100 days CAUTI free in April 2016 NSICU Days Between CAUTI 120 • Synergistic effect between 100 Daily Goals Tool & institutional 80 initiative 60 40 20 0 Date of CAUTI 14
U N C H E A L T H C A R E Ventilator-Acquired Pneumonia Trending Down VAP Per 1000 Vent Days 10 9 8 7 6 Median 5 4 3 2 • 90 days VAP free as of May 1 0 Goal 2016 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 • Not as dramatic improvement as CAUTI NSICU Days Between VAP 100 • Need to develop more rigorous 90 VAP prevention protocols 80 70 60 50 40 30 20 10 0 Date of VAP 15
U N C H E A L T H C A R E NSICU Reliably Discussing Quality & Safety Focus Areas NSICU AM Daily Goal Sheet % Completion (3 week April/May Audit) 100.0% Neuro Resp. Reno/Endo. ID Patient Quality Sign-Off 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% PM Daily Goal Sheet Sign-Off % Completion • Highest consistency on 100.0% Neuro initiatives 80.0% • PM check-in process needs 60.0% more focus 40.0% 20.0% 0.0% RN NP/Resident Both 16
Recommend
More recommend
