By Lee "Monty" Duke II, MD
2008 was another award winning year for Lancaster General Health. Once again, we were named a Thomson Reuters Top 100 Hospital – one of a handful of organizations that have won this award for the 10th time.
U.S. News and World Report recognized Digestive Services for their clinical excellence. HealthGrades distinguished Lancaster General Health as one of America’s 50 Best Hospitals, and for safety, and specialty excellence in a variety of clinical services. While gratifying, these rigorous inspections identified opportunities for improvement, particularly in clinical efficiency and patient length-of-stay.
During the spring, Norma Ferdinand, RN, Senior Vice President and Chief Quality Officer, assembled a multidisciplinary committee, including operational leaders, physicians, nursing and quality representatives, to address organizational throughput and efficiency. Target areas were selected for 90-day rapid cycle improvement plans, which include identifying targets, establishing measures and selecting changes.
Implementation would be in a Plan-Do-Study-Act (PDSA) cycle format which allows for small test of change in a “real work” setting. The first target selected was deployment of clinical information white boards within each patient’s room. This has improved patient communication, and it has also encouraged closer collaboration with the physician and case management to determine an anticipated date of discharge.
Nationally, this has been a best practice in shortening the length-of-stay. After only three months, we are seeing very encouraging results. We are especially pleased with the improved communication between physicians and case managers. Patients are also reporting increased satisfaction with physician communication.
The Committee has been very excited by these preliminary results. Our next target is improving the care efficiency for observational status patients. This is a complex area for both physicians and health care systems, stressing the need for early patient identification, and standardized, quality efficient care.
Look for this initiative in late October or early November 2010. Future consideration will include End of Life Care and, possibly, the discharge process. Thank you for your help on these initiatives.
If you have any questions or concerns, please feel free to call me at 717-544-4695.
Evidence-Based Practices Reduce the Ventilator-Associated Pneumonia Rate for ICU Patients
Lancaster General Hospital
Lancaster, Pennsylvania, USA
Team
The team from Lancaster General Hospital is a participant in the IHI Learning and Innovation Community on Improving Outcomes for Critically Ill and High-Risk Patients on Reducing Ventilator-Associated Pneumonia.
Stacey King MSN, RN, NE-BC, Director of Nursing, Project Leader
Dr. Yaroslav Lando, Physician Support
Aimee Anderson, BS, RN, CCRN, ICU Nurse Manager
Adam Becker, RN, ICU Staff Nurse/Quality Council
Aim
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Achieve a 10 percent reduction in average length of stay (ALOS) on mechanical ventilator from a rate of 3.5 per 1,000 ventilator days in fiscal year 2008 (FY08) to 3.15 per 1,000 ventilator days for fiscal year 2009 (FY09)
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Achieve a 10 percent reduction in ventilator-associated pneumonia (VAP) in the intensive care unit (ICU) from a rate of 4.1 per 1,000 ventilator days in FY08 to 3.7 per 1,000 ventilator days for FY09
Measures
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VAP rate per 1,000 ventilator days
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ALOS for mechanical ventilation per 1,000 ventilator days
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Percent compliance with Ventilator Bundle
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Percent compliance with multidisciplinary rounds and daily goals
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Percent compliance with “sedation vacation”
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Percent compliance with mobility protocol
Changes
In April 2006 Lancaster General Hospital joined the IHI Learning and Innovation Community on Improving Outcomes for Critically Ill and High-Risk Patients on Reducing Ventilator-Associated Pneumonia. The hospital formed a multidisciplinary team to initiate efforts to reduce VAP and ALOS for patients in the ICU on mechanical ventilation and to oversee the improvement efforts. The tests of changes included the following:
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Initiated daily multidisciplinary rounds, which included daily assessment of the Ventilator Bundle components
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Implemented a mobility protocol for ventilated patients
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Improved oral hygiene for ventilated patients using Sage oral care
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Tested new endotracheal tube (ET) holder, which eliminated the bite block and allowed for better oral care
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Established the practice of maintaining the head of the bed at 30 degrees (per the Ventilator Bundle recommendations), including taping the 30 degree mark on the patient’s bed as a visual cue
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Developed and implemented twice daily sedation vacation
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Engaged respiratory therapists to promote head-of-bed elevation and developed a ventilator management protocol that allowed autonomous weaning of ventilator
Results
Summary of Results / Lessons Learned / Next Steps
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The team was able to decrease the VAP rate from 7.35 per 1,000 ventilator days in FY07 (beginning of joining the IHI Community) to 1.95 per 1,000 ventilator days in FY09.
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The team was able to decrease the ALOS on a ventilator from a rate of 3.48 per 1,000 ventilator days in FY07 to 3.03 per 1,000 ventilator days in FY09.
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The most important lessons learned for us were how important a small test of change is, the importance of staff engagement and education, celebrating successes no matter how small, and learning that a failure is not really a failure if you have learned something from it.
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Our next steps are to continue the momentum, focus on mobility of ventilated patients, and continue to decrease our VAP rate.
Contact Information