University of Texas
ICU Collaborative
Lessons Learned…
UT ICU Collaborative Proposal
University of Texas Fellowship for Quality and Patient Safety
Proposed Project Description
Sherry Martin, VP, Quality Management, M.D. Anderson Cancer Center
Intensive Care Units are inherently costly and unsafe. There are nearly 5 million ICU admissions
each year in the U.S.; accounting for about 30% of hospital costs ($180 Billion/yr)(Birkmeyer, 2000).
Nearly every patient admitted to an ICU suffers an adverse event (Pronovost, 2002). Despite more
than 50 years of learning and experience in critical care, ICU mortality rates average 10-20% in most
hospitals. Overall, approximately 500,000 patients die in U.S. ICU’s each year (Zimmerman,1998).
Tremendous attention and resources have been focused on understanding the culture of the ICU with
the intention of enhancing patient safety and outcomes, reducing attributable morbidity and
mortality, and improving the utilization of scarce resources. This impetus for change in the ICU
comes from the medical profession (Society of Critical Care Medicine), regulatory agencies (JCAHO)
and healthcare consumers (Leapfrog Group). Many ICU’s are in the process of identifying and
implementing best practices in order to comply with these requirements. These focused efforts have
led to measurable improvements in outcomes. For example, a 66% reduction in adverse drug events
in ICU’s with clinical pharmacist participation in daily ICU multidisciplinary rounds and a 50%
reduction of LOS using ventilator pneumonia prevention methods (Pronovost, 2002).
UT ICU Collaborative Proposal
University of Texas Fellowship for Quality and Patient Safety
Proposed Project Description
Sherry Martin, VP, Quality Management, M.D. Anderson Cancer Center
Intensive Care Units are inherently costly and unsafe. There are nearly 5 million ICU admissions
each year in the U.S.; accounting for about 30% of hospital costs ($180 Billion/yr)(Birkmeyer, 2000).
Nearly every patient admitted to an ICU suffers an adverse event (Pronovost, 2002). Despite more
than 50 years of learning and experience in critical care, ICU mortality rates average 10-20% in most
hospitals.
Overall, approximately
patients die in U.S. program
ICU’s each year
(Zimmerman,1998).
Project
Purpose:
To create a500,000
multidisciplinary
focused
on ICU
quality
initiatives
thatandwill
enhance
patient
utilization
of resources,
Tremendous
attention
resources
have been
focusedsafety,
on understanding
the culture
of the ICU with
the
intention
of
enhancing
patient
safety
and
outcomes,
reducing
attributable
morbidity
and
and healthcare
provider
satisfaction
and
to
facilitate
collaboration
among
mortality, and improving the utilization of scarce resources. This impetus for change in the ICU
comes from the
medical profession
(Society ofpractices
Critical Carethrough
Medicine), regulatory
agencies (JCAHO)
participating
institutions
to improve
shared knowledge.
and healthcare consumers (Leapfrog Group). Many ICU’s are in the process of identifying and
implementing best practices in order to comply with these requirements. These focused efforts have
led to measurable improvements in outcomes. For example, a 66% reduction in adverse drug events
in ICU’s with clinical pharmacist participation in daily ICU multidisciplinary rounds and a 50%
reduction of LOS using ventilator pneumonia prevention methods (Pronovost, 2002).
ICU Collaborative
“Best Practice Fever”
Shared Knowledge and Experiences
Data-driven Practice
ICU Registry
ICU Collaborative Survey
University of Texas System Health Components Survey
Intensive Care Unit Quality Improvement Strategies
Please complete the following survey about your critical care unit(s). Aggregate results will be
available to participants following the Steering Committee Conference. Please submit any other
information or explanations on a separate sheet. All submitted information will remain
confidential.
Institution:
□ The University of
□ The University of
□ The University of
□ The University of
□ The University of
□ The University of
Texas Southwestern Medical Center , Dallas
Texas Medical Branch, Galveston
Texas Health Science Center, Houston
Texas Health Science Center, San Antonio
Texas Health Center, Tyler
Texas M.D. Anderson Cancer Center
What types of critical care units are present in your institution? (check all that apply):
□ Medical ICU
□ Medical/Surgical ICU
□ Transplant ICU
□ Pediatric ICU
□ Burn ICU
□ Intermediate Care Unit
□ Other: ____________
□ Surgical ICU
□ Cardiothoracic Surgical ICU
□ Coronary Care Unit
□ Neonatal ICU
□ Trauma ICU
□ Telemetry Unit
□ Other: ____________
Do you utilize a multidisciplinary team approach to critical care?
Yes / No
ICU Collaborative Survey
University of Texas System Health Components Survey
Intensive Care Unit Quality Improvement Strategies
Please complete the following survey about your critical care unit(s). Aggregate results will be
available to participants following the Steering Committee Conference. Please submit any other
information
or explanations
on a separateTeam
sheet. All
submitted(check
information
will remain
Who
are the ICU
Multidisciplinary
Members
all that
apply):
confidential.
□ Certified
□ Non ICU-certified Staff Physician
Institution:Intensivist
□ Critical Care
Fellow
□ Resident
□ The
University of Texas Southwestern Medical Center
, Dallas
□ The University of Texas Medical Branch, Galveston
□ Medical Student
□ Nursing Student
□ The University of Texas Health Science Center, Houston
□ Pharmacy □Student
□ Antonio
Physician Assistant
The University of Texas Health Science Center, San
□ The University
of Texas Health Center, Tyler
□ Advanced Practice
Nurse
□ Pharmacist
□ The University of Texas M.D. Anderson Cancer Center
□ Respiratory
□ Physical/Occupational
Therapist
What types of Therapist
critical care units are present in your institution?
(check all that apply):
□ Medical ICU
□ Surgical ICU
□ Nutrition Specialist
□ Clinical Ethicist
□ Medical/Surgical ICU
□ Cardiothoracic Surgical ICU
□ Chaplain □ Transplant ICU
□ Coronary Care Unit □ Other ______________
□ Pediatric ICU
□ Burn ICU
□ Intermediate Care Unit
□ Other: ____________
□ Neonatal ICU
□ Trauma ICU
□ Telemetry Unit
□ Other: ____________
Do you utilize a multidisciplinary team approach to critical care?
Yes / No
ICU Collaborative Survey
University of Texas System Health Components Survey
Intensive Care Unit Quality Improvement Strategies
Please complete the following survey about your critical care unit(s). Aggregate results will be
available to participants following the Steering Committee Conference. Please submit any other
Which
of theorfollowing
ICU
or pathways
are
in use? will
(check
all that apply):
information
explanations
on aprotocols
separate sheet.
All submitted
information
remain
□ ICU
Admission Orders
□ Electrolyte Replacement
confidential.
Institution:
□ Analgesia
□ Sedation
University of Texas Southwestern Medical Center , Dallas
□ Delirium □□ The
□ Neuromuscular Blockade
The University of Texas Medical Branch, Galveston
□ Ventilator Weaning
□ Non-Invasive
□ The University of Texas Health Science
Center, Houston Ventilation
□ The University of Texas Health Science Center, San Antonio
□ Pulmonary□ Toilet
□ Vasoactive Medication
The University of Texas Health Center, Tyler
□ Heparin Infusion
□ Glucose
control/Insulin sliding scale
□ The University of Texas M.D. Anderson
Cancer Center
What types
of critical care units
are present in
institution?
(check all that apply):
□ Glucose
control/Insulin
infusion
□ your
DVT
prophylaxis
□ Medical ICU
□ Surgical ICU
□ GI Stress Ulcer
prophylaxis
□ Enteral
□ Medical/Surgical
ICU
□ Cardiothoracic
Surgicalnutrition
ICU
Transplant ICU
□ Coronary
Unit Product Transfusion
□ Parenteral □Nutrition
PPN/TPN
□ Care
Blood
□ Pediatric ICU
□ Neonatal ICU
□ Empiric Antimicrobial
Therapy
Bowel Management
□ Burn ICU
□ Trauma□ICU
□ IntermediateTherapy
Care Unit □ Telemetry
Unit
□ Renal Replacement
□ Restraints
□ Other: ____________
□ Other: ____________
□ End-of-Life/Palliative Care
□ Intracranial Pressure Management
Do you utilize a multidisciplinary team approach
to critical
care?
Yes / No
□ “Bundles”
□ Other:
__________________
ICU Collaborative Survey
University of Texas System Health Components Survey
Intensive Care Unit Quality Improvement Strategies
Please complete the following survey about your critical care unit(s). Aggregate results will be
available to participants following the Steering Committee Conference. Please submit any other
What
has been
your greatest
Quality
Improvement
success?
information
or explanations
on a ICU
separate
sheet. All
submitted information
will remain
confidential.
Institution:
What
has been your greatest ICU Quality Improvement challenge?
□ The University of Texas Southwestern Medical Center , Dallas
□ The University of Texas Medical Branch, Galveston
What should□be
top priority
for the
University
of Texas System
Thethe
University
of Texas Health
Science
Center, Houston
□ The University of Texas Health Science Center, San Antonio
□ The University of Texas Health Center, Tyler
Components□Intensive
Unit
Improvement
Project?
The UniversityCare
of Texas
M.D.Quality
Anderson Cancer
Center
Health
What types of critical care units are present in your institution? (check all that apply):
□ Medical ICU
□ Medical/Surgical ICU
□ Transplant ICU
□ Pediatric ICU
□ Burn ICU
□ Intermediate Care Unit
□ Other: ____________
□ Surgical ICU
□ Cardiothoracic Surgical ICU
□ Coronary Care Unit
□ Neonatal ICU
□ Trauma ICU
□ Telemetry Unit
□ Other: ____________
Do you utilize a multidisciplinary team approach to critical care?
Yes / No
ICU Collaborative
“Make it easier to ‘Do the Right Thing’”
Terry Clemmer, MD
o “Rapid Cycle Improvement in ICU”
“War Wounds”
Brainstorming
Literature Review
Barriers
 “Changing a tire on a moving vehicle”
 Different Institutions, Different Patients
“OK, but not in my patients”
 Quality Improvement Tools
 Facilitator
“Data Gap”
Glucose Management
Protocol
o Mass Customization
Outcomes
o “Tight Glucose Management”
o Hypoglycemia
Demographics
 Grp1 (Jun - Aug 04)
o
o
o
o
o
o
98 events
0.87% event rate
46 unique patients
Average age - 59 yrs
11 surgical patients
35 medical patients
 Grp2 (Feb - May 05)
o
o
o
o
o
o
116 events
0.55% event rate
59 unique patients
Average age - 51 yrs
16 surgical patients
43 medical patients
Comparison of Patients with Hypoglycemic Events
'On or Off' Insulin Protocols
100%
80%
60%
40%
20%
0%
Yes
No
Yes
No
Yes
No
% Pt w/hypo events on % Pt w/hypo events on % Pt w/hypo events on
SS Prot
IV Insulin Prot
either Insulin Prot
Jun - Aug 04
Feb - May 05
Request for a University of Texas System Grant
To Support System-wide Collaborative Efforts
Introduction:
The University of Texas System ICU Collaborative was formed as a Chancellor’s Health Fellow project in 2004 and has
been operational since that date. The purpose of the ICU Collaborative is to develop the infrastructure and processes
necessary to establish system-wide, enduring collaborations within the UT System healthcare components focused on
the improvement of effective, efficient, and safe patient care. This collaboration provides a pathway for studying
healthcare delivery across a large number of intensive care unit beds, which may be the largest collaborative source of
ICU beds within the nation. The diversity of patient populations within these ICUs enables comparison of methods
and transfer of this learning to organizations cross the nation.
Participants in the Collaborative have been introduced to basic quality improvement methodology. During the first two
years, intensive care units in various healthcare components and affiliated hospitals shared protocols to manage glucose
and control ventilator-associated pneumonia. They agreed upon targets to achieve, shared data and presented their
results in group meetings. Results of these meetings led to changes in their own protocols and subsequently to
modifications of protocols to improve glucose management and ventilator associated pneumonia control..
Request for a University of Texas System Grant
To Support System-wide Collaborative Efforts
Introduction:
The
University
of TexasProtocol
System ICU Collaborative was formed as a Chancellor’s Health Fellow project in 2004 and has
CGMS
Research
been operational since that date. The purpose of the ICU Collaborative is to develop the infrastructure and processes
The complete CGMS Research Protocol as presented to the Institutional Review
necessary to establish system-wide, enduring collaborations within the UT System healthcare components focused on
Boards of
the participating
Institutions
is found
in Attachment
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the improvement
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efficient, and safe
patient care. This
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large number of
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and transfer of this learning to organizations cross the nation.
device as compared to the current glucose measures, publications for the
faculty,
Participants inparticipating
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been introduced to basic quality improvement methodology. During the first two
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monitor is as
modificationsPotential
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associated pneumonia
accurate as current standard of glucose monitoring with hourly blood
draws.
Request for a University of Texas System Grant
To Support System-wide Collaborative Efforts
Introduction:
Information
Systems
Gap
Analysis
The University of Texas System ICU Collaborative was formed as a Chancellor’s Health Fellow project in 2004 and has
been operational since that date. The purpose of the ICU Collaborative is to develop the infrastructure and processes
to establish
system-wide,
collaborations within
the UT System
healthcare
components
Ifnecessary
funded,
the UT
System enduring
ICU Collaborative
proposes
to retain
Sentigy,
an focused on
the improvement
of effective,
efficient,
and safe patient
care. This
provides
a pathway
studying
information
systems
consulting
group
thatcollaboration
falls under
the State
of for
Texas
healthcare delivery across a large number of intensive care unit beds, which may be the largest collaborative source of
Historically
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perform ofthe
gap
ICU beds
within the nation.
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patient populations
within
these ICUs enables
methods
analysis.
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has performed
and transfer
of this learning
to organizations
cross thework
nation.at several of the UT System components
and thus is familiar with the information systems. They will be requested to
Participants in the Collaborative have been introduced to basic quality improvement methodology. During the first two
conduct an evaluation of the ability of the information systems at the
years, intensive care units in various healthcare components and affiliated hospitals shared protocols to manage glucose
participating
organizations
to collect
andtargets
transfer
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that data
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bepresented
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to changes
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research
protocol.
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evaluation
modifications
of protocols
glucose management
and ventilatorcurrently
associated pneumonia
should
includetoaimprove
gap analysis
for organizations
unable control..
to manage data
effectively and recommendations to achieve this goal. This will then address the
first step necessary to achieve a a UT System-wide ICU Registry. The registry
will be a powerful tool similar to tumor registries (such as the M. D. Anderson
Tumor Registry) and trauma registries found in many centers or regions.
Request for a University of Texas System Grant
To Support System-wide Collaborative Efforts
Introduction:
The University of Texas System ICU Collaborative was formed as a Chancellor’s Health Fellow project in 2004 and has
been operational since that date. The purpose of the ICU Collaborative is to develop the infrastructure and processes
Clinical
Safety and Effectiveness (CS&E) Course
necessary to establish system-wide, enduring collaborations within the UT System healthcare components focused on
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participating
insafe
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protocol
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the
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the improvement
of effective,
efficient, and
care.research
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provides
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number
of intensive
care unit beds,
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conduct improvement initiatives. Support is requested for two individuals,
and transfer of this learning to organizations cross the nation.
one physician (the protocol principal investigator) from each participating
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the fall of 2007. These teams will use the CGMS protocol as their course
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the course
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thisassociated
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throughout
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protocols and
to improve
glucose management
and ventilator
pneumonia
control..the
lectures.
ICU Data Gap Analysis
ICU Collaborative
 Healthcare Delivery Projects
o Institutional Projects
o UT System Projects
 Clinical Research Projects
o CGMS Project
o eProtocol insulin
o Indwelling Glucose Monitoring device
UT System Collaboratives
Join one!
Build one!
Support them!