Improving Outcomes in the ICU:
Experience at Exeter Hospital
Richard D. Hollister, MD
Director, ICU
Chairman, ICU Best Practices Committee
Department of Pulmonary/Critical Care
Medicine
“A decade ago, Israeli scientists published a study in
which engineers observed patient care in I.C.U.s for
twenty-four hour stretches. They found that the
average patient required a hundred and seventy-eight
individual actions per day…Remarkably, the nurses
and doctors were observed to make an error in just
one percent of these actions—but that still amounted
to an average of two errors a day with every patient”
“A decade ago, Israeli scientists published a study in
which engineers observed patient care in I.C.U.s for
twenty-four hour stretches. They found that the
average patient required a hundred and seventy-eight
individual actions per day…Remarkably, the nurses
and doctors were observed to make an error in just
one percent of these actions—but that still amounted
to an average of two errors a day with every patient”
The Boeing Model 299: First tested in
flight October 30, 1935. Later known as
the B-17 Flying Fortress.
“The plane roared down the tarmac, lifted off smoothly, and
climbed sharply to three hundred feet. Then it stalled, turned on
one wing, and crashed in a fiery explosion…[The pilot] had
forgotten to release a new locking mechanism on the elevator
and rudder controls. The Boeing model was deemed, as one
newspaper put it, ‘too much airplane to fly.”
www.warbirdalley.com
Why did the 299 crash?
The pilot was not “experienced enough”
The pilot was not “vigilant enough”
The pilot needed “more education”
The airplane was “too complex to fly”
The airplane was “doomed to failure”
www.warbirdalley.com
“They came up with an ingeniously simple
approach: they created a pilot’s checklist, with
step-by-step checks for takeoff, flight, landing
and taxiing…With checklist in hand, the pilots
went on to fly the Model 299 a total of 1.8 million
miles without one accident.”
www.richard-seaman.com
Do checklists and other forms of disciplined,
systematic care work in the ICU?
Yes!
Evidence-Based Examples
Checklists for Central line insertion
 Checklists to prevent ventilator-associated
pneumonia
 Mandatory intensivist consultation for ICU
level patients
 Protocols to treat Septic Shock
 Protocols to manage hyperglycemia
 Multidisciplinary ICU rounds
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How have we
implemented changes
in ICU care at Exeter
Hospital?
ICU is not a place.
ICU is a SYSTEM OF CARE.
ICU leadership structure
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ICU nurse manager: Anne Steele, RN
Physician Directors: Paul Deranian, MD; Alan
Gladstone, MD; Richard Hollister, MD; David London,
MD; Mark Reiner, MD
Administrative Liaisons: Anne Marie Bularzik, VP,
CNE; Barbara Hughes, DNP, RN, VP System Quality
Clinical leaders: Carol Allard, RN; Kellie Cosgrove, RN;
Melissa Keith, RN; Cathy Hackett, RN; Lisa Kennedy,
RN, Margaret Rosset, RN
Nurse educators: Carol Frock, RN (ICU); Chris Bone,
RN (PCU); Melissa Pollard, RN
ICU leadership and direction
Monthly Critical Care committee meeting
represented by Intensivists, IM,
Anesthesia, Cardiology, Hospitalist,
nursing, administration, RN educators,
pharmacy, Infection control.
 Monthly ICU Best Practice committee:
establish and implement protocols that
reflect evidence-based means to optimize
outcomes
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Exeter Hospital
Quality Committee
Critical Care committee
Physician ICU directors
Staff RNs & Clinical leaders
Pharmacy
RN educators
Administration
Infection control
ICU Best Practices
Committee
Medical staff members
Surgical staff members
Administration
Nursing leadership
What constitutes ICU “Best
Practices?”
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Initiation of rapid response teams
Tight glucose control
Prevention of ventilator associated pneumonia
Prevention of catheter-related blood-stream
infections
Intensivist-led ICU/Mandatory consultation
Multidisciplinary rounding approach
Protocols for treatment of severe sepsis/septic
shock
Exeter Hospital ICU pre-2007
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Prior to 2007, our ICU model was “Open”
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Any EH medical staff physician could admit to the ICU
without intensivist oversight
Intensivists were on site but only called in at the sole
discretion of the staff physician
Problems with orchestrating care: multiple
consultants, providers not always immediately
available at the bed side. “Nobody coordinating all of
the patient’s care”
Problems with failure to rescue: intensivists called in
late, after pt “crashed” or after organ failure in
advanced stages.
2007 - Intensivist led ICU
Mandatory phone call to the intensivist for
all ICU admissions
 Intensivists lead the care on all ventilated
patients and on all but the most stable ICU
level patients
 The intensivist reviews the ICU census
every day and reserves the right to
become involved/orchestrate the care of
any ICU level patient at any time.
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Buy-In
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Focus on research/data: Ideas don’t take
flight unless there is a sound basis in
evidence
Pronovost JAMA 2000 Meta-analysis of
Intensivist-led care in the ICU
 Leap-Frog group
 Society of Critical Care Medicine
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Measure outcomes
Buy-In
Communicate
Communicate
Communicate
Buy-In
Medical Division Meeting
 Surgical Division Meeting
 Hospitalist Group Meeting
 Exeter Hospital Quarterly Staff Business
Meeting
 Medical Executive Committee
 Cardiology Group Meeting
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Buy-In
Take every opportunity, formal and
informal, to explain to the
medical/surgical staff why these
initiatives are important
Structuring the ICU System:
Multidisciplinary Rounds
“I not only use the brains that I have but all
that I can borrow.”
-Woodrow Wilson
Multidisciplinary Rounds in the ICU: Who
participates?
Intensivist
 Patient’s nurse for the day
 ICU clinical leader
 Respiratory therapy
 PhD clinical Pharmacist
 Nutrition
 Social Work
 Palliative care
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Multidisciplinary Rounds in the ICU: Nuts
and Bolts
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Data is collated by nursing including 24 hour
events, vital signs, I/O’s, iv infusions, line and
endotracheal tube insertion dates, tube feed
rates, skin integrity, lab data, culture data,
ventilator data and abg’s.
The data is read off to the entire team while the
intensivist documents in his note
Respiratory therapy confirms vent settings
PhD pharmacist recites all medications and
dosages in front of team based on EMR.
Rick Hollister, MD
Intensivist
Jennifer Devaney, RN
Kristen LeBoeuf,
RN
Paul Deranian, MD Lindsay Brooks,
Pharm. D.
Intensivist
Vickie Irwin, RD
Not pictured: Patrick Clary, MD
Palliative Care
Carol Allard, RN
Clinical Leader
Robyn Fortney,
LICSW
David Hill, RT
Multidisciplinary Rounds in the ICU:
Generating a daily plan
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Sedation and vent changes are made in real time while team is
present (very important for vent weaning)
Nutrition recommendations are made in the proper clinical context
and account for nursing, physician and patient perspectives
Questions are encouraged and answered.
Medication dosing adjustments are made according to pharmacist’s
input in real time reducing possibility of dosing errors or failing to
dose drugs in therapeutic range.
Social issues are communicated to the whole team allowing for one
unified message to reach patients and their families during the day.
Major therapeutic goals for the day are shared amongst all
team members
Quantifying ICU outcomes
 Ventilated
patient Mortality
 Catheter-related blood stream
infections
 Ventilator associated pneumonia
 Measuring Severity of Illness
 Reporting Illness-adjusted
Outcomes
Ventilator-associated pneumonia: What
Works?
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REMOVAL OF THE ENDOTRACHEAL TUBE
Hand washing between pt contacts
Elevate the HOB
Scheduled drainage of condensate from
ventilator circuits (we use heated wire circuits
that prevent condensation build-up)
Continuous subglottic suctioning
Maintenance of adequate cuff pressure in the
ETT
Ventilator-associated pneumonia
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“It’s hard to get VAP if you are not intubated”
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Daily sedation vacation
Daily spontaneous breathing trial once FiO2 below
50% and PEEP of 5 or less
All intubated patients are managed by board-certified
intensivists
Stress ulcer prophylaxis
Tight blood glucose control that is protocol
driven
Nursing Care of the Ventilated
Patient
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Mouth care with special kits every 4 hours.
Keeping the head of the bed > 30 degrees
(when possible)—track and trend.
Stress ulcer disease prophylaxis—track and
trend.
Deep vein thrombosis prophylaxis—track and
trend.
Daily sedation vacations—track and trend.
Exeter Hospital: Ventilator
Associated Pneumonia
ZERO ventilator
associated pneumonias
in over 400 patient ventdays
Catheter-related bloodstream
infections
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“You can’t get a line infection if you don’t have a
line”
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Daily nursing and physician examination of line site
Daily assessment of line necessity: Can we take it out?
Use of PICC lines when appropriate when access needed only
for TPN, antibiotics or lab draws
Infection control places reminder notes in progress note section
of chart asking physicians to document why line remains in place
(outside of the ICU)
Experienced operators insert the vast majority of central
lines: Board certified Intensivists, General and Vascular
surgeons
Tight blood glucose control that is protocol driven
Catheter-related bloodstream
infections
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Arrow antimicrobial triple lumen catheter
kits that contain
Chlorhexidine prep
 Full sterile barrier
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All other triple lumen catheter kits have
been removed from patient care areas
(OR, ER, ICU). We use only one kit type.
Nursing Care of the Patient with
a Central Line
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Change dressing every 6 days or as needed
Daily assessment of need for central line in
multidisciplinary rounds
Survey on central line insertions (hand washing
prior to procedure, use of sterile gown, gloves,
and large drape, mask, cap, chlorhexadine prep,
and site used)—tracking and monitoring.
Exeter Hospital: Catheter related
blood stream infections
ZERO line infections
in over 800 patient
line-days
APACHE IV
Acute Physiology And Chronic Health
Evaluation
Quantifying severity of illness and
predicting mortality in the ICU
APACHE: What is it?
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A rigorously validated set of equations that
predict the likelihood of ICU mortality and
ICU length of stay based on numerous
physiologic and clinical parameters that
are easily identified and quantified.
APACHE IV
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Data derived from
104 ICUs
 45 hospitals
 Over 100,000 patients
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Components of APACHE IV
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Acute Physiology
Score (max points)
Pulse:
Mean BP:
Respiratory Rate:
PaO2 or A-aDO2:
Hematocrit:
WBC:
Creatinine:
UOP:
BUN:
Sodium:
Albumin:
Bilirubin:
Glucose:
17
18
18
15/14
3
19
7
15
12
4
11
18
8
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Glasgow Coma Score
Age
Chronic Health Conditions
ICU admission Data
Admitting Diagnosis
Goals for FY 2008: In Progress
Implement Induced Hypothermia protocol
for cardiac arrest
 APACHE IV Scoring (Continue)
 Severe Sepsis/Septic shock protocol
 Roll out Multidisciplinary Rounds to the
Progressive Care Unit
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How do we continue to change?
How do we continue to adapt?
“In command and out
of control”*
“The first thing I told our staff is that we
Would be in command and out of
control…By that I mean that the
Overall guidance and the intent were
provided by me and the senior
leadership, but the forces in the field
wouldn’t depend on intricate orders
coming from the top. They were to use
their own initiative and be innovative as
they went forward.” *originally attributed to management
guru, Kevin Kelly