Why are QI methods needed?
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1 Quality Improvement for ICU Rehab, Sedation & Delirium Why are QI methods needed? Dale M. Needham, MD, PhD Professor, Pulmonary & Critical Care, and Physical Med network.org Quality Improvement Methods to Fill Gap in Translational Super Highway Quality Improvement Methods to Fill Gap in Translational Super Highway Pothole in translational superhighway 4 5 Where are we going CLINICALLY? Crit Care Med Apr 2014 Is there really a pot hole in the super highway for early ICU rehab? In 783 patients at 116 German ICUs: 1
2 Where are we going CLINICALLY? More info here Arch Phys Med Rehabil 2010;91: In 514 patients at 34 Aus/NZ ICU: 2. Identify local barriers to implementation: understand the process and context of work 2. Identify local barriers to implementation: understand the process and context of work J Crit Care Jun;25(2): Understanding barriers specific to the project is key to designing the correct KT intervention (Shojania Health Affairs 2005) Time requirements and adequate staffing Need for staff training Need for team work and coordination Over sedation of ICU patients Dislodgement of devices (CVC, ETT, feeding tubes) Worsening gas exchange Unstable hemodynamics Inadequate patient comfort, pain control 3. Measure performance Also Rehabilitation Specific Metrics Example performance measures : Staffing: Proportion of ICU patients with no therapy Safety: Safety events during PT Benefits: ICU and Hospital LOS Top Stroke Rehabil 2010;17(4):
3 interventions interventions: Engage Engage stakeholders to understand why interventions important Invited patients to return to MICU to share stories (e.g. weakness, physical impairment) Share data regarding MICU performance vs peer hospitals Invite guest speakers to discuss their approach interventions: Educate Educate stakeholders of evidence supporting interventions QI research made available to staff via: newsletter, posters, bulletin boards & invited speakers PT & OT educate RNs on rehab interventions RT orient PTs to vent settings for ambulating patients 2 large group training sessions held with RTs 16 small group discussions with RNs by MICU MD interventions: Execute Execute: design an intervention toolkit targeted at barriers Tips: standardization, checks/reminders, & convenience Dedicated PT and OT in the MICU Simple guidelines for PT & OT MICU consult Coordinator screens patients & prompts MD for PT referral Patients screened daily by PT/OT for mobilization activity MICU tech assists PT & OT with patient mobilization interventions: Evaluate Evaluate: regularly assess performance & unintended problems Review performance measures at weekly meetings Discuss any problems that arise Brainstorm ways to resolve unintended problems interventions: Evaluate Arch Phys Med Rehabil 2010;91: Results of Johns Hopkins MICU Rehab QI Project: Significant in sedative drug use & deep sedation Median Narc: 71 v. 24 mg/day (p=0.01), Benzo: 47 v. 15 mg/day (p=0.09) MICU days alert: 30 v. 67% (p<0.001) No difference in pain scale (0 10): 0.6 v. 0.6 (p=0.79) More ICU days without delirium No delirium: 21% vs 53% (p=0.003) PT consults: 59% vs. 93% of pts (p=0.04) ICU days with no PT/OT: 41% vs. 7% (p=0.004) MICU & hosp LOS by 30% and 18%, respec vely (p<0.03) 3
4 Follow up results. JHH MICU over 2.5 years (June 2009 Dec 2011) 1,110 admissions with >= 1 PT session 5,267 total PT tx (not individual activities) 66% of PT days: sitting at edge of bed or higher 37 JHH MICU over 2.5 years (June 2009 Dec 2011) 34 potential safety events in 25 admissions 0.6% of PT sessions (i.e., 6 per 1000 PT tx) 80% of events = transient physiological (HR, BP, Sp02) 4 events required any Tx (0.08% of all PT tx) 2 NG tube, 1 A line, 1 fall with laceration & suture A Quality Improvement Project Sustainably Decreased Time to Onset of Active PT Intervention in ALI Patients M. Zanni, PT, DScPT, Objectives to evaluate: Sustainability of MICU early rehab QI over 5yrs Other factors w/ timing of active PT Design: Pre post evaluation consecutive ARDS patients pre QI ( ) versus post QI ( ) 38 A Quality Improvement Project Sustainably Decreased Time to Onset of Active PT Intervention in ALI Patients Victor D. Dinglas, MPH, Ann M. Parker, MD, Dereddi Raja S. Reddy, MD, Elizabeth Colantuoni, PhD, Jennifer M. Zanni, PT, DScPT, Alison E. Turnbull, DVM, MPH, PhD, Archana Nelliot, BS, Nancy Ciesla, DPT, MS, Dale M. Needham, FCPA, MD, PhD Probability of 1 st PT in post vs. pre QI Annals of the American Thoracic Society, In press Post QI earlier PT (HR 8.38, p<0.01) significant each of 5 yr post QI Factors assoc d with delayed PT: opioid infusion (0.47, p=0.02) deep sedation (0.24, p<0.01) worse organ failure (0.93, p<0.01) increasing hypoxia (0.86, p=0.04) LOS Trends Early rehab QI assoc d with BIG decrease in time to onset of active PT and sustained for 5years 4
5 Crit Care Med 2013;41: Putting Evidence into Practice: QI Process: 4 E s Engage: Get clinicians interested in the problem! Day & night nurses: by nurse educator Interns & resident physicians: by QI physician champions Attending physicians: grand rounds & faculty meetings Educate: new sedation protocol, RASS/CAM, delirium prev n For RN: didactics, one on one teaching, case studies, quiz Physicians: Sedation and Delirium Survival Card Hager et al, 2013; Crit Care Med; 41: New Sedation Protocol Sedation Goal: see below Hager et al, 2013; Crit Care Med; 41: RASS goal: 0 Fentanyl & versed (A 1) Avoid infusions, use prn Initially q 5 min (if needed) Then q 1 2hr Daily stop of prn & infusion Avoid delirium drugs Anticipate agitation Do no use benzo Use IV haldol (check QTc) QI Process: 4 E s Model Execute: Sedation protocol replaced in EMR RN reported RASS score + CAM ICU at bedside rounds Super users available to answer questions Evaluate: Monthly review of barriers by QI team MICU pharmacist feedback at bedside rounds: sedation protocol adherence delirium screening and management Audit and feedback: RN regular review of RASS & CAM ICU documentation Overall RASS & CAM ICU results for MICU Hager et al, 2013; Crit Care Med; 41: Results of QI: Changes in Sedation of ARDS Patients Median (IQR), per patient analysis ARDS Severity & Day 1 Sedation (sickest) High severity of illness: median APACHE II = 29 Before QI 10/04 4/07 (n=120) After QI 7/09 4/11 (n=82) P value* Narcotic infusion (% days) 74 (50, 100) 33 (10, 65) <0.001 On Benzodiazepine infusion (% days) ) 70 (46, 94) 22 (0, 50) <0.001 Median RASS Score** 4( 5, 2) 1.5 ( 3, 0) <0.001 Awake &Not delirious 0(0, 18) 19 (0, 50) <0.001 No sig. dif btwn groups in ARDS severity Half severe ARDS Sig. decr in infusions; Only 25 31% in QI Hager et al. Critical Care Medicine 2013;41: e241 e243 5
6 New Target: Sleep Deprivation Without heavy sedation, pt not sleeping in ICU Sleep disruption risk factor for delirium ICU not conducive to sleep Need effort to reduce noise & promote sleep Crit Care Med 2013;41: Multi stage QI project (using SAME QI model): Baseline (2 mo.): daily sleep Richards Campbell Sleep Questionnaire 6 questions Phase I: Environmental change (1 mo.): Minimized intercom usage after 10 pm Bathing and Assessments completed by 10 pm Lights out in pt rooms by 10 pm Group RN assessments and tests (eg, morning x rays) Phase II: non drug tx (1 mo.): music, ear plug, eye mask Phase III: med guideline (2 mo.): non delirium med to sleep Questions? Some members of the OACIS Group at Hopkins 6
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