Transforming ICU Culture to Facilitate Early Mobility
Section snippets
Need for culture change
Available literature suggests that interdisciplinary collaboration and a coordinated approach to management improves short-term quality and outcomes while reducing costs [6], [7], [8], [9], [10], [11]. Growing interest in reducing costs for patients requiring long-term mechanical ventilation has led to development of different care delivery models, but none have been tested in scientifically rigorous clinical trials [12]. Nonetheless, financial pressures, coupled with increasing expectations
Development of the respiratory failure care process model
Before the development of their respiratory failure care model, the authors retrospectively reviewed data for all patients treated in the ICU at LDS Hospital from June 1, 1995, through May 31, 1996. Of the 4424 critically ill patients, 112 (2.5%) had respiratory failure. The respiratory failure patients' mean hospital length of stay was greater than 3 weeks, accounting for 29% of ICU patient days and 53% of mechanical ventilation days. Total hospital average cost per case for the group was
Implementation of the respiratory care process model
To implement the care process model, the authors had to make significant changes in the RICU, which included changes in how the RICU staff worked together. Teamwork and collaboration in the ICU too often is nonexistent between disciplines, or at best is fraught with problems [15], [16]. Clemmer and colleagues [17] argue that working together to attain a common purpose is inseparable from change. To effect change, the authors needed cooperation of multiple disciplines, including physicians,
Reliability and quality in ICU care delivery
Numerous publications have highlighted problems in the quality and reliability of healthcare. The most important consensus statement comes from the 1999 Institute of Medicine assessment that almost 100,000 patients suffer avoidable death in American hospitals each year [24]. Furthermore, there is evidence that this situation has not improved much 5 years later [25]. The Institute for Healthcare Improvement (www.ihi.org) has taken a leading role in improving healthcare reliability.
Early activity—a case study of successful change in the ICU
Critical illness is associated with poor physical outcomes [1], [27], [28]. Patients often have persistent weakness with motor and sensory deficits, fatigue, and difficulty with mobilization after prolonged hospitalization [29]. Prolonged immobilization may play a significant role in the neuromuscular abnormalities and complicate the clinical course of most critically ill patients [30]. The authors developed their activity protocol to address problems of prolonged immobilization in patients
Measuring effectiveness of the activity protocol
The authors studied the safety and feasibility of activity in the RICU including a total of 1449 activity events. The activity events included 233 (16%) sitting on a bed, 454 (31%) sitting in a chair, and 762 (53%) ambulating [19]. The authors also monitored adverse activity-related events with a frequency of less than 1%, including fall to the knees without injury, feeding tube removal, systolic blood pressure (BP) greater than 200 mm Hg, systolic BP less than 90 mm Hg, and desaturation less
The cost of improvement
One of the key considerations in any improvement process is how the costs of improvement are borne. It is almost always necessary to fund improvements in a budget-neutral manner. If there is no new capital, then one must learn to work smarter, because asking staff to work harder over the long run is not viable. Although many quality improvement processes save money, the insurance companies that pay for health care—rather than the improvement process or the institution—typically realize such
Improving the respiratory ICU safety and teamwork climate
The climate (culture) of an institution is talked about frequently, yet it is hard to understand fundamentally. Survey tools developed by Sexton and colleagues [15] allow a semiquantitative assessment of healthcare culture. As with cost, the authors wanted to make sure that their improvements were not made at the expense of deteriorating unit culture. The authors' anecdotal experience has been that climate improves when front-line staff is engaged in meaningful projects to improve patient care.
Summary
ICU culture can be transformed in a way that results in improved and more reliable care, including early mobility, while stabilizing or even decreasing cost. A side benefit of front-line staff involvement in improvement projects has been the simultaneous development of a culture of safety and teamwork.
Acknowledgments
The authors are indebted to Polly Bailey, APRN, and Louise Bezdjian, APRN for their input and for reviewing the manuscript, to Larissa Rodriguez for database support and graphics, and to Nathan Dean, MD, for reviewing the manuscript.
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