University of Texas

1
University of Texas ICU Collaborative
Lessons Learned
2
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. ICUs 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 ICUs 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 ICUs with clinical pharmacist participation
  in daily ICU multidisciplinary rounds and a 50
  reduction of LOS using ventilator pneumonia
  prevention methods (Pronovost, 2002).

3
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. ICUs 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 ICUs 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 ICUs with clinical pharmacist participation
  in daily ICU multidisciplinary rounds and a 50
  reduction of LOS using ventilator pneumonia
  prevention methods (Pronovost, 2002).

Project Purpose To create a multidisciplinary
program focused on ICU quality initiatives that
will enhance patient safety, utilization of
resources, and healthcare provider satisfaction
and to facilitate collaboration among
participating institutions to improve practices
through shared knowledge.
4
ICU Collaborative

• Best Practice Fever
• Shared Knowledge and Experiences
• Data-driven Practice
• ICU Registry

5
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 Texas Southwestern Medical
Center , Dallas ? The University of Texas
Medical Branch, Galveston ? The University of
Texas Health Science Center, Houston ? The
University of Texas Health Science Center, San
Antonio ? The University of Texas Health Center,
Tyler ? The University of Texas M.D. Anderson
Cancer Center What types of critical care units
are present in your institution? (check all that
apply) ? Medical ICU ? Surgical ICU ?
Medical/Surgical ICU ? Cardiothoracic Surgical
ICU ? Transplant ICU ? Coronary Care Unit ?
Pediatric ICU ? Neonatal ICU ? Burn ICU ?
Trauma ICU ? Intermediate Care Unit ? Telemetry
Unit ? Other ____________ ? Other
____________ Do you utilize a multidisciplinary
team approach to critical care? Yes / No
6
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 Texas Southwestern Medical
Center , Dallas ? The University of Texas
Medical Branch, Galveston ? The University of
Texas Health Science Center, Houston ? The
University of Texas Health Science Center, San
Antonio ? The University of Texas Health Center,
Tyler ? The University of Texas M.D. Anderson
Cancer Center What types of critical care units
are present in your institution? (check all that
apply) ? Medical ICU ? Surgical ICU ?
Medical/Surgical ICU ? Cardiothoracic Surgical
ICU ? Transplant ICU ? Coronary Care Unit ?
Pediatric ICU ? Neonatal ICU ? Burn ICU ?
Trauma ICU ? Intermediate Care Unit ? Telemetry
Unit ? Other ____________ ? Other
____________ Do you utilize a multidisciplinary
team approach to critical care? Yes / No
Who are the ICU Multidisciplinary Team Members
(check all that apply) ? Certified
Intensivist ? Non ICU-certified Staff
Physician ? Critical Care Fellow ? Resident ?
Medical Student ? Nursing Student ? Pharmacy
Student ? Physician Assistant ? Advanced
Practice Nurse ? Pharmacist ? Respiratory
Therapist ? Physical/Occupational Therapist ?
Nutrition Specialist ? Clinical Ethicist ?
Chaplain ? Other ______________
7
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 Texas Southwestern Medical
Center , Dallas ? The University of Texas
Medical Branch, Galveston ? The University of
Texas Health Science Center, Houston ? The
University of Texas Health Science Center, San
Antonio ? The University of Texas Health Center,
Tyler ? The University of Texas M.D. Anderson
Cancer Center What types of critical care units
are present in your institution? (check all that
apply) ? Medical ICU ? Surgical ICU ?
Medical/Surgical ICU ? Cardiothoracic Surgical
ICU ? Transplant ICU ? Coronary Care Unit ?
Pediatric ICU ? Neonatal ICU ? Burn ICU ?
Trauma ICU ? Intermediate Care Unit ? Telemetry
Unit ? Other ____________ ? Other
____________ Do you utilize a multidisciplinary
team approach to critical care? Yes / No
Which of the following ICU protocols or pathways
are in use? (check all that apply) ? ICU
Admission Orders ? Electrolyte Replacement ?
Analgesia ? Sedation ? Delirium ?
Neuromuscular Blockade ? Ventilator Weaning ?
Non-Invasive Ventilation ? Pulmonary Toilet ?
Vasoactive Medication ? Heparin Infusion ?
Glucose control/Insulin sliding scale ? Glucose
control/Insulin infusion ? DVT prophylaxis ? GI
Stress Ulcer prophylaxis ? Enteral nutrition ?
Parenteral Nutrition PPN/TPN ? Blood Product
Transfusion ? Empiric Antimicrobial Therapy ?
Bowel Management ? Renal Replacement Therapy ?
Restraints ? End-of-Life/Palliative Care ?
Intracranial Pressure Management ? Bundles ?
Other __________________
8
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 Texas Southwestern Medical
Center , Dallas ? The University of Texas
Medical Branch, Galveston ? The University of
Texas Health Science Center, Houston ? The
University of Texas Health Science Center, San
Antonio ? The University of Texas Health Center,
Tyler ? The University of Texas M.D. Anderson
Cancer Center What types of critical care units
are present in your institution? (check all that
apply) ? Medical ICU ? Surgical ICU ?
Medical/Surgical ICU ? Cardiothoracic Surgical
ICU ? Transplant ICU ? Coronary Care Unit ?
Pediatric ICU ? Neonatal ICU ? Burn ICU ?
Trauma ICU ? Intermediate Care Unit ? Telemetry
Unit ? Other ____________ ? Other
____________ Do you utilize a multidisciplinary
team approach to critical care? Yes / No
What has been your greatest ICU Quality
Improvement success? What has been your greatest
ICU Quality Improvement challenge? What should
be the top priority for the University of Texas
System Health Components Intensive Care Unit
Quality Improvement Project?
9
ICU Collaborative

• Make it easier to Do the Right Thing
• Terry Clemmer, MD
• Rapid Cycle Improvement in ICU
• War Wounds
• Brainstorming

10
Literature Review
11
Barriers

• Changing a tire on a moving vehicle
• Different Institutions, Different Patients
• OK, but not in my patients
• Quality Improvement Tools
• Facilitator
• Data Gap

12
(No Transcript)
13
Glucose Management

• Protocol
• Mass Customization
• Outcomes
• Tight Glucose Management
• Hypoglycemia

14
Demographics

• Grp1 (Jun - Aug 04)
• 98 events
• 0.87 event rate
• 46 unique patients
• Average age - 59 yrs
• 11 surgical patients
• 35 medical patients

• Grp2 (Feb - May 05)
• 116 events
• 0.55 event rate
• 59 unique patients
• Average age - 51 yrs
• 16 surgical patients
• 43 medical patients

15
Comparison of Patients with Hypoglycemic Events
'On or Off' Insulin Protocols
16
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
Chancellors 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..
17
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
Chancellors 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..
CGMS Research Protocol The complete CGMS Research
Protocol as presented to the Institutional
Review Boards of the participating Institutions
is found in Attachment A The expected outcomes of
the CGMS protocol include The determination of
the accuracy of the continuous glucose
monitoring device as compared to the current
glucose measures, publications for the
participating faculty, A potential decrease in
number of invasive sticks or phlebotomy that a
patient may encounter in the ICU when on an
insulin drip Potential decrease in nursing
workload if continuous glucose monitor is as
accurate as current standard of glucose
monitoring with hourly blood draws.
18
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
Chancellors 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..
Information Systems Gap Analysis If funded, the
UT System ICU Collaborative proposes to retain
Sentigy, an information systems consulting group
that falls under the State of Texas Historically
Underutilized Business (HUB) classification, to
perform the gap analysis. Sentigy has performed
work at several of the UT System components and
thus is familiar with the information systems.
They will be requested to conduct an evaluation
of the ability of the information systems at the
participating organizations to collect and
transfer data that will be required to
participate effectively in the ICU CGMS research
protocol. This evaluation should include a gap
analysis for organizations currently unable 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.
19
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
Chancellors 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..
Clinical Safety and Effectiveness (CSE)
Course ICU teams participating in the CGMS
research protocol will attend the M. D. Anderson
CSE course to develop skills and knowledge
necessary to conduct improvement initiatives.
Support is requested for two individuals, one
physician (the protocol principal investigator)
from each participating UT organization and one
nurse from the affiliated hospitals ICU. Each
team will participate in the CSE course to be
held at M. D. Anderson in the fall of 2007. These
teams will use the CGMS protocol as their course
projects and the course will emphasize this
protocol throughout the lectures.
20
ICU Data Gap Analysis
21
ICU Collaborative

• Healthcare Delivery Projects
• Institutional Projects
• UT System Projects
• Clinical Research Projects
• CGMS Project
• eProtocol insulin
• Indwelling Glucose Monitoring device

22
UT System Collaboratives

• Join one!
• Build one!
• Support them!