Rethinking critical care: decreasing sedation, increasing delirium monitoring, and increasing patient mobility

Rick Bassett, Kelly McCutcheon Adams, Valerie Danesh, Patricia M Groat, Angie Haugen, Angi Kiewel, Cora Small, Mark Van-Leuven, Sam Venus, E Wesley Ely, Rick Bassett, Kelly McCutcheon Adams, Valerie Danesh, Patricia M Groat, Angie Haugen, Angi Kiewel, Cora Small, Mark Van-Leuven, Sam Venus, E Wesley Ely

Abstract

Background: Sedation management, delirium monitoring, and mobility programs have been addressed in evidence-based critical care guidelines and care bundles, yet implementation in the ICU remains variable. As critically ill patients occupy higher percentages of hospital beds in the United States and beyond, it is increasingly important to determine mechanisms to deliver better care. The Institute for Healthcare Improvement's Rethinking Critical Care (IHI-RCC) program was established to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. Case studies of a convenience sample of five participating hospitals/health systems chosen in advance of the determination of their clinical outcomes are presented in terms of how they got started and process improvements in sedation management, delirium management, and mobility.

Methods: The IHI-RCC program involved one live case study and five iterations of an in-person seminar in a 33-month period (March 2011-November 2013) that emphasized interdisciplinary teamwork and culture change.

Results: Qualitative descriptions of the changes tested at each of the five case study sites demonstrate improvements in teamwork, processes, and reliability of daily work. Improvement in ICU length of stay and length of stay on the ventilator between the pre- and postimplementation periods varied from slight to substantial.

Conclusion: Changing critical care practices requires an interdisciplinary approach addressing cultural, psychological, and practical issues. The key lessons of the IHI-RCC program are as follows: the importance of testing changes on a small scale, feeding back data regularly and providing sufficient education, and building will through seeing the work in action.

Figures

Figure 1
Figure 1
This figure represents the ALOS and ALOSV data for Rapid City’s (Case Study 1) MICU ICU and includes 6 months pre-implementation and 18 months post-implementation data. A linear trend line represents each metric and demonstrates gradual improvement pre- vs. post-implementation.
Figure 2
Figure 2
This figure represents the ALOS and ALOSV data for Mission’s (Case Study 2) ICU and includes 6 months pre-implementation and 18 months post-implementation data. A linear trend line represents each metric and demonstrates slight improvement in ALOS and more substantial improvement in ALOSV pre- vs. post-implementation.
Figure 3
Figure 3
This figure represents the ALOS and ALOSV aggregate data for St. Luke’s (Case Study 3) 3 ICUs and includes 6 months pre-implementation and 18 months post-implementation data. A linear trend line represents each metric and demonstrates substantial improvement pre- vs. post-implementation in both ALOS and ALOSV.
Figure 4
Figure 4
This figure represents two metrics: percent of patients at RASS goal of 0 to -1, and percent of patients with a daily mobility event. It is aggregate data for St. Luke’s (Case Study 3) three ICUs. The RASS metric demonstrates substantial improvement in the percent of patients meeting the target RASS score. The mobility metric shows modest improvement.
Figure 5
Figure 5
This figure represents the ALOS data for Orlando Health (Case Study 4) ICU and includes 3 months pre-implementation and 3 months post-implementation data. A linear trend line represents each metric and demonstrates substantial improvement pre- vs. post-implementation in both ALOS.
Figure 6
Figure 6
This figure represents the ALOSV data for Orlando Health (Case Study 4) ICU and includes 3 months pre-implementation and 12 months post-implementation data. A linear trend line represents the metric and demonstrates improvement pre- vs. post-implementation in ALOSV.
Figure 7
Figure 7
This figure represents the ALOS and ALOSV data for Samaritan (Case Study 5) ICU and includes 6 months pre-implementation and 18 months post-implementation data. A linear trend line represents each metric and demonstrates slight improvement pre- vs. post-implementation in ALOSV.See each figure of definition of pre and post implementation data periods ALOS = Average Length of Stay ALOSV = Average Length of Stay on the Ventilator RASS = Richmond Agitation Sedation Scale

Source: PubMed

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