Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit.

OBJECTIVE: To demonstrate that by using the knowledge and skills of the primary care provider and by applying statistical and scientific principles of quality improvement, outcomes can be improved and costs significantly reduced. DESIGN: A before and after quasi-experimentally designed trial using historical controls plus an analysis of costs in areas not influenced by intensive care unit (ICU) practice to control for possible secular changes. SETTING: A tertiary ICU. PATIENTS: All patients admitted to the above-mentioned ICU from January 1, 1991, through December 31, 1995. INTERVENTIONS: a) A focused program that applied statistical and scientific quality improvement processes to the practice of intensive care. b) An organized effort to modify the culture, thinking, and behavior of the personnel who practice in the ICU. MEASUREMENTS: Severity of illness, ICU and hospital lengths of stay, ICU and hospital mortality rates, total hospital costs as analyzed by the cost center, and measures of improvement in specific areas of care. MAIN RESULTS: Significant improvement in glucose control, use of enteral feeding, antibiotic use, adult respiratory distress syndrome survival, laboratory use, blood gases use, radiograph use, and appropriate use of sedation. A severity adjusted total hospital cost reduction of $2,580,981 in 1991 dollars when comparing 1995 with the control year of 1991, with 87% of the reduction in those cost centers directly influenced by the intervention. CONCLUSIONS: A focused quality improvement program in the ICU can have a beneficial impact on care and simultaneously reduce costs.

Cooperation: the foundation of improvement.

Cooperation--working together to produce mutual benefit or attain a common purpose--is almost inseparable from the quest for improvement. Although the case for cooperation can be made on ethical grounds, neither the motivation for nor the effects of cooperation need to be interpreted solely in terms of altruism. Cooperation can be a shrewd and pragmatic strategy for accomplishing personal goals in an interdependent system. Earlier papers in this series have explored the conceptual roots of modern approaches to improvement, which lie in systems theory. To improve systems, we must usually attend first and foremost to interactions. Among humans, "better interaction" is almost synonymous with "better cooperation." Physicians have ample opportunities and, indeed, an obligation to cooperate with other physicians in the same or different specialties, with nurses and other clinical workers, with administrators, and with patients and families. Many intellectual disciplines have made cooperation an object of study. These include anthropology; social psychology; genetics; biology; mathematics; game theory; linguistics; operations research; economics; and, of course, moral and rational philosophy. Scientifically grounded methods to enhance cooperation include developing a shared purpose; creating an open, safe environment; including all who share a common purpose and encouraging diverse viewpoints; negotiating agreement; and insisting on fairness and equity in the application of rules. These methods apply at the organizational level and at the level of the individual physician. This paper describes the application of these methods at the organizational level and focuses on one especially successful example of system-level cooperation in a care delivery site where interactions matter a great deal: the modern intensive care unit.

Developing and gaining acceptance for patient care protocols.

The purpose of developing protocols and guidelines is greater than reducing variation in practice. The process also creates new paradigms and changes the culture in which health care is delivered. The protocol itself is designed to be transient. The new environment and perceptions of how to improve health care in the future, along with new relationships and processes to accomplish this, are the real power of learning to develop and implement protocols and guidelines. Framing the process of protocol development, therefore, is more important than the resulting document. In developing protocols, attention to changing the thinking and practice of the front-line practitioners, establishing new relationships, and devising new methods of delivering and improving care is key. The process of developing protocols should include all practitioners. They should remain in control of patient care using new methods that allow: a) the monitoring of process and outcomes, b) identification of problems, and c) the evaluation and validation of the effectiveness of implemented change. Evidence from the literature of strategies for protocol development and implementation which are effective in creating change are reviewed, and an example of a known effective method which improves practice is given.

Medical Information Bus usage for automated IV pump data acquisition: evaluation of usage patterns.

OBJECTIVE: To identify factors which influence the choice of nurses to use automated collection of i.v. pump data from a prototype Medical Information Bus. DESIGN: Observational study for a duration of three and one-half months. SETTING: Four intensive care units, each with different missions, in an adult hospital. SUBJECTS: One hundred fifty-eight registered nurses including both full and part time. MEASUREMENTS AND MAIN RESULTS: Data were collected from the hospital information system about infusion orders including the type of medication, the number of rate changes, the method of documenting rate changes and the infusion methods. The method of documentation for infusion rate changes was defined as either automated, using a prototype Medical Information Bus (MIB), or manual, using the keyboard at a bedside computer terminal. The method of infusion was defined as either straight gravity feed without an i.v. pump ('no pump'), infusion using a pump but without connection to the hospital information system ('pump only') and infusion using a pump which was connected to the hospital information system using a prototype Medical Information Bus ('automated'). A total of 22,199 rate changes were documented during the study period and of those, 22,055 (99.35%) used the 'automated' method. Medications with the highest average rate change per single container were; Nitroprusside Sodium (9.50), Epinephrine (9.08) and Epoprostenol (7.50). CONCLUSIONS: The nurses used automated i.v. pump data acquisition with medications which required frequent rate changes.