Enhancing Outcomes in a Surgical Intensive Care Unit by Implementing Daily Goals Tools
2009; American Association of Critical-Care Nurses; Volume: 29; Issue: 6 Linguagem: Inglês
10.4037/ccn2009663
ISSN1940-8250
Autores Tópico(s)Healthcare Decision-Making and Restraints
ResumoSuccessful teamwork requires strategic communication to address and meet common goals for patient care.Medical errors and patient safety remain prime concerns in health care.1 The sometimes hazardous environment of the intensive care unit (ICU) may be due to an increased prevalence of chronic diseases, higher patient acuity, and advances in technology and pharmaceutical agents.2 Potential fragmentation of care because of multiple specialty providers increases these concerns.3 Some experts4 think the greatest potential for harm stems from a combination of factors such as system failures, faulty processes, poor teamwork, and communication breakdown.In this article, I discuss enhancing patient safety and outcomes in a surgical ICU (SICU) by using a quality improvement tool to increase communication and teamwork. I further describe the effects of these tools on 6 outcome measures evaluated for 1 year before use of the tools and for the subsequent 2½ years. A case study of a critically ill patient exemplifies use of the tools.The relationship between safety and communication has been recognized for some time. Strong team-work and effective communication between nurses, physicians, and personnel from other disciplines have been associated with improved outcomes such as decreased lengths of stay and reduced mortality rates.5 However, health care providers occasionally do not recognize that effective communication is crucial to create teams that foster safe environments. Reviews of critical incidents indicate that poor communication is a major contributing factor.5 The annual report on quality and safety by the Joint Commission6 has consistently indicated inadequate communication between care providers or between care providers and patients and patients’ families as the root cause in sentinel events.Communication challenges between nurses and physicians and a culture of physician hierarchy still persist at times in daily practice. Donchin and colleagues7 found that communication between nurses and physicians occurred in only 2% of all activities performed in an ICU yet were associated with a third of identified errors. In addition, in another study8 in an ICU, physicians regarded the quality of the teamwork more positively than nurses did. This disconnect may be due to different perceptions of teamwork and diverse professional focuses between the disciplines.4 At times, the priorities of each discipline differ, and both physicians and nurses sometimes do not realize that their relationship is interdependent.4 Therefore, successful teamwork requires strategic communication to address and meet common goals for patient care.The aviation industry is also faced with communication and teamwork challenges. Members of that industry recognize that error is inevitable in human performance. One method used in aviation to enhance safety is training in crew resource management. These training programs simultaneously support assertiveness training for junior associates and encourage modification of traditional hierarchal behaviors in leaders that focus on individual preferences.9 Formal teamwork training focuses on 7 skills: situation awareness, adaptability and flexibility, leadership, communication, decision making, assertiveness, and mission analysis.10 Additional tactics include simplifying complex tasks by using checklists and redundancies, taking proactive measures to prevent mistakes, promoting visibility of errors before harm occurs, and developing strategies for managing error.8Similar to aviation, health care is a high-risk environment, often has a distinct hierarchy, requires the performance of complex tasks, and includes use of advanced technology. Unfortunately, health care has lagged behind other high-risk industries in using tools of improvement. Health care providers are just beginning to prioritize communication and team-work as essential elements for success. Tools such as the Daily Goals Tools and other redundant processes can help in simplifying complex tasks, improving team-work, promoting effective communication and shared decision making, and enhancing patient safety, particularly in high-risk environments such as the ICU.8The SICU at Advocate Lutheran General Hospital (Park Ridge, Illinois) is an open unit with a diverse population of patients. Multiple physicians, including hospitalists, intensivists, cardiologists, general surgeons, trauma surgeons, cardiovascular surgeons, nephrologists, orthopedists, pulmonologists, neurologists, neurosurgeons, and internists, contribute to the care of the patients. Nurses often must deal with multiple orders from several services that require clarification, coordination, and discussion among the services. An example is use of a potassium protocol.The protocol enables nurses to replace and monitor potassium as needed, including as indicated by the results of laboratory tests of samples obtained at 4 am. A resident reviewing the results of laboratory tests places an order for a one-time potassium phosphate infusion via computer data entry. An internal medicine attending physician then comes in to see the patient. The physician is not aware of the potassium protocol, does not see the order placed in the computer by the resident, and also orders a one-time potassium phosphate infusion. Fortunately, the only replacement the patient receives is the one indicated by the potassium protocol because personnel in nursing and the pharmacy telephoned the resident and the attending physician about the problem. Simple communication measures could eliminate this potential serious error.Personnel in multiple services also place orders for computed tomography, magnetic resonance imaging, and special procedures. A formal communication tool can assist in the coordination of multiple tests and reduce the amount of time and resources needed to provide care. Most importantly, use of the tool can decrease the stress experienced by patients who are taken from their room for tests several times a day.Finally, nurses are often involved in promoting conversations between patients’ families and the patients’ physicians. When a patient or the patient’s family asks when a fracture will be repaired or an abdominal closure performed, nurses are often the health care providers who facilitate these conversations with the consulting services.In 2003, the results of a prospective cohort study conducted collaboratively by the Volunteer Hospital Association, the Institute for Healthcare Improvement, and Johns Hopkins Hospital on use of a daily goals worksheet were published.11 Their Daily Goals Worksheet focused on the care team’s understanding of the patient’s needs, empowering nurses, increasing nursing morale, avoiding duplicate work, and facilitating explicit communication.In 2005, the Daily Goals Tool (DGT; Table 1) and Daily Goals Tool Reference (DGTR; Table 2) were developed and customized for the SICU at Advocate Lutheran General Hospital. The purposes of these tools are similar to the purpose of the Daily Goals Worksheet, but the tools include an additional focus on developing multidisciplinary patient- centered goals, improving communication, fostering collaboration and coordination of care between all disciplines, avoiding fragmentation of care, facilitating daily communication between patients, patients’ families, and care providers, and ultimately enhancing patient safety and improving patient outcomes.The DGT facilitates a comprehensive daily review of 12 major aspects of care and provides a framework for evidence-based practices. Several key questions are given for each aspect of care, and space is provided for up to 7 days’ information on a single sheet. A challenge recognized during development of the DGT was the diverse population of patients cared for in the SICU. The original Daily Goals Worksheet was developed for a small specialty ICU; thus, the DGT had to be adapted to address the needs of the patients in the SICU.The DGTR helps care providers determine the specific needs of diverse patients with wide age ranges and multiple preexisting medical problems. The tool provides greater detail on each of the 12 aspects of care and is aligned with the DGT for an all-inclusive review. The DGTR was laminated and put on individual nurses’ clipboards along with the DGT. Use of the tools was implemented in January 2006.Comprehensive education was provided on the goals and use of the DGT and the DGTR in December of 2005, before use of the tools began. The education included information on evidence-based practices, care based on use of a protocol, and the concept of “bundles.” Bundles were defined as groupings of evidence-based best practices that, when completed, result in improved patient outcomes.12 Additional instruction integrated the components of the ventilator bundle (Table 3), the central catheter bundle (Table 4), and the Surgical Care Improvement Project (SCIP) bundle (Table 5). Providers also reviewed the processes needed to eliminate or reduce incidences of ventilator-associated pneumonia (VAP), central catheter infections, and surgical site infections.Nurses were additionally taught about “sedation vacation” or providing patients a daily break from sedation (unless contraindicated) and assessing patients’ readiness to be extubated. Regular interruptions in sedation can markedly reduce the duration of mechanical ventilation and the ICU length of stay.15 In addition, the simple practice of elevating the head of the bed greater than 30° can decrease the risk of VAP.16 Nurses learned that SCIP is a partnership of organizations that focus on reducing surgical complications and improving surgical care and they learned what components are included in the SCIP bundle. Finally, the importance of completing all measures in the bundles was stressed. Education was completed at the end of December 2005, and use of the tools was implemented in early January 2006 during daily rounds.The DGT and DGTR encompass 12 major aspects of care.The first aspect on the DGT is safety and transfer and prompts the health care team to determine each patient’s greatest safety issue. The DGT further addresses what must happen for the patient’s progress and transfer out of the SICU. An example of this aspect is the collaborative development of a plan to prevent a severely agitated patient from self-harm.The second aspect reviews the components of the ventilator bundle. The DGT elaborates on using venous Doppler imaging for surveillance and reviews the need for anticoagulation. This part of the tool also helps in identifying the need for an inferior vena cava filter for patients who cannot be given anticoagulants. Daily assessment of when to consider a tracheostomy is also reviewed. Inclusion of the ratio of arterial oxygen pressure to fraction of inspired oxygen on the DGTR reinforces the potential need for early kinetic therapy.The third aspect of the DGT incorporates the review of the results of laboratory tests, radiographs, and other studies such as computed tomography and magnetic resonance imaging. The health care team focuses on the results of these studies and other tests and procedures. Additional orders or the need to discontinue unnecessary orders is further reviewed. Glycemic management is incorporated in the review of laboratory results.The aspect on neurological and pain management includes completion of the standing orders for acute brain injury/intracranial pressure in adults. This aspect also addresses cervical spine clearance with the trauma service. The health team further assesses each patient’s current neurological status and the recommendations from the consulting service. Pain control is also evaluated. The potential need for pentobarbital coma is addressed in the DGTR. Although pentobarbital coma is not used often, it is part of the treatment of patients with refractory intracranial hypertension.The fifth aspect includes cardiac rhythm, hemodynamic status, oxygen transport calculations, and medications. The team determines if any issues or problems exist, including the need to insert a pulmonary artery catheter or remove one that is no longer needed. The DGTR calls for a review of oxygen transport calculations. Again, although the calculations are not performed for many patients, in some clinical situations, assessment of oxygen delivery and consumption is imperative.Volume status affects many surgical patients. Consequently, the number of fluid boluses, base deficit, 24-hour intake and output, and filling pressures are carefully examined. The team determines if the current rate of administration of intravenous fluids is adequate or if diuresis may be needed.The aspect of care concerned with parameters, notification of a physician, and need for consultations provides a comprehensive review of vital signs and hemodynamic parameters; use of β-blockers is resumed or initiated if appropriate per the SCIP bundle. Hemodynamic parameters are clearly established and communicated to eliminate confusion about notification of abnormalities to the managing service. The care team examines care from all the services and focuses on streamlining coordination of tests and procedures ordered by all consultants. In addition, the team appraises the need for additional consultations.Gastrointestinal assessment and nutrition are addressed next. Early initiation of enteral feedings (24–72 hours) is ordered as appropriate, and nutritional needs are determined by the nutritionist. The health care team reviews the potential need for placement of a gastrostomy tube. The nurses ensure that the enterostomy nurse is notified for patients with new ostomies and that appropriate diet orders are written for patients who are ready to resume oral intake.For the infectious disease aspect, for each patient with an infectious disease, the team assesses the patient’s 24-hour temperature maximum, treatment, potential causes of infection, and results of cultures of specimens. Need for an infectious disease consultation is determined. In addition, the team evaluates antibiotic levels, isolation status, and screening for methicillin-resistantAssurance of appropriate completion of antibiotic treatment within 24 hours is determined, along with establishment of normothermia per the SCIP bundle.During review of central and arterial catheters, the team analyzes the length of time since an original catheter has been inserted and the appearance of the site of insertion. Changing the site or arranging for placement of a peripherally inserted catheter is determined, along with the need for an arterial catheter. Any unnecessary catheters are removed.The health care team addresses any skin care issues and ensures that orders are obtained for pressure reduction measures. Wound care is reviewed, along with activity level, mobilization, and the need for physical therapy or a wound consultation.Finally, but most importantly, the team recognizes the patient and the patient’s family and incorporates them into the plan of care. Patient-centered care focuses on the culture, traditions, personal preferences, religion, values, developmental stage of life, family circumstances, and lifestyle choices of each patient and his or her family. In patient-centered care, patients and their families are recognized as vital members of the care team. Including a patient and the patient’s family empowers them to cope more effectively with a rapidly changing and often challenging health status. Last, the health care team provides ongoing information to patients and patients’ families about the plan of care in a clear, honest, and understandable manner.17 During this time, the team may decide to discuss a patient’s code status or set up a time for a care conference with the patient’s family and all care providers. The following case study illustrates use of the DGT and the importance of communication with a patient’s family.Use of the DGT and DGRT greatly facilitated a comprehensive approach in meeting Mrs P’s multiple complex needs. Use of the tools also fostered communication and coordination of care between the managing service, the multiple consulting physicians, and nurses. Multiple evidence-based practices and protocol-driven care were instituted, including glycemic control, use of the ventilator and central catheter bundles, and use of best practices for treatment of acute respiratory distress syndrome. However, the greatest strength of the tools was fostering communication between the team and the family, including the family’s presence during end-of-life care.The DGT was originally fashioned as a 1-sheet-per-day tool that was initiated by a patient’s nurse, discussed during rounds with the physicians, and updated throughout the day as appropriate. However, it quickly became apparent that a new sheet every day was quite cumbersome. Subsequently, 3 weeks into implementation, a revised tool that could be used daily for an entire week was incorporated.Three months after implementation, a questionnaire with a Likert-type scale was given to nurses for input on the use of the DGT, including a section for comments (Table 6). The response rate was 46%. In total, 87% of the respondents strongly agreed or agreed that they were using the DGT and DGRT regularly. A total of 59% strongly agreed or agreed that the tools improved communication between nurses and physicians, and 72% strongly agreed or agreed that using the tools was beneficial to patient care. A total of 63% of nurses strongly agreed or agreed that the tools enhanced communication between members of the nursing team, and 68% strongly agreed or agreed that the tools improved patient safety. In the additional comments, several nurses reported that the tools were excellent educational resources and promoted evidence-based care. Several physicians provided feedback. One suggestion included adding to the DGTR daily consideration of when to perform a tracheostomy. Additional elements such as the new diabetes protocol and the SCIP bundle were added as the elements were implemented.Also recognized was the need for additional input from the night shift. Many night nurses thought they did not have to complete the tool because they were often not involved with formal rounds. However, in the SICU, most members of the nursing staff work 12-hour shifts. Without input from the night nurses, valuable information from half of a patient’s day would be lacking. Specimens for laboratory tests are obtained at 4 am, and results are often available by 5 am or 6 am. Residents and some surgeons also begin to examine patients and review laboratory findings by 5:30 am to 6 am. After reinforcement of the goals of the DGT, night nurses began to facilitate formal communication with physicians and provide input into the plan of care, such as electrolyte replacement, weaning from mechanical ventilation, erythematous arterial catheter sites, and the concerns of patients’ families. This formal communication was then turned over to the next shift to be continued during interdisciplinary rounds.Evidence-based practices that may be added to the DGT and DGTR in the future include incorporation of the severe sepsis bundle, continuous electroencephalographic monitoring, monitoring of brain tissue oxygen, and guidelines for fever reduction in patients with traumatic brain injuries, stroke, or other neurosurgical problems.An original purpose for development of the tools was improvement in patients’ outcomes. Therefore, baseline data obtained from January 2005 through December 2005, before implementation of the DGT, were compared with data collected from January 2006 through December 2006, after implementation of the tool. Data from 2007 and 2008 were also collected. Variables tracked included the following:Improvements occurred in all 6. The mean length of stay decreased from 4.4 days in 2005 to 4.0 days in 2006, 3.2 days in 2007, and 3.16 days for the first 10 months of 2008 (Figure 1). Compliance with the bundle for VAP was not measured until 2006. However, compliance increased sharply from 92% in January of 2006 to 98% to 100% for the rest of 2006 (Figure 2). Except for January 2007, when compliance was 94%, the rate has remained at 98% to 100%. The rates of VAP (Figure 3) and bloodstream infection (Figure 4) decreased to zero by the end of 2006. Except for 1 month in 2007 and 1 month in 2008, VAP rates have remained at zero. The rate of bloodstream infections had a slight increase in 1 month of 2007 and again in 1 month of 2008 but otherwise has remained at zero. The number of falls was reduced to zero by the end of 2006 (Figure 5), and the number of decubitus ulcers was reduced to zero by the third quarter of 2006 (Figure 6). The number of falls remained below the 2005 rates except for the first quarter of 2007. The rates of decubitus ulcers have remained well below the 2005 rates.In the ICU, nurses, physicians, and members of other health care disciplines often care for the most critically ill or injured patients. Health care providers focus heavily not only on life-sustaining measures and meeting the complex needs of the patients but also on protocol-driven care. Members of the health care team care deeply about the quality of care they provide for their patients.19 The importance of team-work and communication in preventing errors and improving patients’ outcomes has been well documented. Attention to the tactics used by the aviation industry has slowly filtered into health care. The ICU Safety Reporting System funded by the Agency for Healthcare Research and Quality is a strategy that allows for voluntary, anonymous, confidential Web-based reporting of adverse events and near misses. In addition, in the fall of 2006, the Agency for Healthcare Research and Quality and the Department of Defense announced the availability of a new resource for training health care providers in better teamwork practices.1 Every year the Joint Commission updates its patient safety goals to reflect changes in patient safety concerns. Many health care systems throughout the United States are committed to this effort. They have invested in research and educational programs that support a culture of safety.2Health care providers continue to recognize that interdisciplinary teamwork and communication are necessary to ensure safe, quality care for patients.20 In addition, increasing emphasis is being placed on identifying communication skills and/or tools that can help in promoting effective teamwork and communication, enhancing safety, and improving patient outcomes.5 The DGT is a simple yet powerful tool that incorporates the concept of checklists and redundancy.13 It allows for mutual participation in decision making by not only nurses but also residents, pharmacists, nutritionists, patients, and patients’ family members. Team members contribute valuable information, including different point of views, and members with more influence are encouraged to listen.In addition to facilitating explicit communication, the DGT and DGTR are excellent educational resources and ensure integration of evidence-based practice into daily patient care.13 The DGT and DGTR can be modified for almost any area and can have additional prompts added, such as measures for assuring compliance with the severe sepsis bundle and fever management guidelines. In addition, use of the tools improves the likelihood that all patients receive comprehensive evidence-based care, and the DGT and DGTR can also be used as a mechanism for examination when some patients do not receive such care.13 Despite the concern for patient safety in critical care, ICUs can serve as catalysts for change.1 Use of the DGT and DGTR can enhance teamwork, facilitate communication, and create a climate that supports patient safety and ultimately improves outcomes.
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