ICU埃克塞特改善英文课件.ppt

1、Improving Outcomes in the ICU:Experience at Exeter Hospital,Richard D. Hollister, MD Director, ICU Chairman, ICU Best Practices Committee Department of Pulmonary/Critical Care Medicine,“A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-

2、four hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per dayRemarkably, the nurses and doctors were observed to make an error in just one percent of these actionsbut that still amounted to an average of two errors a day with every patient”,

3、“A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per dayRemarkably, the nurses and doctors were observed to make an error

4、 in just one percent of these actionsbut that still amounted to an average of two errors a day with every patient”,The Boeing Model 299: First tested in flight October 30, 1935. Later known as the B-17 Flying Fortress.,“The plane roared down the tarmac, lifted off smoothly, and climbed sharply to th

5、ree hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosionThe pilot had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as one newspaper put it, too much airplane to fly.”,The pilot was not “experienced enoug

6、h” The pilot was not “vigilant enough” The pilot needed “more education” The airplane was “too complex to fly” The airplane was “doomed to failure”,Why did the 299 crash?,“They came up with an ingeniously simple approach: they created a pilots checklist, with step-by-step checks for takeoff, flight,

7、 landing and taxiingWith checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident.”,www.richard-,Do checklists and other forms of disciplined, systematic care work in the ICU?,Yes!,Evidence-Based Examples,Checklists for Central line insertion Check

8、lists to prevent ventilator-associated pneumonia Mandatory intensivist consultation for ICU level patients Protocols to treat Septic Shock Protocols to manage hyperglycemia Multidisciplinary ICU rounds,How have we implemented changes in ICU care at Exeter Hospital?,ICU is not a place.,ICU is a SYSTE

9、M OF CARE.,ICU leadership structure,ICU nurse manager: Anne Steele, RN Physician Directors: Paul Deranian, MD; Alan Gladstone, MD; Richard Hollister, MD; David London, MD; Mark Reiner, MD Administrative Liaisons: Anne Marie Bularzik, VP, CNE; Barbara Hughes, DNP, RN, VP System Quality Clinical leade

10、rs: Carol Allard, RN; Kellie Cosgrove, RN; Melissa Keith, RN; Cathy Hackett, RN; Lisa Kennedy, RN, Margaret Rosset, RN Nurse educators: Carol Frock, RN (ICU); Chris Bone, RN (PCU); Melissa Pollard, RN,ICU leadership and direction,Monthly Critical Care committee meeting represented by Intensivists, I

11、M, Anesthesia, Cardiology, Hospitalist, nursing, administration, RN educators, pharmacy, Infection control. Monthly ICU Best Practice committee: establish and implement protocols that reflect evidence-based means to optimize outcomes,Exeter Hospital Quality Committee,Critical Care committee Physicia

12、n ICU directors Staff RNs & Clinical leaders Pharmacy RN educators Administration Infection control,ICU Best Practices Committee Medical staff members Surgical staff members Administration Nursing leadership,What constitutes ICU “Best Practices?”,Initiation of rapid response teams Tight glucose cont

13、rol Prevention of ventilator associated pneumonia Prevention of catheter-related blood-stream infections Intensivist-led ICU/Mandatory consultation Multidisciplinary rounding approach Protocols for treatment of severe sepsis/septic shock,Exeter Hospital ICU pre-2007,Prior to 2007, our ICU model was

14、“Open” Any EH medical staff physician could admit to the ICU without intensivist oversight Intensivists were on site but only called in at the sole discretion of the staff physician Problems with orchestrating care: multiple consultants, providers not always immediately available at the bed side. “N

15、obody coordinating all of the patients care” Problems with failure to rescue: intensivists called in late, after pt “crashed” or after organ failure in advanced stages.,2007 - Intensivist led ICU,Mandatory phone call to the intensivist for all ICU admissions Intensivists lead the care on all ventila

16、ted patients and on all but the most stable ICU level patients The intensivist reviews the ICU census every day and reserves the right to become involved/orchestrate the care of any ICU level patient at any time.,Buy-In,Focus on research/data: Ideas dont take flight unless there is a sound basis in

17、evidence Pronovost JAMA 2000 Meta-analysis of Intensivist-led care in the ICU Leap-Frog group Society of Critical Care Medicine Measure outcomes,Buy-In,Communicate,Communicate,Communicate,Buy-In,Medical Division Meeting Surgical Division Meeting Hospitalist Group Meeting Exeter Hospital Quarterly St

18、aff Business Meeting Medical Executive Committee Cardiology Group Meeting,Buy-In,Take every opportunity, formal and informal, to explain to the medical/surgical staff why these initiatives are important,“I not only use the brains that I have but all that I can borrow.” -Woodrow Wilson,Multidisciplin

19、ary Rounds in the ICU: Who participates?,Intensivist Patients nurse for the day ICU clinical leader Respiratory therapy PhD clinical Pharmacist Nutrition Social Work Palliative care,Multidisciplinary Rounds in the ICU: Nuts and Bolts,Data is collated by nursing including 24 hour events, vital signs,

20、 I/Os, iv infusions, line and endotracheal tube insertion dates, tube feed rates, skin integrity, lab data, culture data, ventilator data and abgs. The data is read off to the entire team while the intensivist documents in his note Respiratory therapy confirms vent settings PhD pharmacist recites al

21、l medications and dosages in front of team based on EMR.,Multidisciplinary Rounds in the ICU: Generating a daily plan,Sedation and vent changes are made in real time while team is present (very important for vent weaning) Nutrition recommendations are made in the proper clinical context and account

22、for nursing, physician and patient perspectives Questions are encouraged and answered. Medication dosing adjustments are made according to pharmacists input in real time reducing possibility of dosing errors or failing to dose drugs in therapeutic range. Social issues are communicated to the whole t

23、eam allowing for one unified message to reach patients and their families during the day. Major therapeutic goals for the day are shared amongst all team members,Quantifying ICU outcomes,Ventilated patient Mortality Catheter-related blood stream infections Ventilator associated pneumonia Measuring S

24、everity of Illness Reporting Illness-adjusted Outcomes,Ventilator-associated pneumonia: What Works?,REMOVAL OF THE ENDOTRACHEAL TUBE Hand washing between pt contacts Elevate the HOB Scheduled drainage of condensate from ventilator circuits (we use heated wire circuits that prevent condensation build

25、-up) Continuous subglottic suctioning Maintenance of adequate cuff pressure in the ETT,Ventilator-associated pneumonia,“Its hard to get VAP if you are not intubated” Daily sedation vacation Daily spontaneous breathing trial once FiO2 below 50% and PEEP of 5 or less All intubated patients are managed

26、 by board-certified intensivists Stress ulcer prophylaxis Tight blood glucose control that is protocol driven,Nursing Care of the Ventilated Patient,Mouth care with special kits every 4 hours. Keeping the head of the bed 30 degrees (when possible)track and trend. Stress ulcer disease prophylaxistrac

27、k and trend. Deep vein thrombosis prophylaxistrack and trend. Daily sedation vacationstrack and trend.,Exeter Hospital: Ventilator Associated Pneumonia,ZERO ventilator associated pneumonias in over 400 patient vent-days,Catheter-related bloodstream infections,“You cant get a line infection if you do

28、nt have a line” Daily nursing and physician examination of line site Daily assessment of line necessity: Can we take it out? Use of PICC lines when appropriate when access needed only for TPN, antibiotics or lab draws Infection control places reminder notes in progress note section of chart asking p

29、hysicians to document why line remains in place (outside of the ICU) Experienced operators insert the vast majority of central lines: Board certified Intensivists, General and Vascular surgeons Tight blood glucose control that is protocol driven,Catheter-related bloodstream infections,Arrow antimicr

30、obial triple lumen catheter kits that contain Chlorhexidine prep Full sterile barrier All other triple lumen catheter kits have been removed from patient care areas (OR, ER, ICU). We use only one kit type.,Nursing Care of the Patient with a Central Line,Change dressing every 6 days or as needed Dail

31、y assessment of need for central line in multidisciplinary rounds Survey on central line insertions (hand washing prior to procedure, use of sterile gown, gloves, and large drape, mask, cap, chlorhexadine prep, and site used)tracking and monitoring.,Exeter Hospital: Catheter related blood stream inf

32、ections,ZERO line infections in over 800 patient line-days,APACHE IVAcute Physiology And Chronic Health Evaluation,Quantifying severity of illness and predicting mortality in the ICU,APACHE: What is it?,A rigorously validated set of equations that predict the likelihood of ICU mortality and ICU length of stay based on numerous physiologic and clinical parameters that are easily identified and quantified.,APACHE IV,Data