Upload
merryl-johnson
View
213
Download
0
Tags:
Embed Size (px)
Citation preview
Impact of Quality Improvement in the CICU
Santiago Borasino MD, MPHAssociate Professor of Pediatrics, Section of Cardiac Critical Care
University of Alabama at Birmingham
Standardization in Oncology: Quality and Research Hand by Hand
• Most patients enrolled• Meticulous Data
collection• Adjustment of
treatments as new therapies become available
• Comparison with previous protocol
Standardization: CVICU
• High complexity dynamic environment• Multiple decisions per day• Admission can be classified by their surgical
procedure and required similar care most of the time
• Multiple processes are performed in all patients at some point (feeds, ventilator weaning, etc.)
Standardization: Pro
• Simplification of Complex Processes– Time to concentrate on more important decisions
• Allow expert opinion to the bedside efficiently• Training and Retraining• Anticipatory care: all members of the team understand the
process and their role(s)• Detect protocol deviations and allow for corrections• Protocol adjustments and comparisons (QI)• Reduction of practice variation (care should change for the
patient, not the physician)• Research
Standardization: Cons
• “Loss” of physician’s judgment and experience– All patients are different– Decrease practice variation to adapt to the patient
(or is it to adapt to the physician?)• Rigidity
How to approach QI in the CVICU?• Have the Will Power• Tools
– LEAN, Six Sigma, etc.
• Include all the important stakeholders– Especially the frontline clinicians
(Nurse and bedside doctors)
• Use Data to create your guidelines– Internal/External– Evidence Based Medicine
• Have a plan to measure the effects
Quality Improvement in our Unit
• Admission Order Sets (CPOE)• Feeding
– Pre-op Neonatal Feeding guidelines– Feeding guidelines – Swallowing and Aspiration Evaluation
• Potassium Management• Anticoagulation
– General – ECMO
• Postoperative Hemorrhage • Transport Check Off List
Quality Improvement in our Unit cont.
• Resuscitation– Debriefing– Resuscitation Committee evaluation– ASAP’s– RAP
• Respiratory– Intubation “kits”– Ventilator Weaning Protocol– 3 person ETT suction– Tracheostomy Care – Oxygen Management Guidelines
• Cardiac Echo – HLHS pre and postoperative imaging schedule
Quality Improvement in our Unit cont.
• Chylothorax• Laboratory Studies • CVL
– Placement (All US)– Maintenance (Access, dressing changes)
• Sedation weaning• HLHS• ECMO • Transport off Unit Check list
Potassium Replacement Protocol
• IV potassium is considered a high risk medication
• Appropriate threshold for K replacement is not clear in pediatrics
• Enteral potassium is a safe alternative
51464136312621161161
35
30
25
20
15
10
5
0
Nu
mb
er
of
Bo
luse
s
_X=1.68
UCL=5.13
Pre Post
IV Potassium Bolus Pre and Post Intervention
Protocol implementation
Total intravenous KCL doses, n 336 47
Total enteral KCL doses, n 1143 1733
Intravenous KCL doses per 100 patient days, n 17.6 2.5 <0.01
Enteral KCL doses per 100 patient days, n 59.8 92.0 <0.01
Cost of KCL supplementation per patient admission, US dollar
36.23 15.66 <0.01
Total intravenous KCL fluid administration, ml 6226 3451
Total enteral KCL fluid administration, ml 1070 3181
Total KCL fluid supplementation per patient admission, ml
40.5 18.2 <0.01
Abbreviations: KCL, potassium chloride; ml, milliliters; US, United States
Outcomes: Doses, fluid and cost
Before
ProtocolAfter Protocol p value
Episodes of serum potassium >6.0mEq/Lper 100 patient days
1.6 0.6 <0.01
Episodes of serum potassium <3.5mEq/L per 100 patient days
47.9 50.7 0.4
Average morning serum potassium level, mEq/L mean (SD)
3.5 (0.6) 3.4 (0.6) 0.49
Arrhythmias per 100 patient days, n 1.5 1.7 0.34
Abbreviations: SD, standard deviation
Outcomes: Clinical
Laboratory Use
• 2012 CPOE was introduced• Standardization through Order Sets• Recurrent Daily Lab orders entered on admission• Increase use of laboratory studies drive cost up
but does not necessarily increase quality of care• QI project : Decrease laboratory use by changing
Order Sets and asking Health Care Team to evaluate needs for labs each day
241217193169145121977349251
9
8
7
6
5
4
3
2
1
0
Days
lab
dra
ws
_X=2.67
UCL=4.84
LCL=0.50
Baseline New Protocol
Total Lab Draws per Patient Days
X=3.56
Pre-Protocol Post-Protocol
241217193169145121977349251
5
4
3
2
1
0
Days
lab
s d
raw
n
_X=0.809
UCL=1.698
Baseline New Protocol
VBGs drawn per Patient Day
X=1.564
Pre-Protocol Post-Protocol
Blood Product Utilization and Bleeding
• Multidisciplinary Effort– Anesthesia– CV surgery– CVICU
• Data Collection• Primary Drivers and secondary drivers
identified• Leading to Standardization
Total Intubation Times (Median)
1 2 3 40
5
10
15
20
25
30
1211
16
28.5
5
8.37.5
19.2
3.8
6.7 7
17
2012 VWP (Initial) VWP (Overall)
RACHS
Hou
rs
6
60
50
100
150
200
250224
72 72
Postoperative Feeding Protocol Improves Outcomes Following Arterial Switch Operation
Moellinger, A., Torsch, S., Abernathy, S., Borasino, S., Alten, J. 1. Department of Pediatrics, Division of Critical Care, 2. Department of Surgery,
Division of Cardiothoracic Surgery; University of Alabama at Birmingham
HLHS: Norwood/Sano
• Includes Daily Care plan– Standardization of Management and goals of Care
• Hemodynamic Data Collection- Trends• Algorithms
– Hypotension and Hypoxia• Allows for:
– Early recognition of deviation• Team meeting: Cardiologist, Intensivist and
Surgeon
Name____________________ Lesion __________________ Surgery__________________ Date_________________
Norwood Procedure Post Operative Hemodynamic Goals Worksheet
SEND VENOUS GAS FROM in ORDER of PREFERENCE: IJ > UVC > FEMORAL. DRAW ABG and SVO2 and RECORD NON-INVASIVE MEASURES at SAME TIME .
Lactate to be sent every 4 hours until normalized; goal: decreased in half at 12 hours – normal after 24 hours SVO2 should reach its nadir at 6-12 hours post-op
Other Goals for first 72 hours: HgB > 15; temperature 36 to 37 – turn down warmer and give Tylenol for any temp > 37.5; systolic BP 55 – 75; diastolic BP > 35; Heart Rate 120-170; PIP on vent < 35; iCa 1.2 to 1.4
Qp/Qs = (SaO2 – SvO2) / (97 – SaO2) Oxygen Excess Factor = SaO2 / (SaO2 –SvO2)
Hour postop Admit 2 hr 4 hr 6 hr 8 hr 12 16 20 24 30 36 42 48 54 60 66 72 Time
SaO2 (ABG) target 70-80
SvO2 target 45-55
Pulse Ox target 75-85
MAP target 45-55
CVP target 8-12
cNIRS target > 50
rNIRS target > 60
SaO2 – SvO2 target < 25
Qp/Qs target <1.5
Arterial pH 7.35-7.45
PaCO2 target 35-45
Hemoglobin target 14-16
Lactate
Cardiac Arrest
• Debriefing- Standardized Tool• Event Review
– Team of Nurses and Physicians• Resuscitation Committee
– Systems Problems– Education: ASAP (Arrest Summary and Action
Plan)• RAP (Resuscitation Action Plan)
PC4Quality.org
Identify “Real”
Variation
Study High Performers
Identify Practices
Associated with
Performance
Disseminate best practices
Improve quality
PC4: Other Benefits
• Risk adjustment• Outcome Metrics• Real Time Feedback• Opportunities for Knowledge Sharing
– Multicenter QI initiatives