Reducing Unnecessary Invasive Device Days in a Community ICU with a Physician Daily Note and Daily Multidisciplinary Rounds

Background:

Health care‐acquired infections (HAIs) represent a far too common risk and cost of hospitalization. Urinary catheter‐associated urinary tract infection is the most common cause of HAIs, with prolonged catheter use conferring a relative risk of 5.1‐6.8. Ventilator‐associated pneumonia (VAP) is the leading cause of death among patients with HAIs with an attributable mortality as high as 30%. An estimated 250,000 cases of central line‐associated bloodstream infection occur annually, with an attributable mortality of 18% and a marginal cost of $25,000 per episode.

We theorized that quality improvement strategies that systematically improve situational awareness of existing invasive devices and their ongoing indications could hasten removal of those devices and comply with CDC recommendations for prompt removal of unnecessary devices to reduce HAIs.

Methods:

We conducted a before‐after study of a standardized daily note in a community hospital ICU. The note was carefully blended into the work flow, permitted mass customization, and prompted documentation of catheter and endotracheal tube days. Concurrently we introduced daily multidisciplinary ICU rounds that were structured around a daily goals sheet to prompt review of the care plan and the ongoing need for invasive devices.

Baseline data were collected from January 20 to March 2, 2006, and postintervention data were collected from March 3 to April 8. Variables included ICU length of stay (LOS) and the process measure of number of days of exposure to each invasive device. Proportions were compared using the chi‐square test, and continuous variables were compared with the Wilcoxon rank sum test.

Results:

A total of 113 consecutive ICU admissions in the preintervention group and 115 in the postintervention group were analyzed. Results of an interim analysis of 61% of the patients are presented. Age, diagnosis, and status as an admission or consult were analyzed; there was no significant difference between the patients admitted before and after the intervention. After the intervention, median ICU LOS was reduced from 1.87 to 1.47 days (P = .24). Foley catheter days were reduced from 4.30 to 2.64 (P = .12). Central line days were reduced from 5.80 to 2.91 (P = .04). Ventilator days were reduced from 1.56 to 1.38 (P = .82). This occurred despite an increase in the total census managed by the service during the study period.

Conclusions:

Implementation of a standardized ICU daily note with prompts to record device days, combined with ICU daily rounds, reduced ICU LOS and device days in a community ICU. Only the decrease in central line days reached statistical significance at the interim analysis. This composite of quality improvement strategies—a provider reminder plus organizational change—appears to be effective in triggering at least 2 useful mechanisms: enhanced situational awareness and person‐to‐person accountability at a key moment of medical decision making.

Author Disclosure:

S. G. Chernetsky Tejedor, None; J. Stein, Society of Hospital Medicine, consulting fees or other remuneration (payment); sanofi‐aventis, consulting fees or other remuneration (payment); M. V. Williams, Society of Hospital Medicine, consulting fees or other remuneration (payment); Journal of Hospital Medicine, employment (full‐ or part‐time).