Friday, September 17, 2010

Keeping the Success Going

It is not easy to change our way of doing things, to go from no particular approach to treating severe sepsis, for example, to actually adopting a stance and systematically giving every patient the best shot of survival that is available to them and to us.  As difficult as it is to make some changes and to see some successes, it is even more arduous to continue the changes we've made and the successes we've had.

At the University of Kansas Hospital, where I work, we had some success in the past 2 to 3 years in reducing our rates of nosocomial urinary tract infection.  By instituting some changes in Foley catheter maintenance, we had driven the rate down to well below one infection per thousand catheter days.  Yet, in the most recent two quarters our rates have risen again, almost to pre-intervention levels.  Simply put, we did not sustain the measures that we had put in place to drive the infection rate down.  We are looking now to determine why the measures fell by the wayside; we are analyzing what factors may have impeded our ability to keep doing them routinely.

This problem illustrates a couple of things about sustaining change, though.  The first, which we have done an OK job of, is that if an outcome is important you must track it.  We must not assume that the measures we took continue to be at play, nor that the outcome we desire continues to be present.  The second is that the outcome has to be apparent to all the right people.  If we at KU have made a mistake to this point, I believe that it lies in not keeping bedside nurses sufficiently informed of a) the tremendous job they did in making a change and saving patients from UTI and possible severe sepsis and b) the fact that we began to lose ground.  If we do not know whether our actions are making a difference, it is difficult for us to do anything that may slow us down.  On the other hand, the pride of knowing that even some things that seem small are making a difference, can often sustain our efforts, especially at those seemingly little things.

Two years ago, we explored in the MWCCC mechanisms for preventing nosocomial UTI, and I know that several of our member hospitals were successful in reducing their rates of infection.  I have two questions for those of you who have been successful.  Have you been able to sustain your changes?  How have you done it?  If it's because you have a simple protocol or standard operating procedure, please share it with us.

This time, it's my hospital.  Next time, it could be yours, in one area or another of critical care.  Remember, the MWCCC is here to help all of us get  the best achievable outcomes all the time.  Please talk about it here, and if you have documents to upload for sharing, send them to me at sqsimpson@mwcritcare.org. I will post them to the MWCCC web site.

Friday, September 3, 2010

Helping Us Help Our Hospitals

We all spend a fair amount of time recognizing and treating severe sepsis.  One thing we can do for our hospitals is to make sure that we allow them to code appropriately for the patients we care for.  Here is a story that illustrates a) how hospital coders should look out for our diagnoses and b) how we can help them.  We must not lose sight of the fact that coders can only code for what we write in the charts.  If we help our hospitals to recover adequate reimbursement for what we're doing, we'll be able to do it for a lot more people.  Notice in this story that when the physician diagnoses "urosepsis"  it is coded (and must be coded) as a simple urinary tract infection, when the actual circumstance is that this is severe sepsis with acute organ failure resulting from a urinary tract source.  This is a common mistake that physicians make, costing hospitals tens of thousands of dollars over the course of a year.  We're all in this boat together, so we should make the ride as easy for one another as we can.  It doesn't take any longer to document the correct complex diagnosis than it does to document the simple one.

Tuesday, January 12, 2010

How We Incorporate Evidence Into Our Practice

I'm participating in a multisociety task force (ACCP, SCCM, ATS) to develop an approach or a guide to how to incorporate clinical evidence into clinical practice.  The task force met yesterday at the SCCM.  Part of the impetus for the group is the cantankerous point/counterpoint sort of presentations that seem to be occurring with some regularity at national meetings.  Such debates you may have seen over the use of drotrecogin alpha, the use of steroids, degree of glucose control, Hgb administration in severe sepsis, and the list goes on.  One of the things that we are addressing is our current approach to incorporating evidence, with discussion about whether, indeed, placebo-controlled, double-blind, randomized trials trump all other forms of evidence.  We approach the question of when clinical, i.e. physiologic evidence should guide a person to step outside of guidelines, or whether that is ever the case.  We talk about when retrospective evidence is adequate and when it is not.  When we should standardize and when we should not.  And I hope I have convinced others that regardless of how that choice is or was made, that outcomes must be followed, so that we can adjust our care. All of us in the collaborative face decisions every day about what evidence to follow and when and how to do so.  I hope this document and the sessions at various society meetings that will follow will make for some practical help to make those decisions.  

Monday, January 11, 2010

At the SCCM

I'm at the SCCM meeting for a few days.  Yesterday I gave a talk called "Strategies for 24-hour Coverage of Rural ICUs".  I used Kansas as a paradigm for rural states.  Did you know that approximately 51% of our population lies outside the counties of Sedgwick, Shawnee, Wyandotte, and Johnson.  That's of interest, because according to the census bureau only one in four Americans lives in a rural area.  I did a quick poll at the beginning of the talk to see how many people in the room had grown up in a town of 25,000 or smaller.  In keeping with national census data, about 25 % of the room raised their hands.  I then asked how many people (critical care specialists) live or work in towns of that size today.  Far fewer hands.  Statistics show that 10% of physicians live or work in rural areas, vs. 25% of the population liiving there.  Of the critical care physicians in our state, my count shows about 10% outside of the major metropolitan counties, though the number fluctuates over time.  One can easily see that the possibilities for 24-hour intensivist coverage are limited.  I'm planning to do this talk for our meeting on January 14, so that we can discuss our options and what we're already doing to ensure that midwesterners all receive the highest quality critical care services.



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