Long Term Outcomes of Critical Care

Those of you who regularly attend our monthly meetings or who view them after they are posted online will realize that the Midwest Critical Care Collaborative will be working on improving our long term critical care survival and outcomes, and not just hospital survival.  To that end, we have developed a wiki for members to post their best practices.  All MWCCC members will be invited to post.  Remember that the wiki is not a bulletin board or a forum, i.e. it is not for asking questions about mechanics of how to do something, but rather a posting of best practices that individual members are using to achieve better outcomes. Jana Braklow and I will be moderating, so as to edit entries that are not evidence based or in the right format.  We ask that you include references for your best practice, if they are available. However, we also recognize that some of you will have innovations on your own that have proven helpful; if that's what you're posting, please let others know.  Good writing! And good luck with your outcomes.

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.

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.

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.  

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.

H1N1 - How We Can Help

I've been asleep at the wheel, and I'll be the first to admit it. In a conversation with Elizabeth Cowboy this week, she pointed out that an ideal use of our critical care collaborative would be to track cases of H1N1 influenza in our ICUs. Those of us who participate in the Midwest Critical Care Collaborative represent the lion's share of ICU beds in the state of Kansas and in several metropolitan areas, including Wichita, Topeka, Kansas City, and Lincoln. We are in an ideal position to volunteer information of use to officials at the state, county, and regional levels as they and we respond to the growing epidemic. Some of us have been involved at the state and local levels, preparing ourselves for a surge in requirements for ventilators and ICU beds, all the while wondering when and if such a surge would hit and wondering how we would actually know when it did. This is a mechanism whereby we can help ourselves.

I have set up a web-based form to track the important information. The form will ask about 4 types of patients: confirmed H1N1, likely H1N1 not yet confirmed, seasonal influenza, and post-influenza pneumonia. We will assess how many of these sorts of patients are in our ICUs and how many of them are ventilated. We would like to collect this information weekly, by 5 PM Wednesday for the next 8 or 10 months, or until the epidemic has ultimately dissipated. The information will be shared with state and county epidemiologists on a hospital by hospital basis, and published on our web site by region or county. As of now, we have not planned to track deaths, but that is possible, if collaborative members desire it.

My plan is to send reminder emails every week, to collate what comes in by Wednesday, and to have current information posted by Thursday of every week on the mwcritcare web site. The reporting form is live now, and we are ready to rock and roll. Follow the links on the web site (www.mwcritcare.org) to find the active form.

It may be that government officials are coming by this information in another way, but it seems to me that having the info available at least helps us to achieve our goal of helping one another to reach the highest possible quality of critical care for our patients. In this case, if some of the more dire predictions come to fruition, the highest achievable quality could literally mean that more midwesterners survive, because we help each other.

The survey form doesn't ask for a lot of information, and it should be easily completed by almost anyone. Member hospitals may want to ask one person to do it every week. If we get surveys from more than one person at any hospital, we'll probably send emails to the individuals to determine which data to use (unless they are identical). The first questions in the survey ask about numbers of ICU beds and numbers of ventilators in your hospital. Those likely will not change a lot over time.

If you receive my periodic emails, then your hospital is included. Please consider getting together with your colleagues to provide the information every week. Some of you monitor ICU beds at other hospitals; please consider either providing their information or working with people in those hospitals to get them plugged in to the collaborative and providing their own information. If you have colleagues at hospitals that you don't see listed on the mwcritcare web site, please ask them to get involved.

The data collection form is at our web site, www.mwcritcare.org. Look for page links at the bottom of the home page and follow the H1N1 link. If anyone has questions, post them to this blog or contact me at sqsimpson@mwcritcare.org.

What a Mistake!

I've been concerned for awhile that no one in the collaborative had any responses to our blog posting. I fretted over why no one cared about the topic. Until this afternoon. I discovered that I had set up the comments so that only "registered" users could comment. And I had not set up a way to register. So my post sat here contemplating its navel for 3 weeks, hoping that someone had read it. I don't know whether to have any higher hopes for this one, as in it may be literally true that no one is reading - but there's only one way to find out! Happy commenting, and please comment on the last post, as well, if you have any ideas.