In September, Society of Critical Care Medicine (SCCM) Member Peter J. Pronovost, MD, PhD, began implementation of a $1 million, two-year grant, Statewide Efforts to Improve Care in Intensive Care Units, which aims to improve critical care and patient outcomes in the state of Michigan. The Agency for Healthcare Research and Quality (AHRQ) is funding the statewide initiative with the Michigan Hospital Association (MHA) as the implementation partner. Blue Cross Blue Shield of Michigan has committed a total of $10 million to pay hospitals to participate. As of publication date, approximately 40 hospitals are participating in the project and the program continues to welcome new hospitals.

The program focuses on reporting adverse events, staffing intensive care units (ICUs) with physicians trained in critical care, improving the culture of safety and communication among caregivers, reducing catheter-related bloodstream infections, preventing deep venous thrombosis, controlling blood glucose, and preventing peptic ulcer disease and aspiration pneumonia in mechanically-ventilated patients. “This is a large-scale tactical effort to transform and dramatically improve critical care quality across an entire state. The key is combining evidence-based medicine with quality improvement,” says Dr. Pronovost, associate professor, departments of anesthesiology and critical care, surgery, and health policy and management; and medical director of the Center for Innovations in Quality Patient Care at The Johns Hopkins University School of Medicine in Baltimore, Maryland. “I believe there should be no room left to compete on safety and quality. Instead, those are rights that patients should already have when they are admitted to a hospital. There are quality attributes patients should simply expect.”

Intensive care units were recruited for the study with the help of MHA. A public notice of the program was disseminated to all Michigan hospitals, which provided the opportunity to volunteer and outlined the interventions involved. All types of ICUs are welcome in the program and do not have to function under the intensivist model to participate in the study.

Each site will have a quality and safety oversight team to assure that all interventions are on track. The team will include a senior hospital executive, an ICU nurse or nurse manager and a department administrator. Teams begin with the comprehensive unit-based safety program and each of the other four interventions will be added one at a time, every six months. At the end of two years, every unit will be using all five interventions, with an evaluation at the end. The program process includes:

1. Implement comprehensive unit-based safety program (CUSP), including the ICU safety reporting system (ICUSRS)
Hypothesis: The CUSP with the ICUSRS will lead to measurable improvements in patient safety and safety climate.

2. Implement intervention to improve communication and staffing in ICUs
Hypothesis: The use of targeted interventions will lead to significant improvements in ICU mortality and length of stay.

3. Implement intervention to reduce or eliminate catheter-related bloodstream infections in ICUs.
Hypothesis: This intervention will eliminate or reduce catheter-related bloodstream infections in Michigan ICUs.

4. Implement intervention to improve the care of ventilated patients in ICUs.
Hypothesis: This intervention will eliminate or reduce ventilator-associated pneumonia, duration of mechanical ventilation and ICU length of stay.

5. Implement intervention to reduce ICU mortality.
Hypothesis: Focused intervention can reduce ICU mortality.

6. Evaluate characteristics of ICU teams and senior leaders that are associated with successful improvements in patient outcomes.
Hypothesis: Leadership involvement, dedicated staff time and a physician champion are associated with successful improvement efforts.

The grant team at Johns Hopkins will collect and analyze data from all hospitals involved in the comprehensive unit-based safety program and the ICU safety reporting system. The data collection for the other interventions will be conducted at each individual ICU.

Dr. Pronovost notes that all interventions in the study, which aim to improve safety, communications, bloodstream infections, and ventilator-associated pneumonia, have been demonstrated to make dramatic improvements in more than 50 ICUs. Gains through the intensivist model are also well documented.

“The improvements seen when we have implemented these interventions are truly unprecedented and make us question the relevancy of traditional benchmarks,” says Dr. Pronovost. “We have approximately 10 ICUs that have eliminated or nearly eliminated bloodstream infections. In addition, we have a similar number that have eliminated ventilator-associated pneumonia. Other physicians find this difficult to believe.

“We are seeing that benchmarks are based on broken processes — people not reliably doing what ought to be done. When a system ensures people unfailingly receive the interventions that are known to improve outcomes, performance will be achieved that has never been seen or anticipated. To have that number of ICUs go to zero infections is an historical achievement.”

Social support is an important ingredient of any successful quality improvement effort for general care. State organized improvements such as this project have many advantages. Travel costs are reduced and participants can self-organize and self-support while learning what is working in their environment. Local collaborations are highly successful, according to Dr. Pronovost, and he is an advocate for the expansion of such programs.

“I would like to see this type of collaboration within SCCM at the local chapter level,” he adds. “The grant is posted on the Critical Connections page on the SCCM Web site (www.sccm.org/publications) so members can access tools and interventions to begin local collaborations. Local chapters could use the program outline to refocus their meetings from political to patient-centered issues.”

The grant can also significantly improve the interrelationship between health organizations and the insurance industry. Dr. Pronovost says that when the business case for ICU quality is debated, one of the key realizations is that insurers will benefit financially from reductions in length of stay and complications. This project offers a model for hospitals or hospital groups to request insurers to realign incentives.

To view an excerpt of the grant, click here.