Decreased mortality resulting from a multicomponent intervention in a tertiary care medical intensive care unit

Abstract

Objective To evaluate whether a multicomponent intervention, particularly increasing staff, can achieve reductions in patient mortality in an already high-intensity, Leapfrog-compliant medical intensive care unit. Design Retrospective, observational study. Setting Medical intensive care unit of a tertiary care, academic medical center. Patients A total of 1,263 patients admitted between April 19, 2004 and April 18, 2006 (before the organizational change) were compared with 2,424 patients admitted between September 5, 2006 and September 4, 2008. Interventions A multicomponent intervention including the physical move from a 10-bed to a 29-bed medical intensive care unit with larger patient rooms, the initiation of 24-hr critical care specialist coverage in the medical intensive care unit, an increase in the respiratory therapist:patient ratio, and the addition of a clinical pharmacist to the multidisciplinary team. Measurements and Main Results Measurements were made based on mortality in the intensive care unit and in-hospital. Patient comorbidity as measured by the Charlson score did not change after the intervention (2.7 ± 2.7 vs. 2.8 ± 2.6, p = .62), nor did the acuity of illness as measured by the case mix index (3.0 ± 3.7 vs. 3.1 ± 3.8, p = .69). The unadjusted medical intensive care unit mortality decreased from 18.4% to 14.9% (p = .006), as did in-hospital mortality (from 25.8% to 21.7%, p = .005). The reduction in medical intensive care unit mortality was consistent in the multivariable regression with adjustment for multiple possible confounders (odds ratio = 0.74, 95% confidence interval: 0.61– 0.91, p = .003), as was the reduction in hospital mortality (odds ratio = 0.74, 95% confidence interval: 0.62– 0.88, p = .001). In mechanically ventilated patients, there was an increase in median 28-day ventilator-free days (21, interquartile range 0 –25 vs. 22, interquartile range 0 –26, p = .04). An increase in median medical intensive care unit (2.4, interquartile range 1.1–5.2 vs. 2.7, interquartile range 1.3–5.9), p = .009) but not hospital (8.3, interquartile range 4.1–17.0 vs. 8.2, interquartile range 4.0 –16.8; p = .851) length of stay in days occurred with the intervention. The mean daily dosing of fentanyl and lorazepam decreased after the intervention. Conclusions A multicomponent reorganization of medical intensive care unit services was associated with important reductions in mortality for medical intensive care unit patients, as well as an increased number of ventilator-free days. Substantial and sustained changes in clinically important outcomes may be obtained from organizational changes.

Respiratory Therapy Organizational Changes Are Associated With Increased Respiratory Care Utilization

“…Previous analysis of the MICU patient population pre-and post-intervention showed that the case mix remained stable over the entire period studied. 12 Our study does have certain limitations. Although we found no difference between the 2 groups with regard to illness severity and comorbidities using the Case Mix Index and Charlson score, respectively, and no difference between the 2 groups of mechanically ventilated patients with regard to primary diagnosis, residual confounding may still have occurred, which is possible in quasi-experimental studies.…”

“…These included the implementation of a 24-hour in-house intensivist and the addition of a clinical pharmacist to the care team. 15 It is difficult to isolate their relative contribution to the overall change in resource utilization, though we believe that it was the combination of these that maximized the benefit of the RT intervention.…”

“…15 These changes are shown in Figure 1. The RTs' scope of practice, including the procedures performed, did not change.…”

“…11 In a prior study evaluating this cohort and utilizing the same data, we found that a multi-component reorganization of medical ICU resources, including changes in RT staffing and orientation, was associated with a reduction in mortality and an increase in 28-day ventilator free days. 12 The reorganization of respiratory care services included an increase in the RT/patient ratio, improved RT orientation and education, and the formation of a core staffing model. In assessing potential mechanisms for this improvement in outcomes, we hypothesized that this intervention was associated with increased utilization of best-practice procedures, including spontaneous breathing trials (SBTs) and BALs (bronchoscopic and non-bronchoscopic) in both ventilated and non-ventilated patients in the ICU.…”

Safe, High Quality Care Around the Clock: What will it Take to Get us There?

“…In California, the minimum staffing levels for direct care nurses are mandated and thus must be consistent on weekends and nights, None of the cited studies demonstrating care disparities on nights and weekends were able to correlate outcome differences to staffing levels, whether for nurses or physician providers. [3][4][5][6]9 Pharmacists and therapists have been shown to improve care as part of multidisciplinary care teams, [12][13][14][15][16] though a relationship between ancillary staffing levels and patient outcomes has not been well studied. Other hospital personnel critical to the delivery of care such as radiology technicians may be more lightly staffed on weekends and nights, potentially delaying needed imaging and increasing the length of hospital stay.…”