Deep Vein Thrombosis and Stress Ulcer Prevention in the SCH Critical Care Units

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Deep Vein Thrombosis and Stress Ulcer Prevention
in the SCH Critical Care Units
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St. Cloud Hospital background

• Community hospital
• 2 units that are med/surg/cardiac
• Cardiovascular surgery program
• Strong hospitalist program
• New Intensivist program
• CNS
• Pharmacists present in the unit
• Strong administrative support

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Preface to change

• Every great idea is always brought forth by a
  heretic
• Everybody wants things to get better but nobody
  wants things to change
• Life is a process with grace and patience being
  good things

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Assumptions

• All patients on mechanical ventilation need
• Stress ulcer prophylaxis
• Deep vein thrombosis prophylaxis
• HOB 30 degrees unless contraindicated
• Sedation vacation
• Tight glucose control

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SCH Process

• A multidiscipline committee was gathered to hear
  the new paradigm for care.
• Introduction of bundle methodology was part of
  many changes associated with the new
  Intensivist-directed ICU program.
• CNS, MD, charge RNs, staff RN, Pharm, RT and MD
  extender RN
• Met weekly

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SCH Process for Bundles

• Define quality
• Processes e.g. stress ulcer prophylaxis (leading
  
• 
  data)
• Outcome e.g. GI bleeds (trailing data)

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SCH Process

• Measure ourselves
• a) 30 charts
• b) simple yes/no tool

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SCH Process

• The committee determined a standard treatment
  that everyone could live with
• a) what drug
• b) contraindications

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SCH Process

• Tried to build in independent redundancy
• a) This is the difference between a protocol
• and bundle methodology in our
  hospital
• b) This was/is the biggest area of push-back

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SCH Process

• Asked of input from all stakeholders
• Educated staff
• Trialed them
• Looked at the data
• The medical staff executive committee made them
  mandatory
• tweaked them

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Barriers

• Were already a great unit
• Getting together to meet
• more work push back this and my regular
  work
• The doctor passing the work and risk on to the
  nurse and/or pharmacy
• EMR compliance concern
• data

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What helped us

• Having a culture of multidiscipline trust and
  enjoyment
• Empowering everyone (e.g. social workers,
  dieticians etc) to look for the same thing
• Multidiscipline rounds
• Publishing the data
• Bullet points rather than check boxes
• Having a CNS
• IHI, VHA, SCCM publications/resources
• Being open minded rather than controlling

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What we would do differently next time..

• Post the data more clearly, more often, more
  places
• Educate, educate, educate ongoing
• Think big, act small.many changes at once is
  difficult
• Bedside instead of chart audit
• Try to standardize all groups pre-printed orders