Introduction

Christiana Care Health System (Wilmington, DE) was selected as a finalist for the inaugural Health Devices Achievement Award, announced in June 2006, for its program to group ventilator-dependent patients who are being cared for outside the intensive care unit (ICU).

The Health Devices Achievement Award recognizes outstanding initiatives undertaken by member healthcare institutions to improve patient safety, reduce costs, or otherwise facilitate better strategic management of health technology. Learn about the other submissions that achieved recognition.

ECRI congratulates the applicants: Dianne Bradtke RN, Michele Campbell RN, Alan Lipschultz PE CCE, Maureen Seckel RN, Gerald O'Brien MD, and Billie Speakman RT. 

Discussion

As part of the organization's Performance Improvement Program, Christiana Care convened an interdisciplinary team to examine whether proactive measures could help the facility prevent ventilator-related injury and death for non-ICU patients. The team—which included nurses, clinical engineers, respiratory therapists, information services specialists, and medical staff—conducted a failure mode and effects analysis (FMEA) to assess the risk associated with response to ventilator alarm system conditions in the non-ICU environment.

As a result of its analysis, the team determined that two potential failure modes—failure to hear an alarm and failure to respond to an alarm—were the most critical to patient safety. The team then designed and implemented risk-reduction strategies to address these failure modes, focusing on technological, human factors, and environmental solutions.

Recognizing the role that technology can play in improving patient safety, the team at Christiana Care evaluated ventilator alarm system technology. The team ultimately selected a ventilator management system that enabled both audible and visual ventilator alarms to be activated at the ventilator and at a central monitor and that allowed the alarms to be communicated (by pager) to both a respiratory therapist and a registered nurse. The applicants from Christiana Care report that the enhanced alarm management system has increased the timeliness of ventilator alarm response, resulting in expedited patient intervention.

In examining human factors issues, the team at Christiana Care recognized that staff competency, education, and training were key contributors in all potential failure modes. To address these issues, the health system designed and implemented several initiatives—for example:

• It updated a clinical practice guideline for the management of ventilator patients.

• It revised job descriptions and annual review requirements for staff who work with ventilated patients to require ventilator management as a critical skill.

• It established baseline skills requirements for agencies approved for supplying temporary staffing.

• It developed a self-learning packet for relevant internal and external caregivers. While valuable individually, these technological and human factors solutions were made more practical and effective by the team's approach to addressing environmental factors.

To minimize the impact of environmental factors on patient care, the health system implemented a program whereby patients requiring ventilator assistance are grouped into a designated care unit. This program involved redesigning the process for assigning beds upon admission and during the episode of care. With this program, newly admitted patients with pulmonary-related diagnoses requiring ventilator assistance are assigned to one designated unit in each of Christiana Care's two facilities. Similarly, patients requiring ventilatory support outside the ICU during the episode of care are transferred to this designated unit.

According to our members at Christiana Care, this grouping—or "cohorting"—process yielded several benefits:

• It allowed enhanced ventilator technology to be implemented in a cost-effective fashion.

• It established the infrastructure necessary to support the team's human factors risk-reduction strategies.

• As a result of the more focused staffing approach, it enhanced the competency levels of the nursing and respiratory therapy staff assigned to care for patients requiring ventilator assistance, while significantly reducing annual training expenditures. For example: Rather than providing 1,200 staff nurses with the requisite orientation and training for mastery of this critical skill, as would have been required prior to the redesign, the health system now has a total of 106 skilled staff nurses who provide care in the designated units. These specialized caregivers are highly proficient at caring for ventilator-dependent patients and can therefore most effectively ensure the patient's safety. Follow-up surveys conducted by the health system show that staff feel personally more confident in their ventilator skills.

Now, every Christiana Care patient with a pulmonary-related diagnosis requiring ventilator assistance is cared for in a specialized unit by highly trained experts and monitored by technology that alarms in the patient room and at a central station and also pages key members of the care team. The facility reports that it has found that this approach ensures exceptional care and safety for ventilator-dependent patients outside the ICU environment.

As an example, our members at Christiana Care related an anecdote about "Mrs. P"—an 89-year-old woman who was suffering from ventilator-associated pneumonia and multiple medical problems at a neighboring hospital. Mrs. P was transferred to Christiana Care for ventilator management, and within 10 days had undergone a tracheostomy. Four days after that procedure, she was transferred to the designated non-ICU care area for ventilator patients at Christiana Care. Although she remained on a ventilator until her discharge five months later to an extended-care facility, Mrs. P remained outside the ICU environment. She enjoyed daily visits from her 92-year-old husband while still having her care needs met by her respiratory therapist and the nursing staff. Mrs. P and her family felt she was safe and well cared for throughout her stay, despite her being outside the ICU.

In their submission to ECRI, the applicants from Christiana Care reported that since the project's completion and the implementation of the recommended environmental, technological, and human factors improvements, the facility had experienced no patient events related to the failure to respond to ventilator alarms.