Enhancing Outcomes in a Surgical Intensive Care Unit by Implementing Daily Goals Tools

Peggy Siegele
Crit Care Nurse 2009;29:58-69 doi: 10.4037/ccn2009663
2009 American Association of Critical-Care Nurses Published online http://www.cconline.org Personal use only. For copyright permission information: http://ccn.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT

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Critical Care Nurse is the official peer-reviewed clinical journal of the American Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright 2009 by AACN. All rights reserved.

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Management

Enhancing Outcomes in a Surgical Intensive Care Unit by Implementing Daily Goals Tools
Peggy Siegele, RN, BSN, CCRN, TNS

PRIME POINTS

requires strategic communication to address and meet common goals for patient care.

Successful teamwork

Our Daily Goals Tool includes a focus on developing multidisciplinary patient-centered goals, improving and facilitating communication, and avoiding fragmentation of care.
of the tools was fostering communication between the team and the family, including the familys presence during end-oflife care.

The greatest strength

edical errors and patient safety remain prime concerns in health care.1 The sometimes hazardous environment of the intensive care unit (ICU) may be due to an increased prevalence of chronic diseases, higher patient acuity, and advances in technology and pharmaceutical agents.2 Potential fragmentation of care because of multiple specialty providers increases these concerns.3 Some experts4 think the greatest potential for harm stems from a combination of factors such as system failures, faulty processes, poor teamwork, and communication breakdown. In this article, I discuss enhancing patient safety and outcomes in a surgical ICU (SICU) by using a quality improvement tool to increase communication and teamwork. I further describe the effects of these tools on 6 outcome measures
2009 American Association of CriticalCare Nurses doi: 10.4037/ccn2009663

evaluated for 1 year before use of the tools and for the subsequent 212 years. A case study of a critically ill patient exemplifies use of the tools.

Safety, Communication, and Teamwork

The relationship between safety and communication has been recognized for some time. Strong teamwork and effective communication between nurses, physicians, and personnel from other disciplines have been associated with improved outcomes such as decreased lengths of stay and reduced mortality rates.5 However, health care providers occasionally do not recognize that effective communication is crucial to create teams that foster safe environments. Reviews of critical incidents indicate that poor communication is a major contributing factor.5 The annual report on quality and safety by the Joint Commission6 has consistently indicated inadequate communication between care providers or between care providers and patients and patients families as the root cause in sentinel events.

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Communication challenges between nurses and physicians and a culture of physician hierarchy still persist at times in daily practice. Donchin and colleagues7 found that communication between nurses and physicians occurred in only 2% of all activities performed in an ICU yet were associated with a third of identified errors. In addition, in another study8 in an ICU, physicians regarded the quality of the teamwork more positively than nurses did. This disconnect may be due to different perceptions of teamwork and diverse professional focuses between the disciplines.4 At times, the priorities of each discipline differ, and both physicians and nurses sometimes do not realize that their relationship is interdependent.4 Therefore, successful teamwork requires strategic communication to address and meet common goals for patient care. The aviation industry is also faced with communication and teamwork challenges. Members of that industry recognize that error is inevitable in human performance. One method used in aviation to enhance safety is training in crew resource management. These training programs simultaneously support assertiveness training for junior associates and encourage modification of traditional hierarchal behaviors in leaders that focus on individual preferences.9

Formal teamwork training focuses on 7 skills: situation awareness, adaptability and flexibility, leadership, communication, decision making, assertiveness, and mission analysis.10 Additional tactics include simplifying complex tasks by using checklists and redundancies, taking proactive measures to prevent mistakes, promoting visibility of errors before harm occurs, and developing strategies for managing error.8 Similar to aviation, health care is a high-risk environment, often has a distinct hierarchy, requires the performance of complex tasks, and includes use of advanced technology. Unfortunately, health care has lagged behind other high-risk industries in using tools of improvement. Health care providers are just beginning to prioritize communication and teamwork as essential elements for success. Tools such as the Daily Goals Tools and other redundant processes can help in simplifying complex tasks, improving teamwork, promoting effective communication and shared decision making, and enhancing patient safety, particularly in high-risk environments such as the ICU.8

Rationale for Development of the Daily Goals Tool/ Daily Goals Tool Reference
The SICU at Advocate Lutheran General Hospital (Park Ridge, Illinois)

Author
Peggy Siegele is a critical care educator at Advocate Lutheran General Hospital in Park Ridge, Illinois. She has more than 20 years of critical care experience and is currently in graduate school for a masters degree in nursing.
Corresponding author: Peggy Siegele, RN, BSN, CCRN, TNS, Advocate Lutheran General Hospital, 1775 Dempster Rd., 4T 4107, Park Ridge, IL 60068 (e-mail: Peggy.Siegele@advocatehealth.com). To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

is an open unit with a diverse population of patients. Multiple physicians, including hospitalists, intensivists, cardiologists, general surgeons, trauma surgeons, cardiovascular surgeons, nephrologists, orthopedists, pulmonologists, neurologists, neurosurgeons, and internists, contribute to the care of the patients. Nurses often must deal with multiple orders from several services that require clarification, coordination, and discussion among the services. An example is use of a potassium protocol. The protocol enables nurses to replace and monitor potassium as needed, including as indicated by the results of laboratory tests of samples obtained at 4 AM. A resident reviewing the results of laboratory tests places an order for a one-time potassium phosphate infusion via computer data entry. An internal medicine attending physician then comes in to see the patient. The physician is not aware of the potassium protocol, does not see the order placed in the computer by the resident, and also orders a one-time potassium phosphate infusion. Fortunately, the only replacement the patient receives is the one indicated by the potassium protocol because personnel in nursing and the pharmacy telephoned the resident and the attending physician about the problem. Simple communication measures could eliminate this potential serious error. Personnel in multiple services also place orders for computed tomography, magnetic resonance imaging, and special procedures. A formal communication tool can assist in the coordination of multiple tests and reduce the amount of time

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and resources needed to provide care. Most importantly, use of the tool can decrease the stress experienced by patients who are taken from their room for tests several times a day. Finally, nurses are often involved in promoting conversations between patients families and the patients physicians. When a patient or the patients family asks when a fracture will be repaired or an abdominal closure performed, nurses are often the health care providers who facilitate these conversations with the consulting services.

Daily Goals Tool and Daily Goals Tool Reference

In 2003, the results of a prospective cohort study conducted collaboratively by the Volunteer Hospital Association, the Institute for Healthcare Improvement, and Johns Hopkins Hospital on use of a daily goals worksheet were published.11 Their Daily Goals Worksheet focused on the care teams understanding of the patients needs, empowering nurses, increasing nursing morale, avoiding duplicate work, and facilitating explicit communication. In 2005, the Daily Goals Tool (DGT; Table 1) and Daily Goals Tool Reference (DGTR; Table 2) were developed and customized for the SICU at Advocate Lutheran General Hospital. The purposes of these tools are similar to the purpose of the Daily Goals Worksheet, but the tools include an additional focus on developing multidisciplinary patient- centered goals, improving communication, fostering collaboration and coordination of care between all disciplines, avoiding fragmentation of care, facilitating

daily communication between patients, patients families, and care providers, and ultimately enhancing patient safety and improving patient outcomes. The DGT facilitates a comprehensive daily review of 12 major aspects of care and provides a framework for evidence-based practices. Several key questions are given for each aspect of care, and space is provided for up to 7 days information on a single sheet. A challenge recognized during development of the DGT was the diverse population of patients cared for in the SICU. The original Daily Goals Worksheet was developed for a small specialty ICU; thus, the DGT had to be adapted to address the needs of the patients in the SICU. The DGTR helps care providers determine the specific needs of diverse patients with wide age ranges and multiple preexisting medical problems. The tool provides greater detail on each of the 12 aspects of care and is aligned with the DGT for an all-inclusive review. The DGTR was laminated and put on individual nurses clipboards along with the DGT. Use of the tools was implemented in January 2006.

Education
Comprehensive education was provided on the goals and use of the DGT and the DGTR in December of 2005, before use of the tools began. The education included information on evidence-based practices, care based on use of a protocol, and the concept of bundles. Bundles were defined as groupings of evidencebased best practices that, when completed, result in improved patient outcomes.12 Additional instruction integrated the components of the

ventilator bundle (Table 3), the central catheter bundle (Table 4), and the Surgical Care Improvement Project (SCIP) bundle (Table 5). Providers also reviewed the processes needed to eliminate or reduce incidences of ventilator-associated pneumonia (VAP), central catheter infections, and surgical site infections. Nurses were additionally taught about sedation vacation or providing patients a daily break from sedation (unless contraindicated) and assessing patients readiness to be extubated. Regular interruptions in sedation can markedly reduce the duration of mechanical ventilation and the ICU length of stay.15 In addition, the simple practice of elevating the head of the bed greater than 30 can decrease the risk of VAP.16 Nurses learned that SCIP is a partnership of organizations that focus on reducing surgical complications and improving surgical care and they learned what components are included in the SCIP bundle. Finally, the importance of completing all measures in the bundles was stressed. Education was completed at the end of December 2005, and use of the tools was implemented in early January 2006 during daily rounds.

Using the DGT and the DGTR

The DGT and DGTR encompass 12 major aspects of care.
Safety and Transfer

The first aspect on the DGT is safety and transfer and prompts the health care team to determine each patients greatest safety issue. The DGT further addresses what must happen for the patients

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Table 1
Goals

Daily Goals Toola

Initials/Date

1. Safety/Transfer What is the patients greatest safety need? What needs to be done for patient to transfer? 2. Pulmonary/Ventilator/Sedation HOB up 30-45 degrees? Sedation Vacation? DVT/PUD prophylaxis? Venous Dopplers? IVC Filter? Assessment of readiness to extubate Eye protection? Date to tracheostomy? 3. Lab/X-rays/Tests/Procedure results What does chest x-ray or other tests show? Glycemic control/Diabetic protocol? Lab results reviewed? Tests needed? 4. Neurological/Pain management Acute head injury/Intracranial pressure orders? CT scan results? Neurological assessment? Cervical spine cleared? 5. Rhythm/Hemodynamics/Oxygen transport calculations/Medications Drips? Weaning? Hemodynamic parameters? Ideal pulmonary capillary wedge pressure? Cardiac output? What medications can be discontinued? Beta-blockers resumed/order? 6.Volume status Low urine output? Base deficit? Fluid bolus? 7. Parameters/Physician notification/Consultations Vital signs? Hemodynamic parameters? Status of care from consultations? 8. Gastrointestinal/Nutrition/Bowel regimen Parenteral/enteral nutrition? Tube feeding goal? Residuals? Bowel sounds? Distended? 9. ID/Cultures Consult? Febrile? Cultured? Methicillin-resistant Staphylococcus aureus (MRSA) screening? Results? Normothermia achieved? 10. Central/Arterial/PIC line Need? Insertion date? PIC? Discontinue/femoral lines out? Appearance of sites? 11. Skin/Wounds/Mobilization Skin integrity? Pressure reduction mattress? 12. Code status/Family Addressed? Family updated on plan of care?
* 9 1 1 1 7 2 *

ADULT ICU DAILY GOALS TOOL

Patient Label

91-1172

11/08

Not part of the medical record

2008 Advocate Health Care

Abbreviations: CT, computed tomography; DVT, deep vein thrombosis; HOB, head of bed; ID, infectious disease; IVC, inferior vena cava; Lab, laboratory; PIC, peripherally inserted catheter; PUD, peptic ulcer disease. a Reprinted with permission of Advocate Lutheran General Hospital, Park Ridge, Illinois.

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Table 2

Daily Goals Tool Referencea,b

1. Safety/Transfer Fall risk? Self-extubation? Dangerously agitated? Restraints? Order current? To where would transfer be anticipated? Sitter? 2. Pulmonary/Ventilation/Sedation Pulmonary secretions? Amount? PaO2/FIO2 (PF) ratio? Acceptable respiratory rate and oxygen saturation? Ventilator pathway orders? Rotation? If head-of-bed elevation is contraindicated, is it documented? Reverse Trendelenberg? (remember that is only 15 degrees) Wean sedation? Discontinue neuromuscular blockade? 3. Labs/X-rays/Tests/Procedure Results Electrolyte replacement? What labs are not needed anymore? Drug level results? Pentobarbital level? Dilantin level? What additional tests need to be ordered? Echocardiogram? Special procedures? 4. Neurological/Pain Management Next CT scan? MRI? Intracranial pressure? Under control? Methylprednisone drip? Aspen collar in place? Following commands? Pain control? Epidural? Patient-controlled analgesia? 5. Cardiac Rhythm/Hemodynamics/Oxygen Transport Calculations/Medications Review results of hemodynamic and oxygen transport calculations? Frequency? Parameters? Goal? Ideal pulmonary artery diastolic pressure? New medications? 6. Volume Status 24-hour fluid balance? Blood urea nitrogen/creatinine? Hydration? Diuresis? Total IV fluid rate? Total number of fluid boluses? 7. Parameters/or Physician Notification/Consultations? Additional consults (orthopedics, infectious disease, critical care) notified? 8. Gastrointestinal/Nutrition/Bowel Regimen Abdominal assessment? Bowel movement? G-tube? Diarrhea? Clostridium difficile? Ostomy color? Ostomy nurse notified? (ext. 8815) 9. Infectious Disease (ID)/Cultures Notified of abnormal culture results? Antibiotic levels? Peak and trough? Isolation? Antibiotics completed within 24 hours for surgical patients and 48 hours for cardiac surgery patients? 10. Central Lines/Arterial lines/Catheters/Peripherally Inserted Catheter (PIC) Central line bundle sheet completed with new insertion? 11. Skin Care/Wounds/Mobilization Braden scale? Decubitus? Wound consult? Wound vacutainer? Chair? Cardiac chair? Physical therapy/occupational therapy? Foot drop prevention? Special care beds? Rotating bed? 12. Code Status/Family Advanced directives? Care conference needed? Translation needed? Social services notified? Psychologist? Substance abuse? Central access? Pastoral care?
Abbreviations: CT, computed tomography; FIO2, fraction of inspired oxygen; G-tube, gastrostomy tube; ID, infectious disease; IV, intravenous; MRI, magnetic resonance imaging; PF, ratio of PaO2 to FIO2; PIC, peripherally inserted catheter, a Reprinted with permission of Advocate Lutheran General Hospital, Park Ridge, Illinois. b The Daily Goals Tool Reference provides greater detail on the 12 aspects of care and is aligned with the Daily Goals Tool for an all-inclusive review.

venous Doppler imaging for surveillance and reviews the need for anticoagulation. This part of the tool also helps in identifying the need for an inferior vena cava filter for patients who cannot be given anticoagulants. Daily assessment of when to consider a tracheostomy is also reviewed. Inclusion of the ratio of arterial oxygen pressure to fraction of inspired oxygen on the DGTR reinforces the potential need for early kinetic therapy.
Results of Laboratory Tests, Radiographs, and Procedures

The third aspect of the DGT incorporates the review of the results of laboratory tests, radiographs, and other studies such as computed tomography and magnetic resonance imaging. The health care team focuses on the results of these studies and other tests and procedures. Additional orders or the need to discontinue unnecessary orders is further reviewed. Glycemic management is incorporated in the review of laboratory results.
Neurological and Pain Management

progress and transfer out of the SICU. An example of this aspect is the collaborative development of a plan to prevent a severely agitated patient from self-harm.

Pulmonary, Ventilator, and Sedation

The second aspect reviews the components of the ventilator bundle. The DGT elaborates on using

The aspect on neurological and pain management includes completion of the standing orders for acute brain injury/intracranial pressure in adults. This aspect also addresses cervical spine clearance with the trauma service. The health team further assesses each patients current neurological status and the recommendations from the consulting service. Pain control is also evaluated. The potential need for pentobarbital coma is addressed in the DGTR. Although pentobarbital coma is not used often, it is part of the treatment of patients with refractory intracranial hypertension.

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Table 3

Key elements of the ventilator bundlea

1. Elevation of the head of bed 30 or more 2. Daily assessment of readiness to extubate 3. Sedation vacation 4. Peptic ulcer prophylaxis 5. Deep vein thrombosis prophylaxis
a

Based on data from Winters and Dorman.13

Table 4

Key elements of the central catheter bundlea

1. Optimal central catheter site selection with Subclavian as the first choice Internal jugular as the second choice Use of the femoral site strongly discouraged 2. Use of chlorhexidene prep 3. Masks for all in the room during insertion 4. A checklist to ensure compliance
a

transport calculations. Again, although the calculations are not performed for many patients, in some clinical situations, assessment of oxygen delivery and consumption is imperative.
Volume Status

parameters; use of -blockers is resumed or initiated if appropriate per the SCIP bundle. Hemodynamic parameters are clearly established and communicated to eliminate confusion about notification of abnormalities to the managing service. The care team examines care from all the services and focuses on streamlining coordination of tests and procedures ordered by all consultants. In addition, the team appraises the need for additional consultations.
Gastrointestinal Assessment, Nutrition, and Bowel Regimen

Based on data from Winters and Dorman.

13

Volume status affects many surgical Table 5 Key elements of the Surgical Care Improvement Project bundlea patients. Consequently, 1. Administration of antibiotic within 1 hour of surgery the number (2 hours for vancomycin) of fluid 2. Discontinuation of antibiotics within 24 hours of surgery (48 hours for cardiac surgery) boluses, base 3. Establishment of normothermia for colorectal patients on deficit, 24admission to intensive care unit hour intake 4. Postoperative glucose control for cardiac surgery patients and output, 5. Prophylaxis of venous thromboembolism and filling 6. Resumption of -blockers for patients receiving them pressures are preoperatively carefully a Based on data from Springer. examined. The team determines if Cardiac Rhythm, Hemodynamic the current rate of administration Status, Oxygen Transport of intravenous fluids is adequate or Calculations, and Medications if diuresis may be needed. The fifth aspect includes cardiac rhythm, hemodynamic status, oxyParameters, Physician Notification, gen transport calculations, and and Consultations medications. The team determines The aspect of care concerned if any issues or problems exist, with parameters, notification of a including the need to insert a pulphysician, and need for consultations monary artery catheter or remove provides a comprehensive review one that is no longer needed. The of vital signs and hemodynamic DGTR calls for a review of oxygen
14

Gastrointestinal assessment and nutrition are addressed next. Early initiation of enteral feedings (24-72 hours) is ordered as appropriate, and nutritional needs are determined by the nutritionist. The health care team reviews the potential need for placement of a gastrostomy tube. The nurses ensure that the enterostomy nurse is notified for patients with new ostomies and that appropriate diet orders are written for patients who are ready to resume oral intake.
Infectious Diseases and Cultures

For the infectious disease aspect, for each patient with an infectious disease, the team assesses the patients 24-hour temperature maximum, treatment, potential causes of infection, and results of cultures of specimens. Need for an infectious disease consultation is determined. In addition, the team evaluates antibiotic levels, isolation status, and screening for methicillin-resistant Staphylococcus aureus. Assurance of appropriate completion of antibiotic treatment within 24 hours is determined, along with establishment of normothermia per the SCIP bundle.

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Central, Arterial, and Peripheral Catheters

The Patient and the Patients Family

During review of central and arterial catheters, the team analyzes the length of time since an original catheter has been inserted and the appearance of the site of insertion. Changing the site or arranging for placement of a peripherally inserted catheter is determined, along with the need for an arterial catheter. Any unnecessary catheters are removed.
Skin Care, Wound Care, and Mobilization

The health care team addresses any skin care issues and ensures that orders are obtained for pressure reduction measures. Wound care is reviewed, along with activity level, mobilization, and the need for physical therapy or a wound consultation.

Finally, but most importantly, the team recognizes the patient and the patients family and incorporates them into the plan of care. Patientcentered care focuses on the culture, traditions, personal preferences, religion, values, developmental stage of life, family circumstances, and lifestyle choices of each patient and his or her family. In patient-centered care, patients and their families are recognized as vital members of the care team. Including a patient and the patients family empowers them to cope more effectively with a rapidly changing and often challenging health status. Last, the health care team provides ongoing information to patients and patients families about the plan of care in a clear, honest, and understandable

manner.17 During this time, the team may decide to discuss a patients code status or set up a time for a care conference with the patients family and all care providers. The following case study illustrates use of the DGT and the importance of communication with a patients family.

Evaluation of the DGT and DGRT

Use of the DGT and DGRT greatly facilitated a comprehensive approach in meeting Mrs Ps multiple complex needs. Use of the tools also fostered communication and coordination of care between the managing service, the multiple consulting physicians, and nurses. Multiple evidence-based practices and protocol-driven care were instituted, including glycemic control, use of the ventilator and central catheter

CASE STUDY
rs P was a 66-year-old pedestrian who had been hit by a car. She arrived in the emergency department on a late summer afternoon. Her medical history included coronary artery disease and type 2 diabetes mellitus. The cardiovascular surgeon and trauma team took Mrs P to the operating room for exploratory thoracotomy because of a massive hemothorax. The surgeons resected part of a lung; aggressively replaced fluids, and subsequently transferred Mrs P to the SICU. She was in extremely critical condition. Additional injuries included multiple unstable cervical and thoracic fractures and a fracture of the right femur. Daily use of the DGT during the next several weeks facilitated identification of multiple patient-centered goals. Mrs P required sedation, pain control, and neuromuscular blockade almost immediately because of her severely compromised pulmonary status. Continuous infusions of morphine, midzolam, and vecuronium were used to provide this treatment. Nurses evaluated her sedation state by using a peripheral nerve stimulator, pain assessment,

and sedation scoring. Artificial tears and a lubricant eye ointment were used to protect her eyes. Adult respiratory distress syndrome developed by day 2. Daily interruption of sedation was deferred initially because of her tenuous pulmonary status. However, the team incorporated use of best practices such as using low tidal volumes of 6 mL/kg and positive end-expiratory pressure and maintaining plateau pressures at less than 30 cm H2O to prevent ventilator-induced lung injury and to facilitate optimal ventilation and oxygenation.18 Because plateau pressures could not be maintained, Mrs Ps ventilator mode was changed to pressure control. Multiple consulting personnel on the health care team reviewed the unstable cervical and lumbar fractures. The trauma service, along with providers from orthopedics and neurosurgery, discussed with Mrs Ps family the inability to perform magnetic resonance imaging and establish stabilization because of the patients extremely grave pulmonary status. Spinal precautions were maintained. Pressure-control ventilation helped the team manage Mrs Ps respiratory status. However, her fluid status remained a challenge. Mrs P had both metabolic and

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bundles, and use of best practices for treatment of acute respiratory distress syndrome. However, the greatest strength of the tools was fostering communication between the team and the family, including the familys presence during end-oflife care. The DGT was originally fashioned as a 1-sheet-per-day tool that was initiated by a patients nurse, discussed during rounds with the physicians, and updated throughout the day as appropriate. However, it quickly became apparent that a new sheet every day was quite cumbersome. Subsequently, 3 weeks into implementation, a revised tool that could be used daily for an entire week was incorporated. Three months after implementation, a questionnaire with a Likerttype scale was given to nurses for

Table 6
Item

Evaluation of the daily goals tools

% of respondentsa Strongly Agree Undecided Disagree Strongly disagree agree 23 64 13 0 0

1. I am using the daily goals tools. 2. The Daily Goals Worksheet enhances communication between nurses and physicians. 3. The daily goals tools are beneficial to patient care. 4. The daily goals tools enhance communication with patients and families 5. The daily goals tools enhance communication within the nursing team. 6. The daily goals tools improve patient safety. Comments:

23

36

18

14

36

36

18

18

32

36

18

45

18

36

32

27

Because of rounding, not all percentages total 100.

respiratory acidosis. Consequently, because of her medical history, massive fluid replacement, and severely compromised pulmonary status, a pulmonary artery catheter was inserted. The pulmonary artery catheter was useful for oxygen transport calculations and assessment of oxygen delivery and consumption. The goal of this strategy was to optimize organ perfusion. The team discussed the inability to give Mrs P anticoagulants prophylactically for venous thrombosis. Advanced age, multiple trauma, multiple fractures, and immobility are all risk factors for venothromboembolism. Mrs Ps risk for this complication was quite high, and just 3 days after admission, venous Doppler imaging revealed a large thrombus in the left common femoral artery. Unfortunately, Mrs Ps clinical status was too unstable for placement of an inferior vena cava filter, and she could not be given anticoagulatants. The team discussed these challenges with her family. Mrs Ps family members disagreed about how much medical intervention should be used. Mrs Ps children thought that many of the interventions were only increasing her suffering and prolonging her death. Her husband,

however, did not share this sentiment and said that he did not want to give up. Ongoing dialogue between the team, the family, and the clinical ethicist enabled Mrs Ps children to understand the treatments while still honoring the wishes of her decision maker: her husband. The team thought that if Mrs P recovered from acute respiratory distress syndrome, her fractures could be repaired and she might survive. The team reinforced previous statements to the family that recovery would be a long process. Three weeks into her stay, Mrs Ps renal and cardiovascular systems began to deteriorate. Measures to sustain her blood pressure were not successful, and early one morning her family was called to come to the hospital. They arrived and the team spoke to her husband and children. The entire family understood the severity of the situation and came to the agreement that every effort had been made to try and save Mrs P. The husband and children allowed her to die peacefully as they remained at her bedside. Death occurred within the hour. Despite his sorrow, Mr P indicated that he felt comfortable with his decision and confident that everything had been done.

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input on the use of the DGT, including a section for comments (Table 6). The response rate was 46%. In total, 87% of the respondents strongly agreed or agreed that they were using the DGT and DGRT regularly. A total of 59% strongly agreed or agreed that the tools improved communication between nurses and physicians, and 72% strongly agreed or agreed that using the tools was beneficial to patient care. A total of 63% of nurses strongly agreed or agreed that the tools enhanced communication between members of the nursing team, and 68% strongly agreed or agreed that the tools improved patient safety. In the additional comments, several nurses reported that the tools were excellent educational resources and promoted evidencebased care. Several physicians provided feedback. One suggestion included adding to the DGTR daily consideration of when to perform a tracheostomy. Additional elements such as the new diabetes protocol and the SCIP bundle were added as the elements were implemented. Also recognized was the need for additional input from the night shift. Many night nurses thought they did not have to complete the tool because they were often not involved with formal rounds. However, in the SICU, most members of the nursing staff work 12-hour shifts. Without input from the night nurses, valuable information from half of a patients day would be lacking. Specimens for laboratory tests are obtained at 4 AM, and results are often available by 5 AM or 6 AM. Residents and some surgeons also begin to examine patients and review laboratory findings by 5:30 AM to 6 AM. After reinforcement of

the goals of the DGT, night nurses began to facilitate formal communication with physicians and provide input into the plan of care, such as electrolyte replacement, weaning from mechanical ventilation, erythematous arterial catheter sites, and the concerns of patients families. This formal communication was then turned over to the next shift to be continued during interdisciplinary rounds. Evidence-based practices that may be added to the DGT and DGTR in the future include incorporation of the severe sepsis bundle, continuous electroencephalographic monitoring, monitoring of brain tissue oxygen, and guidelines for fever reduction in patients with traumatic brain injuries, stroke, or other neurosurgical problems.

Quality Indicators
An original purpose for development of the tools was improvement in patients outcomes. Therefore, baseline data obtained from January

2005 through December 2005, before implementation of the DGT, were compared with data collected from January 2006 through December 2006, after implementation of the tool. Data from 2007 and 2008 were also collected. Variables tracked included the following: 1. SICU length of stay 2. VAP bundle compliance rates 3. VAP rate 4. Bloodstream infection rate 5. Number of falls 6. Decubitus ulcer rate Improvements occurred in all 6. The mean length of stay decreased from 4.4 days in 2005 to 4.0 days in 2006, 3.2 days in 2007, and 3.16 days for the first 10 months of 2008 (Figure 1). Compliance with the bundle for VAP was not measured until 2006. However, compliance increased sharply from 92% in January of 2006 to 98% to 100% for the rest of 2006 (Figure 2). Except for January 2007, when compliance was 94%, the rate has remained at 98% to 100%. The rates of VAP (Figure 3)

8 7 Length of stay, d 6 5 4 3 2 1 0
Se pt em be r No ve m be r Ja nu ar M ar ch M ay Ju ly y

2005 2006 2007 2008

Month

Figure 1 Length of stay for surgical intensive care unit January 2005 through October 2008.

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and bloodstream infection (Figure 4) decreased to zero by the end of 2006. Except for 1 month in 2007 and 1 month in 2008, VAP rates have remained at zero. The rate of bloodstream infections had a slight increase in 1 month of 2007 and again in 1 month of 2008 but otherwise has remained at zero. The number of falls was reduced to zero by the end of 2006 (Figure 5), and the number of decubitus ulcers was reduced to zero by the third quarter of 2006 (Figure 6). The number of falls remained below the 2005 rates except for the first quarter of 2007. The rates of decubitus ulcers have remained well below the 2005 rates.

102 100 Compliance, % 98 96 94 92 90 88

Se pt em be r No ve m be r Ja nu ar M ar ch M ay Ju ly y

2006 2007 2008

Month

Figure 2 Compliance with ventilator-associated pneumonia bundle after implementation of the daily goals tools January 2006 through October 2008.

14

Summary
In the ICU, nurses, physicians, and members of other health care disciplines often care for the most critically ill or injured patients. Health care providers focus heavily not only on life-sustaining measures and meeting the complex needs of the patients but also on protocoldriven care. Members of the health care team care deeply about the quality of care they provide for their patients.19 The importance of teamwork and communication in preventing errors and improving patients outcomes has been well documented. Attention to the tactics used by the aviation industry has slowly filtered into health care. The ICU Safety Reporting System funded by the Agency for Healthcare Research and Quality is a strategy that allows for voluntary, anonymous, confidential Web-based reporting of adverse events and near misses. In addition, in the fall of 2006, the Agency for Healthcare Research and Quality and the Department of

No. of cases/1000 device-days

12 10 8 6 4 2 0

2005 2006 2007 2008

Month

Figure 3 Ventilator-associated pneumonia per 1000 device-days in the surgical intensive care unit January 2005 through September 2008.

No. of infections/1000 device-days

7 6 5 4 3 2 1 0

Se pt em be r

No ve m be r

M ay

Ja nu ar

M ar ch

Ju ly

2005 2006 2007 2008

Month

Figure 4 Catheter-associated bloodstream infections per 1000 device-days in the surgical intensive care unit January 2005 through September 2008.
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Se pt em be r

No ve m be r

M ay

Ja nu ar

M ar ch

Ju ly

2.5

No. of falls/1000 patient days

2.0 2005 2006 1.0

1.5

2007 2008

0.5

0.0

1st

2nd Quarter

3rd

4th

Figure 5 Total falls per 1000 patient days in the surgical intensive care unit first quarter 2005 through second quarter 2008.

35 Patients with ulcers, % 30 25 20 15 10 5 0

2005 2006 2007 2008

1st

2nd Quarter

3rd

4th

Figure 6 Percentage of patients with unit-acquired pressure ulcers in the surgical intensive care unit first quarter 2005 through second quarter 2008.

Defense announced the availability of a new resource for training health care providers in better teamwork

To learn more about enhancing patient safety, read Competence and Certification of Registered Nurses and Safety of Patients in Intensive Care Units, by Deborah KendallGallagher and Mary A. Blegen in the American Journal of Critical Care 2009;18:106-113. Available at www.ajcconline.org.

d tmore

practices.1 Every year the Joint Commission updates its patient safety goals to reflect changes in patient safety concerns. Many health care systems throughout the United States are committed to this effort. They have invested in research and educational programs that support a culture of safety.2 Health care providers continue to recognize that interdisciplinary

teamwork and communication are necessary to ensure safe, quality care for patients.20 In addition, increasing emphasis is being placed on identifying communication skills and/or tools that can help in promoting effective teamwork and communication, enhancing safety, and improving patient outcomes.5 The DGT is a simple yet powerful tool that incorporates the concept of checklists and redundancy.13 It allows for mutual participation in decision making by not only nurses but also residents, pharmacists, nutritionists, patients, and patients family members. Team members contribute valuable information, including different point of views, and members with more influence are encouraged to listen. In addition to facilitating explicit communication, the DGT and DGTR are excellent educational resources and ensure integration of evidence-based practice into daily patient care.13 The DGT and DGTR can be modified for almost any area and can have additional prompts added, such as measures for assuring compliance with the severe sepsis bundle and fever management guidelines. In addition, use of the tools improves the likelihood that all patients receive comprehensive evidence-based care, and the DGT and DGTR can also be used as a mechanism for examination when some patients do not receive such care.13 Despite the concern for patient safety in critical care, ICUs can serve as catalysts for change.1 Use of the DGT and DGTR can enhance teamwork, facilitate communication, and create a climate that supports patient safety and ultimately improves outcomes. CCN

68 CriticalCareNurse Vol 29, No. 6, DECEMBER 2009

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eLetters
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Financial Disclosures
None reported.

References
1. Clancy CM. Patient safety in the intensive care unit: challenges and opportunities. J Patient Saf. 2007;3(1):6-8. 2. Swihart D. Are we safe yet? Adv Nurses. 2005;7:15-19. 3. Mrayyan MT, Huber DL. The nurses role in changing health policy related to patient safety. JONAS Healthc Law Ethics Regul. 2004;5(1):13-18. 4. Evanhoff B, Potter P, Wolf L, Grayson D, Dunagan C, Boxerman S. Can we talk? Priorities for patient care differed among health care providers. In: Advances in Patient Safety: From Research to Implementation. Vol. 1. AHRQ Publication No. 05-0021-1 Agency for Healthcare Research and Quality Web site. http://www.ncbi.nlm.nih.gov/books /bv.fcgi?rid=aps.section.22. Published February 2005. Accessed September 24, 2009. 5. Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin Crit Care. 2007;13(6):

732-736. 6. Joint Commission. Improving Americas hospitals: The Joint Commissions annual report on quality and safety 2007. Joint Commission Web site. http://www .jointcommissionreport.org/pdf/JC_2008 _Annual_Report-updated.pdf. Published November 2008. Accessed October 6, 2009. 7. Donchin Y, Gopher D, Opin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995;23(2):294-300. Cited by: Reader TW, Flin R, Cuthbertson BH. Communication skills and error in the intensive care unit. Curr Opin Crit Care. 2007;13(6):732-736. 8. Pronovost PJ, Wu AW, Sexton JB. Acute decompensation after removing a central line: practical approaches to increasing safety in the intensive care unit. Ann Intern Med. 2004;140(12):1025-1033. 9. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol. 1999;9(1):19-32. 10. Kosnik KL, Brown J, Maund T. Patient safety: learning from the aviation industry. Nurs Manage. 2007;38(1):25-30. 11. Pronovost P. ICU daily goals worksheet. Institute for Healthcare Improvement Web site. http://www.ihi.org/IHI/Topics /CriticalCare/IntensiveCare/Tools /ICUDailyGoalsWorksheet. Accessed September 24, 2009. 12. McMillan TR, Hyzy RC. Bringing quality

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improvement into the intensive care unit. Crit Care Med. 2007;35(2)(suppl):S59-S65. Winters B, Dorman T. Patient-safety and quality initiatives in the intensive care unit. Curr Opin Anaesthesiol. 2006;19(2):140-145. Springer R. The Surgical Care Improvement Projectfocusing on infection control. Plastic Surg Nurs. 2007;27(3):163-167. Kress JP, Pohlman AS, OConnor MF, Hall JB. Daily interruption of sedative infusion in critically ill patients undergoing mechanical ventilation. N Engl J Med. 2000;342(20): 1471-1477. Dodek P, Keenan S, Cook D, et al. Evidencebased clinical practice guideline for the prevention of ventilator-associated pneumonia. Ann Intern Med. 2004;141(4):305-314. Auerbach S, Kiesler D, Wartell J, Rausch S, Ward K, Ivatury R. Optimism, satisfaction with needs met, interpersonal perceptions of the healthcare team, and emotional distress in patients family members during critical care hospitalization. Am J Crit Care. 2005;14(3):202-210. Donahoe M. Basic ventilator management: lung protective strategies. Surg Clin North Am. 2006;86(6):1389-1408. Simpson S, Person D, OBrien-Ladner A. Development and implementation of an ICU quality improvement checklist. AACN Adv Crit Care. 2007;18(2):183-189. Fewster-Thuente L, Velsor-Friedrich B. Interdisciplinary collaboration for healthcare professionals. Nurs Adm. 2008;32(1):40-48.

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CriticalCareNurse CCN Fast Facts Enhancing Outcomes in a Surgical Intensive Care Unit by Implementing Daily Goals Tools
The journal for high acuity, progressive, and critical care

Facts
Effective communication is crucial to create care teams that foster safe environments; however, communication challenges between nurses and physicians still persist at times in daily practice. The priorities of each discipline differ, and both physicians and nurses sometimes do not realize that their relationship is interdependent. Therefore, successful teamwork requires strategic communication to address and meet common goals for patient care. Tools such as the Daily Goals Tools (DGT) can help in simplifying complex tasks, improving teamwork, promoting effective communication and shared decision making, and enhancing patient safety. The DGT and the Daily Goals Tools Reference (DGTR) were developed at our institution for the surgical intensive care unit. The DGT facilitates a comprehensive daily review of 12 major aspects of care and provides a framework for evidencebased practices. The DGTR provides greater detail on each of the 12 aspects of care. These 12 major aspects of care include the following:
Safety and transfer What is the patients greatest safety need? What needs to be done for the patient to transfer? Pulmonary, ventilator, and sedation Head of bead up 30 to 45? Sedation vacation? Deep vein thrombosis/peptic ulcer prophylaxis? Venous Dopplers? Inferior vena cava filter? Readiness to extubate? Eye protection? Date to tracheostomy? Results of laboratory tests, radiographs, and procedures What does chest radiograph or other test show? Glycemic control/diabetic protocol? Laboratory results reviewed? Tests needed?

Neurological and pain management Acute head injury/intracranial pressure orders? Computed tomography scan results? Neurological assessment? Cervical spine cleared? Cardiac rhythm, hemodynamic status, oxygen transport calculations, and medications Drips? Weaning? Hemodynamic parameters? Ideal pulmonary capillary wedge pressure? Cardiac output? What medications can be discontinued? -Blockers resumed/order? Volume status Low urine output? Base deficit? Fluid bolus? Parameters, physician notification, and consultations Vital signs? Hemodynamic parameters? Status of care from consultations? Gastrointestinal assessment, nutrition, and bowel regimen Parenteral/enteral nutrition? Tube feeding goal? Residuals? Bowel sounds? Distended? Infectious diseases and cultures Consult? Febrile? Cultured? Methicillin-resistant Staphylococcus aureus screening? Results? Normothermia achieved? Central, arterial, and peripheral catheters Need? Insertion date? Peripherally inserted catheter? Discontinue/femoral catheters out? Appearance of sites? Skin care, wound care, and mobilization Skin integrity? Pressure reduction mattress? Code status and family Addressed? Family updated on plan of care?
Peggy Siegele. Enhancing Outcomes in a Surgical Intensive Care Unit by Implementing Daily Goals Tools. Crit Care Nurse. 2009;29(6):58-70. This article can be found at www.ccnonline.org.

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