Biomedical subjects

Sean Berenholtz

Publications and source records attributed to Sean Berenholtz.

7 recordsLinked to original sources

PubMed2006

An intervention to decrease catheter-related bloodstream infections in the ICU.

BACKGROUND: Catheter-related bloodstream infections occurring in the intensive care unit (ICU) are common, costly, and potentially lethal. METHODS: We conducted a collaborative cohort study predominantly in ICUs in Michigan. An evidence-based intervention was used to reduce the incidence of catheter-related bloodstream infections. Multilevel Poisson regression modeling was used to compare infection rates before, during, and up to 18 months after implementation of the study intervention. Rates of infection per 1000 catheter-days were measured at 3-month intervals, according to the guidelines of the National Nosocomial Infections Surveillance System. RESULTS: A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P< or =0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval [CI], 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. CONCLUSIONS: An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

Adult↗

PubMed2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

OBJECTIVE: Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. DESIGN: We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. SETTING: Health care institutions. RESULTS: Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. CONCLUSION: The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.

Forecasting↗

PubMed2006

Team care: beyond open and closed intensive care units.

PURPOSE OF REVIEW: Evidence supporting dedicated intensivist staffing in intensive care units is growing. Despite clinical and economic benefits, medical staff politics and a shortage of intensivists impede the intensivist model. The purpose of this paper is to accelerate patient's exposure to the benefits of intensivists, and introduce team care in the intensive care unit. RECENT FINDINGS: The cost savings achieved through intensivist staffing range from $510,000 to $3.3 million. The intensivist model may only have been adopted by 4% of intensive care units. Barriers to implementing the model are shortage of intensivists, reimbursement for intensivists, and political will. Four attributes make the model ideal: physical presence, knowledge of critical care practice, coordination of team care, and unit management. It may be helpful to not label intensive care units as open or closed and consider team care, whereby hospitals seek to achieve the attributes of the model given their resources and culture. SUMMARY: Intensivists save lives and costs. By working toward team care, hospitals may achieve a successful intensivist model, and patients may realize the benefits of spending less for healthcare and living longer. To achieve this model, physician and hospital leaders must form a partnership.

Cost Savings↗

PubMed2003

Medication reconciliation: a practical tool to reduce the risk of medication errors.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Continuity of Patient Care↗

PubMed2003

Improving communication in the ICU using daily goals.

BACKGROUND: Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. PURPOSE: The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form. DESIGN: We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form. RESULTS: At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days. CONCLUSION: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine.

Cohort Studies↗

PubMed2003

Barriers to translating evidence into practice.

PURPOSE OF REVIEW: The demand for high-quality care is increasing. A variety of therapies have been shown to improve patient outcomes in critical care. Nevertheless, relatively little research has focused on identifying how to deliver those therapies effectively and efficiently. As a result, the most cost-effective opportunity to improve patient outcomes will likely come not from discovering new therapies but from discovering how to deliver therapies that are known to be effective. RECENT FINDINGS: The authors review the evidence regarding changing behavior of physicians and discuss barriers to translating evidence into practice. They also provide practical examples of how they applied the concepts of teamwork, independent redundancy, and reduced complexity to change the behavior of physicians and improve quality of care. SUMMARY: Because quality is a multidimensional construct, it is unlikely that a single approach will be effective. ICU physicians and hospital leaders must assume a leadership role, implementing a combination of different approaches and developing appropriate systems for patient care.

Critical Care↗

PubMed2002

Reducing failed extubations in the intensive care unit.

BACKGROUND: Failed extubation is associated with substantially increased morbidity, mortality, and costs for patients receiving mechanical ventilation. A study was designed in 1998 to identify risk factors for failed extubation and use a quality improvement model to reduce failed extubation rates in a surgical intensive care unit (SICU) in an academic hospital. METHODS: Study design involved a prospective cohort SICU with a concurrent control SICU. The primary outcome was rate of failed extubations per 1,000 ventilator days. Information on risk factors for failed extubations was also collected. Performance improvement staff identified failed extubation patients, and respiratory therapy provided information on ventilator days. The quality improvement model implemented three phases between October 1998 and June 2000: (1) identifying factors associated with failed extubation, (2) developing a guideline to reduce failed extubation, and (3) implementing the guideline. RESULTS: Significant factors associated with failed extubation included suctioning more frequently than every 4 hours versus the current model of "every 4 hours or greater" (odds ratio [OR] 11.3; 95% confidence interval [CI] 1.5-88.3), being agitated or sedated versus being alert (OR 4.5, CI: 1.2-14.7), and oxygen saturation < or = 95% versus > or = 95% (OR 4.0; CI: 1.2-13). Failed extubation rate in the SICU decreased from 8/1,000 in October 1998 to 1.5/1,000 in June 2000, and control SICU rates remained unchanged (8/1,000). DISCUSSION: The intervention significantly reduced the rate of failed extubation in the SICU. By employing a quality improvement model and identifying risk factors for failed extubation, providers should be able to decrease risk of failed extubation for SICU patients.

Academic Medical Centers↗