Reducing ICU length of stay with BayCare health system

The Challenge

The standard treatment for patients who are unable to breathe on their own is to sedate them and put them on a ventilator. In a hospital ICU (Intensive Care Unit), patients on ventilators are typically weaned off the device after a few days when it’s determined that their lungs are capable of sustaining them.

"The longer you’re on a ventilator, the less your lungs will work naturally," says BayCare Black Belt Angi Jennings. As she learned on her first Six Sigma project, there’s a 'honeymoon' period when it is advisable to be on a ventilator. However, patients who are not weaned off ventilation soon enough are in danger of developing related complications – ventilator associated pneumonia, internal infections and oral ulcers, along with and bed sores and other conditions associated with prolonged immobility.

Jennings was assigned a DMAIC project for St. Anthony’s Hospital, one of nine hospitals in the BayCare Health System in Tampa Bay, Florida. In addition to the facility’s 20-bed ICU, St. Anthony’s has a 10-bed cardiovascular ICU. The project goal was to reduce the number of ventilator days in both ICUs by 30 percent. A secondary goal was to reduce the overall length of stay (LOS) for vented ICU patients.

In addition to improving patient care – the number one goal at BayCare – the project’s forecasted savings were $775,000 attributed to the projected decrease in ICU LOS and a decrease in cost per case.

The Process

Since the project was BayCare’s first clinical project, the project team took advantage of several Six Sigma tools in the Define phase, including a SIPOC diagram, macro-level process map and a stakeholder analysis. Jennings recalls that the Affinity Diagram was helpful to get the team thinking about the many clinical variables that affected the process.

In all, eight departments interacted with vented patients on a daily basis. Thus, process mapping was also important. “When I interviewed each department separately, they each had their own idea of the way the process flow was supposed to be,” Jennings says. “I asked each department ‘If you could pick an ideal situation for this patient, what would it be?’ And that’s the way we migrated as a consensus to the future state process.”

In addition to the large variety of stakeholders, the team discovered during the Measure phase that there was no shortage of data related to the process. The team gathered data on nearly 430 patients, using a combination of continuous and discrete data from a variety of electronic and manual sources. They grouped the data into three categories: demographics, clinical and post-vent care. The result? More than 16,000 data points – a bit overwhelming for the inexperienced team, but a great learning opportunity.

A variety of statistical tools – including ANOVA and regression analysis – helped Jennings pare down the data bit by bit. The analysis revealed an interesting trend: 96 percent of the process variability could be contributed to clinical variables. Treatments such as AGBs (Arterial Blood Gases), chest x-rays and “sedation vacations” were not always performed, or the results were inconsistently reported.

The data also showed a lack of standardized processes and protocols, and an opportunity to improve communication between the different departments involved. Jennings says that there was little incentive for each area to note what the other areas were doing in the care of the patient. Thus, the status quo became a collective lack of accountability for weaning the patient off ventilation sooner rather than later.

Proposing improvements presented a challenge for Jennings, a non-clinician. “I didn’t ask anyone on the team to do anything that they didn’t already do,” she says. “I just asked them to be accountable and to document it, and to have it available at certain times.”

Still, there was some resistance to suggested improvements, such as daily rounding by an interdisciplinary team with representatives from all eight departments. A lack of time and resources was frequently cited as an obstacle.

The project Champion encouraged the departments to pilot the interdisciplinary rounding for a month. On the first day, the team took 2.5 hours to complete rounds for only six patients – not a very timely result. Jennings attributes the difficulty to a lack of preparation, but without assigning any blame. “When we went down through this rounding sheet and asked very specific questions about specific care elements, people didn’t know the answers because nobody had asked them those type of questions before.”

The team adapted quickly, however, and within two weeks was seeing positive results. At that point, Jennings says, “everybody began to change their work habits. It was probably one of the best exhibits of culture change I have ever seen, because people realized that they made a difference.”

In addition to the daily rounds, the team agreed on several other improvements, many of which were essential pre-requisites to the daily rounds. These included a standard process flow, a weaning protocol and a rounding sheet, which the team used a DOE (Design of Experiments) to fine tune. The team also came up with the idea of interdisciplinary lunch and learns to promote a more global, less departmental, view of the process.

The Results

As a result of this project, St. Anthony’s ICUs achieved a 38 percent reduction in ventilator days and a 23 percent reduction in length of stay for vented ICU patients. Since the project was completed, the process has remained in control and the hospital has realized $650,000 in hard savings. Perhaps more impressive is that St. Anthony’s recently received a Beacon Award for excellence in its ICUs.

The project also got BayCare’s performance excellence program off to a good start. It demonstrated perfectly how the DMAIC process can reduce a huge number of inputs to a critical few, and how important data can be to supporting process improvements. It also proved to be a good training ground for the team. “The most rewarding thing,” says Jennings, “is hearing clinicians say to me, ‘Participating on this project is one of the best things that’s happened to me in my career.’”