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AN AM FAST HUG: IMPACTING QUALITY METRICS IN AN INTENSIVE

CARE UNIT BY RESTRUCTURING ROUNDING AND THE ROLE OF

CRITICAL CARE NURSES

Omar Rahman MD, Amy Gearhart RN, BSN, Diane Penny RN, CCRN, Kathleen Jones

RN, Jennifer Small RRT, Robert Stone RN, Deb Gardill RN, CCRN, Janet Comrey RN

Department of Critical Care Medicine

The Adult Intensive Care / Shock Trauma UnitGeisinger Medical Center

100 N. Academy Avenue

Danville, PA 17822

Key Contact Email:orahman2@geisinger.edu

BACKGROUNDCritically ill patients are at a greater risk for adverse events, nosocomial infections and iatrogenic

complications1 leading to higher morbidity, mortality and healthcare costs2. Our project centered

on involving critical care bedside nurses to improve quality metrics and implementing a rounding

mechanism that addressed national patient safety goals.

PURPOSETo evaluate the impact on ICU related quality metrics and national patient safety goals by:

1. Developing and implementing a rounding checklist addressed by physicians and nurses.2. Ensuring presence and participation of nurses in rounds and decision-making.

METHODS

Before and after evaluation study design.

The adult ICU is a 24 bed med-surgical trauma unit in a tertiary care center. Monthly admissions

range: 105 to 120 patients. Patients are assigned to three different teams and rounds are conducted

in the morning. Bedside rounding team is composed of intensivist, the patients nurse, residents,fellows and pharmacist. Respiratory therapists are present in the unit at the time of rounds.

Quality data is routinely collected at a unit and system level. Opportunities of improvement were

identified in areas of ICU related nosocomial infections, length of stay, completion of advanced

directives and medication reconciliation. Data showed that the presence and participation of the

patients nurse was not consistent at morning rounds.

The following process was implemented on Feb 1, 2009:Establishing paging and communication system to ensure nurse presence.

Respiratory therapists joined rounds for mechanically ventilated patients.

Set rounds time: 8.30 AM to 12.00 PM

The nurse and physicians go over the checklist acronym AM FAST HUG:

A-Advanced directives and consents, Anemia-blood conservation

M=Medication reconciliation, Mobility & pressure ulcers

F=Feeding, Fluids, Family updates & Fall prevention

A=Accessories (need, remove, renew): lines, catheters, drains, vents, restraints

mailto:orahman2@geisinger.edumailto:orahman2@geisinger.edumailto:orahman2@geisinger.edumailto:orahman2@geisinger.edu

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S=Sedation/Analgesia

T=Thrombo-embolism prophylaxis

H=Head of bed > 30 degrees, Hand washing

U=Ulcer prophylaxis

G=Glucose control

The patients nurse was given authority to stop the line if above process was not

adhered to.Education regarding process and nurse empowerment was imparted to ICU physicians,

fellows, nursing staff and respiratory therapists over a period of 4 to 6 weeks.

Data review was conducted for the 6 month period before and after implementation.

RESULTS(Fig 1 to 5)

Average LoS per patient admission month: 6.28 to 5.84

Advanced directives completion: 38.6 % to 83.2 %

Medication reconciliation: 17 % to 65.2 %

Nurses presence on rounds: From 33% to 93.2 %

Device utilization rates: Foley 0.73 to 0.68, CVC 0.61 to 0.55, Mechanical Vent 0.60 to

0.55

Additionally,

Hand washing compliance: From 50.6 % to 90.3 %

Pressure ulcers / 1000 days: 10.54 to 8.4

CONCLUSIONS AND IMPLICATIONSOur data shows that a structured, nurse empowered program can improve compliance with

advanced directives as well as reduce the burden of medication errors by timely reconciliation.

An improvement in quality metrics is clearly demonstrated and further prolonged periods of study

are needed to determine impact on cost, morbidity and mortality outcomes.

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Figure 1

5.87

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ALOS PER PATIENT ADMISSION MONTH

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Figure 2

GMC ADVANCED DIRECTIVE COMPLETION: AICU

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Advanced Directives 8 0 0 3 0 0 44 0 38 44 67 70 72 100 91

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Figure 3

GMC ADMISSION/TRANSFER MEDICATION RECONCILATION: AICU

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MR done by Physician

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MR done by Physician 0 14 7 11 16 0 45 15 16 10 9 88 60 40 73

# Cases 20 14 18 48 45 10 40 54 13 24 9 34 23 10 32

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Figure 4

33%

84%

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0%

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Pre test of change Mar-09 Apr-09 May-09 Jun-09 Jul-09

Compliance

AMFASTHUG ROUNDS NURSING PRESENCE: AICU

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Figure 5

REFERENCES

1Pittoni GM, Scatto A. Economics and outcomes in the intensive care unit. Current Opin Anestheiol. 2009;

22 (2): 232-6

2Pronovost PJ, Miller MR, Dorman T et al. Developing and implementing measures of quality of care in

the intensive care unit. Current Opin Crit Care 2001; 4(7):297-303

0.73

0.61 0.60

0.68

0.55 0.55

00.050.1

0.15

0.20.250.3

0.350.4

0.450.5

0.550.6

0.650.7

0.750.8

0.850.9

0.951

FOLEY CVC MECH VENT

Utilization

Rate

Oct 2008To Feb2009

Mar 2009To Jul2009