Changes within MICU

The idea that tens of thousands of lives might be saved each year if intensive care units made the right investments has gained credence among critical care experts in recent years. Organizations like the American College of Critical Care Medicine and the Leapfrog Group, publishers of a national comparison of patient safety at various hospitals, had called for changes in facilities and staffing levels, but no unit had studied the impact of putting all of the new ideas into practice.

So when it came time to move into a new space to meet a growing regional need, the Medical Intensive Care Unit (MICU) at the University of Maryland Medical Center (UMMC) set out to achieve a best-in-field staffing model as it moved into a cutting-edge facility. The MICU went from daytime-only physician staffing to 24/7 coverage by physicians specializing in critical care medicine (intensivists), daily coverage by dedicated clinical pharmacists and a lower ratio of respiratory therapists to patients. After the move, the team saw that the changes were saving lives, and decided a formal study1 was needed to measure the combined worth of the interventions.

What they found when comparing the two years before and after the move was that mortality had dropped by an astounding 19%. The number is more remarkable considering that the “old” ICU was already a Leapfrog-compliant tertiary care unit with a high-intensity staffing model and best practices in place. According to the study authors, the adoption by all U.S. urban ICUs of both the Leapfrog criteria and added changes captured in the MICU study could potentially save 70,000 lives each year.

“In an ICU where people arrive severely ill for many reasons, it is terribly difficult to make changes that all at once increase survival across all patients,” says principal investigator Giora Netzer, M.D., a pulmonologist and critical care specialist at the University of Maryland Medical Center who is an assistant professor of medicine, epidemiology and preventive medicine at the School of Medicine. “Even the arrival of a powerful new drug does not always move the needle on mortality, so you can see why we are so excited.”

Real world impact

Published online in Critical Care Medicine in November 2010, the MICU study was a single-center, retrospective and observational study. It compared the outcomes of 1,263 patients admitted to the medical center between April 19, 2004, and April 18, 2006, before the move to new quarters, to those of 2,424 patients admitted between Sept. 5, 2006, and Sept. 4, 2009, after the changes. There were no differences in patients admitted before and after the move in terms of gender, co-existing illnesses, risk factors or expected intensity of care.

In its new setting, the MICU supported 24-hour intensivist staffing and daily, bedside case review by multidisciplinary teams (intensivist, nurse manager, pharmacist and respiratory therapist). The joint teams worked to reduce sedation where possible and move patients off of respirators more quickly, both of which have been shown to reduce complications, infections and mortality. The nursing practice was expanded as well with the move to a larger facility, but because it was already among the best before the move — achieving Magnet status for nursing excellence — it was not highlighted in the study.

Along with a 19% relative reduction in MICU mortality, the authors found that the study interventions had decreased mortality by 16% hospital-wide during the study, arguing that the measures had a durable benefit (did not result from shifting mortality from one part of a patient’s hospital stay to another).

Improved survival came with a 5% increase in ventilator-free days (VFDs) and a significant decrease in the use of sedative medications, both of which contributed to the improved outcomes.

The average length of stay for the MICU actually increased after the move, leading to speculation that, by living longer, patients spent more time on the unit. While the current study was not designed to determine which component in the multi-component package was most responsible for decreased mortality, some 20 studies had suggested that each individual intervention had some value. “The study simply looked at whether driving staffing levels higher than the highest standard as we moved into a new facility could make a superior ICU better,” says Jeffrey D. Hasday, M.D., head of the division of pulmonary and critical care medicine at the Medical Center and professor of medicine at the School of Medicine. “What we found was that the study interventions achieved greater increases in survival even than previously estimated in studies of traditional, high-intensity physician staffing. We believe the study results should inspire a national conversation about targeted investments needed in ICUs to save more lives.”

Among the study’s limitations was that it had to be conducted as a before-and-after study rather than a randomized clinical trial. While the possibility that random case mix differences could have contributed to the drop in mortality cannot be completely eliminated, the team conducted a set of statistical analyses (e.g., Wilcoxon rank-sum test, statistical regression), which confirmed that the observed reduction in mortality was not random.

The authors’ excitement about the results was also tempered by realization that they will not be applicable to every ICU. Some will not have the resources to change their physical plants and staffing levels. One solution may be to start by ensuring that each region has at least one center of excellence capable of delivering care at this level.

Another limit on the study’s potential impact on emergency medicine is a profound nationwide shortage of intensivists. According to the Leapfrog Group, there are not enough to cover even every major urban ICU 24/7, let alone all ICUs, but the problem could be fixed in four years if their training became a national priority. UMMC seeks to do its part to address the problem with multiple training programs in place for medical, surgical and pulmonary care intensivists.

A larger movement

The MICU study serves as a case study for the value of larger patient safety efforts at UMMC, which is one of only two hospitals in the nation to be named to the Leapfrog Group’s list of top hospitals for patient safety and quality care for the sixth year in a row. A growing culture of quality was coalescing at the Medical Center at the time of the move. The MICU leadership had already decided that it wanted to provide better compensation and training to address staffing shortages that were in place before a proposed expansion made them more urgent. The team also decided to re-focus on professionalism, by shifting from temp workers to full-time staffing and by placing a premium on professional development. One measure of the success of this effort is the steady stream of journal publications now emanating from the medical center’s 11 ICUs. “There was a shared vision between the Medical Center and School of Medicine that we were going to do this right from the start with the new MICU,” says Professor of Medicine Carl Shanholtz, M.D., study co-author and medical director of the MICU. “What started as an examination of staffing needs around an expansion became a determination to conduct an experiment in quality, to rethink staffing as a factor affecting quality of care.”