A practical approach is a hit in intensive care

THE BALTIMORE SUN

It seemed so obvious: Patients in intensive care improve faster if doctors and nurses set specific goals for their recovery. But until two years ago, no one had explicitly tried this approach.

Now, a Johns Hopkins University study has found that setting daily goals for all patients can help them get better sooner.

The method Hopkins tested also requires that everyone involved in a patient's care - doctors, residents, nurses, attending physicians, pharmacists and others - go on rounds together, visiting each patient.

After examining the patient, the team discusses the daily goals for the patient, and then fill out a printed form that makes everything clear.

"It's really revolutionizing the way we approach patient care," said Dr. Peter Pronovost, who helped develop the new procedure for Hopkins and then conducted the study, which appeared in the June issue of The Journal of Critical Care. The technique not only improves communication, but increases nurses' job satisfaction, he and others said.

Pronovost studied a Johns Hopkins intensive care unit that treated cancer patients after surgery. He found that without use of a daily form for each patient, less than 10 percent of residents and nurses understood the goals for individual patients on the ward.

After the form was used, more than 95 percent understood those goals, and the average length of stay in the ward was halved, from two days to one.

The one-day decrease in ICU stays is significant, said researcher Carol Haraden of the Institute for Healthcare Improvement, a nonprofit group dedicated to making medical care safer and more efficient.

"Every day in ICU is an opportunity for harm," she said. "It's a high-risk environment, it's an expensive environment, and it's not a good place for families."

Haraden co-wrote the study and helped Pronovost develop the goal-oriented procedure. They looked at several models, including NASA's approach to aviation safety.

They found that the space agency had a goal-oriented safety program that involved everyone on the crew, from pilots to mechanics to engineers. Pronovost took this method and adjusted it for use in ICUs, and began using it in the Hopkins oncology unit two years ago.

The key, said Hareden, is "concrete, measurable goals everyone can all share." In a typical ICU, for example, the doctor on rounds might tell a nurse to wean the patient from the respirator. But without details, a nurse might have little idea of whether the patient should be weaned by noon or 9 p.m. Now the entire team will pinpoint a specific time, and check back later in the day to see if it's been accomplished.

"It makes a difference," said Michael Hass, a fifth-year surgical resident who is now working in the oncology ICU. "It's very clear what the daily care plan will be for each of the patients. The daily goal checklist becomes imprinted in your mind."

With its emphasis on team communication, the new method improves everyone's understanding, said Pronovost, who developed an interest in health care safety and efficiency in medical school - when his father died as a result of a hospital error.

Because the new setup enables non-doctors to have more input, they enjoy their jobs more. "Before, the nurses weren't asked many questions, weren't involved in developing a plan for the patient," said Rhonda Wyskieo, a nurse in the Hopkins oncology ward. "Now we're much more empowered."

The goal system is now in place at five other Hopkins ICUs and has spread to at least 70 hospitals across the country.

Among them is the surgical ICU at Hartford Hospital in Connecticut. Since the ward implemented the goal system 18 months ago, mortality has decreased from 11.2 percent to 8.4 percent. "I can't prove it, but I'm certain that [the goal technique] is the cause," said ICU director Eric Dobkin. "That's the only variable that's changed."

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