Joanne McGovern

Utilization of an innovative tool to improve oncology patient outcomes.

231 Background: Introduction of an electronic board can improve interdisciplinary communication to ensure early intervention and improve patient outcomes. Early detection and prevention is key. The early stages of physiologic demise may be demonstrated by subtle changes in the patients vital signs. The purpose of this study was to implement a visual tool to indicate and update the acuity of patients on the oncology unit. The parameters displayed included vital signs, Hendrich, and Braden scale. The goal of the electronic board was to create a continuously accessible resource for the interdisciplinary team for rapid assessment of the patients condition throughout rounds and all shifts. METHODS This electronic board produces a color-coded alarm for abnormal parameters. Vital signs highlighted in red indicate the urgency for assessment and intervention. The Hendrich score displayed in yellow alerts all disciplines of fall risk patients. The Braden scale, color-coded purple, identifies patients at risk for skin breakdown. Improvement in early and rapid identification of patient deterioration and risk was analyzed using two months of post implementation data from the electronic health record. A survey was sent to all disciplines to qualitatively measure the value of this tool. RESULTS Abnormal vital signs identified from the facility board led to clinician interventions impacting 27% of admitted patients in the first two months. Falls decreased by 33% after the first month of implementation. The number of specialty beds ordered increased by 32% for patients identified at risk for skin breakdown. Twenty-five survey responses illustrated 71% of the interdisciplinary team that replied used the facility board and 68% confirmed improvement in interdepartmental communication. CONCLUSIONS There is a significant association between early intervention and decreased mortality rate in acutely ill cancer patients. The continuous display of pertinent patient data on an electronic board holds clinicians accountable to recognize and provide early intervention thus impacting oncology patient outcomes. This innovative tool will further enhance outcomes as we move to interfacing our vital signs monitor into our electronic health record.

1013: SUSTAINING POSITIVE OUTCOMES WITH A PROGRESSIVE UPRIGHT MOBILITY PROGRAM PROTOCOL IN CANCER PATIENTS

Critical Care Medicine • Volume 46 • Number 1 (Supplement) www.ccmjournal.org Learning Objectives: Critical illness associated with immobility leads to significant morbidity including increased ICU and hospital lengths of stay (LOS) and prolonged deconditioning. Several prior studies have demonstrated improvements in LOS and ventilator days when early institution of mobility programs are utilized; however, malignancy and short expected life span have been exclusions from all prior studies. The purpose of this retrospective investigation was to examine the safety and effectiveness of a Progressive Upright Mobility Program (PUM) in critically ill ventilated cancer patients. Methods: After twelve months of baseline data was collected investigating ventilator days, ICU LOS and hospital LOS, a stepwise multidisciplinary PUM protocol was developed and followed in all mechanically ventilated patients admitted to a single subspecialty cancer hospital ICU. Exclusions to protocol included hemodynamic instability or need for continuous sedation or neuromuscular blockade. Data from control period (Pre) was compared to twelve month postintervention (Post) data. To determine sustainability, an additional twelve months of data was collected and compared to the Pre and Post intervention groups. Compared data included demographics, severity of illness, ventilator days, and LOS. Results: Statistical analysis of the data included comparison of means and analysis of variance (ANOVA). The Post protocol implementation group demonstrated statistically significant outcomes in the three areas measured; mean ventilator days reduced from 6.3 to 3.7 (p = 0.001755), ICU LOS 10.2 to 7.5 (p = 0.011016), and hospital LOS 20.9 to 14.1 (p = 0.000364). The mean APACHE IV score for the patient population was 93 with a 50.7% predicted mortality rate, demonstrating higher severity of illness in comparison to the national average APACHE IV score of 50. Conclusions: Despite oncology patients having a high severity of illness and likely functional decline, they proved to show the same beneficial results of early mobilization as previously studied groups. The results reflect consistencies with current literature supporting the absence of complications in early mobilization of patients in the ICU. To our knowledge, this has been the first mobilization study conducted in an oncology critical care setting.

Reducing hospital aquired pneumonia (HAP) with Massey Screen.

232 Background: Hospital Acquired Pneumonia (HAP) is a leading cause of prolonged hospitalization in patients. The oncology population is especially susceptible to critical illness related to an immunocompromised state. The purpose of this study was to implement the Massey Bedside Swallowing Screen upon admission to the oncology telemetry unit to detect any deficits that could potentially lead to HAP, in conjunction with strict oral care for identified high risk patients. METHODS The importance of the Massey Bedside Swallowing Screen upon admission and the knowledge that early detection leads to better patient outcomes was educated to the nursing staff. Every patient admitted to the oncology telemetry unit was screened with the Massey Bedside Swallowing Screen. Patients identified as high-risk were placed on nothing-by-mouth (NPO) precaution. A Speech and Swallow Evaluation was ordered to further evaluate the patient. Acutely ill oncology patients unable to perform their own oral care were placed on a strict oral care regimen performed by the nursing staff. The charge nurse audited compliance with this protocol. RESULTS The pre-intervention phase of the study evaluated January - April 2015 included 1,605 patient days. The data revealed 4 HAPs acquired on the oncology telemetry unit, demonstrating 2.45 incidence/1000 patient days. Post-intervention [May - August 2015] indicated 2 HAPs acquired on the oncology telemetry unit, signifying 1.35 incidence/1000 patient days. With the implementation of the Massey Bedside Swallowing Screen for each patient upon admission, and strict oral care regimen for high-risk patients, the overall incidence of HAP on the unit decreased by 50%. CONCLUSIONS Oncology patients assessed with the Massey Bedside Swallowing Screen upon admission to the oncology telemetry unit were noted to have improved outcomes and lower rates of HAP. Every oncology patient admitted to an acute care unit should have an admission screen in place to evaluate risk for aspiration. Early detection of patients at high-risk for HAP and implementation of interventions to improve oral care in high-risk patients lead to improved patient outcomes through lower incidence of HAP in the acute care setting.

Integrating Lean Six Sigma in the daily operations of an ICU to achieve safe, quality patient care.

230 Background: Developing and maintaining a culture of safety and quality in delivering patient care is critical in the intensive care unit (ICU) especially an oncology ICU. Incorporating the Lean Six Sigma program into daily operations of the ICU achieves, simplifies, and sustains continuous improvement in the delivery of safe quality patient care. This program engages the ICU team through visual management of quality, safety, and budget indicators including medication scanning, falls, sharps exposure, infection prevention including blood stream, catheter, hospital and ventilator acquired pneumonias, venous embolism prevention, and staffing compliance. METHODS The initiative focused on stakeholder development to increase professional certifications, improve engagement through development and implementation of educational events, and enhance participation in monthly journal club. Discussion of evidence-based research projects aligned each shift with data, metrics, and outcomes. Cost containment through charge capture, reduction in wasted supplies, and appropriate level of care order was implemented. With the support of Lean Six Sigma, the lean daily management board came to life each shift. RESULTS Outcomes included medication scanning rates increasing from 94% to 99.5%. Hospital acquired infection and pressure ulcer rates remained 0%. Venous thromboembolism prophylaxis rates increased form 77% to 100%. Staffing compliance increased from 90% to 100%. The number of chemotherapy certified nurses increased from 56% to 71%. The number of nurses with specialty certification improved from 28% to 47%. Stakeholders engaged in 32 professional educational events, and 12 journal clubs were led by the ICU nurses. Product charge capture began at

637: IMPACT OF OVER-SEDATION AND INADEQUATE PAIN CONTROL ON DURATION OF INTUBATION IN ONCOLOGY PATIENTS

0 ending in an average of

Post-operative vital signs: How often is too often?

1342 per month from 0% charge capture to 100% charge capture each month. CONCLUSIONS Team alignment around daily production, patient flow, and staff development enables real-time problem solving around the daily issues of safety, quality, productivity, and stakeholder development. In this oncology critical care unit it has not only enhanced daily communication but every twelve hour shift engagement as well.

Sustaining operational excellence in the oncology intensive care unit.

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) the ICU, just like in the operating room. Monitoring the effect of NMBDs on neuromuscular junction has traditionally been done by using a peripheral nerve stimulator (PNS), designed for use in the operating room. However, the validity of using PNS to monitor the function of the neuromuscular junction in critically ill patients has not been studied. We designed a prospective pilot study to compare PNS and electromyography (EMG) in monitoring the neuromuscular junction with or without the use of NMBDs. Methods: We conducted a pilot study of 17 adult subjects who were admitted to ICU and who received or expected to receive neuromuscular blocking agents. Enrolled patients received repetitive nerve stimulation (train of four (TOF)) using PNS and EMG at left wrist for ulnar nerve stimulation. Train of Four was delivered via a handheld device (MiniStim® MS-1B) at 2Hz frequency with 50mAmp current. Same surface electrodes and frequency was used with the EMG machine. However, the current intensity and duration of stimulation was determined individually, based on eliciting the supra maximal response. TOF was delivered and responses recorded using both PNS and EMG in each study session. Measurements were repeated, at least 48 hr apart, up to a total of three sessions. Results: The supramaximal stimulus determined by the EMG machine was higher than the maximum current (50mA) that could be delivered by the PNS, for every single patient who was tested. The mean supramaximal current in the patient population was 83.48 ± 16.2. There was no difference in TOF counts elicited by using the PNS and EMG. Conclusions: Conventional PNS devices designed for use in the operating room may not monitor NMBD effect accurately in critically ill patients, due to a higher current required to achieve supramaximal stimulus.