Maintaining quality of care 24/7 in a nontrauma surgical intensive care unit
The Journal of Trauma and Acute Care Surgery, 05/04/2012
McMillen MA et al. – Annual mortality immediately improved at a busy nontrauma hospital with rapid, structured consultation by the surgical intensive care unit (SICU) team, comprehensive daily rounds guided by critical care best practices, and daytime in–unit surgical intensivists. Low mortality was maintained over 9years as surgery volume nearly doubled but did not improve further with 24/7 in–unit coverage by surgical intensivists and cardiac surgeons. The process of care in an SICU may be more important than 24hour a day, 7days a week intensivists.Methods
- In 2001, a new surgical critical care service was created for an 800-bed urban teaching hospital with a 12-bed surgical intensive care unit (SICU).
- Consults, daily rounds, daily notes, and adherence to best practices were standardized over the next 9years for a team of postgraduate year-1 and -2 surgical residents, physician assistants and surgical intensivists.
- The Fundamentals of Critical Care Support course was given as basic introduction, and published guidelines for ventilators, hemodynamics, cardiac, infections, and nutrition management were implemented.
- A "beyond FCCS" curriculum was repeated every resident rotation.
- A 12-bed stepdown unit was developed for the more stable patients, mostly run by SICU physician assistants with SICU attending coverage.
- The first 5years, night coverage was by the daytime intensivist from home.
- The last 4years, night coverage was in-unit surgical intensivists or cardiac surgeons.
- Data for 13,020 patients drawn from 152,154 operations over 9years is reported.
- Surgery grew 89% to 24,000cases/year in 2010.
- Half the patients were general, gastrointestinal oncology, or vascular surgery.
- Ninety-two percent were perioperative.
- The 8% nonoperative patients were mostly gastrointestinal bleeding, abdominal pain, or pancreatitis.
- In the first year, annual SICU mortality decreased from an average of 4.5% the 5 previous years to 1.96% (2002) and remained 1.75% (2003), 2.1% (2004), 1.9% (2005), 1.5% (2006), 1.5% (2007), 2.2% (2008), 2.4% (2009), and 2.1% (2010).