April 19, 2023 1

Daily Goals Facilitates VAE Prevention

Nishi Rawat, M.D.Armstrong Institute for Patient Safety and Quality

Department of Anesthesia and Critical Care Medicine

Johns Hopkins Medicine

Program support provided by MHA Keystone Center. Scientific expertise and educational presentations provided by Harvard Medical School.

Objectives• Identify the basics of communication• Discuss the importance of having Daily Goals• Discover how Daily Goals can foster independent

redundancy                                                   • Improve interdisciplinary communication through the use of

Daily Goals • Understand that Daily Goals is a tool to improve teamwork and

communication AND supports interventions to prevent VAE• Explore implementation of Daily Goals in your unit

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Outline

• Communication and healthcare• Communication and the ICU

– Importance of multi-disciplinary rounds• Daily Goals rounding tool

– Background– Use– Evidence in support

• Next steps

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CUSP & VAE Prevention

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CUSP VAE

1. Educate on the science of safety

2. Identify defects

3. Assign executive to adopt unit

4. Learn from Defects

5. Implement teamwork tools

1. Head of bed elevation

2. Spontaneous breathing trials

3. Spontaneous awakening trials

4. Subglottic endotracheal tube

5. Early mobility

6. Structural Measures

Communication and Healthcare

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Most Frequently Identified Root Causes of Sentinel Events Reviewed by The Joint Commission by Year

Joint Commission Office of Quality MonitoringApril 19, 2023

Communication and Healthcare

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Frequency of Contributing Factors to Patient Safety Events by Setting

Lawton et al. BMJ Qual Saf 2012;21:369-80April 19, 2023

Communication and the ICU

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“This multidisciplinary team approach best provides cost-effective, high quality critical care services that will improve patient safety satisfaction and outcomes.”

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Communication and the ICU

High performing ICUs share the following qualities: team-oriented, shared beliefs, education, collegiality, informal but direct communication, collaborative problem-solving

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Communication and the ICU

“In a large population-based sample of hospitals, dailyrounds by a multidisciplinary care team were independentlyassociated with lower mortality in ICU patients.”

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Communication and the ICU

“1 in 4 family members of patients surviving to discharge from our hospital’s neuro ICU and MICU perceived that they had received inconsistent information from ICU staff….more than 1 in 3 perceived such episodes to occur more than 1 occasion during admission.”

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Daily Goals Rounding Tool

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“use of this daily or short-term goals sheet…was associated with improved communication among providers and a 50% reduction in ICU LOS.”

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Daily Goals and Outcomes

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• Understanding Patient Care Goals • Impact on ICU Length of Stay

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00.10.20.30.40.50.60.70.80.91

1 2 3 4 5 6

Residents

Nurses

Daily Goals

Pronovost J Crit Care 2003;18(2):71-5

Daily Goals

Weeks

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Crew Resource Management

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• Safety training program focused on effective team management to improve performance

• Targets cognitive and interpersonal skills• Stresses the use of all possible informational sources• Goal: improve situational and self-awareness,

communication, flexibility, assertiveness, adaptability• Create culture with freedom to question authority

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Communication and Aviation Accidents

April 19, 2023 14Lawton et al. BMJ Qual Saf 2012;21:369-80

Physician Rounds

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Conventional Rounds

• Communication defects are common

• Rounds are generally provider rather than patient centered

• Discussion on rounds is divergent (brainstorming) rather than convergent (explicit plan)

• Prevents effective real-time or future feedback regarding plan of care

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Rounds with Daily Goals

• Creates explicit goals and enables feedback toward goals to achieve more for the patient

• Standardizes communication to reduce encoding and decoding errors, and creates independent checks

• Adds convergent thinking to often divergent rounds

• Helps ensure diverse input

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Example of Daily Goals Tool

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How is Daily Goals used?

• Be explicit

• Address important questions– What needs to be done to get the patient off the ventilator?– What will we do today?– What is the patient’s greatest safety risk?

• Complete on rounds and nurse reads back

• Stays with bedside nurse

• Modify to fit your unit

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Evidence in Support of Daily Goals• Part of multifaceted interventions associated with significant and sustained

reductions in HAIs (Pronovost 2006, Berenholtz 2011, Berenholtz 2014)• Observational studies demonstrate improved:

– ICU length of stay (Narasimhan 2006)– Provider communication (Schwartz 2008, Siegele 2009)

• Identifying gaps in care • Standardizing tasks• Coordinating care for complex patients

– Understanding of patient care goals and plan (Agarwal 2008)– Compliance with VAP prevention interventions (DuBose 2007)

• Improved outcomes across diverse community and tertiary ICUs: medical, surgical, trauma, burn, and pediatrics

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What should you do now?

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Daily Goals preparation:

1) Assess the current state of rounds on your unit (next slide)

2) Look at the samples of Daily Goals

3) Educate providers using the Daily Goals Fastfacts sheet

4) Present the idea to your ICU team

5) Obtain support from an ICU physician to champion the effort

6) Draft a Daily Goals tool suitable for your unit

7) Pilot the Daily Goals tool during rounds and get feedback

What is the state of rounds on your unit?

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1. Describe the structure of the participating unit(s). For example, the type unit (i.e. ICU, Med Surg, Ancillary), open vs. closed, intensivists vs. hospitalists, how many beds.

2. Are rounds currently held on the participating unit(s)?

3. How often are rounds held?

4. Who usually attends rounds?

5. What are the roles of each member?

6. Where do rounds usually take place?

7. Is there a defined structure/process for rounds? If so what is it? Or does it depend on who is running them?

8. Are Daily Goals part of the rounding structure/process?

9. How have rounds made a difference in the past year in improving performance?

10. What is the major barrier for multidisciplinary round and Daily Goals implementation on your unit?

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Next Steps for CUSP

Conduct a culture assessment (HSOPS) Establish an interdisciplinary CUSP team Partner with a Senior Executive Review the Science of Safety training Identify defects Download results from your culture assessment (HSOPS) and

share with team Meet regularly with your CUSP team Use the Daily Goals tool in your ICU

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Next Steps for Data Collection

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Unit Lead completes Structural Assessment Unit staff complete HSOPS Unit Lead/Data Facilitator enters Daily Process Measures Unit Lead/Data Facilitator enters monthly VAE rates Unit Lead/Data Facilitator enters Early Mobility Measures Unit staff complete Exposure Receipt Assessment via survey link Data Facilitator contemplates next steps for collecting Objective

Outcomes Measures Unit Lead/Data Facilitator pulls data reports from the data portal and

share the feedback with your frontline staff

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Questions

Contact the CUSP 4 MVP-VAP Help Desk at cusp4mvp@jhmi.edu for all questions!

The Daily Goals Fastfacts sheet and Daily Goals examples may be found at the CUSP 4 MVP Portal:https://armstrongresearch.hopkinsmedicine.org/cusp4mvp/webinars.aspx

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References• Joint Commission: Sentinel Event. Available at: http://www.jointcommission.org/sentinel_event.aspx. Last accessed

February 28, 2014. • Lawton R, McEachan RR, Giles SJ, et al: Development of an evidence-based framework of factors contributing to

patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf 2012;21:369-380.• Zimmerman JE, Shortell SM, Rousseau DM, et al: Improving intensive care: observations based on organizational

case studies in nine intensive care units: a prospective, multicenter study. Crit Care Med 1993;21:1443-1451.• Kim MM, Barnato AE, Angus DC, et al: The effect of multidisciplinary care teams on intensive care unit mortality.

Arch Intern Med 2010; 170:369-76. • Hwang DY, Yagoda D, Perrey HM, et al: Consistency of communication among intensive care unit staff as perceived

by family members of patients surviving to discharge. J Crit Care 2014;29:134-138. • Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care

2003; 18:71-75.• Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in

the ICU. N Engl J Med 2006;355:2725-2732. • Berenholtz SM, Pham JC, Thompson DA, et al: Collaborative cohort study of an intervention to reduce ventilator-

associated pneumonia in the intensive care unit. Infect Control Hosp Epidemiol 2011;32:305-314. • Berenholtz SM, Lubomski LH, Weeks K, et al. On the CUSP: Stop BSI program. Eliminating central line-associated

bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol 2014;35:56-62.

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References (cont’d)

• Narasimhan M, Eisen LA, Mahoney CD, et al. Improving nursephysician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Care 2006;15:217-22.

• Schwartz JM, Nelson KL, Saliski M, et al. The daily goals communication sheet: a simple and novel tool for improved communication and care. Jt Comm J Qual Patient Safety 2008;34:608-13.

• Siegele P. Enhancing outcomes in a surgical intensive care unit by implementing daily goals tools. Crit Care Nurse 2009;29:58-69.

• Agarwal S, Frankel L, Tourner S, et al. Improving communication in a pediatric intensive care unit using daily patient goal sheets. J Critical Care 2008;23:227-235.

• Dubose JJ, Inaba K, Shiflett A, et al. Measurable outcomes of quality improvement in the trauma intensive care unit: The impact of a Daily Quality Rounding Checklist. J Trauma 2008;64:22-29.

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