Critical Care Medicine

Critical care medicine refers to intensive care of medicine (non-surgical) patients. All intensive care units (sometimes called critical care units) exist for one reason... to provide specialized, intensive care and treatment to people who are very seriously ill, critically ill or injured, and to provide close monitoring of patients whose conditions are unstable and unpredictable. Patients requiring intensive care may need support to stabilize their blood pressure or breathing, kidney function, heart rhythm or support organs that are not functioning.

Our Critical Care Medicine Unit or CCMU is a 20-bed unit that provides intensive observation and specialized nursing care for critically ill adult medical patients, including patients with respiratory failure, acute respiratory problems and H1N1 flu (also called swine flu), liver failure, kidney failure, sepsis, gastrointestinal bleeding, and hormonal or fluid imbalances. Physicians in the CCMU are experts in the field of acute respiratory distress syndrome (ARDS) and are members of a national network of researchers that tests new therapies to improve care for ARDS patients.

The physicians in our CCMU surpass national ICU staffing standards. And, mortality rates for CCMU patients are better than national benchmarks. The equipment used in the ICU can sustain life but can also increase the risk of infection. We work hard to prevent infections; our bloodstream infection rate is very low compared to national benchmarks.

Clinicians in the CCMU have been leaders in several important quality initiatives, including the statewide Keystone project that implemented practices now being adopted by ICUs across the country to reduce bloodstream infections. Their work was recognized in 2011, when the US Department of Health and Human Services conferred the CCMU with an Outstanding Leadership Award in Achievements in Eliminating Central Line-Associate Bloodstream Infections. The CCMU is now implementing new practices to encourage early mobility and improve physical functioning and quality of life for patients.

In evaluating our performance, it is important to consider several types of measures, including physician staffing standards, adherence to best practices (or care process) and the success (or outcome) of care.

A growing body of scientific evidence suggests that quality of care in hospital ICUs is strongly influenced by whether the ICU employs physicians who are specialists at providing care to critically ill patients (called "intensivists") and whether these physicians provide care exclusively in the ICU. The University of Michigan fully adheres to ICU staffing standards developed by the Leapfrog Group, a consortium of large companies that measures hospital practices that promote quality of care and patient safety.

Physician Staffing
Higher Value = Better Performance

Details

Why is This Measure Important?

This measure, from the Leapfrog Group, used to assess compliance with standards for physician staffing by intensivists. The specific Leapfrog standard is written as:

Hospitals fulfilling the ICU Physician Staffing Standard will operate adult or pediatric general medical and/or surgical ICUs and neuro ICUs that are managed or co-managed by intensivists who:

  1. Are present during daytime hours and provide clinical care exclusively in the ICU.
  2. When not present on site or via telemedicine, return pages at least 95% of the time, (i) within five minutes and (ii) arrange for a physician, physician assistant, nurse practitioner, or a FCCS-certified nurse to reach ICU patients within five minutes.

How is UMHS Performing?

The University of Michigan CCMU fully adheres to the Leapfrog Group ICU physician staffing standards.

UMHS Source: Documented evaluation of CCMU staffing practices.
Comparison Group Source: Leapfrog Group ICU Physician Staffing standard

 

This section displays measures that describe the extent to which the University of Michigan Health System follows best practices when caring for intensive care patients who are on a ventilator. A ventilator is used to help patients breathe when they are unable to breathe on their own. While very important for sustaining life, ventilators increase the risk of pneumonia, which can be life-threatening in a critically ill patient. The following measures are used to assess our adherence to care processes that are designed to prevent ventilator-associated pneumonia.

Ventilator Bundle
Higher Value = Better Performance

Details

Why is This Measure Important?

A ventilator is used to help patients breathe when they are unable to breathe on their own. While very important for sustaining life, ventilators increase the risk of pneumonia, which can be life-threatening in a critically ill patient.

Our goal is to try to prevent ventilator-associated pneumonia. One method is by employing the "ventilator bundle", which describes 5 actions designed to reduce the risk of pneumonia. The positive impact of these actions is increased when they are implemented together rather than individually.

The components of the ventilator bundle are:

  1. Elevate the head of the patient's bed
  2. Reduce the patient’s sedation (if possible) so that they can be evaluated for weaning from the ventilator
  3. Assess of the patient’s readiness to be weaned from the ventilator
  4. Give medication to prevent blood clots in the legs that can occur in patients who are bed-ridden
  5. Give medication to prevent stomach ulcers due to stress  

How is UMHS Performing?

The University of Michigan CCMU has achieved significantly positive results in all five elements of the ventilator bundle.

UMHS Source: Hospital chart review.
Comparison Group Source: Institutional goal set by UMHS.

 

This section displays measures of our success in treating intensive care patients, including measures of patient mortality and occurrence of complications. In the following graphs, lower percentages indicate better performance. The risk of mortality and of complications depends on many factors, including the patient's health condition. Because the risks differ between patients, we try to compare our performance to benchmarks for similar types of patients.

The graphs show that the University of Michigan mortality and bloodstream infection rates are lower (better) than the benchmark comparisons.

Mortality
Lower Value = Better Performance

Details

Why is This Measure Important?

Patients treated in ICUs are critically ill and have a high risk of death. However, each patient's risk is different. So, for this measure, we compare our observed mortality rate to an expected mortality rate. The expected rate is calculated using a national critical care benchmarking system, called Acute Physiology and Chronic Health Evaluation (APACHE). Many hospitals across the country use the APACHE system to evaluate their success in managing critically ill patients.

This measure is expressed as a ratio of observed-to-expected mortality. A number less than 1.0 is a good result and means that fewer patients died than expected.

How is UMHS Performing?

For this and all other outcome measures, lower measurement results are better. This measure is expressed as a ratio of observed-to-expected mortality and numbers less than 1.0 mean that fewer patients died than expected.

The University of Michigan Health System's performance is consistently less than 1.0, and currently is at 0.82. This means that fewer patients died than expected (about 20% fewer), according to the APACHE critical care benchmarking system. These results demonstrate that although the University of Michigan Health System treats many complex patients in the CCMU who have serious medical problems, we are successful in managing these complex clinical cases

UMHS Source: Hospital chart review.
Comparison Group Source: Acute Physiology and Chronic Health Evaluation (APACHE).

Ventilator-Associated Pneumonia
Lower Value = Better Performance

Details

Why is This Measure Important?

A ventilator is used to help patients breathe when they are unable to breathe on their own. While very important for sustaining life, ventilators increase the risk of pneumonia, which can be life-threatening in a critically ill patient. The risk of death is much higher in ventilated patients who develop ventilator-associated pneumonia (VAP) compared to ventilated patients who do not develop VAP.

Rates of VAP are expressed as the number of VAP per 1,000 ventilator days. Our rates are compared to rates from the Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) national average for medical intensive care units in major teaching hospitals. Some critically ill patients, particularly those with compromised immune systems, are more susceptible to infection. Unfortunately, the CDC national average is not adjusted to correct for the patients' risk for infection. The risk of the patients we treat may be greater than the risk of patients represented in the CDC national average, because the University of Michigan Health System treats many complex patients who have lung diseases and compromised immune systems. Despite this, our goal is to prevent ventilator-associated pneumonia or VAP through use of the ventilator bundle and other methods. (See ventilator bundle measurement results in "Process".)

How is UMHS Performing?

For this and all other outcome measures, lower rates are better.

The University of Michigan Health System has reduced ventilator-associated pneumonia (VAP) rates in the CCMU but results are slightly higher than the CDC national average for medical intensive care units, despite the success the unit has shown in adhering to elements of the ventilator bundle. Staff and physicians in the CCMU conduct "root cause analyses" to identify factors that may be contributing to the occurrence of VAP and formulate improvement plans.

UMHS Source: Hospital chart review and Infection Control & Epidemiology department findings.
Comparison Group Source: Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN).

Blood Stream Infections
Lower Value = Better Performance

Details

Why is This Measure Important?

Central lines are often used in ICUs to provide physicians and nurses access to the patient's bloodstream in order to administer medications or monitor blood pressure. Central lines are inserted through the skin, making infection with bacteria possible. Infection may spread to the bloodstream, which can increase the risk of organ failure and death.

Rates of central-line-associated bloodstream infections (CLA-BSI) are expressed as the number of CLA-BSI per 1,000 central line days. Our rates are compared to rates from the Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN) national average for surgical intensive care units. Some critically ill patients, particularly those with compromised immune systems, are more susceptible to infection. Unfortunately, the CDC national average is not adjusted to correct for the patients' risk for infection. The risk of the patients we treat may be greater than the risk of patients represented in the CDC national average, because the University of Michigan Health System treats many complex patients who have compromised immune systems. Despite this, our goal is to prevent CLA-BSI.

How is UMHS Performing?

For this and all other outcome measures, lower rates are better.

The University of Michigan Health System treats many patients who are susceptible to central line-associated bloodstream infections (CLA-BSI). Our efforts to prevent these infections have been successful and can be linked to our methodical approach to inserting lines using sterile techniques that reduce the risk of infection from the skin. While we have not eliminated them, our CLA-BSI rates are declining and are statistically significantly lower than the CDC national average for medical intensive care units at major teaching hospitals.

UMHS Source: Hospital chart review and Infection Control & Epidemiology department findings.
Comparison Group Source: Centers for Disease Control (CDC) National Healthcare Safety Network (NHSN).