ICU model helps hospital identify preventable patient health issues

A new data-rich rounding process has helped to contribute to better patient safety, decreased mortality and shorter stays in an intensive care unit for chronically ill patients.

Developed by Rutgers and RWJBarnabas Health System, the new model for intensive care—called Leadership, Ownership, Transformation, Unity and Sustainability (LOTUS)—identifies preventable and previously overlooked factors that often result in patients going to the ICU, according to researchers.

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LOTUS was developed at Robert Wood Johnson University Hospital Hamilton, a 248-bed community hospital in central New Jersey, following its 2016 merger with the newly formed RWJBarnabas Health System.

At the time, the hospital’s ICU transitioned to a single, mixed closed unit utilizing a doctor-focused rounding system in which the critical care physician was the dedicated attending clinician for all patients. However, this model was unable to support “corporate leadership expected transparency in quality metrics,” according to a recent study published in the journal Creative Nursing.

“The unit’s nursing leadership, in partnership with leadership from each discipline, seized the opportunity to address the team dynamics and rounding process to assure that accountability could be demonstrated through reliable quality metric data assessment,” state the authors. “Simultaneously, the unit’s nursing leadership was charged with capturing care delivery quality metrics for the system-wide ICU report card.”

“Faced with two parallel priorities, the clinical director formed a small workgroup and developed a daily rounding tool to align each initiative and capture real-time activity,” added the authors. “Key data points would be collected during daily rounds and capture real-time activity. Key data points would be collected during daily rounds to capture real-time information and minimize labor-intensive manual data retrieval.”

The new model replaced an old one that had no formal structure for rounds and in which patient care decisions were exclusively led by the ICU physician, without routine focus on patient goals or significant input from nurses, pharmacists and other members of the ICU team.

“We took a model that was fragmented and sometimes strayed from keeping the patients’ own wishes central to the decision-making process—and developed one that is much more efficient, thoughtful and deliberative,” said lead researcher Liza Barbarello Andrews, a clinical associate professor at Rutgers’ Ernest Mario School of Pharmacy and critical care pharmacy specialist at Robert Wood Johnson University Hospital.

The new model found that key areas of quality critical care focus—such as ventilator indicators or antimicrobial stewardship—were not routinely addressed on rounds, and that rounding styles varied greatly, which directly impacted the dialogue of the ICU team.

The model also provided an analysis of where the ICU was not routinely identifying the causes of health issues that sent patients to the hospital in the first place—and, in the process, missed opportunities to prevent admissions, according to Andrews.

“Many patients present with life-threatening complications due to failure to take their diabetes or blood pressure medications,” she added. “We would treat the resulting problem, but hadn't been routinely investigating what led to the issue or designed a solution to prevent it from happening again in the future. Under the LOTUS model, by focusing on the patient perspective, we discovered that some patients had received confusing, mixed messages about the medicine from their healthcare providers. Other patients were struggling with financial or emotional problems that made self-care difficult.”

Thanks to the LOTUS model, Andrews contends that ICU social workers are better able to address those issues with patients and their families so they do not arise again.

Currently, other RWJBarnabas Health System campuses are assessing how the model can be implemented by their ICU teams.