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Dedicated Trauma ICU Cuts Infection Rates
Marko Bukur, MD, an attending trauma physician at both Broward Health Medical Center in Fort Lauderdale, Florida, and Delray Medical Center in nearby Delray Beach, set out to study the differences in trauma patient outcomes between the two facilities’ intensive care units (ICUs). Broward has a mixed ICU, whereas Delray has a dedicated trauma ICU (TICU).
Burkur’s observations, based on working in both units, led him to hypothesize that outcomes would be better in a dedicated TICU, according to an article posted on the HealthLeaders Media website.
Burkur saw that care at the dedicated unit was more cohesive, had more organized nurse involvement during rounds, and relied less on consultants than did the mixed ICU. He and his colleagues conducted a retrospective review of the ICUs that were both level-I trauma centers and covered by a single group of surgical intensivists.
The researchers examined the outcomes for 3,833 patients over 5 years. TICU patients were significantly older than those in the mixed ICU (57.8 vs. 47.0 years, respectively; P < 0.0001); had a significantly higher Charlson score (2 vs. 1; P = 0.001); had significantly more-severe head injuries (Head Abbreviated Injury Scale [AIS] score greater than or equal to 3: 50.0% vs. 37.5%; P < 0.0001), and had a significantly greater injury burden (Injury Severity Score [ISS] of greater than 16: 49.6% vs. 38.6%; P < 0.0001) The need for immediate operative intervention was similar between the two units (18.0% vs. 17.6%; P = 0.788).
“There were pretty striking differences in the amount of ICU complications that occurred,” Bukur told HealthLeaders Media. Specifically, the researchers found the following:
- Overall complications were significantly higher in trauma patients admitted to the mixed ICU compared with those admitted to the dedicated TICU (27.5% vs. 17.0%, respectively; P < 0.0001).
- Failure to rescue was also significantly more common in trauma patients admitted to the mixed ICU (3.7% vs. 1.8%; P < 0.0001).
- Trauma patients admitted to the dedicated TICU had a significantly lower chance of developing a post-injury complication (P < 0.0001).
- The overall mortality rate was significantly lower among patients in the TICU (P < 0.0001).
The findings were published in the May 2015 issue of the Journal of Trauma and Acute Care Surgery.
When Robyn Farrington, RN, trauma program manager at Broward, saw the study results, she made some fundamental changes in her ICU.
First, the placement of trauma beds was changed simply by reassigning where on the unit trauma patient beds were located.
Previously, “trauma patients could really be scattered anywhere within those 24 beds,” Farrington said. Now, the higher-number beds — about eight to 12 of them — are designated for trauma patients so that all of these patients are near each other on the unit.
The other big change was assigning a core group of ICU nurses to work as dedicated trauma nurses. “The nurse manager engaged the staff to determine those nurses who really wanted to work the trauma patients,” Farrington said.
As a result, trauma patients are now cohorted together and cared for by a dedicated nursing staff, thus creating a “closed” unit without physically closing it off, putting up walls, or doing any costly construction.
In addition to reassigning the beds, the nurse manager reached out to the nursing staff to determine who would be part of the new trauma team, and to ensure that they had their Trauma Nursing Core Course (TNCC) certifications up to date and current. After that, it was simply a matter of creating new schedules.
The changes have resulted in cost reductions and patient outcome improvements within the ICU, Farrington told HealthLeaders Media. She later said via email that since its inception in August 2014, the changes have so far led to the following improvements:
- Decreased length-of-stays have led to a savings of slightly more than $100,000.
- Prior to implementation of the dedicated TICU at Broward, there were nine or ten cases of pneumonia per quarter. In the final quarter of 2014, there were four cases; and in the first quarter of 2015, there has been only one case of pneumonia.
- Four central line-associated bloodstream infections (CLABSIs) were documented in the 8 months before the change; for the past 9 months, only one CLABSI has been reported in the trauma population.