title: Rethinking critical care: decreasing sedation, increasing delirium monitoring, and increasing patient mobility.
abstract: BACKGROUND
  Sedation management, delirium monitoring, and mobility programs have been addressed in evidence-based critical care guidelines and care bundles, yet implementation in the ICU remains variable. As critically ill patients occupy higher percentages of hospital beds in the United States and beyond, it is increasingly important to determine mechanisms to deliver better care. The Institute for Healthcare Improvement's Rethinking Critical Care (IHI-RCC) program was established to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. Case studies of a convenience sample of five participating hospitals/health systems chosen in advance of the determination of their clinical outcomes are presented in terms of how they got started and process improvements in sedation management, delirium management, and mobility.
  
  
  METHODS
  The IHI-RCC program involved one live case study and five iterations of an in-person seminar in a 33-month period (March 2011-November 2013) that emphasized interdisciplinary teamwork and culture change.
  
  
  RESULTS
  Qualitative descriptions of the changes tested at each of the five case study sites demonstrate improvements in teamwork, processes, and reliability of daily work. Improvement in ICU length of stay and length of stay on the ventilator between the pre- and postimplementation periods varied from slight to substantial.
  
  
  CONCLUSIONS
  Changing critical care practices requires an interdisciplinary approach addressing cultural, psychological, and practical issues. The key lessons of the IHI-RCC program are as follows: the importance of testing changes on a small scale, feeding back data regularly and providing sufficient education, and building will through seeing the work in action.
authors.affiliation: St. Luke's Hospital Boise/Meridian, Idaho, USA.
authors.forename: Rick
authors.initials: R
authors.lastname: Bassett
authors.forename: Kelly McCutcheon
authors.initials: KM
authors.lastname: Adams
authors.forename: Valerie
authors.initials: V
authors.lastname: Danesh
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Groat
authors.forename: Angie
authors.initials: A
authors.lastname: Haugen
authors.forename: Angi
authors.initials: A
authors.lastname: Kiewel
authors.forename: Cora
authors.initials: C
authors.lastname: Small
authors.forename: Mark
authors.initials: M
authors.lastname: Van-Leuven
authors.forename: Sam
authors.initials: S
authors.lastname: Venus
authors.forename: E Wesley
authors.initials: EW
authors.lastname: Ely
mesh_terms: D003422:Critical Care / Q000458:organization & administration*; D003693:Delirium / Q000175:diagnosis / Q000628:therapy*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage; D007362:Intensive Care Units / Q000458:organization & administration*; D007902:Length of Stay; D059408:Pain Management / Q000379:methods*; D064872:Patient Care Bundles; D011787:Quality of Health Care / Q000458:organization & administration*; D015203:Reproducibility of Results; D012121:Respiration, Artificial / Q000379:methods; D014481:United States; D016138:Walking
chemical_list: D006993:Hypnotics and Sedatives