Quality Assurance and Patient Safety in The Intensive Care Unit

1 How is quality assessed?

The definition of quality encompasses many things but clearly involves meeting the expectations of the consumer. In health care, this standard usually involves the satisfaction of patients, physicians, and payers, as well as good clinical outcomes, appropriate resource use, cost containment, and attention to patient safety.

2 What is benchmarking?

To benchmark means to compare one’s own performance-related data with similar data from another institution. The Joint Commission requires that hospitals benchmark with other hospitals. This process has grown tremendously, and numerous quality indicators are now reported and available to the public. The Surgical Care Improvement Project was a benchmarking process with a goal to reduce the incidence of surgical complications by 25% by 2010. The appropriate use of deep vein thrombosis prophylaxis is an example of a quality indicator that when compared among different hospitals gave insight into the quality of care they provided.

3 What is the relationship between the intensive care unit (ICU) organization and quality of care?

Evidence indicates that the structure and organization of an ICU can influence outcome. A collaborative relationship among members of the health care team is critical. A multidisciplinary approach with the addition of a full-time intensivist greatly improves the quality of patient care in the ICU, as does the presence of critical care nurses with appropriate staffing ratios and clinical pharmacists on the unit. The use of clinical protocols continues to expand, with reliable data about their use leading to an improvement of care in critically ill patients. The use of spontaneous breathing trials has been validated in multiple studies, but worldwide its use remains stagnant at best. Not using a protocolized weaning system is an example of the need for organizational improvement in an ICU to improve care. Resistance to protocol use has come in many forms, but one of the primary arguments has been the unwillingness of physicians to reduce medicine to a cookbook profession and the need for individual tailored care for each patient. An inherent mistake in this argument is a lack of recognition of the individualized clinical data from each patient that is analyzed and used to treat the patient in a logical manner.

Resistance to change in the practice of critical care medicine is reflective of a broader problem in medicine in which studies suggest that 30% to 40% of patients do not receive care consistent with current medical knowledge.

4 List the uses to which severity of illness scoring systems are commonly applied

Stratification: Multiple scoring systems exist to stratify the severity or acuity of illness of critically ill patients. Examples of such classification systems are the:

Acute Physiology and Chronic Health Evaluation (APACHE)

Simplified Acute Physiology Score (SAPS)

Sequential Organ Failure Assessment (SOFA)

Multiple Organ Dysfunction Score (MODS)

These systems allow comparison of outcomes related to differing therapeutic approaches and attempt to match patients for severity of illness. The multiple scoring systems have not been compared in a prospective manner. Scoring systems for specific disease processes in critically ill patients exist, such as the risk, injury, failure, loss (complete loss of kidney function × 4 weeks) and end-stage kidney disease (complete loss of kidney function × 3 months) (RIFLE) criteria for kidney injury. Disease-specific scoring systems allow for standardized assessment enabling uniformity for research.

Efficiency of care delivery: Efficiency can be measured only if objective measures of resources are used together with models that define a population’s acuity of illness. It is important that the stratification of illness models have some validity in predicting outcome. These may be provided by the APACHE system and the Therapeutic Intervention Scoring System, among others.

Decision making in clinical management: Decision making may be aided by considering the information provided by scoring systems as these models allow physicians to stratify patients into cohorts. However, clinicians must be cognizant that scoring systems provide population illness overview, not specific patient prognosis. Individual patient data must be used when providing prognostic information for patients and their families.

Economics: Scoring of patients can assist in appropriate billing and reimbursement code application.

5 How is performance improvement carried out in the ICU?

The unit director in collaboration with the nurse manager and other members of the health care team should identify areas for improvements in care delivery. Performance improvement committees exist for monitoring performance indicators in ICUs and noting deficiencies. A formal process to address problems should exist. Common systems used are the PDSA process (plan, do, study, act) or PDCA process (plan, do, check, act). One proposed method for creating solutions for quality improvement in ICU is the barrier identification and creating solutions tool. It involves the creation of an interdisciplinary team that is given the authority to observe, interview, and simulate process in the ICU. The team is responsible for compiling the data and developing an action plan to create solutions to barriers to improvement in critically ill patients. This process is an example of a performance improvement method that can be generalized to solve many quality deficiencies in ICUs.

6 List a number of observations on which to base assessment of outcome

Although a variety of indicators can be used to assess outcome, the following usually provide a reasonable database and can be used for benchmarking when similar data are available from other institutions:

7 How applicable to the ICU is the clinical or critical pathway approach to the maintenance of cost-effective care delivery?

Although the development of so-called clinical pathways has had considerable success in reducing costs while maintaining or improving standards of care and clinical outcomes, this methodology appears to be applicable mainly to patients with diagnoses wherein there is a fairly homogeneous group of patients who run broadly similar courses. Good examples of these diagnoses are acute coronary syndromes and hip fractures. In the case of the patient population in a mixed adult medical-surgical ICU, however, there is no such homogeneity, and it is often virtually impossible to describe an average course for a given diagnosis. Such a diversity of progression exists that relates primarily to the individual patient circumstances that it is of little value to compare the course of an individual patient with the clinical pathway. A much better approach in the ICU is to write treatment algorithms applicable to discrete segments of the patient’s care within the continuum of the entire illness (e.g., weaning with use of therapist-driven protocols or use of the ventilator bundle, Centers for Disease Control and Prevention line insertion bundle, or sepsis bundle) (Box 88-1). The use of this approach maintains all the advantages of getting groups together to discuss and agree on a unified approach toward aspects of care (thus reducing expensive diversity) without wasting time and energy on trying to define nonexistent average courses of these illnesses.

8 Is patient safety a concern in ICUs?

Medical errors occur frequently in ICUs and can adversely affect outcome in critically ill patients. Errors occur more frequently in patients with more organ failures and in larger ICUs. Although individual mistakes may lead to errors in patient care, the solution to improving practice may be found in organizational changes.

9 How can patient safety be improved?

Health care providers can commit to a culture of safety to improve patient care. The Institute for Healthcare Improvement’s 100,000 Lives Campaign and its later 5 Million Lives Campaign helped health care organizations set specific goals and targets to improve patient safety. These goals forced health care providers to reexamine the acceptance of previously tolerated errors that increased morbidity and mortality. A zero tolerance for errors and innovative strategies from other high-risk professions have helped physicians understand that safety can be improved. For example, although significant differences exist between the airline industry and the delivery of critical care medicine, one glaring similarity exists. Mistakes can have horrendous consequences. The use of checklists in aviation has led to increased safety, and the similar use of checklists has dramatically decreased surgical complications (see Box 88-2).

10 Can you give an example of a patient safety project that dramatically improved patient care in critically ill patients?

Multiple examples exist in the medical literature, but among the most dramatic was the Michigan Health & Hospital Association Keystone ICU project, which addressed central line–associated bloodstream infections (CLABSI). Catheter-related bloodstream infections cause close to 30,000 deaths in ICUs annually, and each infection leads to accrued cost over $40,000. The safety project used five proven techniques to reduce CLABSI (see Box 88-3). After 18 months of intervention, CLABSI decreased by 60%, and in a follow-up study the results were sustained at 36 months.

11 What are common barriers to improvements in patient safety?

Introducing change into health care organizations is often fraught with difficulty. Common barriers to change include an unwillingness to abandon cultural and historical precedents that constrain a culture of safety. Health care providers must consider the partial loss of autonomy to promote patient care, such as the use of protocols in the critically ill. Education about safety deficits and also an improvement in communication among interdisciplinary team members remain important goals. Finally, resources must be invested into creating a culture of patient safety even when immediate benefits are not apparent.