2. What is Quality ? the degree to which health services
increase the likelihood of desired health outcomes and are
consistent with current professional knowledge Institute of
Medicine, 1990 ResultsQuality = Objectives Quality is defined
byQuality is defined by goalsgoals
3. ICU and Aircraft Safety is primary goal Technological
innovation Multiple sources of threat Teamwork is essential
4. ICU versus aircraft Patients more varied than aircraft
Patients more complex than aircraft Many more staff to coordinate
Many more possible complications An ICU stay is far longer than any
flight
5. The science of safety Understand system performance Use
strategies to improve system performance Standardize Create
Independent checks for key process Learn from Mistakes Apply
strategies to both technical work and team work. Recognize that
teams make wise decisions
6. Adverse Events inAdverse Events in Hospitalized
PatientsHospitalized Patients 13.5% of Medicare patients experience
a serious13.5% of Medicare patients experience a serious adverse
event during hospitalizationadverse event during hospitalization
(134,000 pts/month)(134,000 pts/month) Most common causes:Most
common causes: Medications (31%)Medications (31%) Ongoing patient
care (28%)Ongoing patient care (28%) Surgery (26%)Surgery (26%)
Infection (15%)Infection (15%) Office of Inspector General. Adverse
events in hospitals: National incidence among Medicare
beneficiaries. November 2010.
7. Audit from Latin auditus = act of hearing Synonyms:
examination, analysis, checkup, inspection, perlustration, review,
scan, scrutiny, survey, view Related: investigation, probe, check,
control, corrective
8. Reasons for auditing your ICU Audit is an essential tool for
quality improvement you only manage what you measure Audit is in
the interest of your patients to ensure safe and evidence-based
care Audit is in the interest of your ICU team to enhance team
culture, professionalism, job satisfaction Audit is in the interest
of health systems to ensure efficient and fair use of resources
Audit is an essential tool for quality improvement you only manage
what you measure Audit is in the interest of your patients to
ensure safe and evidence-based care Audit is in the interest of
your ICU team to enhance team culture, professionalism, job
satisfaction Audit is in the interest of health systems to ensure
efficient and fair use of resources
9. A. Valentin 10/2004 Tidalvolume 6ml PBW in ARDS/ALI:
Lungprotective Ventilation in Reality Brunckhorst F, Crit Care Med
2008 Perceived adherence:Perceived adherence: 80%80% Real
adherence:Real adherence: 3%3% Perceived adherence:Perceived
adherence: 80%80% Real adherence:Real adherence: 3%3%
10. A thorough, systematic examination of the processes and
results of a health care service. External Audit External Audit
Internal Audit Internal Audit Benchmarking Internal Benchmarking
Internal Quality Indicators Quality Indicators Benchmarking
External Benchmarking External
11. Paradigm of Quality Good-Bad + - t good bad Q + - t Q
Good-Better
12. A. Valentin 10/2004 Another reason for auditing your
ICUAnother reason for auditing your ICU If you dont compare your
ICU with others someone else will do it ! If you dont compare your
ICU with others someone else will do it !
13. Purpose of an audit to blame to improve to enhance to
ensure to change ASSESSMENT AND IMPROVEMENTASSESSMENT AND
IMPROVEMENT OF QUALITYOF QUALITY
14. To audit means to compare Objectives and Reality Structure
what you need vs what is provided Process what you should do vs.
what you do Outcome what you expect vs. what you find
15. Time Indicator Single ICU Internal comparisonInternal
comparison
17. Audit What is it? A search for opportunities to improveA
search for opportunities to improve Who should do it? Yourself with
the help of experts & networksYourself with the help of experts
& networks Can we identify high quality ICUs? Probably, but not
at a quick glanceProbably, but not at a quick glance Combining
measures May be helpful, but models need to be developedMay be
helpful, but models need to be developed Audit What is it? A search
for opportunities to improveA search for opportunities to improve
Who should do it? Yourself with the help of experts &
networksYourself with the help of experts & networks Can we
identify high quality ICUs? Probably, but not at a quick
glanceProbably, but not at a quick glance Combining measures May be
helpful, but models need to be developedMay be helpful, but models
need to be developed
18. Quality Areas and Management Tools
19. Quality Indicator (QI) This is a measure of a structure,
process or outcome that could be used by local teams to improve
care. A QI helps to understand a system, compare it and improve it
but they all will have limitations. They can only serve as flags or
pointers
20. List of indicators Presence of an intensivist in the ICU
24h/365d Critical incident reporting system in use Early enteral
nutrition Mild therapeutic hypothermia after CPR Reintubation
Ventilator associated pneumonia Unplanned readmission Mortality
after severe brain trauma Standardised mortality ratio
StructureProcessOutcome STER RE ICH ISC HES ZEN TRU M FR D OK UM EN
TA TION U ND QU ALIT TS- SIC HERU NG IN DE R INTE NSIVMED IZIN
ASDI
21. Ffundamental Quality Indicators !!!!Ffundamental Quality
Indicators !!!! Early ASS in ACSEarly ASS in ACS Early reperfusion
in STEMIEarly reperfusion in STEMI Semirecumbent position in
MVSemirecumbent position in MV Surgical intervention in TBISurgical
intervention in TBI with SDH of EDHwith SDH of EDH ICP in severeTBI
withICP in severeTBI with pathologic CTpathologic CT Early
management of severeEarly management of severe sepsis/septic
shocksepsis/septic shock Early enteral nutritionEarly enteral
nutrition GI-bleeding prophylaxis in MVGI-bleeding prophylaxis in
MV Appropriate sedationAppropriate sedation Early ASS in ACSEarly
ASS in ACS Early reperfusion in STEMIEarly reperfusion in STEMI
Semirecumbent position in MVSemirecumbent position in MV Surgical
intervention in TBISurgical intervention in TBI with SDH of EDHwith
SDH of EDH ICP in severeTBI withICP in severeTBI with pathologic
CTpathologic CT Early management of severeEarly management of
severe sepsis/septic shocksepsis/septic shock Early enteral
nutritionEarly enteral nutrition GI-bleeding prophylaxis in
MVGI-bleeding prophylaxis in MV Appropriate sedationAppropriate
sedation Pain management in unsedatedPain management in unsedated
ptspts Inappropriate transfusion of RBCInappropriate transfusion of
RBC Organ donorsOrgan donors Compliance with hand-washingCompliance
with hand-washing protocolsprotocols Information to
familiesInformation to families Withholding/Withdrawing
lifeWithholding/Withdrawing life supportsupport Quality survey at
ICU dischargeQuality survey at ICU discharge Presence of
intensivist 24h/dayPresence of intensivist 24h/day Adverse event
registerAdverse event register Pain management in unsedatedPain
management in unsedated ptspts Inappropriate transfusion of
RBCInappropriate transfusion of RBC Organ donorsOrgan donors
Compliance with hand-washingCompliance with hand-washing
protocolsprotocols Information to familiesInformation to families
Withholding/Withdrawing lifeWithholding/Withdrawing life
supportsupport Quality survey at ICU dischargeQuality survey at ICU
discharge Presence of intensivist 24h/dayPresence of intensivist
24h/day Adverse event registerAdverse event register
22. Unintended Event : An occurrence that harmed or could have
harmed a patient SEE: multicenter, multinational, single day study
in ICU Reporting by all ICU staff members : Voluntarily Anonymously
- Confidential
23. Selected Events Medication wrong drug, dose, or route
Airway unplanned extubation artificial airway obstruction cuff
leakage Lines, Drains dislodgement Catheters inappropriate
opening/disconnection Equipment power supply, oxygen supply,
failure ventilator, infusion pump Alarms inappropriate turn off SEE
STUDYSEE STUDY
24. SEE Study participating Countries 1 1 1 1 1 1 1 1 1 1 1 2 2
2 2 2 2 3 6 7 7 8 11 12 14 19 22 27 28 35 0 5 10 15 20 25 30 35 40
Australia USA Estonia Indonesia Macedonia Norway Poland Romania
Singapore Latvia Slovakia Albania Finland Brasil Belgium
Netherlands Slovenia Hongkong Greece Denmark India France
Switzerland Germany Czech Republic Spain Portugal UK Austria Italy
Number of ICUs 220 ICUs in 29 countries 2090 patients
25. Adverse events in ICU Frequent and in relation with
Severity of the patients Procedures Impact on : Morbidity and
mortality Finance : Iatrogenic pneumothorax : 17,312 US$ DVP and
post operative pulmonary emboli : 21,709 US$ Legal issues
Psychology and competency of the team Preventability ?
26. You should conclude that this is a very dangerous ICU No
documentation of events No evaluation No corrective action
27. If you hear this I am proud to say that I have no adverse
event in my ICU May be even no patient in that ICU
28. Critical Care Bundles Ventilator Bundle Central Line Bundle
Severe Sepsis Bundles
29. Bundles A "bundle" is a group of evidence-based care
components for a given disease that, when executed together, may
result in better outcomes than if implemented individually.
30. Bundle Design Guidelines The bundle has three to five
interventions (elements), with strong clinician agreement. Each
bundle element is relatively independent. The bundle is used with a
defined patient population in one location. The multidisciplinary
care team develops the bundle. Bundle elements should be
descriptive. Compliance with bundles is measured using all-or-none
measurement, with a goal of 95 percent or greater.
31. VAP BUNDLE
32. Ventilator-Associated Pneumonia (VAP)Bundle DVT prophylaxis
GI prophylaxis Head of bed (HOB) elevated to 30-45 Daily Sedation
Vacation Daily Spontaneous Breathing Trial
33. DVT prophylaxis Include deep venous prophylaxis as part of
your ICU order admission set and ventilator order set. Include deep
venous prophylaxis as an item for discussion on daily
multidisciplinary rounds. Empower pharmacy to review orders for
patients in the ICU. Post compliance with the intervention in a
prominent place in your ICU to encourage change and motivate
staff.
34. Head of Bed elevation Implement a mechanism to ensure
head-of-the-bed elevation, such as including this intervention on
nursing flow sheets and as a topic at multidisciplinary rounds.
Create an environment where respiratory therapists work
collaboratively with nursing to maintain head-of-the-bed elevation.
Involve families in the process by educating them about the
importance of head-of-the-bed elevation.
35. Daily sedation vacation/ Spontaneous Breathing Trials
Assess that compliance is occurring each day on multidisciplinary
rounds. Consider implementation of a sedation scale such as the
Riker scale to avoid oversedation. Post compliance with the
intervention in a prominent place in your ICU to encourage change
and motivate staff.
36. Central line bundle Hand Hygiene Maximal Barrier
Precautions Upon Insertion Chlorhexidine Skin Antisepsis Optimal
Catheter Site Selection, with Avoidance of the Femoral Vein Daily
Review of Line Necessity with Prompt Removal of Unnecessary
Lines
37. Hand Hygiene Include hand hygiene as part of your checklist
for central line placement. Keep soap/alcohol-based hand washing
dispensers prominently placed and make universal precautions
equipment, such as gloves, only available near hand sanitation
equipment.
38. Hand Hygiene Post signs at the entry and exits to the
patient room as reminders. Initiate a campaign using posters
including photos of celebrated hospital doctors/employees
recommending hand washing. Create an environment where reminding
each other about hand washing is encouraged. Signs often become
"invisible" after just a few days. Try to alter them weekly or
monthly (color, shape size).
39. Maximal Barrier Precautions Upon Insertion Include maximal
barrier precautions as part of your checklist for central line
placement. Keep equipment ready stocked in a cart for central line
placement to institute maximal barrier precautions.
40. Chlorhexidine skin antisepsis: Include Chlorhexidine
antisepsis as part of your checklist for central line placement.
Include Chlorhexidine antisepsis kits in carts storing central line
equipment. Many central line kits include povidone-iodine kits and
these must be avoided. Ensure that solution dries completely before
an attempted line insertion.
41. Daily review of Lines/ Prompt removal Include daily review
of line necessity as part of your multidisciplinary rounds. Include
assessment for removal of central lines as part of your daily goal
sheets. Record time and date of line placement for record keeping
purposes and evaluation by staff to aid in decision making.
42. SEVERE SEPSIS BUNDLES
43. severe sepsis bundles The sepsis resuscitation bundle The
sepsis management bundle
44. Sepsis resuscitation bundle describes seven tasks that
should begin immediately, but must be accomplished within the first
6 hours of presentation for patients with severe sepsis or septic
shock. Some items may not be completed if the clinical conditions
described in the bundle do not prevail in a particular case, but
clinicians should assess for them. The goal is to perform all
indicated tasks 100 percent of the time within the first 6 hours of
identification of severe sepsis.
45. SURVIVING SEPSIS CAMPAIGN BUNDLES TO BE COMPLETED WITHIN 3
HOURS 1) Measure lactate level 2) Obtain blood cultures prior to
administration of antibiotics 3) Administer broad spectrum
antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or
lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS 5) Apply
vasopressors (for hypotension that does not respond to initial
fluid resuscitation to maintain a mean arterial pressure [MAP] 65
mm Hg) 6) In the event of persistent arterial hypotension despite
volume resuscitation (septic shock) or initial lactate 4 mmol/L (36
mg/dL): -Measure central venous pressure (CVP) -Measure central
venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial
lactate was elevated
46. Quality is not about individual performanceQuality is not
about individual performance Structures and processes in the ICU
that ensure that every patient, every time, receives every
applicable evidence-based best practice Structures and processes in
the ICU that ensure that every patient, every time, receives every
applicable evidence-based best practice
47. What a team needs to knowWhat a team needs to know What are
our goals ? Do we reach our goals ? What are our strengths ? What
are our weak points ? Are we getting better ? What are our goals ?
Do we reach our goals ? What are our strengths ? What are our weak
points ? Are we getting better ?
