Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices:

Systemwide change of sedation wean protocol following pediatric laryngotracheal reconstruction

IMPORTANCE

Pediatric laryngotracheal reconstruction (LTR) remains the standard surgical technique for expanding a stenotic airway and necessitates a multidisciplinary team. Sedation wean following LTR is a critical component of perioperative care. We identified variation and communications deficiencies with our sedation wean practice and describe our experience implementing a standardized sedation wean protocol.

OBJECTIVE

To standardize and decrease length of sedation wean in pediatric patients undergoing LTR.

DESIGN, SETTING, AND PARTICIPANTS

Using Institute for Healthcare Improvement (IHI) methodology, we implemented systemwide change at a tertiary care center with the goal of improving care based on best practice guidelines. We created a standardized electronic sedation wean communication document and retrospectively examined our experience in 29 consecutive patients who underwent LTR before (n = 16, prewean group) and after (n = 13, postwean group) wean document implementation.

INTERVENTIONS

Implementation of a standardized sedation protocol.

MAIN OUTCOMES AND MEASURES

Presence of sedation wean document in the electronic medical record, length of sedation wean, and need for continued wean after discharge.

RESULTS

The sedation wean document was used in 92.3% patients in the postwean group. With the new process, the mean (SD) length of sedation wean was reduced from 16.19 (11.56) days in the prewean group to 8.92 (3.37) days in the postwean group (P = .045). Fewer patients in the postwean group required continued wean after discharge (81.3% vs 33.3%; P = .02).

CONCLUSIONS AND RELEVANCE

We implemented a systemwide process change with the goal of improving care based on best practice guidelines, which significantly decreased the time required for sedation wean following LTR. Our methodological approach may have implications for other heterogeneous patient populations requiring a sedation wean.

Reorganizing a hospital ward as an accountable care unit

Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

A multicenter study of the point prevalence of drug-induced hypotension in the ICU

OBJECTIVE

To determine the point prevalence of drug-induced hypotension episodes in critically ill patients, to assess the episodes resulting from error, and to describe how episodes are treated.

DESIGN

Multicenter observational, 24-hour snapshot study.

SETTING

Forty-seven ICUs in 27 institutions located in the United States, Canada, and Singapore.

PATIENTS

A total of 688 ICU patients were evaluated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were included in the study if they had an episode of hypotension in the 24 hours prior to the clinical pharmacists' evaluation. The definition for a hypotensive episode is either a systolic blood pressure less than 90 mm Hg or a decrease in systolic blood pressure of 30 mm Hg over a 2-hour period. Each episode of unintentional hypotension was assessed for suspected drug-related causes. When a drug-related cause was suspected, an objective assessment tool, the modified Kramer, was used to determine causality. A score of at least "possible" was considered drug induced, referred to as a "drug-related hazardous condition." A drug-related hazardous condition is the temporal gap (intermediate stage) between the identification of an adverse drug reaction and the subsequent onset of drug-induced injury, known as an "adverse drug event." Drug-induced episodes were evaluated for medication errors and treatment. One hundred fifty-eight patients experienced 204 hypotensive episodes that were considered unintentional and drug related. Common drugs implicated included propofol, fentanyl, metoprolol, lorazepam, hydralazine, and furosemide. A total of 54 episodes (26.5%) resulted from medication errors. Common error types were improper dose/quantity (46%) and prescribing (25%). A total of 56.9% episodes were treated.

CONCLUSIONS

Many hypotensive episodes in the ICU are drug related and require treatment. A substantial portion of these episodes result from errors and are therefore preventable. This presents opportunities to improve prescribing including optimizing drug dosing to avoid possible patient harm from drug-induced hypotension.

Reductions in invasive device use and care costs after institution of a daily safety checklist in a pediatric critical care unit

BACKGROUND

In the critical care unit, complexity of care can contribute to both medical errors and increased costs, particularly when clinicians are forced to rely on memory. Checklists can be used to improve safety and reduce cost. A number of omission-related adverse events in 2010 prompted the development of a checklist to reduce the possibility of similar future events.

METHODS

The PICU Safety Checklist was implemented in the pediatric ICU (PICU) at Children's Hospitals and Clinics of Minnesota. During a 21-month period, the checklist was used to prompt the care team to address quality and safety items during rounds. The initial checklist was paper, with two subsequent versions being incorporated into the electronic medical record (EMR).

RESULTS

The daily safety checklist was successfully implemented in the PICU. Work-flow improvements based on regular multidisciplinary feedback led to more consistent use of the checklist. Improvements on all quality and safety metrics were identified, including invasive device use, medication costs, antibiotic and laboratory test use, and compliance with standards of care. Staff satisfaction rates were > 80% for safety, communication, and collaboration.

CONCLUSION

By using a daily safety checklist in the pediatric critical care unit, we improved quality and safety, as well as the collaborative culture among all clinicians. Incorporating the checklist into the EMR improved compliance and accountability, ensuring its application to all patients. Clinicians now often individually address many checklist items outside the formal rounding process, indicating that the checklist content has become part of their usual practice. A successful implementation showing tangible clinical improvements can lead to interest and adoption in other clinical areas within the institution.

Improved perception of communication and compliance with a revised, intensive care unit-specific bedside communication sheet

Although many pediatric intensive care units (PICUs) use beside communication sheets (BCSs) to highlight daily goals, the optimal format is unknown. A site-specific BCS could improve both PICU communication and compliance completing the BCS. Via written survey, PICU staff at an academic children's hospital provided recommendations for improving and revising an existing BCS. Pre- and post-BCS revision, PICU staff were polled regarding PICU communication and BCS effectiveness, and daily compliance for completing the BCS was monitored. After implementation of the revised BCS, staff reporting "excellent" or "very good" day-to-day communication within the PICU increased from 57% to 77% (P = .02). Compliance for completing the BCS also increased significantly (75% vs 83%, P = .03). Introduction of a focused and concise BCS tailored to a specific PICU leads to improved perceptions of communication by PICU staff and increased compliance completing the daily BCS.

Prompting physicians to address a daily checklist for antibiotics: do we need a co-pilot in the ICU?

PURPOSE OF REVIEW

Failed opportunities to reduce morbidity and mortality occur when evidence-based therapies are not fully implemented in clinical practice. We reviewed the recent literature on implementation strategies in the intensive care unit, with particular attention to antibiotic therapy.

RECENT FINDINGS

Emphasis in implementation science has shifted to new models that focus more on direct, point-of-care interaction with providers as opposed to an administrative or top-down approach. Prompting physicians to use a multifaceted checklist was associated with a decrease in severity-adjusted mortality and length of stay. The majority of the benefit appears to correlate with decreased use of empirical antibiotics. A subsequent study demonstrated that face-to-face prompting regarding empirical antibiotics alone was still superior to an electronic checklist, but that long-term changes in use of empirical antibiotics resulted from the previous prompting study. Other studies demonstrate that checklists result in enhanced communication between caregivers, which may be a major explanation for their benefit.

SUMMARY

Newer implementation strategies focused on real-time, point-of-care interventions have been associated with greater impact. The most common of these new interventions is use of checklists. Greater checklist use has led to the realization that a prompting or forcing function is required for optimal benefit.

Bedside pleural procedures by pulmonologists and non-pulmonologists: a 3-year safety audit

BACKGROUND AND OBJECTIVE

Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists.

METHODS

A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed.

RESULTS

Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold.

CONCLUSIONS

Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.

Venous thromboembolism risk assessment, prophylaxis practices and interventions for its improvement (AVAIL-ME Extension Project, Iran)

BACKGROUND

Venous thromboembolism (VTE) is a major health issue worldwide. Data about VTE prophylaxis practices in developing countries are scarce.

OBJECTIVES

The primary objectives of this survey were to define the VTE risk factors in hospitalized patients, to determine the rates of VTE prophylaxis administration and guideline compliance and to assess the effects of an educational program on VTE prophylaxis practices in Iran.

PATIENTS AND METHODS

Data on 1219 patients from twenty hospitals in Iran were extracted from the AVAIL-ME Extension project main databank. VTE risks were categorized according to the Caprini Risk Assessment Model. Logistic regression analysis was carried out to assess factors influencing VTE prophylaxis. We also examined the impact of an educational program which consisted of awareness, risk assessment, internal protocol implementation and re-assessment, on VTE prophylaxis practices.

RESULTS

Of 1219 patients, 789 (65%) and 430 (35%) were surgical and medical, respectively. VTE risks, categorized in low, moderate, high and very high were detected in 14%, 17%, 26% and 43% of patients respectively with a total of 1042(85%) patients being at risk for VTE. Of 882 (85%) eligible patients for VTE prophylaxis, 737 (83.5%) received any drug prophylaxis of whom 265 (62%) were medical and 472 (60%) were surgical. ACCP guidelines compliance was 60% and 33% in surgical and medical patients respectively. Any VTE prevention, drug prophylaxis, mechanical prophylaxis and guideline adherence were, 48% vs. 64%, 45% vs. 60%, 6% vs. 9% and 34% vs. 45% respectively (p<00.1) before and after implementation of the VTE educational program.

CONCLUSIONS

Despite an overall improvement in VTE prevention, areas such as inappropriate use of VTE prophylaxis in a large number of patients, significant under-use of mechanical devices and guideline adherence require closer attention. VTE awareness education is beneficial in improving VTE prophylaxis in Iran.

The effects of safety checklists in medicine: a systematic review

BACKGROUND

Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes.

METHODS

The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included.

RESULTS

The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists.

CONCLUSION

Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

Structured Approach to Early Recognition and Treatment of Acute Critical Illness

Well-known global health priorities (malaria, pneumonia, sepsis, diarrhea, human immunodeficiency virus [HIV], tuberculosis, trauma), although very different threats to an individual’s health, share a common consequence: Development of acute, life-threatening illness. In the developed world, such illness is routinely treated in an intensive care unit (ICU) by highly specialized physicians, nurses and support staff. This model of intensive care is spreading rapidly to low and middle income countries and as it spreads, challenges and limitations to this model arise [1].

A clinical trial comparing physician prompting with an unprompted automated electronic checklist to reduce empirical antibiotic utilization

OBJECTIVES

To determine whether face-to-face prompting of critical care physicians reduces empirical antibiotic utilization compared to an unprompted electronic checklist embedded within the electronic health record.

DESIGN

Random allocation design.

SETTING

Medical ICU with high-intensity intensivist coverage at a tertiary care urban medical center.

PATIENTS

Two hundred ninety-six critically ill patients treated with at least 1 day of empirical antibiotics.

INTERVENTIONS

For one medical ICU team, face-to-face prompting of critical care physicians if they did not address empirical antibiotic utilization during a patient's daily rounds. On a separate medical ICU team, attendings and fellows were trained once to complete an electronic health record-embedded checklist daily for each patient, including a question asking whether listed empirical antibiotics could be discontinued.

MEASUREMENTS AND MAIN RESULTS

Prompting led to a more than four-fold increase in discontinuing or narrowing of empirical antibiotics compared to use of the electronic checklist. Prompted group patients had a lower proportion of patient-days on which empirical antibiotics were administered compared to electronic checklist group patients (63.1% vs 70.0%, p = 0.002). Mean proportion of antibiotic-days on which empirical antibiotics were used was also lower in the prompted group, although not statistically significant (0.78 [0.27] vs 0.83 [0.27], p = 0.093). Each additional day of empirical antibiotics predicted higher risk-adjusted mortality (odds ratio, 1.14; 95% CI, 1.05-1.23). Risk-adjusted ICU length of stay and hospital mortality were not significantly different between the two groups.

CONCLUSIONS

Face-to-face prompting was superior to an unprompted electronic health record-based checklist at reducing empirical antibiotic utilization. Sustained culture change may have contributed to the electronic checklist having similar empirical antibiotic utilization to a prompted group in the same medical ICU 2 years prior. Future studies should investigate the integration of an automated prompting mechanism with a more generalizable electronic health record-based checklist.

Outcome of adverse events and medical errors in the intensive care unit: a systematic review and meta-analysis

Adverse events and medical errors (AEs/MEs) are more likely to occur in the intensive care unit (ICU). Information about the incidence and outcomes of such events is conflicting. A systematic review and meta-analysis were conducted to examine the effects of MEs/AEs on mortality and hospital and ICU lengths of stay among ICU patients. Potentially eligible studies were identified from 4 major databases. Of 902 studies screened, 12 met the inclusion criteria, 10 of which are included in the quantitative analysis. Patients with 1 or more MEs/AEs (vs no MEs/AEs) had a nonsignificant increase in mortality (odds ratio = 1.5; 95% confidence interval [CI] = 0.98-2.14) but significantly longer hospital and ICU stays; the mean difference (95% CI) was 8.9 (3.3-14.7) days for hospital stay and 6.8 (0.2-13.4) days for ICU. The ICU environment is associated with a substantial incidence of MEs/AEs, and patients with MEs/AEs have worse outcomes than those with no MEs/AEs.

Measurable outcomes of quality improvement using a daily quality rounds checklist: two-year prospective analysis of sustainability in a surgical intensive care unit

BACKGROUND

The use of a "quality rounds checklist" (QRC) is an effective tool for improving compliance with evidence-based preventative measures and outcomes in the surgical intensive care unit (SICU). Our aim was to evaluate the long-term sustainability and outcome impact of this quality improvement strategy.

METHODS

Prospective observational study evaluates the use of the QRC in the SICU from July 2009 to June 2011. Daily compliance with evidence-based prophylactic measures was assessed using the QRC and reviewed monthly at a multidisciplinary meeting. Logistic regression was performed to evaluate patterns of compliance over time. Current compliance was compared with previously reported rates, and the impact on outcomes including catheter-related blood stream infection and ventilator-associated pneumonia rates was examined.

RESULTS

Over 2 years, 2,472 patients were admitted to the SICU. Mean (SD) age was 42.2 (22.4) years, 79% were male, and 35% had an Injury Severity Score (ISS) of greater than 15. The rate of compliance with head-of-bed elevation significantly improved during the study period (p = 0.01 for trend), with an overall compliance of 97%. Both deep venous thrombosis prophylaxis and gastrointestinal bleed prophylaxis compliance remained stable, with overall rates of 98% and 96%, respectively. The use of sedation holidays also remained stable, with an overall compliance rate of 94%. Compared with our previously published data, the compliance rates with preventative measures were stable or significantly improved; the incidence of catheter-related blood stream infections was lower (0.85/1,000 vs. 4.98/1,000 catheter days, p < 0.001); and the incidence of ventilator-associated pneumonia downtrended (1.66/1,000 vs. 8.74/1,000 ventilator days, p = 0.07).

CONCLUSION

Two years after implementation of a QRC, sustainable high rates of compliance with clinically relevant preventative measures in a SICU was demonstrated with minimal fading of clinically relevant outcomes.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Effect of a pleural checklist on patient safety in the ultrasound era

BACKGROUND AND OBJECTIVE

Bedside ultrasound allows direct visualization of pleural collections for thoracentesis and tube thoracostomy. However, there is little information on patient safety improvement methods with this approach. The effect of a checklist on patient safety for bedside ultrasound-guided pleural procedures was evaluated.

METHODS

A prospective study of ultrasound-guided pleural procedures from September 2007 to June 2010 was performed. Ultrasound guidance was routine practice for all patients under the institution's care and the freehand method was used. All operators took a half-day training session on basic thoracic ultrasound and were supervised by more experienced operators. A 14-item checklist was introduced in June 2009. It included systematic thoracic scanning and a safety audit. Clinical and safety data are described before (Phase I) and after (Phase II) the introduction of the checklist.

RESULTS

There were 121 patients in Phase I (58.7 ± 18.9 years) and 134 patients in Phase II (60.2 ± 19.6 years). Complications occurred for 10 patients (8.3%) in Phase I (six dry taps, three pneumothoraces, one haemothorax) and for 2 patients (1.5%) in Phase II (one significant bleed, one malposition of chest tube) (P = 0.015). There were no procedure-related deaths. The use of the checklist alone was associated with fewer procedure-related complications. This was independent of thoracostomy rate, pleural effusion size and pleural fluid ultrasound appearance.

CONCLUSIONS

A pleural checklist with systematic scanning and close supervision may further enhance safety of ultrasound-guided procedures. This may also help promote safety while trainees are learning to perform these procedures.

Surgical safety checklists: a review

BACKGROUND

Surgical checklists are designed to improve patient outcomes following surgery. While such checklists have been widely implemented worldwide, few studies examine surgical checklists within an Australian context. For this purpose, we have performed a literature review using data from OECD member nations to determine the effectiveness of surgical checklists in improving patient outcomes and factors that contribute to their successful implementation.

METHOD

The databases, Pubmed, Medline, EMBASE, Cochrane and CINAHL were searched using the keywords ('surgical' AND 'checklist') and ( (surgical) AND checklist) AND ( (implementation) OR (utilization) OR (usage) ). Studies were limited to those written in the English language, peer-reviewed, published between January 2000 and December 2012, and including an abstract.

RESULTS

Our search yielded 2242 papers, of which 72 papers were identified for their potential relevance and selected for full text review. Of these, nine papers met the inclusion criteria and were reviewed in detail. Evidence that supports the use of surgical checklists in countries with a large number of protocols already in place is limited. Adequate checklist implementation plays a central role in checklist effectiveness, which in turn is dependent on multiple factors.

CONCLUSION

Although evidence from OECD member countries is non-conclusive, it does suggest that surgical checklists, when effectively implemented, have the potential to be effective at reducing complication and mortality rates following surgery. Within an Australian context, more studies are needed to fully establish the potential effectiveness of surgical checklists and to monitor checklist use compliance in order to ensure greater patient safety.

Hospice patient evacuation: a case for using a checklist for safe disaster response

This study was conducted to provide lessons learned from the experience of a small, rural hospice care organization to an actual crisis that required evacuation of the facility. A process improvement framework using the emergency response certification guidelines was used to first provide details of the incident, second analyze the effectiveness of disaster planning and response in response to an actual crisis, and third discuss the post-event review, lessons learned, and process improvement. This case study revealed 5 emerging themes-disaster can happen at the most inopportune times, facilities should focus on the most likely hazards, written agreements are needed even in small tight-knit communities, redundancy of resources is needed, and disaster planning and response is a process that should be continually improved.

Neurosurgical checklists: a review

Morbidity due to avoidable medical errors is a crippling reality intrinsic to health care. In particular, iatrogenic surgical errors lead to significant morbidity, decreased quality of life, and attendant costs. In recent decades there has been an increased focus on health care quality improvement, with a concomitant focus on mitigating avoidable medical errors. The most notable tool developed to this end is the surgical checklist. Checklists have been implemented in various operating rooms internationally, with overwhelmingly positive results. Comparatively, the field of neurosurgery has only minimally addressed the utility of checklists as a health care improvement measure. Literature on the use of checklists in this field has been sparse. Considering the widespread efficacy of this tool in other fields, the authors seek to raise neurosurgical awareness regarding checklists by reviewing the current literature.

Empiric antibiotic, mechanical ventilation, and central venous catheter duration as potential factors mediating the effect of a checklist prompting intervention on mortality: an exploratory analysis

Background

Checklists are clinical decision support tools that improve process of care and patient outcomes. We previously demonstrated that prompting critical care physicians to address issues on a daily rounding checklist that were being overlooked reduced utilization of empiric antibiotics and mechanical ventilation, and reduced risk-adjusted mortality and length of stay. We sought to examine the degree to which these process of care improvements explained the observed difference in hospital mortality between the group that received prompting and an unprompted control group.

Methods

In the medical intensive care unit (MICU) of a tertiary care hospital, we conducted face-to-face prompting of critical care physicians if processes of care on a checklist were being overlooked. A control MICU team used the checklist without prompting. We performed exploratory analyses of the mediating effect of empiric antibiotic, mechanical ventilation, and central venous catheter (CVC)duration on risk-adjusted mortality.

Results

One hundred forty prompted group and 125 control group patients were included. One hundred eighty-three patients were exposed to at least one day of empiric antibiotics during MICU admission. Hospital mortality increased as empiric antibiotic duration increased (P<0.001). Prompting was associated with shorter empiric antibiotic duration and lower risk-adjusted mortality in patients receiving empiric antibiotics (OR 0.41, 95% CI 0.18-0.92, P=0.032). When empiric antibiotic duration was added to mortality models, the adjusted OR for the intervention was attenuated from 0.41 to 0.50, suggesting that shorter duration of empiric antibiotics explained 15.2% of the overall benefit of prompting. Evaluation of mechanical ventilation was limited by study size. Accounting for CVC duration changed the intervention effect slightly.

Conclusions

In this analysis, some improvement in mortality associated with prompting was explained by shorter empiric antibiotic duration. However, most of the mortality benefit of prompting was unexplained.

Development, implementation, and evaluation of an institutional daily awakening and spontaneous breathing trial protocol: a quality improvement project

INTRODUCTION

While one controlled trial found that a daily awakening and spontaneous breathing trial (DA-SBT) decreases time on mechanical ventilation (MV), there is a paucity of real-world data surrounding the development, implementation, and impact of DA-SBT protocols. We describe a multidisciplinary process improvement effort in 2, 10-bed medical intensive care units (MICUs) at a 330-bed academic medical center that focused on the development, implementation, and evaluation of a new DA-SBT protocol.

METHODS

A DA-SBT protocol, developed using results from a nursing survey literature and available institutional resources, was implemented after extensive clinician education and institution of quality reminders to boost use. Postprotocol compliance was evaluated. Use of sedation, DA and SBT practices, and clinical outcomes were retrospectively compared between the before and after DA-SBT protocol groups (ie, consecutive MICU patients requiring a continuously infused sedative [CIS] ≥24 hours).

RESULTS

In the after group (n = 32), the DA and SBT compliances were 44% and 84%, respectively. Compared with the before group (n = 33), after group patients received CIS on fewer days of MV (100% vs 67%, P = .003) and had their CIS down-titrated by ≥25% on more days of CIS (40% vs 71%, P = .006). Neither total CIS dose (P = .49), total MV days (P = .75), days of MV where a SBT occurred (P = .38), nor episodes of self-extubation (15% vs 6%, P = .43) differed between the 2 groups.

CONCLUSION

Despite the implementation of a DA-SBT protocol that was individualized to clinician preferences and institutional resources and accompanied by substantial education and reminders for use, compliance to the DA component of this protocol was low and duration of MV remained unchanged. Additional quality improvement strategies are needed to overcome barriers to DA-SBT protocol use that may not exist in controlled clinical trials.

Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care

OBJECTIVE

Although successful models for palliative care delivery and quality improvement in the intensive care unit have been described, their applicability in surgical intensive care unit settings has not been fully addressed. We undertook to define specific challenges, strategies, and solutions for integration of palliative care in the surgical intensive care unit.

DATA SOURCES

We searched the MEDLINE database from inception to May 2011 for all English language articles using the term "surgical palliative care" or the terms "surgical critical care," "surgical ICU," "surgeon," "trauma" or "transplant," and "palliative care" or "end-of- life care" and hand-searched our personal files for additional articles. Based on review of these articles and the experiences of our interdisciplinary expert Advisory Board, we prepared this report.

DATA EXTRACTION AND SYNTHESIS

We critically reviewed the existing literature on delivery of palliative care in the surgical intensive care unit setting focusing on challenges, strategies, models, and interventions to promote effective integration of palliative care for patients receiving surgical critical care and their families.

CONCLUSIONS

Characteristics of patients with surgical disease and practices, attitudes, and interactions of different disciplines on the surgical critical care team present distinctive issues for intensive care unit palliative care integration and improvement. Physicians, nurses, and other team members in surgery, critical care and palliative care (if available) should be engaged collaboratively to identify challenges and develop strategies. "Consultative," "integrative," and combined models can be used to improve intensive care unit palliative care, although optimal use of trigger criteria for palliative care consultation has not yet been demonstrated. Important components of an improvement effort include attention to efficient work systems and practical tools and to attitudinal factors and "culture" in the unit and institution. Approaches that emphasize delivery of palliative care together with surgical critical care hold promise to better integrate palliative care into the surgical intensive care unit.

Surgical prophylaxis and other complication avoidance care bundles

Individual health care quality measures that have been shown to improve outcome can be combined together into what are called care bundles, with the expectation that this set of practices produces further improvements in outcome. Prevention of surgical site infection is the focus of several quality measures put forward by the Surgical Care Improvement Project; these can collectively be considered a bundle as well. Whether these process measures, which include several components related to the administration of antibiotic prophylaxis, are effective in decreasing rates of surgical site infection has come under considerable debate recently.

Preventing errors in oncology: perspective of a physician who is also a cancer patient

This article presents my personal experiences as a physician who underwent laryngectomy for hypopharyngeal squamous cell carcinoma. I describe the numerous medical and surgical errors that occurred during my hospitalization at three different medical centers. It is my hope that my presentation will contribute to the reduction of such errors and lead to a safer hospital environment for patients.

Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients

OBJECTIVE

The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented.

STUDY DESIGN

Prospective study from July 1, 2009, to February 1, 2011.

SETTING

Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital.

METHODS

Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed.

RESULTS

A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients.

CONCLUSION

There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.

Systematic review of safety checklists for use by medical care teams in acute hospital settings--limited evidence of effectiveness

BACKGROUND

Patient safety is a fundamental component of good quality health care. Checklists have been proposed as a method of improving patient safety. This systematic review, asked "In acute hospital settings, would the use of safety checklists applied by medical care teams, compared to not using checklists, improve patient safety?"

METHODS

We searched the Cochrane Library, MEDLINE, CINAHL, and EMBASE for randomised controlled trials published in English before September 2009. Studies were selected and appraised by two reviewers independently in consultation with colleagues, using inclusion, exclusion and appraisal criteria established a priori.

RESULTS

Nine cohort studies with historical controls studies from four hospital care settings were included-intensive care unit, emergency department, surgery, and acute care. The studies used a variety of designs of safety checklists, and implemented them in different ways, however most incorporated an educational component to teach the staff how to use the checklist. The studies assessed outcomes occurring a few weeks to a maximum of 12 months post-implementation, and these outcomes were diverse.The studies were generally of low to moderate quality and of low levels of evidence, with all but one of the studies containing a high risk of bias.The results of these studies suggest some improvements in patient safety arising from use of safety checklists, but these were not consistent across all studies or for all outcomes. Some studies showed no difference in outcomes between checklist use and standard care without a checklist. Due to the variations in setting, checklist design, educational training given, and outcomes measured, it was unfeasible to accurately summarise any trends across all studies.

CONCLUSIONS

The included studies suggest some benefits of using safety checklists to improve protocol adherence and patient safety, but due to the risk of bias in these studies, their results should be interpreted with caution. More high quality and studies, are needed to enable confident conclusions about the effectiveness of safety checklists in acute hospital settings.

The AVAIL ME Extension: a multinational Middle Eastern survey of venous thromboembolism risk and prophylaxis

BACKGROUND

Venous thromboembolism (VTE) is a major worldwide problem.

OBJECTIVES

The primary objectives of this survey were to identify patients at risk for VTE, to define the rate of patients receiving appropriate VTE prophylaxis and to examine the frequency of the presence of guidelines and their application.

PATIENTS AND METHODS

Ten countries, 101 hospitals and a total of 4983 patients were included in this multinational cross-sectional survey. Standardized case report forms were filled out by trained individuals on one predefined day. Risks were categorized according to the Caprini Risk Assessment Model. Logistic regressions were carried out to assess factors that determined VTE prophylaxis.

RESULTS

Of 4983 patients, 3368 (68%) and 1615 (32%) were surgical and medical, respectively. Seven hundred and seventy-two (15.5%) were considered to be at low risk, 1001 (20%) at moderate risk, 1289 (26%) at high risk and 1921 (38.5%) at very high risk for VTE. Of 3575 (72%) patients who were eligible to receive VTE prophylaxis, 2747 (77%) received any drug prophylaxis. Among these patients 720/1056 (68%) and 2027/2519 (80%) were medical and surgical patients, respectively. The overall compliance with ACCP guidelines was 38%, being 24% for medical patients and 44% for surgical patients.

CONCLUSIONS

The results of this large multinational survey, although indicating overall improvement in VTE prophylaxis, identify a considerable number of patients who either did not receive any VTE prophylaxis or received it inappropriately. Although more medical patients were at risk for VTE, they were given prophylaxis less frequently than surgical patients. Concordance with VTE prophylaxis guidelines was higher in surgical patients, but overall application of these tools was unacceptably low.

Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study

RATIONALE

Checklists may reduce errors of omission for critically ill patients.

OBJECTIVES

To determine whether prompting to use a checklist improves process of care and clinical outcomes.

METHODS

We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting.

MEASUREMENTS AND MAIN RESULTS

One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients.

CONCLUSIONS

In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.

Making the literature palatable at the bedside: Reference poster promotes oral feeding best practice

Neonatal nurses often draw upon prior experiences and intuition to feed neonates. Such experience and skill vary from nurse to nurse and may not be based on recent research, nor tailored to each neonate's feeding skill. An evidence-based neonatal oral feeding guideline was produced to improve oral feeding practices among nurses and parents. The implementation was initially less than ideal, resulting in poor compliance. A bedside reference poster was designed to serve as a visual succinct reminder of the oral feeding guideline.

Application of a trauma intensivist model to a Level II community hospital trauma program improves intensive care unit throughput

BACKGROUND

Critical care-trained trauma surgeons are the ideal care provider for severely injured patients. This "captain of the ship" (COS) assumes complete responsibility of the patient, from initial resuscitation to eventual discharge. Unlike American College of Surgeons-verified Level I centers, many nonacademic, community hospital trauma centers use a more fragmented approach, with care in the intensive care unit (ICU) delegated to a committee of multiple specialists. We hypothesized that dedicated trauma intensivists as COS in a community hospital could improve ICU outcome.

METHOD

Beginning from September 2005, dedicated full-time trauma intensivists, without any resident coverage, assumed primary responsibility of all trauma patients admitted to a Level II Pennsylvania state verified trauma center. The ICU care was uninterrupted 24 hours a day, 365 days a year. Subspecialty consultations, for recommendations in care only, were selectively obtained as clinically indicated. We compared the 3 years before the implementation of the COS model (PRE: 2003-2005) with the 3 years after the model (POST: 2006-2008). A p-value ≤ 0.05 was considered significant.

RESULTS

There were equal numbers of patients admitted to the ICU setting in both the periods. In the PRE and POST periods, both age (46.9 years vs. 52.4 years; p < 0.001) and Injury Severity Score (16.1 vs. 16.7; p = 0.01) were of significance. We observed significant differences in ventilator days (mean, 8 days vs. 6 days; p = 0.002) and mean ICU days (4.9 days vs. 4.4 days; p < 0.001) across the study periods. Days to tracheostomy also achieved statistical significance (9.1 vs. 8.1; p = 0.03). The number of medical consults decreased by 19% in the POST group (p < 0.001). Hospital stay days were not statistically different (7.4 vs. 7.2; p = 0.18). After adjusting for higher age and Injury Severity Score in the POST period, we noted no difference in the expected mortality rate.

CONCLUSION

A trauma intensivist-driven model can be successfully adopted in a nonacademic community trauma program, without the need for a residency program. A decentralized ICU care model produces inefficiencies, diminishes the role of the trauma service, and decreases the overall throughput of trauma patients.

Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care

Workforce shortages, late referrals, and palliative care program resource constraints present significant barriers to meeting the needs of hospitalized patients facing serious illnesses. The Center to Advance Palliative Care convened a consensus panel to select criteria by which patients at high risk for unmet palliative care needs can be identified in advance for a palliative care screening assessment. The consensus panel developed primary and secondary criteria for two checklists-one to use for screening at the time of admission and one for daily patient rounds. The consensus panel believes that by implementing a checklist approach to screening patients for unmet palliative care needs, combined with educational initiatives and other system-change work, hospital staff engaged in day-to-day patient care can identify a majority of such needs, reserving specialty palliative care services for more complex problems.

Peer reviewing critical care: a pragmatic approach to quality management

Critical care medicine frequently involves decisions and measures that may result in significant consequences for patients. In particular, mistakes may directly or indirectly derive from daily routine processes. In addition, consequences may result from the broader pharmaceutical and technological treatment options, which frequently involve multidimensional aspects. The increasing complexity of pharmaceutical and technological properties must be monitored and taken into account. Besides the presence of various disciplines involved, the provision of 24-hour care requires multiple handovers of significant information each day. Immediate expert action that is well coordinated is just as important as a professional handling of medicine's limitations.Intensivists are increasingly facing professional quality management within the ICU (Intensive Care Unit). This article depicts a practical and effective approach to this complex topic and describes external evaluation of critical care according to peer reviewing processes, which have been successfully implemented in Germany and are likely to gain in significance.

Quality and safety in intensive care-A means to an end is critical

BACKGROUND

To achieve improvement in healthcare quality and safety, all four domains (outcome, process, structure and culture) must be considered in conjunction with the best available clinical evidence to improve patient care and reduce harm. A range of improvement initiatives have targeted processes of care in recognition of: (1) complexities of patient care and (2) evidence that a large portion of adverse events are preventable, occur during ongoing care, and result in poorer patient outcomes.

PURPOSE

The aims of this paper are to: (1) outline national and international quality and safety initiatives; (2) identify evidence-based processes of care applicable to the general adult ICU patient population; (3) summarise the literature on relevant quality improvement strategies.

METHODS

An integrative literature review was conducted by: (1) database search of Ovid Medline, CINAHL, EMBASE and Cochrane for articles published between 1996 and October 2009; (2) identification of additional studies from articles obtained; (3) purposive internet search identifying relevant quality and safety initiatives.

FINDINGS

Quality improvement initiatives across the globe were identified, with ensuing focus on how the development, implementation and evaluation of evidence-based processes of care can lead to improvements in the delivery and outcomes of intensive care practice. Variation in practice and methodological limitations of existing studies were also noted, highlighting the need for innovative approaches to improving processes in the ICU.

CONCLUSION

This integrative review has outlined potential for achieving practice improvements in intensive care and highlighted the need for further evaluative research to improve patient care at the bedside.