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Rashid K, Ansar F, Khan Y, Rashad N, Rehman H, Shah SZ, Ullah S, Waheed M. Impact of staffing levels and resources of intensive care units on compliance to standard mechanical ventilator guidelines: A city-wide study in times of COVID-19 pandemic. Nurs Crit Care 2023; 28:218-224. [PMID: 35362171 PMCID: PMC9115488 DOI: 10.1111/nicc.12768] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The COVID-19 pandemic has affected millions and resulted in a considerable strain on healthcare systems around the world. Intensive care units (ICUs) are reported to be affected the most because significant percentage of ICU patients requires respiratory support through mechanical ventilation (MV). AIM This study aims to examine the staffing levels and compliance with a ventilator care bundle in a single city in Pakistan. METHODS A cross-sectional survey of 14 ICUs including medical and surgical ICUs was conducted through a self-structured questionnaire including a standardized ventilator care bundle. We assessed the compliance of ICU staff to ventilator care bundle and calculated the correlation between staffing patterns with compliance to this bundle. RESULTS The unit response rate was 64% (7/11 hospitals). Across these seven hospitals, there were 14 functional ICUs (7 surgical and 7 medical). The Mean (SD) numbers of beds and ventilators were 8.14 (3.39) and 5.78 (3.68) while the average patient-to-nurse and patient-to-doctor ratio was 3: 1 and 5:1 respectively. The median ventilator care bundle compliance score was 26 (IQR = 21-28) out of 30, while in medical and surgical ICUs, median scores were 24 (IQR = 19-26) and 28 (IQR = 23-30) respectively. The perceived least compliant component was head elevation in ventilated patients. Correlation analysis revealed that 24 h a day, 7 days a week onsite cover of Advanced Cardiovascular Life Support certified staff was positively correlated with the ventilator care bundle score (rs = 0.654, p value = .011). Similarly, 24-h cover of senior ICU nurses was significantly correlated with the application of chlorhexidine oral care (rs = 0.676, p value = .008) while routine subglottic aspiration was correlated with the number of doctors (rs = 0.636, p value = .014). CONCLUSION Our study suggests that ICUs in Peshawar are not well staffed in comparison with international standards and the compliance of ICUs with the ventilator care bundle is suboptimal. We found only a few aspects of ventilator care bundle compliance were related to nursing and medical staffing levels. RELEVANCE TO CLINICAL PRACTICE Critical care staffs at most of the medical ICUs in Peshawar are not compliant with the standard guidelines for patients on mechanical ventilation. Moreover, the staffing levels at these ICUs are not in accordance with international standards. However, this study suggests that staffing levels may not be the only cause of non-compliance with standard mechanical ventilator guidelines. There is an urgent need to design and implement a program that can enhance and monitor the quality of nursing care provided to mechanically ventilated patients. Lastly, nurse staffing of ICUs in Pakistan must be increased to enable high quality care and more doctors should be trained in critical care.
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Affiliation(s)
| | | | - Yahya Khan
- Pak International Medical College, Peshawar, Pakistan
| | | | | | | | - Shahid Ullah
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Balas MC, Tan A, Pun BT, Ely EW, Carson SS, Mion L, Barnes-Daly MA, Vasilevskis EE. Effects of a National Quality Improvement Collaborative on ABCDEF Bundle Implementation. Am J Crit Care 2022; 31:54-64. [PMID: 34972842 PMCID: PMC9972543 DOI: 10.4037/ajcc2022768] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND The ABCDEF bundle (Assess, prevent, and manage pain and Delirium; Both spontaneous awakening and breathing trials; Choice of analgesia/sedation; Early mobility; and Family engagement) improves intensive care unit outcomes, but adoption into practice is poor. OBJECTIVE To assess the effect of quality improvement collaborative participation on ABCDEF bundle performance. METHODS This interrupted time series analysis included 20 months of bundle performance data from 15 226 adults admitted to 68 US intensive care units. Segmented regression models were used to quantify complete and individual bundle element performance changes over time and compare performance patterns before (6 months) and after (14 months) collaborative initiation. RESULTS Complete bundle performance rates were very low at baseline (<4%) but increased to 12% by the end. Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. Performance rates were lowest for spontaneous awakening/breathing trials and early mobility. CONCLUSIONS Quality improvement collaborative participation resulted in clinically meaningful, but small and variable, improvements in bundle performance. Opportunities remain to improve adoption of sedation, mechanical ventilation, and early mobility practices.
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Affiliation(s)
- Michele C. Balas
- University of Nebraska Medical Center College of Nursing, Omaha, Nebraska
| | - Alai Tan
- Center for Research and Health Analytics, College of Nursing, The Ohio State University, Columbus, Ohio
| | - Brenda T. Pun
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, and at the Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center, Nashville, Tennessee
| | - Shannon S. Carson
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lorraine Mion
- Center of Healthy Aging, Self-Management and Complex Care, The Ohio State University College of Nursing
| | | | - Eduard E. Vasilevskis
- Division of General Internal Medicine and Public Health, Section of Hospital Medicine; the Center for Health Services Research; the Center for Quality Aging; and the Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, and a staff physician, Tennessee Valley Veterans Affairs Geriatric Research Education and Clinical Center
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3
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Rodríguez-Fanjul J, Guitart C, Bobillo-Perez S, Balaguer M, Jordan I. Procalcitonin and lung ultrasound algorithm to diagnose severe pneumonia in critical paediatric patients (PROLUSP study). A randomised clinical trial. Respir Res 2020; 21:255. [PMID: 33032612 PMCID: PMC7543673 DOI: 10.1186/s12931-020-01476-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 07/29/2020] [Indexed: 12/25/2022] Open
Abstract
Background Lung ultrasound (LUS) in combination with a biomarker has not yet been studied. We propose a clinical trial where the primary aims are: 1. To assess whether an algorithm with LUS and procalcitonin (PCT) may be useful for diagnosing bacterial pneumonia; 2. To analyse the sensitivity and specificity of LUS vs chest X-ray (CXR). Methods/design A 3-year clinical trial. Inclusion criteria: children younger than 18 years old with suspected pneumonia in a Paediatric Intensive Care Unit. Patients will be randomised into two groups: Experimental Group: LUS will be performed as first lung image. Control Group: CXR will be performed as first pulmonary image. Patients will be classified according to the image and the PCT: a) PCT < 1 ng/mL and LUS/CXR are not suggestive of bacterial pneumonia (BN), no antibiotic will be prescribed; b) LUS/CXR are suggestive of BN, regardless of the PCT, antibiotic therapy is recommended; c) LUS/CXR is not suggestive of BN and PCT > 1 ng/mL, antibiotic therapy is recommended. Conclusion This algorithm will help us to diagnose bacterial pneumonia and to prescribe the correct antibiotic treatment. A reduction of antibiotics per patient, of the treatment length, and of the exposure to ionizing radiation and in costs is expected. Trial registration NCT04217980.
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Affiliation(s)
- Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit, Department of Paediatrics, Hospital Germans Trias i Pujol, Autonomous University of Barcelona, Badalona, Spain
| | - Carmina Guitart
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, P° Sant Joan de Déu, 2, 08950 Esplugues, Barcelona, Spain.,Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Sara Bobillo-Perez
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, P° Sant Joan de Déu, 2, 08950 Esplugues, Barcelona, Spain.,Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Mònica Balaguer
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, P° Sant Joan de Déu, 2, 08950 Esplugues, Barcelona, Spain.
| | - Iolanda Jordan
- Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, University of Barcelona, P° Sant Joan de Déu, 2, 08950 Esplugues, Barcelona, Spain.,Immunological and Respiratory Disorders in the Paediatric Critical Patient Research Group, Institut de Recerca Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Paediatric Infectious Diseases Research Group. Institut de Recerca Sant Joan de Déu, CIBERESP, Barcelona, Spain
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Loreto M, Lisboa T, Moreira VP. Early prediction of ICU readmissions using classification algorithms. Comput Biol Med 2020; 118:103636. [PMID: 32174313 DOI: 10.1016/j.compbiomed.2020.103636] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 01/08/2023]
Abstract
CONTEXT Determining which patients are ready for discharge from an Intensive Care Unit (ICU) presents a huge challenge, as ICU readmissions are associated with several negative outcomes such as increased mortality, length of stay, and cost compared to those patients who are not readmitted during their hospital stay. For these reasons, enhancing risk stratification in order to identify patients at high risk of clinical deterioration might benefit and improve the outcomes of critically ill hospitalized patients. Existing work on predicting ICU readmissions relies on information available at the time of discharge, however, in order to be more useful and to prevent complications, predictions need to be made earlier. GOALS In this work, we investigate the hypothesis that the basal characteristics and information collected at the time of the patient's admission can enable accurate predictions of ICU readmission. MATERIALS AND METHODS We analyzed an anonymized dataset of 11,805 adult patients from three ICUs in a Brazilian university hospital. After excluding 1879 patients who died during their first ICU admission, our final dataset contained 9,926 patients. Of these, 658 patients (6.6%) had been readmitted to the ICU. The original dataset had 185 attributes, including demographics, length of stay prior to ICU admission, comorbidities, severity indexes, interventions, organ support care during ICU stay and laboratory results. The problem of predicting ICU readmissions was modeled as a binary classification task. We tested eight classification algorithms (including Bayesian algorithms, decision trees, rule-based, and ensemble methods) over different sets of attributes and evaluated their results based on six metrics. RESULTS Predictions made solely based on the attributes collected at the admission are highly accurate. Their quality in terms of prediction is no different from predictions made using the complete set of attributes for our dataset and for a subset of attributes selected by a feature selection method. Furthermore, our AUROC score of 0.91 (95% CI [0.89,0.92]) is higher than existing results published in the literature for other datasets. DISCUSSION AND CONCLUSION The results confirm our hypothesis. Our findings suggest that early markers can be used to anticipate patients at high risk of clinical deterioration after ICU discharge.
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Affiliation(s)
- Melina Loreto
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Thiago Lisboa
- Programa de Pós-Graduação Ciencias Pneumologicas - UFRGS, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Universidade LaSalle, Canoas, RS, Brazil
| | - Viviane P Moreira
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil.
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Balas MC, Pun BT, Pasero C, Engel HJ, Perme C, Esbrook CL, Kelly T, Hargett KD, Posa PJ, Barr J, Devlin JW, Morse A, Barnes-Daly MA, Puntillo KA, Aldrich JM, Schweickert WD, Harmon L, Byrum DG, Carson SS, Ely EW, Stollings JL. Common Challenges to Effective ABCDEF Bundle Implementation: The ICU Liberation Campaign Experience. Crit Care Nurse 2019; 39:46-60. [PMID: 30710036 DOI: 10.4037/ccn2019927] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Although growing evidence supports the safety and effectiveness of the ABCDEF bundle (A, assess, prevent, and manage pain; B, both spontaneous awakening and spontaneous breathing trials; C, choice of analgesic and sedation; D, delirium: assess, prevent, and manage; E, early mobility and exercise; and F, family engagement and empowerment), intensive care unit providers often struggle with how to reliably and consistently incorporate this interprofessional, evidence-based intervention into everyday clinical practice. Recently, the Society of Critical Care Medicine completed the ICU Liberation ABCDEF Bundle Improvement Collaborative, a 20-month, nationwide, multicenter quality improvement initiative that formalized dissemination and implementation strategies and tracked key performance metrics to overcome barriers to ABCDEF bundle adoption. The purpose of this article is to discuss some of the most challenging implementation issues that Collaborative teams experienced, and to provide some practical advice from leading experts on ways to overcome these barriers.
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Affiliation(s)
- Michele C Balas
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus.
| | - Brenda T Pun
- Michele Balas is an associate professor, Center of Excellence in Critical and Complex Care, College of Nursing, and a nurse scientist, Wexner Medical Center, The Ohio State University, Columbus
| | - Chris Pasero
- Chris Pasero is a pain management clinical consultant, El Dorado Hills, California
| | - Heidi J Engel
- Heidi Engel is a physical therapist, Department of Rehabilitative Services, University of California, San Francisco
| | - Christiane Perme
- Christiane Perme is a physical therapist, Houston Methodist Hospital, Houston, Texas
| | - Cheryl L Esbrook
- Cheryl Esbrook is an occupational therapist, University of Chicago Medicine, Chicago, Illinois
| | - Tamra Kelly
- Tamra Kelly is a respiratory therapist, Sutter Health, Sacramento, California
| | - Ken D Hargett
- Ken Hargett is a respiratory therapist, Houston Methodist Hospital
| | - Patricia J Posa
- Patricia Posa is a population health clinical integration leader, Saint Joseph Mercy Health System, Ann Arbor, Michigan
| | - Juliana Barr
- Juliana Barr is a staff intensivist and anesthesiologist, VA Palo Alto Health Care System, Palo Alto, California, and an associate professor, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, California
| | - John W Devlin
- John Devlin is a professor of pharmacy, Northeastern University, and a clinical scientist, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Mary Ann Barnes-Daly
- Mary Ann Barnes-Daly is a clinical performance improvement consultant, Sutter Health
| | - Kathleen A Puntillo
- Kathleen Puntillo is a professor of nursing emeritus, Department of Physiological Nursing, School of Nursing, University of California, San Francisco
| | - J Matthew Aldrich
- J. Matthew Aldrich is medical director, critical care medicine, and an associate clinical professor, University of California, San Francisco Medical Center, San Francisco
| | - William D Schweickert
- William Schweickert is an associate professor of clinical medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lori Harmon
- Lori Harmon is director of quality, Society of Critical Care Medicine, Mount Prospect, Illinois
| | - Diane G Byrum
- Diane Byrum is a quality implementation consultant, Innovative Solutions for Healthcare Education, LLC, Charlotte, North Carolina
| | - Shannon S Carson
- Shannon Carson is a critical care pulmonologist, University of North Carolina School of Medicine, Chapel Hill
| | - E Wesley Ely
- E. Wesley Ely is a professor of medicine, Vanderbilt University School of Medicine, and associate director, VA Tennessee Valley Geriatric Research Education Clinical Center, Nashville, Tennessee
| | - Joanna L Stollings
- Joanna Stollings is a clinical pharmacist, Department of Pharmaceutical Services, Vanderbilt University Medical Center
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6
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Roos-Blom MJ, Gude WT, de Jonge E, Spijkstra JJ, van der Veer SN, Peek N, Dongelmans DA, de Keizer NF. Impact of audit and feedback with action implementation toolbox on improving ICU pain management: cluster-randomised controlled trial. BMJ Qual Saf 2019; 28:1007-1015. [PMID: 31263017 PMCID: PMC6934240 DOI: 10.1136/bmjqs-2019-009588] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 05/30/2019] [Accepted: 06/08/2019] [Indexed: 11/21/2022]
Abstract
Background Audit and feedback (A&F) enjoys widespread use, but often achieves only marginal improvements in care. Providing recipients of A&F with suggested actions to overcome barriers (action implementation toolbox) may increase effectiveness. Objective To assess the impact of adding an action implementation toolbox to an electronic A&F intervention targeting quality of pain management in intensive care units (ICUs). Trial design Two-armed cluster-randomised controlled trial. Randomisation was computer generated, with allocation concealment by a researcher, unaffiliated with the study. Investigators were not blinded to the group assignment of an ICU. Participants Twenty-one Dutch ICUs and patients eligible for pain measurement. Interventions Feedback-only versus feedback with action implementation toolbox. Outcome Proportion of patient-shift observations where pain management was adequate; composed by two process (measuring pain at least once per patient in each shift; re-measuring unacceptable pain scores within 1 hour) and two outcome indicators (acceptable pain scores; unacceptable pain scores normalised within 1 hour). Results 21 ICUs (feedback-only n=11; feedback-with-toolbox n=10) with a total of 253 530 patient-shift observations were analysed. We found absolute improvement on adequate pain management in the feedback-with-toolbox group (14.8%; 95% CI 14.0% to 15.5%) and the feedback-only group (4.8%; 95% CI 4.2% to 5.5%). Improvement was limited to the two process indicators. The feedback-with-toolbox group achieved larger effects than the feedback-only group both on the composite adequate pain management (p<0.05) and on measuring pain each shift (p<0.001). No important adverse effects have occurred. Conclusion Feedback with toolbox improved the number of shifts where patients received adequate pain management compared with feedback alone, but only in process and not outcome indicators. Trial registration number NCT02922101.
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Affiliation(s)
- Marie-José Roos-Blom
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands .,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Wouter T Gude
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Evert de Jonge
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Jaap Spijkstra
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Sabine N van der Veer
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Niels Peek
- Centre for Health Informatics, Division of Informatics, Imaging and Data Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Dave A Dongelmans
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Nicolette F de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
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Readmission to the Intensive Care Unit: Incidence, Risk Factors, Resource Use, and Outcomes. A Retrospective Cohort Study. Ann Am Thorac Soc 2017; 14:1312-1319. [DOI: 10.1513/annalsats.201611-851oc] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Abstract
OBJECTIVES The rate of unplanned ICU readmissions is often considered a measure of hospital performance. However, the degree to which these readmissions are preventable and the causes of preventable readmissions are unknown, creating uncertainty about the feasibility and value of reducing ICU readmission rates. To inform this issue, we sought to determine the frequency and underlying causes of potentially preventable ICU readmissions. DESIGN Retrospective cohort study. SETTING Urban, academic medical center in the mid-Atlantic United States. PATIENTS Adult patients discharged alive from their first ICU admission with an unplanned readmission within 48 hours of discharge. MEASUREMENTS AND MAIN RESULTS Each patient's medical chart was reviewed by two independent investigators who rated each readmission's preventability according to standardized scale and assessed the etiology of both preventable and nonpreventable readmissions. We assessed concordance between raters using the κ statistic and resolved disagreements through iterative discussion. Of 136 readmissions in the final analysis, 16 (11.8%; 95% CI, 6.9-18.4) were considered preventable and 120 (88.2%; 95% CI, 81.5-93.1) were considered nonpreventable. Of nonpreventable readmissions, 67 were due to a new clinical problem and 53 were due to an existing clinical problem. Among preventable readmissions, six were attributable to system errors, six were attributable to management errors, two were attributable to procedural events, one was attributable to a diagnostic error, and one was attributable to a medication error. Compared to nonpreventable readmissions, preventable readmissions tended to have shorter index ICU lengths of stay (2 vs 3 d; p = 0.05) and a shorter duration of time on the ward prior to readmission (16.6 vs 23.6 hr; p = 0.05). CONCLUSIONS The majority of early ICU readmissions are nonpreventable, raising important concerns about ICU readmission rates as a measure of hospital performance.
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van der Sluijs AF, van Slobbe-Bijlsma ER, Chick SE, Vroom MB, Dongelmans DA, Vlaar APJ. The impact of changes in intensive care organization on patient outcome and cost-effectiveness-a narrative review. J Intensive Care 2017; 5:13. [PMID: 28138389 PMCID: PMC5264296 DOI: 10.1186/s40560-016-0207-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/29/2016] [Indexed: 11/10/2022] Open
Abstract
The mortality rate of critically ill patients is high and the cost of the intensive (ICU) department is among the highest within the health-care industry. The cost will continue to increase because of the aging population in the western world. In the present review, we will discuss the impact of changes in ICU department organization on patient outcome and cost-effectiveness. The general perception that drug and treatment discoveries are the main drivers behind improved patient outcome within the health-care industry is in general not true. This is especially the case for the ICU department, in which the past decades' organizational changes were the main drivers behind the reduction of ICU mortality. These interventions were at the same time able to reduce cost, something which is rare for drug and treatment discoveries. The organization of the intensive care department has been changed over the past decades, resulting in better patient outcome and reduction of cost. Major changes are the implementation of the "closed format" and electronic patient record. Furthermore, we will present possible future options to improve the organization of the ICU department to further reduce mortality and cost such as pooling of dedicated ICU into mixed ICU and embedding business strategies such as lean and total quality management. Challenges are ahead as the ICU is taking up the largest share of national health-care expenditure, and with the aging of the population, this will continue to increase. Besides future improvements of organizational structures within the ICU, the focus should also be on the implementation of and compliance with proven beneficial organizational structures.
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Affiliation(s)
- Alexander F van der Sluijs
- Department of Intensive Care Medicine, Academic Medical Center, Room C3-343, Meibergdreef 9, Amsterdam, 1105 AZ The Netherlands
| | | | - Stephen E Chick
- INSEAD Healthcare Management Initiative, INSEAD, Fontainebleau, France
| | - Margreeth B Vroom
- Department of Intensive Care Medicine, Academic Medical Center, Room C3-343, Meibergdreef 9, Amsterdam, 1105 AZ The Netherlands
| | - Dave A Dongelmans
- Department of Intensive Care Medicine, Academic Medical Center, Room C3-343, Meibergdreef 9, Amsterdam, 1105 AZ The Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Academic Medical Center, Room C3-343, Meibergdreef 9, Amsterdam, 1105 AZ The Netherlands.,INSEAD Healthcare Management Initiative, INSEAD, Fontainebleau, France
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10
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Gudivada KK, Krishna B, Sriram S. Evaluation of Quality Indicators in an Indian Intensive Care Unit Using "CHITRA" Database. Indian J Crit Care Med 2017; 21:841-846. [PMID: 29307965 PMCID: PMC5752793 DOI: 10.4103/ijccm.ijccm_303_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: Quality indicators (QIs) are essential for maintaining quality of care in the critically ill. The Indian Society of Critical Care Medicine proposed benchmarks and enabled Indian Intensive Care Units (ICUs) to capture data in an electronic database: Customized Health in Intensive Care Trainable Research and Analysis (CHITRA) tool. The purpose of this study is to report QIs in an Indian ICU using this database. Materials and Methods: Data from patients admitted to ICU between October 2015 and January 2017 were entered into CHITRA. The following QIs were analyzed: standardized mortality ratio (SMR), length of ICU stay (LOS-ICU), pressure ulcer (PU) rate, patient fall rate (FR), ICU readmission rate, reintubation rate, ventilator-associated condition (VAC), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and iatrogenic pneumothorax rate. Results: A total of 2642 patient's information was suitable for analysis. Median age of ICU admission was 53 years (interquartile range [IQR]: 36–65), with a mean APACHE score of 18 (SD 7.7). Median LOS-ICU was 3 days (IQR 2–6) and SMR was 1.1 (95% confidence interval 1.05–1.38). Pneumothorax rate, PU rate, and FR were 2.6, 4.1, and 0.3 per 1000 respectively, whereas readmission rate was 0.7% and reintubation rate was 3.5%. VAC, CLABSI, and CAUTI were 8.5, 23, 3.1 per 1000 ventilator and catheter days, respectively. Conclusion: This study has successfully evaluated a range of QIs in a mixed ICU of a tertiary hospital utilizing CHITRA database.
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Affiliation(s)
- Kiran Kumar Gudivada
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Bhuvana Krishna
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
| | - Sampath Sriram
- Department of Critical Care Medicine, St. John's Medical College and Hospital, Bengaluru, Karnataka, India
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11
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Simulation Improves Procedural Protocol Adherence During Central Venous Catheter Placement: A Randomized Controlled Trial. Simul Healthc 2016; 10:270-6. [PMID: 26154250 DOI: 10.1097/sih.0000000000000096] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Simulation training may improve proficiency at and reduce complications from central venous catheter (CVC) placement, but the scope of simulation's effect remains unclear. This randomized controlled trial evaluated the effects of a pragmatic CVC simulation program on procedural protocol adherence, technical skill, and patient outcomes. METHODS Internal medicine interns were randomized to standard training for CVC insertion or standard training plus simulation-based mastery training. Standard training involved a lecture, a video-based online module, and instruction by the supervising physician during actual CVC insertions. Intervention-group subjects additionally underwent supervised training on a venous access simulator until they demonstrated procedural competence. Raters evaluated interns' performance during internal jugular CVC placement on actual patients in the medical intensive care unit. Generalized estimating equations were used to account for outcome clustering within trainees. RESULTS We observed 52 interns placing 87 CVCs. Simulation-trained interns exhibited better adherence to prescribed procedural technique than interns who received only standard training (P = 0.024). There were no significant differences detected in first-attempt or overall cannulation success rates, mean needle passes, global assessment scores, or complication rates. CONCLUSIONS Simulation training added to standard training improved protocol adherence during CVC insertion by novice practitioners. This study may have been too small to detect meaningful differences in venous cannulation proficiency and other clinical outcomes, highlighting the difficulty of patient-centered simulation research in settings where poor outcomes are rare. For high-performing systems, where protocol deviations may provide an important proxy for rare procedural complications, simulation may improve CVC insertion quality and safety.
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Balachandran R, Kappanayil M, Sen AC, Sudhakar A, Nair SG, Sunil GS, Raj RB, Kumar RK. Impact of the International Quality Improvement Collaborative on outcomes after congenital heart surgery: a single center experience in a developing economy. Ann Card Anaesth 2015; 18:52-7. [PMID: 25566712 PMCID: PMC4900307 DOI: 10.4103/0971-9784.148322] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: The International Quality Improvement Collaborative (IQIC) for Congenital Heart Surgery in Developing Countries was initiated to decrease mortality and major complications after congenital heart surgery in the developing world. Objective: We sought to assess the impact of IQIC on postoperative outcomes after congenital heart surgery at our institution. Methods: The key components of the IQIC program included creation of a robust worldwide database on key outcome measures and nurse education on quality driven best practices using telemedicine platforms. We evaluated 1702 consecutive patients ≤18 years undergoing congenital heart surgery in our institute from January 2010-December 2012 using the IQIC database. Preoperative variables included age, gender, weight at surgery and surgical complexity as per the RACHS-1 model. The outcome variables included, in- hospital mortality, duration of ventilation, intensive care unit (ICU) stay, bacterial sepsis and surgical site infection. Results: The 1702 patients included 771(45.3%) females. The median age was 8 months (0.03-216) and the median weight was 6.1Kg (1-100). The overall in-hospital mortality was 3.1%, Over the three years there was a significant decline in bacterial sepsis (from 15.1%, to 9.6%, P < 0.001), surgical site infection (11.1% to 2.4%, P < 0.001) and duration of ICU stay from 114(8-999) hours to 72 (18-999) hours (P < 0.001) The decline in mortality from (4.3% to 2.2%) did not reach statistical significance. Conclusions: The inclusion of our institution in the IQIC program was associated with improvement in key outcome measures following congenital heart surgery over a three year period.
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Affiliation(s)
| | | | - Amitabh Chanchal Sen
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Kochi, Kerala, India
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Brown SES, Ratcliffe SJ, Halpern SD. Assessing the utility of ICU readmissions as a quality metric: an analysis of changes mediated by residency work-hour reforms. Chest 2015; 147:626-636. [PMID: 25393027 DOI: 10.1378/chest.14-1060] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND ICU readmissions are associated with increased mortality and costs; however, it is unclear whether these outcomes are caused by readmissions or by residual confounding by illness severity. An assessment of temporal changes in ICU readmission in response to a specific policy change could help disentangle these possibilities. We sought to determine whether ICU readmission rates changed after 2003 Accreditation Council for Graduate Medical Education Resident Duty Hours reform ("reform") and whether there were temporally corresponding changes in other ICU outcomes. METHODS We used a difference-in-differences approach using Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks). Piecewise regression models estimated changes in outcomes immediately before and after reform in 274,491 critically ill medical and surgical patients in 151 community and academic US ICUs. Outcome measures included ICU readmission, ICU mortality, and in-hospital post-ICU-discharge mortality. RESULTS In ICUs with residents, ICU readmissions increased before reform (OR, 1.5; 95% CI, 1.22-1.84; P < .01), and decreased after (OR, 0.85; 95% CI, 0.73-0.98; P = .03). This abrupt decline in ICU readmissions after reform differed significantly from an increase in readmissions observed in ICUs without residents at this time (difference-in-differences P < .01). No comparable changes in mortality were observed between ICUs with vs without residents. CONCLUSIONS The changes in ICU readmission rates after reform, without corresponding changes in mortality, suggest that ICU readmissions are not causally related to other untoward patient outcomes. Instead, ICU readmission rates likely reflect operational aspects of care that are not patient-centered, making them less useful indicators of ICU quality.
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Affiliation(s)
- Sydney E S Brown
- Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary, Department of Anesthesiology and Critical Care, University of Pennsylvania.
| | - Sarah J Ratcliffe
- Center for Clinical Epidemiology and Biostatistics and Division of Pulmonary
| | - Scott D Halpern
- Allergy, and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Center for Bioethics, Philadelphia, PA
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Sinuff T, Muscedere J, Rozmovits L, Dale CM, Scales DC. A qualitative study of the variable effects of audit and feedback in the ICU. BMJ Qual Saf 2015; 24:393-9. [PMID: 25918432 DOI: 10.1136/bmjqs-2015-003978] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/08/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Audit and feedback is integral to performance improvement and behaviour change in the intensive care unit (ICU). However, there remain large gaps in our understanding of the social experience of audit and feedback and the mechanisms whereby it can be optimised as a quality improvement strategy in the ICU setting. METHODS We conducted a modified grounded theory qualitative study. Seventy-two clinicians from five academic and five community ICUs in Ontario, Canada, were interviewed. Team members reviewed interview transcripts independently. Data analysis used constant comparative methods. RESULTS Clinicians interviewed experienced audit and feedback as fragmented and variable in its effectiveness. Moreover, clinicians felt disconnected from the process. The audit process was perceived as being insufficiently transparent. Feedback was often untimely, incomplete and not actionable. Specific groups such as respiratory therapists and night-shift clinicians felt marginalised. Suggestions for improvement included improving information sharing about the rationale for change and the audit process, tools and metrics; implementing peer-to-peer quality discussions to avoid a top-down approach (eg, incorporating feedback into discussions at daily rounds); providing effective feedback which contains specific, transparent and actionable information; delivering timely feedback (ie, balancing feedback proximate to events with trends over time) and increasing engagement by senior management. CONCLUSIONS ICU clinicians experience audit and feedback as fragmented communication with feedback being especially problematic. Attention to improving communication, integration of the process into daily clinical activities and making feedback timely, specific and actionable may increase the effectiveness of audit and feedback to affect desired change.
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Affiliation(s)
- Tasnim Sinuff
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Muscedere
- Department of Medicine and Critical Care Program, Queens University, Kingston General Hospital, Kingston, Ontario, Canada
| | - Linda Rozmovits
- Independent Qualitative Researcher, Toronto, Ontario, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
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Lee SK, Aziz K, Singhal N, Cronin CM. The Evidence-based Practice for Improving Quality method has greater impact on improvement of outcomes than dissemination of practice change guidelines and quality improvement training in neonatal intensive care units. Paediatr Child Health 2015. [DOI: 10.1093/pch/20.1.e1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Shoo K Lee
- Department of Paediatrics, University of Toronto, Toronto, Ontario
| | - Khalid Aziz
- Department of Pediatrics, University of Alberta, Edmonton
| | - Nalini Singhal
- Department of Pediatrics, University of Calgary, Calgary, Alberta
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Using the Rothman index to predict early unplanned surgical intensive care unit readmissions. J Trauma Acute Care Surg 2014; 77:78-82. [PMID: 24977759 DOI: 10.1097/ta.0000000000000265] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Rothman index (RI) is a numerical score calculated hourly from 26 data points in the electronic medical record by a commercial software package. Although it is purported to serve as an indicator of change in a patient's condition, it has not been extensively evaluated in the literature. Our objective was to determine whether the RI can be used to predict early surgical intensive care unit (SICU) readmissions. METHODS This is a single-institution, retrospective 12-month period review of all patients transferred from the SICU to the surgical floor. Patients readmitted to the SICU within 48 hours were compared with patients who did not require readmission during this time (control). Demographics and continuous RI scores were collected at admission, 24 hours before SICU transfer, and for the first 48 hours on the surgical floor or until readmission to the SICU. RESULTS A total of 1,152 SICU patients were transferred to the surgical floor; 27 patients were readmitted within 48 hours of transfer. Demographics were similar in both groups. The SICU length of stay was longer in the readmission group (mean [SD], 4.7 [8.1] vs. 16.5 [15.2]; p < 0.001). The RI immediately before SICU transfer was higher in the control group (70.4 [20.3] vs. 49.1 [20.9], p < 0.001) and was uniformly improved from the RI at the initial SICU admission. In comparison, readmitted patients had more variable RI trends from admission to SICU transfer (mean Δ, 6.51; range, -54.10 to 48.6), and 40.74% of readmitted patients actually had a decreased RI score on transfer. No patient with a RI score greater than 82.90 required readmission within 48 hours. CONCLUSION An increased RI score or a score greater than 82.90 correlates with appropriateness for SICU transfer to the surgical floor. A decreased RI score is strongly associated with SICU readmission within 48 hours and should be explored as a potential quality metric. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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Martin Delgado MC. [Measuring the quality of intensive care medicine]. Med Intensiva 2014; 39:1-3. [PMID: 24951246 DOI: 10.1016/j.medin.2014.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 04/11/2014] [Indexed: 11/27/2022]
Affiliation(s)
- M C Martin Delgado
- Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Madrid, España.
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Elliott M, Worrall-Carter L, Page K. Intensive care readmission: A contemporary review of the literature. Intensive Crit Care Nurs 2014; 30:121-37. [DOI: 10.1016/j.iccn.2013.10.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Revised: 10/28/2013] [Accepted: 10/30/2013] [Indexed: 11/29/2022]
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Abstract
BACKGROUND Intensive care unit (ICU) readmission rates are commonly viewed as indicators of ICU quality. However, definitions of ICU readmissions vary, and it is unknown which, if any, readmissions are associated with ICU quality. OBJECTIVE Empirically derive the optimal interval between ICU discharge and readmission for purposes of considering ICU readmission as an ICU quality indicator. RESEARCH DESIGN Retrospective cohort study. SUBJECTS A total of 214,692 patients discharged from 157 US ICUs participating in the Project IMPACT database, 2001-2008. MEASURES We graphically examined how patient characteristics and ICU discharge circumstances (eg, ICU census) were related to the odds of ICU readmissions as the allowable interval between ICU discharge and readmission was lengthened. We defined the optimal interval by identifying inflection points where these relationships changed significantly and permanently. RESULTS A total of 2242 patients (1.0%) were readmitted to the ICU within 24 hours; 9062 (4.2%) within 7 days. Patient characteristics exhibited stronger associations with readmissions after intervals >48-60 hours. By contrast, ICU discharge circumstances and ICU interventions (eg, mechanical ventilation) exhibited weaker relationships as intervals lengthened, with inflection points at 30-48 hours. Because of the predominance of afternoon readmissions regardless of time of discharge, using intervals defined by full calendar days rather than fixed numbers of hours produced more valid results. DISCUSSION It remains uncertain whether ICU readmission is a valid quality indicator. However, having established 2 full calendar days (not 48 h) after ICU discharge as the optimal interval for measuring ICU readmissions, this study will facilitate future research designed to determine its validity.
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SCHINDLER AW, SCHINDLER N, ENZ F, LUECK A, OLDEROG T, VAGTS DA. ICU personnel have inaccurate perceptions of their patients' experiences. Acta Anaesthesiol Scand 2013; 57:1032-40. [PMID: 23819844 DOI: 10.1111/aas.12148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intensive care unit (ICU) patient care bases - among others - upon the staff's assumptions about each patient's subjective preferences and experiences. However, these assumptions may be skewed and thus result in client-professional gaps (cp-gaps), which occur in two subtypes, hyperattention and blind spots to certain burdens. cp-gaps typically reduce quality of care. We investigated whether cp-gaps of either subtype exist in a 36-bed ICU of a university hospital. METHODS Observational study on 82 consecutive patients of a 36-bed university ICU, who voluntarily answered a psychometric questionnaire focusing on patients' experiences during an ICU stay. The questionnaire was reliable and valid (Cronbach's alpha, factor analysis). It consisted of 31 Likert-scaled items, which represented three scales of perception (communicative, intrapersonal, somatic) supplemented by 55 binary items for more specific information. Details of the questionnaire are given in the text. Demographic, educational, and medical data were registered too. Patients reported their subjective ICU experience 2-7 days after ICU discharge. Analogously, 60 staff members (physicians and nurses) reported their assumptions about patients' experiences. After correction for a general bias, group differences indicated cp-gaps. RESULTS Twelve cp-gaps were found. Hyperattention was found in four communicative and three intrapersonal items. Blind spots appeared in two communicative, two intrapersonal, and one somatic item. The pattern of cp-gap subtypes (hyperattention/blind spots) goes well with self-attributional bias - a model of social interaction. CONCLUSIONS cp-gaps in ICUs can be identified using analogue questionnaires for patients and staff. Both subtypes of cp-gap occur. cp-gaps are substantially influenced by self-attributional bias.
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Affiliation(s)
| | | | - F. ENZ
- Department of Anesthesiology and Intensive Care Medicine; University Hospital Rostock; Rostock; Germany
| | - A. LUECK
- Department of Anesthesiology and Intensive Care Medicine; University Hospital Rostock; Rostock; Germany
| | - T. OLDEROG
- Department of Anesthesiology and Intensive Care Medicine; Hetzelstift Hospital; Neustadt/Weinstraße; Germany
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Systematic Review and Meta-analysis of the Retroperitoneal versus the Transperitoneal Approach to the Abdominal Aorta. Eur J Vasc Endovasc Surg 2013; 46:36-47. [DOI: 10.1016/j.ejvs.2013.03.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 03/11/2013] [Indexed: 11/18/2022]
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Umegaki T, Nishimura M, Tajimi K, Fushimi K, Ikai H, Imanaka Y. An in-hospital mortality equation for mechanically ventilated patients in intensive care units. J Anesth 2013; 27:541-9. [DOI: 10.1007/s00540-013-1557-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 01/09/2013] [Indexed: 11/25/2022]
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Álvarez-Maldonado P, Cueto-Robledo G, Cerón-Díaz U, Pérez-Rosales A, Navarro-Reynoso F, Cicero-Sabido R. Indicadores de calidad en una unidad de cuidados intensivos respiratorios. Análisis inicial de la base de datos DEDUCIR. Med Intensiva 2012; 36:518-20. [DOI: 10.1016/j.medin.2011.11.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 11/15/2011] [Accepted: 11/17/2011] [Indexed: 11/25/2022]
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Dupont C, Deneux-Tharaux C, Cortet M, Colin C, Touzet S, Rabilloud M, Lansac J, Harvey T, Tessier V, Chauleur C, Pennehouat G, Morin X, Bouvier-Colle MH, Rudigoz RC. Prise en charge des hémorragies graves du post-partum après un accouchement par voie basse : étude en population dans 106 maternités françaises. ACTA ACUST UNITED AC 2012; 41:279-89. [DOI: 10.1016/j.jgyn.2012.02.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 02/04/2012] [Accepted: 02/17/2012] [Indexed: 11/29/2022]
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Lanetzki CS, Oliveira CACD, Bass LM, Abramovici S, Troster EJ. The epidemiological profile of Pediatric Intensive Care Center at Hospital Israelita Albert Einstein. EINSTEIN-SAO PAULO 2012; 10:16-21. [DOI: 10.1590/s1679-45082012000100005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE: This study outlined the epidemiological profiles of patients who were admitted to the Pediatric Intensive Care Center at Albert Einstein Israelite Hospital during 2009. METHODS: Data were retrospectively collected for all patients admitted to the PICC during 2009. A total of 433 medical charts were reviewed, and these data were extracted using the DATAMARTS System and analyzed using the statistical software package STATA, version 11.0. RESULTS: There were no statistically significant differences in regards to patient gender, and the predominant age group consisted of patients between the ages of 1 to 4 years. The average occupancy rate was 69.3% per year, and there was a greater number of admissions during April, August, and October. The average length of stay at the hospital ranged from 9.7 to 19.1 days. Respiratory diseases were the main cause for admission to the Pediatric Intensive Care Center, and the mortality rate of the patients admitted was 1.85%. CONCLUSIONS: Respiratory diseases were the most common ailment among patients admitted to the Pediatric Intensive Care Center, and the highest mortality rates were associated with neoplastic diseases.
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McPeake J, Cantwell S, Booth MG, Daniel M. Central line insertion bundle: experiences and challenges in an adult ICU. Nurs Crit Care 2012; 17:123-9. [PMID: 22497916 DOI: 10.1111/j.1478-5153.2012.00491.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Central venous catheters are used frequently in the intensive care unit (ICU). However, there is an associated morbidity, mortality and cost derived from their infectious and mechanical complications. The Scottish Patient Safety Programme (SPSP) has developed a multi faceted care bundle, with the aim of reducing catheter-related blood stream infections. AIM This paper aims to identify and describe the experience and challenges in implementing the SPSP central line insertion bundle in one adult ICU, in a large inner city teaching hospital. INTERVENTIONS 'Plan-Do-Study-Act' cycles, checklists for insertion and a standardized trolley were adopted to implement the central line insertion bundle in clinical practice. CONCLUSION/IMPLICATIONS Improving the reliability of the central line insertion bundle has reduced infections. Key steps in the process were setting clear aims and ensuring staff understand the change process and measurement of results. This is fundamental to the success of any quality improvement process.
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Affiliation(s)
- Joanne McPeake
- Critical Care Unit, Glasgow Royal Infirmary, Glasgow, UK.
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Bauman KA, Hyzy RC. ICU 2020: five interventions to revolutionize quality of care in the ICU. J Intensive Care Med 2012; 29:13-21. [PMID: 22328598 DOI: 10.1177/0885066611434399] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.
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Affiliation(s)
- Kristy A Bauman
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan Medical Center, Ann Arbor, MI, USA
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Brown SES, Ratcliffe SJ, Kahn JM, Halpern SD. The epidemiology of intensive care unit readmissions in the United States. Am J Respir Crit Care Med 2012; 185:955-64. [PMID: 22281829 DOI: 10.1164/rccm.201109-1720oc] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The incidence of intensive care unit (ICU) readmissions across the United States is unknown. OBJECTIVES To determine incidence of ICU readmissions in United States hospitals, and describe the distribution of time between ICU discharges and readmissions. METHODS This retrospective cohort study used 196,202 patients in 156 medical and surgical ICUs in 106 community and academic hospitals participating in Project IMPACT from April 1, 2001, to December 31, 2007. We used mixed-effects logistic regression, adjusting for patient and hospital characteristics, to describe how ICU readmission rates differed across patient types, ICU models, and hospital types. MEASUREMENTS AND MAIN RESULTS Measurements consisted of 48- and 120-hour ICU readmission rates and time to readmission. A total of 3,905 patients (2%) were readmitted to the ICU within 48 hours, and 7,171 (3.7%) within 120 hours. In adjusted analysis, there was no difference in ICU readmissions across patient types or ICU models. Among medical patients, those in academic hospitals had higher odds of 48- and 120-hour readmission than patients in community hospitals without residents (1.51 [95% confidence interval, 1.12-2.02] and 1.63 [95% confidence interval, 1.24-2.16]). Median time to ICU readmission was 3.07 days (interquartile range, 1.27-6.58). Closed ICUs had the longest times to readmission (3.55 d [interquartile range, 1.42-7.50]). CONCLUSIONS Approximately 2% and 4% of ICU patients discharged to the ward are readmitted within 48 and 120 hours, within a median time of 3 days. Medical patients in academic hospitals are more likely to be readmitted than patients in community hospitals without residents. ICU readmission rates could be useful for policy makers and investigations into their causes and consequences.
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Affiliation(s)
- Sydney E S Brown
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania 19104-6021, USA.
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Balachandran R, Nair SG, Kumar RK. Establishing a pediatric cardiac intensive care unit - Special considerations in a limited resources environment. Ann Pediatr Cardiol 2011; 3:40-9. [PMID: 20814475 PMCID: PMC2921517 DOI: 10.4103/0974-2069.64374] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Pediatric cardiac intensive care has evolved as a distinct discipline in well-established pediatric cardiac programs in developed nations. With increasing demand for pediatric heart surgery in emerging economies, a number of new programs are being established. The development of robust pediatric cardiac intensive care units (PCICU) is critical to the success of these programs. Because of substantial resource limitations existing models of PCICU care cannot be applied in their existing forms and structure. A number of challenges need to be addressed to deliver pediatric cardiac intensive care in the developing world. Limitations in infrastructure, human, and material resources call for a number of innovations and adaptations. Additionally, a variety of strategies are required to minimize costs of care to the individual patient. This review provides a framework for the establishment of a new PCICU program in face of resource limitations typically encountered in the developing world and emerging economies.
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Affiliation(s)
- Rakhi Balachandran
- Pediatric Cardiac Intensive Care, Amrita Institute of Medical Sciences, Kochi, Kerala, India
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Hariharan S, Dey PK. A comprehensive approach to quality management of intensive care services. Int J Health Care Qual Assur 2010; 23:287-300. [DOI: 10.1108/09526861011029352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Siegele P. Enhancing outcomes in a surgical intensive care unit by implementing daily goals tools. Crit Care Nurse 2010; 29:58-69. [PMID: 19952337 DOI: 10.4037/ccn2009663] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Peggy Siegele
- Advocate Lutheran General Hospital, Park Ridge, Illinois 60068, USA. )
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Woiski MD, Hermens RP, Middeldorp JM, Kremer JA, Marcus MA, Wouters MG, Grol RP, Lotgering FK, Scheepers HC. Haemorrhagia post partum; an implementation study on the evidence-based guideline of the Dutch Society of Obstetrics and Gynaecology (NVOG) and the MOET (Managing Obstetric Emergencies and Trauma-course) instructions; the Fluxim study. BMC Pregnancy Childbirth 2010; 10:5. [PMID: 20102607 PMCID: PMC2824637 DOI: 10.1186/1471-2393-10-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 01/26/2010] [Indexed: 11/13/2022] Open
Abstract
Background One of the most important causes of maternal mortality and severe morbidity worldwide is post partum haemorrhage (PPH). Factors as substandard care are frequently reported in the international literature and there are similar reports in the Netherlands. The incidence of PPH in the Dutch population is 5% containing 10.000 women a year. The introduction of an evidence-based guideline on PPH by the Dutch society of Obstetrics and Gynaecology (NVOG) and the initiation of the MOET course (Managing Obstetrics Emergencies and Trauma) did not lead to a reduction of PPH. This implies the possibility of an incomplete implementation of both the NVOG guideline and MOET-instructions. Therefore, the aim of this study is to develop and test a tailored strategy to implement both the NVOG guideline and MOET-instructions Methods/Design One step in the development procedure is to evaluate the implementation of the guideline and MOET-instructions in the current care. Therefore measurement of the actual care will be performed in a representative sample of 20 hospitals. This will be done by prospective observation of the third stage of labour of 320 women with a high risk of PPH using quality indicators extracted from the NVOG guideline and MOET instructions. In the next step barriers and facilitators for guideline adherence will be analyzed by performance of semi structured interviews with 30 professionals and 10 patients, followed by a questionnaire study among all Dutch gynaecologists and midwives to quantify the barriers mentioned. Based on the outcomes, a tailored strategy to implement the NVOG guideline and MOET-instructions will be developed and tested in a feasibility study in 4 hospitals, including effect-, process- and cost evaluation. Discussion This study will provide insight into current Dutch practice, in particular to what extent the PPH guidelines of the NVOG and the MOET-instructions have been implemented in the actual care, and into the barriers and facilitators regarding guideline adherence. The knowledge of the feasibility study regarding the effects and costs of the tailored strategy and the experiences of the users can be used in countries with a relatively high incidence of PPH. Trial Registration ClinicTrials.gov NCT00928863
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Affiliation(s)
- Mallory D Woiski
- Department of Obstetrics and Gynaecology, Radboud University Nijmegen, Nijmegen, the Netherlands.
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Relationship between discharge practices and intensive care unit in-hospital mortality performance: evidence of a discharge bias. Med Care 2009; 47:803-12. [PMID: 19536006 DOI: 10.1097/mlr.0b013e3181a39454] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Current intensive care unit performance measures include in-hospital mortality after intensive care unit admission. This measure does not account for deaths occurring after transfer to another hospital or soon after discharge and therefore, may be biased. OBJECTIVE Determine how transfer rates to other acute care hospitals and early post-discharge mortality rates impact hospital performance assessments using an in-hospital mortality model. DESIGN, SETTING, AND PARTICIPANTS Data were retrospectively collected on 10,502 eligible intensive care unit patients across 35 California hospitals between 2001 and 2004. MEASURES We calculated the rates of acute care hospital transfers and early post-discharge mortality (30-day overall mortality-30-day in-hospital mortality) for each hospital. We assessed hospital performance with standardized mortality ratios (SMRs) using the Mortality Probability Model III. Using regression models, we explored the relationship between in-hospital SMRs and the rates of hospital transfers or early post-discharge mortality. We explored the same relationship using a 30-day SMR. RESULTS In multivariable models, for each 1% increase in patients transferred to another acute care hospital, there was an in-hospital SMR reduction of -0.021 (-0.040-0.001). Additionally, a 1% increase in early post-discharge mortality was associated with an in-hospital SMR reduction of -0.049 (-0.142-0.045). Assessing hospital performance based upon 30-day mortality end point resulted in SMRs closer to 1.0 for hospitals at high and low ends of in-hospital mortality performance. CONCLUSIONS Variations in transfer rates and potentially discharge timing appear to bias in-hospital SMR calculations. A 30-day mortality model is a potential alternative that may limit this bias.
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An innovative telemedicine knowledge translation program to improve quality of care in intensive care units: protocol for a cluster randomized pragmatic trial. Implement Sci 2009; 4:5. [PMID: 19220893 PMCID: PMC2649891 DOI: 10.1186/1748-5908-4-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/16/2009] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are challenges to timely adoption of, and ongoing adherence to, evidence-based practices known to improve patient care in the intensive care unit (ICU). Quality improvement initiatives using a collaborative network approach may increase the use of such practices. Our objective is to evaluate the effectiveness of a novel knowledge translation program for increasing the proportion of patients who appropriately receive the following six evidence-based care practices: venous thromboembolism prophylaxis; ventilator-associated pneumonia prevention; spontaneous breathing trials; catheter-related bloodstream infection prevention; decubitus ulcer prevention; and early enteral nutrition. METHODS AND DESIGN We will conduct a pragmatic cluster randomized active control trial in 15 community ICUs and one academic ICU in Ontario, Canada. The intervention is a multifaceted videoconferenced educational and problem-solving forum to organize knowledge translation strategies, including comparative audit and feedback, educational sessions from content experts, and dissemination of algorithms. Fifteen individual ICUs (clusters) will be randomized to receive quality improvement interventions targeting one of the best practices during each of six study phases. Each phase lasts four months during the first study year and three months during the second. At the end of each study phase, ICUs are assigned to an intervention for a best practice not yet received according to a random schedule. The primary analysis will use patient-level process-of-care data to measure the intervention's effect on rates of adoption and adherence of each best practice in the targeted ICU clusters versus controls. DISCUSSION This study design evaluates a new system for knowledge translation and quality improvement across six common ICU problems. All participating ICUs receive quality improvement initiatives during every study phase, improving buy-in. This study design could be considered for other quality improvement interventions and in other care settings.
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da Silva PSL, de Aguiar VE, Neto HM, de Carvalho WB. Unplanned extubation in a paediatric intensive care unit: impact of a quality improvement programme. Anaesthesia 2008; 63:1209-16. [PMID: 19032255 DOI: 10.1111/j.1365-2044.2008.05628.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Unplanned tracheal extubation is an important quality issue in current medical practice as it is a common occurrence in paediatric intensive care units. We have assessed the effectiveness of a continuous quality improvement programme in reducing the incidence of unplanned extubation over a 5-year period. After a 2-year baseline period, we developed action plans to address the issues identified. Following implementation of the programme, the overall incidence of unplanned extubation decreased from 2.9 unplanned extubations per 100 intubated patient days in the first year to 0.6 in the last year (p = 0.0001). This reduction was the result of a decrease in unplanned extubation in children younger than 2 years of age. Although mortality was similar to that of children who did not experience an unplanned extubation, those with an unplanned extubation had a significantly longer duration of mechanical ventilation, longer stay in the intensive care unit, and longer hospital stay. We found that the implementation of a continuous quality improvement programme is effective in reducing the overall incidence of unplanned extubations.
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Affiliation(s)
- P S L da Silva
- Paediatric Intensive Care Unit, Hospital Estadual de Diadema (UNFESP), Brazil.
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Kuzniewicz MW, Vasilevskis EE, Lane R, Dean ML, Trivedi NG, Rennie DJ, Clay T, Kotler PL, Dudley RA. Variation in ICU Risk-Adjusted Mortality. Chest 2008; 133:1319-1327. [DOI: 10.1378/chest.07-3061] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Identifying and implementing quality improvement measures in the intensive care unit. Curr Opin Crit Care 2007; 13:709-13. [DOI: 10.1097/mcc.0b013e3282f1be5c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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