Quality Of Critical Care Research Articles

Changes in the Rates of Reported Pressure Ulcers in Response to a Regional Critical Care Quality Improvement Project

We used patient safety incident reports to monitor rates of pressure ulcers in response to a skin care bundle introduced at the start of 2012 across the North West of England. The bundle incorporated skin surface interface, patient positioning, incontinence and skin management and improved nutrition. We compared changes in the rates of index sores (category two to four ulcers involving the sacrum, buttocks, genitals or heals) with other sores and wounds. Rates of all reported pressure ulcers increased from 4.1 to 7.0 per 1,000 days between 2009 and 2012 (p<0.001) while the rate of ‘index sores' decreased from 3.1 to 2.0 per 1,000 days between 2011 and 2012 (p<0.001). There was a wide variation in reported pressure ulcers between different units (interquartile range 2.1 to 9.9 per 1,000 days). A care bundle can reduce the rates of significant pressure ulcers. Without ensuring reliable compliance, wide variation remains between units.

The effect of bundle care on central line associated bloodstream infection in a medical intensive care unit

While the central line catheter is a common device used in intensive medical care, it is a frequent source of nosocomial infection. The central line associated bloodstream infection (CLABSI) rate at our medical ICU had increased steadily, with an average rate between January and May 2011 of .47%. We used a cross-team approach to implement bundle care as a strategy to reduce the CLABSI rate. We designed a project to reduce the CLABSI rate below .3% in our ICU. This project was conducted between June 2011 and May 2012. Our strategy included providing a sterile towel, implementing maximal barrier precautions (head to toe), designing an illustration explaining how to use 2% CHG, establishing a procedures and care checklist, implementing quality assurance for procedures and care, and providing education on bundle care. The CLABSI rate reduced to .24% after project implementation. This result was below the target of .30%. We want to share this experience to help other hospitals and units improve critical care quality and to continue working to achieve a zero-tolerance infection rate.

How to Enhance Critical Care in Korea: Challenges and Vision

The goal of critical care is to reverse patients’ acute problems in effective and ethical ways with minimum costs. Unlike in other medical fields, the quality of Korean critical care has lagged behind that of advanced countries. Moreover, the level of critical care quality differs significantly between university hospitals. The suboptimal critical care level has multifactorial causes. The major challenge to Korean intensivists is, therefore, how to overcome barriers in the current critical care delivery system to improve outcomes for critically ill patients and reduce medical errors in error-prone Intensive Care Unit (ICUs). A long-term task force including all stakeholders should address the multifactorial barriers to better outcomes. The Korean Society of Critical Care Medicine should perform the central role to dismantle the barriers step by step with a long-term vision for a desirable critical care delivery system in our society. A capable critical care team with full-time intensivists is the most urgent requirement for proper, timely care in ICUs. Intensivists should focus on basic but essential management so scarcity of resources can be minimized. Publicity about ICU to the general public is also urgently required to draw the attention of medical policy makers to the current suboptimal level of our critical care system.

Coming together to care for the dying in India.

Coming together to care for the dying in India.

Current status of intensive care units registered as critical care subspecialty training hospitals in Korea.

There is a lack of information on critical care in Korea. The aim of this study was to determine the current status of Korean intensive care units (ICUs), focusing on the organization, characteristics of admitted patients, and nurse and physician staffing. Critical care specialists in charge of all 105 critical care specialty training hospitals nationwide completed a questionnaire survey. Among the ICUs, 56.4% were located in or near the capital city. Only 38 ICUs (17.3%) had intensive care specialists with a 5-day work week. The average daytime nurse-to-patient ratio was 1:2.7. Elderly people ≥ 65 yr of age comprised 53% of the adult patients. The most common reasons for admission to adult ICUs were respiratory insufficiency and postoperative management. Nurse and physician staffing was insufficient for the appropriate critical care in many ICUs. Staffing was worse in areas outside the capital city. Much effort, including enhanced reimbursement of critical care costs, must be made to improve the quality of critical care at the national level.

Postoperative Complications and Hospital Readmissions in Surgical Patients

Hospital readmission rates have assumed a central position in the discussion of critical health care quality metrics for American hospitals. This primarily was triggered by the passage of the Patient Protection and Affordable Care Act in October 2010.1 Contained within this piece of legislation is §3025, the Hospital Readmissions Reduction Program. Under this provision, hospitals with a high rate of 30-day readmissions for Medicare patients with pneumonia, myocardial infarction, or congestive heart failure will be penalized with decreased Medicare payments for all Medicare discharges. The Affordable Care Act was challenged for being unconstitutional, but in the summer of 2012, the Supreme Court upheld the law and shortly thereafter the Centers for Medicare & Medicaid Services announced the prospective penalties for hospitals with excess 30-day readmissions that would be in effect in October 2012.2 The scheduled penalties escalate in future years and will apply to broader classes of conditions including patients undergoing surgical procedures.

Project to reduce the central venous catheter-related bloodstream infection rate

Central venous catheter-related bloodstream infection (CRBSI) is an important indicator of care quality. The average CRBSI rate in our unit was 1.027% in 2009. Causes of infection included inadequate CRBSI prevention practices and outdated standard procedures. We designed a project to reduce the CRBSI rate below 0.5% in our intensive care unit. Improvement plans included providing in-service education, establishing a central venous catheter (CVC) care checklist, and updating CRBSI clinical management standards. The CRBSI rate fell to 1.43‰ after implementation. This was significantly below the reduction target of 0.5%. This project effectively reduced CRBSI. We want to share this experience to help other hospitals and units improve critical care quality and reduce healthcare costs.

Registros de trauma: una prioridad sanitaria, un proyecto estratégico para la SEMICYUC

The most efficient approach to traumatologic disease is prevention, but physicians also must supervise care of the victims. An operational and effective trauma registry requires financial support, adequate software, a well-defined population, personnel committed to training, and a detailed process for data collection, reporting, validation and the maintenance of confidentiality. Above all, however, motivation is required. Registries can offer many benefits in relation to these highly prevalent disorders, with an impact in terms of health promotion and even advantages in the form of cost reductions, as well as relief from the suffering caused by trauma (mortality, disability)–contributing to improve the efficiency and quality of critical trauma care. The SEMICYUC has demonstrated its ability to establish and maintain records of national interest, and this should become a priority project.

Building capacity for quality and safety in critical care: A roundtable discussion from the second international patient safety conference in April 9-11, 2013, Riyadh, Saudi Arabia

This paper summarizes the roundtable discussion from the Second International Patient Safety Conference held in April 9-11, 2013, Riyadh, Saudi Arabia. The objectives of the roundtable discussion were to: (1) review the conceptual framework for building capacity in quality and safety in critical care. (2) examine examples of leading international experiences in building capacity. (3) review the experience in Saudi Arabia in this area. (4) discuss the role of building capacity in simulation for patient safety in critical care and (5) review the experience in building capacity in an ongoing improvement project for severe sepsis and septic shock.

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Introduction: Our institution began utilizing Spontaneous Breathing Trials (SBT) in 2005 to assist physicians in liberation decisions. All eligible patients (FiO2<.6, PEEP < 8 and RR < 35) receive a SBT daily and for those patients that pass, recommendation for liberation to the managing physician. The results for each of the 5 ICUs for utilization of the SBT to promote liberation has been tracked and reported to the Critical Care Quality Committee. While there is no National Benchmark, each of the 5 ICUs has been encouraged to increase utilization. In 2011 the Critical Care Quality Committee established a goal of 65% of those patients that passed SBT is liberated. This goal was increased to 75% in 2012. Hypothesis: A standardized approach to implementing SBTs and monthly reporting with established goals will result in increased utilization of this technique to encourage physicians to consider liberation. Methods: This was an observational study. A daily SBT is performed with a PEEP of 0 and with tubing compensation active. SBT duration is 30-120 minutes. Failure criteria include RSBI > 105 and respiratory rate increase > 35 for more than 5 minutes, heart rate increase more than 20%. In 2011 to increase utilization a program was put in place to verify data integrity, increase communication with managing physicians regarding the patient’s status and the program goals of the Quality Committee. SBT results were included in Progress Notes and discussed on rounds. Liberation within 4 hours of the SBT was considered a result of the SBT. The physician’s decision to liberate or not was tracked in the Respiratory Information database and compliance data reported monthly by unit to the Critical Care Quality Committee. Results: Baseline results for the years 2005 to 2010 had a compliance rate of 48-55% of patients liberated following a successful SBT. The 2011 goal of 65% was exceeded at 68.6%. For the first half of 2012 the goal of 75% is exceeded at 78%. Re-intubation rates within 24 hours have been maintained at less than 3%. Conclusions: Continued refinement of the process has resulted in increased physician confidence and an increased number of patients liberated while maintaining a low re-intubation rate.

Assessment and Perceptions of Intensive Care Data Quality, Reporting and Use: A Survey of ICU Directors

It is becoming increasingly common for government bodies, healthcare providers, funders and consumers to seek measures of the quality of critical care. It is important to ensure the quality of intensive care unit (ICU) data is high so these stakeholders can confidently use quality of care measures in decision-making. This paper aims to evaluate the quality of data collected for and submitted to the Australian and New Zealand Intensive Care Society Adult Patient Database, and to investigate the perceptions of NSW ICU directors in relation to ICU data quality, reporting and usage. A survey tool was developed based on an existing framework that consisted of procedures for assessing data quality in medical registries. The survey was distributed to the directors of all NSW ICUs that submitted data in the 2007/2008 financial year. Overall, completeness of the data and its quality was perceived to be good. Participants were less likely to engage in activities involving the detection and correction of data errors, feedback of data or use of data for local purposes. A number of barriers and enablers to good quality ICU data as well as strategies to improve data quality were identified. Inadequate staff, training and resources for data collection were widespread concerns. NSW ICU directors believe more work is required to achieve high quality data and appropriate use of the data collected. Strategies targeting increased resources including updated technology and improved staffing and training, as well as low-cost solutions such as audit, feedback and clinician engagement, have been highlighted.

Prognostic models based on administrative data alone inadequately predict the survival outcomes for critically ill patients at 180 days post–hospital discharge

There is interest in evaluating the quality of critical care by auditing patient outcomes after hospital discharge. Risk adjustment using acuity of illness scores, such as Acute Physiology and Chronic Health Evaluation (APACHE III) scores, derived from clinical databases is commonly performed for in-hospital mortality outcome measures. However, these clinical databases do not routinely track patient outcomes after hospital discharge. Linkage of clinical databases to administrative data sets that maintain records on patient survival after discharge can allow for the measurement of survival outcomes of critical care patients after hospital discharge while using validated risk adjustment methods. ObjectiveThe aim of this study was to compare the ability of 4 methods of risk adjustment to predict survival of critically ill patients at 180 days after hospital discharge: one using only variables from an administrative data set, one using only variables from a clinical database, a model using a full range of administrative and clinical variables, and a model using administrative variables plus APACHE III scores. DesignThis was a population-based cohort study. PatientsThe study sample consisted of adult (>15 years of age) residents of Victoria, Australia, admitted to a public hospital intensive care unit between 1 January 2001 and 31 December 2006 (n = 47,312 linked cases). Logistic regression analyses were used to develop the models. ResultsThe administrative-only model was the poorest predictor of mortality at 180 days after hospital discharge (C = 0.73). The clinical model had substantially better predictive capabilities (C = 0.82), whereas the full-linked model achieved similar performance (C = 0.83). Adding APACHE III scores to the administrative model also had reasonable predictive capabilities (C = 0.83). ConclusionsThe addition of APACHE III scores to administrative data substantially improved model performance to the level of the clinical model. Although linking data systems requires some investment, having the ability to evaluate case ascertainment and accurately risk adjust outcomes of intensive care patients after discharge will add valuable insights into clinical audit and decision-making processes.

Hospital-level variation in the use of intensive care.

To determine the extent to which hospitals vary in the use of intensive care, and the proportion of variation attributable to differences in hospital practice that is independent of known patient and hospital factors. Hospital discharge data in the State Inpatient Database for Maryland and Washington States in 2006. Cross-sectional analysis of 90 short-term, acute care hospitals with critical care capabilities. DATA COLLECTION/METHODS: We quantified the proportion of variation in intensive care use attributable to hospitals using intraclass correlation coefficients derived from mixed-effects logistic regression models after successive adjustment for known patient and hospital factors. The proportion of hospitalized patients admitted to an intensive care unit (ICU) across hospitals ranged from 3 to 55 percent (median 12 percent; IQR: 9, 17 percent). After adjustment for patient factors, 19.7 percent (95 percent CI: 15.1, 24.4) of total variation in ICU use across hospitals was attributable to hospitals. When observed hospital characteristics were added, the proportion of total variation in intensive care use attributable to unmeasured hospital factors decreased by 26-14.6 percent (95 percent CI: 11, 18.3 percent). Wide variability exists in the use of intensive care across hospitals, not attributable to known patient or hospital factors, and may be a target to improve efficiency and quality of critical care.

Measuring quality and outcomes in pediatric cardiac critical care

Measuring quality and outcomes in the pediatric cardiac critical care environment is challenging due to many inherent obstacles. These include a diverse patient mix, difficulty in determining how the care of the intensive care unit team contributes to outcomes and lack of an adequate risk-adjustment method for pediatric cardiac critical care patients. Despite these barriers, new solutions are emerging that capitalizes on lessons learned from other quality improvement initiatives and provide opportunities to build on those successes. The infrastructure is in place to develop robust quality metrics, create benchmarks for patient outcomes and to determine the structures and processes that drive variation in outcomes in the pediatric cardiac critical care setting.

Influência do dimensionamento da equipe de enfermagem na qualidade do cuidado ao paciente crítico

Estudo na modalidade Revisão Integrativa, com objetivo de analisar a influência do dimensionamento do pessoal de enfermagem intensivista na qualidade do cuidado ao paciente crítico adulto. Foram incluídas apenas publicações científicas, das principais bases eletrônicas, veiculadas em periódicos de acesso livre e eletrônico, referentes à última década (janeiro de 2000 a janeiro de 2010), nos idiomas inglês, português e espanhol. Obteve-se um total de 10 publicações, dentre as quais três avaliaram a incidência de mortalidade e extubação acidental no pós-operatório; três avaliaram os reflexos no cuidado resultantes da redução no número de enfermeiros; dois avaliaram o desenvolvimento de infecções; e um, respectivamente, avaliou a incidência de quedas e de pneumonia associada à ventilação mecânica. Os estudos indicam relação entre o subdimensionamento de trabalhadores da enfermagem e o aumento nas taxas de infecções, mortalidade, quedas, pneumonia associada à ventilação mecânica e extubação acidental.

ICU capacity strain and the quality and allocation of critical care

Increasing demand for critical care, with limited potential for comparable expansion of supply, may strain the abilities of ICUs to provide high-quality care in an equitable fashion. Efforts to counter the untoward consequences for the quality and ethics of critical care delivery are limited by the absence of a specific and validated metric of ICU capacity strain. This manuscript presents a conceptual framework for ICU capacity strain, considers what data elements may contribute to it, and suggests methods for determining the optimal metric. Next, it outlines the range of potential consequences of increased capacity strain, in terms of both the quality and ethics of care delivered. Finally, consideration is given to how untoward consequences of ICU capacity strain might be mitigated through better understanding of what makes some ICUs better able than others to withstand temporal fluctuations in the demand for their services. Development of an appropriately accurate and parsimonious measure of ICU capacity strain may augment the precision of future critical care outcomes research by reducing unexplained variance attributable to temporal fluctuations in ICU-level factors; elucidate organizational characteristics that make some ICUs better able to withstand high-capacity strain without substantive degradations in quality; and enhance the transparency of critical care rationing while helping to improve its equity and efficiency, thereby promoting the ethics of this inevitable practice.

Epidemiology of acute kidney injury in Hungarian intensive care units: a multicenter, prospective, observational study

BackgroundDespite the substantial progress in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise during hospital admissions. We conducted a national, multicenter, prospective, epidemiological survey to evaluate the importance of AKI in intensive care units (ICUs) in Hungary. The objectives of this study were to determine the incidence of AKI in ICU patients; to characterize the differences in aetiology, illness severity and clinical practice; and to determine the influencing factors of the development of AKI and the patients' outcomes.MethodsWe analysed the demographic, morbidity, treatment modality and outcome data of patients (n = 459) admitted to ICUs between October 1st, 2009 and November 30th, 2009 using a prospectively filled in electronic survey form in 7 representative ICUs.ResultsThe major reason for ICU admission was surgical in 64.3% of patients and medical in the remaining 35.7%. One-hundred-twelve patients (24.4%) had AKI. By AKIN criteria 11.5% had Stage 1, 5.4% had Stage 2 and 7.4% had Stage 3. In 44.0% of patients, AKI was associated with septic shock. Vasopressor treatment, SAPS II score, serum creatinine on ICU admission and sepsis were the independent risk factors for development of any stage of AKI. Among the Stage 3 patients (34) 50% received renal replacement therapy. The overall utilization of intermittent renal replacement therapy was high (64.8%). The overall in-hospital mortality rate of AKI was 49% (55/112). The ICU mortality rate was 39.3% (44/112). The independent risk factors for ICU mortality were age, mechanical ventilation, SOFA score and AKI Stage 3.ConclusionsFor the first time we have established the incidence of AKI using the AKIN criteria in Hungarian ICUs. Results of the present study confirm that AKI has a high incidence and is associated with high ICU and in-hospital mortality.

Assisted feeding in rabbits

Rabbits are herbivores with an efficient digestive process. During periods of fasting, the rabbit's gastrointestinal health can be severely compromised. Recovery from gut stasis is difficult and not always successful, frequently resulting in devastating consequences to the animal's health. As such, it is vitally important to maintain good intestinal functioning in rabbits that are unwell and this often requires assisted feeding for animals unwilling or unable to eat. The success of assisted feeding plans are highly dependent on the feeding route, frequency of feedings, and the quality of the diet fed. There are a number of quality critical care diets that can be fed to small herbivores in these cases. Supreme Recovery is one such diet that will be investigated in this article.

Editorial: Special Issue on Critical Care Engineering

The aim of this special issue on Critical Care Engineering is to provide a representation of the new trends of engineering involved in critical care. The main focus is on the state of the art in the various areas covered, with an indication of the current developments taking place and the problems and challenges that remain to be addressed. This issue is logically divided into four main areas: (a) critical patient care, (b) improvement of critical care quality, (c) critical care information systems, and (d) critical care facilities. Seventeen papers were selected through our routine rigorous double-blind external peer review by qualified experts. Due to the capacity limitation, some papers have already appeared earlier in the last issue (Volume 1, No. 3). All papers are briefly introduced below:

The Science of Improvement as it Relates to Quality and Safety in the ICU

This paper seeks to explain some of the science and concepts used in quality improvement, including the use of run charts and control charts, the development and use of ‘bundles’ and the need to reduce variability to improve quality in critical care.