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Approach of ICCMU to Quality and KPI

Development
ADMC Intensive Care Intermediate Indicator and KPI Development Workshop
16/6/2005
Government Action Plan IC Services Plan 2001
At a state level:
43 public ICUs
Did not know how many beds
Did/do not have an informed position on role of
intensive care in acute hospital
No forum to interpret health services research
Patient safety
Evidence-based practice
Hence Intensive Care Coordination & Monitoring Unit
(ICCMU)
ICCMU
Similarity with other statewide groups eg ITIM, Burns,
Renal Transplant, Bone Marrow Transplant etc except
wider constituency
Constituency
1633 FTE RNs
63 FTE Specialists
>200 RMOs
Clinicians are ICCMUsmost important stakeholders
Substantial IC assets in level 1 units (9) & level 2 units
(11)
Quality Activities
In NSW ICUs
M&M meetings 86% (not all multidisciplinary)
Regular Quality Meetings 72.4%
J ournal Club 34.88%
Level 1 units:
3 no education
Remainder 1-5 hours per week (except for one
with 20 hours per week)
ICCMU
Foster communication across all key stakeholders including NSW
Health, expert groups, clinicians and consumers at state, national and
international level
Facilitate an understanding of IC service provision including
workforce, patterns of demand including access issues, and other
factors that may impact on effective delivery of IC service in NSW
Promoting excellence in the standard of care of all NSW ICUs by:
Clinical networking, promotion and dissemination of evidence-
based practice
Providing a forum for systematic analysis and assessment of
information regarding the quality of care in NSW ICUs
In practical terms
Monitoring intensive care resources
Developing clinical communication networks ICUConnect
facilitate sharing of information
Website
Community information
Clinician pages
evidence-based practice
repository for Ps & Ps
Guideline development network
Collaborative approach to guideline development
Meeting 14/6/2005 38 nurse educators registered
Groups set up to provide care bundles hygiene, haemodynamic
monitoring, ventilation
ICCMU Quality Group
Provide a forum for the systematic analysis and
assessment of information regarding the quality of
care in NSW ICUs
Promote collection and interpretation of data on
quality
In conjunction with other ICCMU committees
promote quality improvement and evidence-based
practice
Both promote and measure quality
Multi-faceted approach to quality
Risk adjusted outcomes APD VicDRC
Access
MRU data
ICCIS vs white board
Incident monitoring
Process indicators
Incident Monitoring
NSW Patient Safety & Clinical Quality Program
Implementation of Advanced Incident Monitoring
System (AIMS) in every health service
IIMS will provide a consistent means of
identifying, tracking & managing clinical,
workforce and corporate incident information
across NSW
ICCMUQG input into statewide reports
Process Indicators
Emphasis on appropriateness of care -
housekeeping
Growing body of evidence linking process of
care with better outcomes
Pick up omissions
Checklist?
Process indicators
Pronovost used process measures to assess quality
of care in 13 intensive care units wide variation
in results many patients not receiving
appropriate therapy
Pronovost, Berenholtz et al J Crit Care 2003
Pronovost - used daily goals form to improve
effectiveness of communication significant
improvement in understanding of daily goals by staff
decreased LOS
Pronovost, Berenholtz, Dorman et al J Crit Care 2003
Checklist
In Hartford ICU used daily goals form as a
checklist or check-off rather than to do list
Claimed:
Marked improvement in understanding of goals
of therapy
Reduction in LOS by av. 1.5 days
Reduction in ventilator days by av. 1 day
Decrease of in unit mortality from 11.5% to
8.3%
J L Vincent
for effective bedside rounds, a battery of questions
should be raised systematically in front of each
patient
Can he/she be weaned?
Is pain controlled, is sedation well tolerated, does
patient need restraints?
Is nutrition adequate?
Is the head of the bed elevated?
Is DVT prophylaxis implemented?
Is ulcer prophylaxis implemented?
Vincent Chest 2004
Aim
To test the use of a checklist in a tertiary
intensive care unit as a method of ensuring
evidence-based quality processes of care are
performed routinely and systematically
Method
Checklist completed for all adult patients once a day for
approximately one month
Checklist used allowed for recording of demographic data,
information regarding clinical condition (to give context to
answers) and actual checklist questions
Yes, no or not applicable
Intended as a challenge and answer process at the end of
each patient visit
Paper-based data collection
Baseline survey and impact evaluation done
Questions chosen
Pain/sedation
Pain at rest?
Pain with relevant movement?
Pain addressed?
Sedation appropriate response?
Ventilation
If ventilated head of bed raised 30
0
Is patient being weaned?
If not ventilated, sitting out of bed?
Questions chosen
Lines and drugs
Has the age of all lines been checked?
Is the patient being fed ( E, parenteral, oral)
Thromboprophylaxis?
Stress ulcer prophylaxis
Have antibiotics been reviewed?
Path/Micro/Other
Was blood sugar recorded in last 12 hours?
If so was it <10?
Has micro been checked?
Have bowels opened in last 24 hours?
Results
Figures are after not applicables removed
Sedation - >30% oversedated
Pain approx 30% had pain (nearly all treated)
VAP >90% head of bed raised - ?30
0
Weaning - 60%
Results
Sitting out of bed daily (non-ventilated) 63.3%
Age of lines 100%
Nutrition 87.5%
DVT prophylaxis 89.6%
Stress ulcer prophylaxis 84.2%
Results
Antibiotics reviewed 96.9%
BSLs
Most checked in last 12 hours
85.5% <10 mmol/L
Micro checked? 88.9%
Bowels open?
15 patients not open for > 3days
Check list daily goals
A checklist in the intensive care environment could have the
following advantages:
Embeds quality into routine care
Immediate patient safety ieensuring that the patient gets
what he/she needs immediately safety lesson from
aviation
Educational tool constant repetition reinforces the
principle egBSL<8 a method of immediately
implementing evidence based practice
Depending how developed improved communication
Data collection process needs to be worked through
Indicators?
Questions clearly divided into 3 groups:
Prompts weaning, bowels, antibiotics, micro checked?,
sitting out of bed
Has the family been spoken to today?
Cleaning etc
Problematic indicators- not all agree with evidence
level of sedation sedation holidays
BSL
blood transfusion practices etc
appropriate benchmarks?
Indicators?
Evidence-based with:
Common acceptance of evidence
Clear definitions of yes, no or N/A ieclear unit
protocol
Iemeaningful numerator and denominator
thromboprophylaxis, elevated head of bed, stress ulcer
prophylaxis (NB J CAHO)
If there is a clear unit policy then close to 100%
compliance should be possible
Discussion
Well accepted by all staff more interest in process of
care
Has changed practice:
More attention to pain scores and pain in general
Talk about collecting process indications PDA etc
Prompts asked on morning round:
Can central line be removed?
Bowels open last 24 hours?
If no is faecal impaction present?
Has micro been checked?
Can patient sit out of bed?
Can any antibiotics be stopped?