A Toolkit for Intensive Care Units

to Improve the Safety and Quality of Patient Care

ICU Operational Procedures

In contrast to the structures of care that address infrastructure and multidisciplinary teams, ICU operational procedures address the processes of care used to manage ICU patients. Operational procedures include the criteria for admitting patients to the ICU and discharging them from the ICU. Operational procedures also include the criteria by which decisions are made regarding transferring patients from one facility to another. Additionally, operational procedures include various safety practices used during the provision of direct patient care at the bedside and elsewhere. Decisions related to admission and discharge from the ICU are crucial safety concerns and have been discussed at length in an article published in Critical Care Medicine. 22 The MH&SC ICU physician staffing guideline recommends that these decisions be made by the intensivist or appropriately qualified physician responsible for the ICU.

Protocols for ICU Admission and Discharge

Every ICU should have and use admission and discharge criteria. The criteria should be endorsed by the intensivist or other appropriately qualified physician. In hospitals where there is no intensivist or appropriately qualified physician, the Medical Executive Committee should endorse the criteria. ICU admission and discharge criteria should address the following: 23 24 1. 2. 3. 4. In hospitals where physicians other than the intensivist or appropriately qualified physician have admitting privileges into the ICU, the hospital should have a plan for decertifying physicians. An interim step for hospitals where physicians other than the intensivist have admitting privileges is to have the intensivist or other appropriately qualified physician review all admissions within 24 hours to determine if the patient was admitted appropriately or should be transferred to another unit. Hospitals should have in place plans and protocols for transferring patients as needed. Hospitals should have in place regional referral networks for complex cases so every hospital (and critically ill patient) has access to the specialty and subspecialty care required by critically ill patients with complex illnesses. Every hospital should assess its ability to provide a complete range of care, identify the gaps in care that it can provide and develop plans for referring patients to other hospitals for care it cannot provide.

Protocols for Patient Care

Every ICU should have protocols for patient care that have been developed by the intensivist or other appropriately qualified physician and other multidisciplinary team members. The protocols should establish procedure as it relates to:

Daily rounds. Protocols should stipulate when and how multidisciplinary team rounds should be conducted; that daily multidisciplinary team rounds should be conducted; and that the rounding team member constituency should include the intensivist or appropriately qualified physician, nurse, pharmacist, respiratory therapist, social worker, physical therapist and other ancillary staff as needed (e.g., chaplain). When an intensivist or appropriately qualified physician is not available, the rounds should include the primary or attending physician. The structure and schedule for multidisciplinary team rounds should be established by ICU and hospital leadership as appropriate. Patient plans of care. Protocols should stipulate how plans of care and goals are established and evaluated, the way in which protocols for care reflect local concerns and circumstances and daily goals for each patient. Protocol compliance. Protocols should include a measure to monitor compliance with protocols. One method for accomplishing this criteria could be done in meetings where staff are encouraged to focus on protocols, rather than outcomes by using rapid-cycle improvement methods and to update protocols when circumstances dictate. Protocol topics. The following clinical care areas have well-tested protocols of care and should be adopted by all ICUs. o Central Line-Associated Bloodstream Infection (JCAHO) o Central Line Utilization (JCAHO) o Deep Vein Thrombosis Prevention o Enteral Nutrition o Low Tidal Volume Ventilation/Acute Respiratory Distress Syndrome o Management of Agitation and Use of Sedation o Stress Gastritis Prevention o Tight Glycemic Control o Ventilator Weaning

ICU Safety Tips

The MH&SC recommends that all ICUs adopt the safety tips developed by theSociety of Critical Care Medicine. The following list of items are recommended strategies for improving patient safety in the ICU.

Open communication among all staff is a key element for successful teamwork. Ask questions and avoid making assumptions. Clearly label patient beds; consider having a removable sign at the foot of the bed with the patient's name and bed number. Verify patient identification by verbally communicating with the patient and/or check patient's identification band. Institute a standard change of shift policy, where nurses handing off patients personally review orders during their shift with oncoming nurses to clarify complete and incomplete orders. Perform a medication audit on each patient once during each shift, which could be performed at change of shift.

Create a mentoring culture for medical students, residents, nurses and other ICU staff where every question is welcomed and proper supervision is exercised. Check the Pyxis machines daily to ensure medications and doses are stored in appropriate bins. Incorporate "check backs" during provider team and patient interactions, where providers repeat an order during a handoff to help verify information transfer. Remove concentrated esmolol from Pyxis and replace it with prefilled syringes. Incorporate independent redundancies into patient care. An independent redundancy is when more than one person checks to make sure a clinical process is executed properly. For example, when a physician orders a medication, a nurse checks the medication order (first redundancy) for patient allergies and other drug interactions. This action is followed by a pharmacist who also checks the medication order (second redundancy) for patient allergies and multiple drug interactions. Reconcile drugs at the time a patient is discharged. Specifically, a nurse should complete a standardized form and confirm allergies and home medications, and resolve discrepancies before the patient is discharged. Use a rolling line cart to keep all sterile supplies needed for insertion and maintenance of central line catheters.

22 Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. (1999). Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27:3 633-638. 23 Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. (1999). Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27(3) 633-638. 24 Thompson DR, Clemmer TP, Applefeld JJ, et al. (1994). Regionalization of critical care medicine: Task force report of the American College of Critical Care Medicine. Crit Care Med 22(8) 1306-1313. 2004 Michigan Health and Safety Coalition