icu quialty

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Quality indicators for ICU: ISCCM guidelines for ICUs in India

B. Ray,D. P. Samaddar, S. K. Todi,N. Ramakrishnan, George John, and Suresh Ramasubban

Author information !o"yright and #i$ense information

This arti$%e has been$ited byother arti$%es in P&!.

Go to'

Foreword by Chair

Intensive care has had a phenomenal growth since its inception during the Copenhagen

Poliomyelitis outbreak in 1952. Few specialities have grown with that much pace as that o

Intensive Care! in such a short period. "rue! it is a #capital intensive$ care! but it saves lives!

which otherwise would not have been possible! and even contributes! with precision! toperception o the uture course o the disease and thereore to instituting remedial measures

well ahead o time% as these patients re&uire critical care therapies. "arget'oriented therapies

and bundles are becoming the preerred modalities to improve outcomes and there are

deinite indications that such therapies are helpul. Intensive therapy outcomes have been

constantly improving! notwithstanding the variations in deployment o processes! resources!

drugs! consumables and techni&ues in dierent IC(s. )hile disease outcomes are relatively

easy to appreciate and account or! intensive care outcomes are not so easy to appreciate and

account or! because o the very nature o the units and the way we practice intensive care!

particularly in our country with a large number o open! very ew semi'closed and even ewerclosed units. In order to develop the right kind o unit and practice optimum therapies to

provide best &uality treatment to our critically ill patients! we need to develop appropriate key

perormance indicators! which relect the aspirations o patients! relatives and intensivists.

*eveloping key perormance indicators and monitoring! auditing and improving those

parameters is a dynamic process which re&uires standardi+ation! improvement and innovation

, the three arms o any improvement process in industry or service scenario. )hile

standardi+ation means #removing the outliers!$ i.e. reducing the standard deviation!

improvement denotes gradual bettering o a parameter rom the previous level with a degree

o irreversible consistency. Innovation is! however! sporadic and oten re&uires a thinking

cap! which while maintaining the speed o standardi+ation and improvement! &uickly takes

the parameters to a new level. In "otal -uality anagement /"-0 parlance! the irst two are

a part or product o daily management and the last one is a part or product o policy

management. )hile standardi+ation and improvement come with all'round participation in

the unit! the innovation comes rom a particular individual or a section o the people

connected with the unit.

mall improvements through small group activities /3s0! previously known as -uality

Circles! are central to any improvement in a unit and bring about pride and involvementamongst the sta in IC(. )hile isolated improvement activities are important to engage
http://www.ncbi.nlm.nih.gov/pubmed/?term=Ray%20B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ray%20B%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Samaddar%20DP%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Todi%20SK%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ramakrishnan%20N%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ramakrishnan%20N%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=John%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ramasubban%20S%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/citedby/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/citedby/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/citedby/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pubmed/?term=Samaddar%20DP%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Todi%20SK%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ramakrishnan%20N%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=John%20G%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pubmed/?term=Ramasubban%20S%5Bauth%5Dhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/citedby/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pubmed/?term=Ray%20B%5Bauth%5D


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members to start with! institutionali+ing these activities is the ultimate goal o the unit or!

only that will ensure a complete irreversibility o the process. "he latter is possible i the

problems are constantly identiied in the process4procedure and improvement initiatives are

taken to address those. triving or results is etremely important and or that the team needs

to identiy and take care o the #vital ew$ problems leaving the #trivial many%$ something like#triaging$ in mass casualty parlance.

Co'relating the improvement o the process4outcome parameter with the improvement

activities is important% i it does not match! then either one has not chosen the parameter

properly or the parameter needs urther development in the orm o precision and compleity

or the #vital ew$ problems have not been properly identiied. 3 constant engagement with the

improvement process is necessary on the part o the team. "he parameter needs to be

developed! validated and revalidated in the same unit and in dierent units among the similar

and dissimilar case mi beore it is inally accepted.

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Members' Details

*r 6 7ay8 eneral anager /edical ervices0 "ata ain ospital! :amshedpur

moc.leetsatat;yarbrd%

51@

*r * P amaddar8 A* 3naesthesiology and Critical Care! "ata ain ospital! :amshedpur

moc.leetsatat;raddamaspdrd%

92=>551@>9

*r B "odi8 ead o edicine and Critical Care! 37I! Bolkata
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/mailto:dev@nullmailto:dev@nullmailto:dev@nullhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/mailto:dev@nullmailto:dev@null


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because o many reasons including the act that maGority o IC(s in India are being run as

open or semi closed units! with unaccountable custodians. *ependency on the key

perormance indicators practiced by the developed countries! thereore! becomes inevitable

wherever some degree o total &uality management system is being adhered to. It is generally

seen that a ew o the hospitals in India attempt to evolve their own parameters either takingideas rom the Hestablished parameters or rom their eperience in Indian hospitals. ome o

the parameters! when pursued year ater year! do not epress or relect the aspirations o the

intensivists. electing deinitive and sensitive &uality indicators and orming a data base at

national level! is thereore re&uired. "he eecutive committee o the Indian ociety o Critical

Care edicine /ICC0! took a decision in the year 2


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take remedial action through small group activities /3s0 and sel initiated proGects /IPs0.

Ane would see a lot o Plan'*o'Check'3ct /P*C3s0 on the way to evolution o a parameter.

Go to'

Main e!ort

Inde! Page no

1. 6ackground /Introduction08 1E5

2. athering the vidence8 1E5

=. (nits 1E5

>. AbGective 1E?

5. Parameters 1E?

?. *einition o Parameters 1E?

E. *ashboard 1@=

@. Kimitations 1@=

9. Future Course o 3ction 1@=
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Inde! Page no

1

11. Kist o ymbols 1@>

12. 3cknowledgments 1@5

1=. 7eerences /additional0 1@5

1>. 3nneure 1@5

1>.1. -uality Indicators in Critical Care8 3n Averview 1@5

1>.2. -uality Indicators in Critical Care8 Patient aety 192

1>.=. -uality Indicators in Critical Care8 Personnel *evelopment 19>

1>.>. -uality Indicators or IC(8 Process Parameters 19?

1>.5. -uality Indicators in Critical Care8 Autcome Parameters 2.?. -uality Indicators8 Inection Control 2


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Go to'

"# $ac%ground

-uality orientation is an integral part o patient care. "he best possible care at the institutional

level is not considered ade&uate in the present competitive environment. It should be visible!

appreciated and comparable. "otal -uality anagement thereore! is essential to Gudge the

appropriateness and eectiveness o medical care. -uality o service oered! result o

intervention and treatment! undesirable outcomes! and other managerial and treatment related

processes can be analy+ed to deine the scope o improvement. -uality indicators help in

achieving these obGectives. ealthcare is becoming transparent and customer'ocused.

Patients and their relatives have the right to know the standard o care and its cost.

It is thereore becoming more and more mandatory or an institution to monitor &uality

indicators4parameters! and compare their perormance level with the national standard orinternational bench marks. It gives the individual institution an opportunity to improve its

&uality o care through standardi+ation o processes! procedures and treatment protocols.

(nortunately! due to a variety o reasons! perormance levels are not monitored in India and

thereore a national data base does not eist or a meaningul comparison. *ependency on an

international data base! even i not logical or Indian scenario! becomes inevitable in our

strategic design and planning o the service.

In 2


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Annexure:

$Personnel *evelopment *r uresh

%-uality o Processes *r eorge :ohn!

*r D 7amakrishnan

&Autcome Parameters *r eorge :ohn!

*r D 7amakrishnan

'Inection Control *r * P amaddar

Go to'

*# Units

"his report ocuses on adult mied intensive care units! reerences have also been given

/ecept Deonatal IC(0 wherever possible! to benchmark other speciied units0.

3bbreviations used or dierent speciali+ed units are given in"able 1.

"able 1

Go to'
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0001/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0001/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0001/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0001/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0001/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/


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+# ,b-ecti)e

1. elect very common parameters mainly ocusing on the Outcome/mortality and

morbidity0!process, infection, communication, human resource and safety.

2. enerate national data base or comparison with international bench marks and

provide data to participating institutions at national level or comparison with national

data base.

Go to'

.# Parameters

6ased on the obGective o this report! common parameters with their international

benchmarks have been selected to address dierent aspects o patient care! operational issues

and human resource development. Certain basic data! which as such do not relect patient

care! but when used as denominators to the selected parameters! make the parameter more

sensitive and meaningul. amples o these denominators are8 number o admissions! total

patient days in the unit /occupancy0! ventilatory days! central venous and arterial line days!

urinary catheter days etc. In order to avoid conusion and ambiguity o interpretation! it is

essential that purpose and useulness o selected parameters must be understood by the care

providers. 3ll the selected parameters! thereore! are described under certain sub headings as

given in the "able 2! along with eplanations.

"able 2

Go to'

/# Definition of Parameters

/#" Mortality

/#"#" Standardi0ed Mortality ate1SM2

Indicator (tandardi)ed mortality rate *(+,- or risk adjusted mortality rate

*escription ortality rates are not oten the indicators o perormance even i those are oten reerred

to. owever! mortality rate related to prior prediction is a sensitive indicator or
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0002/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0002/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0002/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/table/T0002/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/


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comparison. 7 allows comparison o actual perormance o the institution with

predicted perormance! based on the average mortality as epressed by national or

international data.

7ationality 7isk o death varies with severity o disease state! age! and co' morbid conditions. Crude

mortality /overall mortality0! thereore! is not a sensitive indicator. An the basis o

inluencing actors! 7 obviates limitation o crude mortality as data rom a large pool

o patients with similar diagnoses and risk actors are analy+ed to get epected mortality

or that group o patients. *ata can be obtained rom national records or international

records. ortality rate can be obtained rom predictive models such as 3P3C! 3P!

P etc.L2M "he 7 is a very useul parameter! oten used to compare outcomes in two

or more groups under study. It also gives an opportunity to individual IC(s or improving

the processes and techni&ues.

Formula orcalculationL1M

7isk'adGusted ortality 1

N /Abserved 7ate47isk'adGusted epected 7ate0 O1


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7isk adGusted epected rate N Predicted death rate by predictive odel

InterpretationL1M ./ual to "00, hospitalJs mortality rate and the epected average rate are the

same

1"00, hospitalsJ mortality rate is higher than the epected average mortality rate

2"00, hospitals mortality rate is lower than the epected average mortality rate

igher 7 does not necessarily mean that the hospital is unsae! as this is a

snapshot method and simultaneous assessment o other &uality indicators must be

done to draw a logical conclusion. ingle parameter'based Gudgment on

perormance level is not advocated.L2M

Patient

population

3ll patients admitted to critical care units o dierent types

ource o data ospital record or the observed mortality /numerator0

"ype o

parameter

Autcome

6ench mark I the 95 conidence interval o the 7 includes 1! the perormance is considered

average. I the 95 CI Qdoes not include 1! 7s less than 1 and more than 1 are

considered to show good and poor perormances respectively.L=M
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7eerences

1. 3vailable at8 http844www.mayoclinic.org4&uality4adGustedmortality.html

2. 3vailable at8 http844www.&hc.on.ca4body.cmidN5?5

=. 3essa 6! aGic A! Beegan ". Beegan severity o illness and organ ailure

assessment in adult intensive care units. Crit Care Clin 2


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Indicator Iatrogenic Pneumothora!

Patient

population

Intensive care

ource o data ospital record

"ype o

parameter

orbidity! saety

6ench mark


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Indicator Iatrogenic Pneumothora!

2. *elgado C! Pericas KC! oreno :7! et al.-uality indicators in critically ill patients.

ICR(C work groups. 1sted. ay 2


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Indicator Incidence o3 severe Acute ,enal Failure in noncoronary IC

Patient

population

Dominator8 evere renal ailure /F7 S 1< ml4min.0L>M developing in IC( /ecluding

chronic renal ailure patients.0 *enominator8 Patient managed in IC( in a given time rame

ource o data IC( record

"ype o

parameter

Autcome parameter

6ench mark evere 37F 5.EL1M 1M

7eerences 1. (chino ! Bellum :3! 6ellomo 7! *oig ! orimatsu ! orgera ! et al. 3cute

renal ailure in critically ill patients8 a multinational! multicenter study. :33

2


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Indicator Incidence o3 severe Acute ,enal Failure in noncoronary IC

2


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Indicator Decubitus *Pressure- ulcer

calculation

Patient

population

Critically ill

ource o

data

ospital record

"ype o

parameter

orbidity! aety o patients

6ench mark = , 11L1M 22.E1 4 1


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Indicator Decubitus *Pressure- ulcer

7eerences 1. 7evis *7. *ecubitus (lcers. edicine Actober 25th! 2


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Indicator 4ength o3 (tay *4O(-

Formula or

calculation

"otal occupied bed days 4 number o patients in a given time rame /weekly4monthly 4yearly0

Patient

population

3ll admitted patients in the unit

ource o

data

IC( data

"ype o

parameter

Autcome measure

6ench mark 3verage KA in year 2= days
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2


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Indicator 4ength o3 (tay *4O(-

in vascular IC(

7eerences 1. cillan "7! y+y 7C. 6ringing &uality improvement into the intensive care unit.

Crit Care ed 2


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Indicator Compliance to protocol

Formula or

calculation

Dumber o times ollowed4 number o times epected to ollow X 1


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Indicator Compliance to protocol

7eerences 1. cillan "7! y+y 7C. 6ringing &uality improvement into the intensive care

unit. Crit Care ed 2


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Indicator IC readmission rate

Patient

population

3ll patients discharged rom IC( in a time rame./eclusion8 death in CC(0

ource o

data

ospital record

"ype o

parameter

Process! aety o patients

6ench mark IC( readmission rates are around 5,?L1M >L2M

7eerences 1. cillan "7! y+y 7C. 6ringing &uality improvement into the intensive care unit Crit
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2


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Indicator IC readmission rate

Care ed 2

Indicator Patients5 Fall ,ate

*einition 3n untoward event! which results in the patient coming to rest unintentionally on the

ground or another lower surace.L1M

7ationality Fall could be accidental! anticipated physiological or unanticipated physiological. "his is a

saety issue or a patient in IC(. 3ccidental all could lead to morbidity! prolonged stay

and customer dissatisaction.
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Formula or

calculationL1M

all rate N /no. o alls4no. o bed days0 X 1


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6ench

markL2!=M

@.>? alls per thousand bed days with an inGury rate o 12.@5 in 2


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=. Dorton hospital (32


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Indicator +edication error

Patient

population

3ll patients in IC(

ource o

data

IC( record

"ype o

parameter

Patient saety

6ench

marksL1!2M

1. edication errors range rom 1.2 to 9>E per 1.1 per 1


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Indicator +edication error

2. erout P! rstad 6K. edication errors involving continuously inused

medications in a surgical intensive care unit. Crit Care ed 22@,=2.

/#+#* 4d)erse ()ents 7(rror ate

Indicator Adverse .vents6.rror , ate

*escription Common IC( errors are related to treatment! procedure! ordering or carrying out medication

orders! reporting or communication! and ailures to take precautions or ollow protocols.

7ationality Critically ill patients are at high risk or complications due to the severity o medicalconditions! compleity o treatment! poly pharmacy and technology based interventions.

Dearly all IC( patients suer rom potentially harmul events. Dearly hal />50 o the

adverse events are preventable.

Formula or

calculation

3dverse events4 error rate N /no. o error 4no. o bed days0 X 1


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Indicator Adverse .vents6.rror , ate

population

ource o data edical record

"ype o

parameter

aety /patient0

6ench

markL1M

"he rates per 1422=0 were potentially lie'

threatening.

7eerences 1. 7othschild :! Kandrigan CP! Cronin :)! Baushal 7! Kockley )! 6urdick ! et

al. "he Critical Care aety tudy8 "he incidence and nature o adverse events and

serious medical errors in intensive care. Crit Care ed 2


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/#+#+ 5eedle Stic% In-ury ate

Indicator 7eedle (tick Injury ,ate

*escription 3 penetrating stab wound rom a needle /or other sharp obGects0 that may or may not be

associated with eposure to blood or other body luids

7ationality L1MDeedle stick inGuries can cause transmission o blood borne pathogens. Deedle stick inGury

can occur due to aulty handling o needle! syringe with needle! suture needle! recapping o

needle! and aulty disposal. 3nnual incidence ranges rom ?3ccording to C*C estimate =@5!

population

3ll healthcare workers


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ource o

data

IC( record

"ype o

parameter

aety /ealthcare worker0

6ench

markL2M

per 1

7eerences 1. 3vailable rom8 http844www.medterms.com4script4main4art.aspYarticlekeyN25>92.

2. 7osenstock K. tatement or the record on needle stick inGuries. Centers or disease

control and prevention! *epartment o ealth and uman ervices 3vailable

rom8http844www.hhs.gov4asl4testiy4t


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2@ hours o etubation

7ationality 3ccidental etubation and subse&uent reintubation can lead to prolonged stay! longer

ventilation and higher nosocomial pneumonia and mortality

Formula or

calculation

/Dumber reintubated4 Dumber etubated0 X 1


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Indicator ,eintubation ,ate

ource o data IC( record

"ype o

parameter

orbidity! saety

6ench mark 12.2L1M! 12L2M

7eerences 1. cillan "7! y+y 7C. 6ringing &uality improvement into the intensive care

unit. Crit Care ed 2


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commonly monitored variables are8 a0 ventilator associated pneumonia! b0 blood stream

inection and c0 urinary tract inection rate were selected as &uality indicators or this report.

DDI surveillance 2


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Indicator 8entilator Associated Pneumonia *8AP-

*iagnosisL2M ,adiologic (igns

Z 2 serial chest radiographs with at least one o the ollowing8

Dew or progressive andpersistent iniltrate

Consolidation

Cavitation

Clinical (igns *at least one o3 the 3ollo9ing-:

Fever /temperature T=@[C0 with no other recogni+ed cause

Keukopenia /S>.< X 1


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7ales or bronchial breath sounds

)orsening gas echange /e.g.! oygen desaturation ratio LPaA24FiA2M S 2>

increased oygen re&uirement! or increased ventilation demand0

Formula or

calculation

#of patients with VAP#of days mechanically ventilated with endotracheal

tube1000days

Patient population 3ll ventilated patients ecept neonatal intensive care patients

ource o data ospital record o patient

"ype o parameter Inection! outcome! saety

6ench mark /1


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urgical general 5.=

"rauma 9.=

edical 2.5

edical4surgical! maGor! teaching =.=

edical4surgical! all others 2.=

Pediatric medical4surgical 2.1

7eerences

1. adar D! *e+ulian C! Collard 7! aint . Clinical and economic

conse&uences o ventilator'associated pneumonia8 a systematic review. Crit

Care ed 2


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Indicator Blood (tream In3ection Due to Central 4ine

*escription 6lood stream inection rates N number o central line related 6I per 1


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Indicator Blood (tream In3ection Due to Central 4ine

Coronary 2.1

urgical cardiothoracic 1.>

Deurosurgical 2.5

urgical general 2.=

"rauma >.

edical4surgical! maGor! teaching 2..>

urgical cardiothoracic =.2

Deurosurgical ?.@

urgical >.1

"rauma 5.E

edical >.1

edical4surgical! maGor! teaching =.=

edical4surgical! all others =.1

Pediatric medical4surgical 5. hours o transer

during a single hospital stay. 7eported IC( readmission rates are around 5,?.L9!1

entertained in a given unit belonged to poor socio economic status! not covered by medical

insurance and also not supported inancially by state or ree medical care. "his kind o

situation is more oten a rule than eception in India. Considering this background! IC(

ependiture4 patient4day is an important parameter. 3ttempts should be made to minimi+e it

by taking local actors into account while practicing evidence based medicine and

international protocols. Cost conscious units can maintain the same &uality or oer a better

&uality with lesser and Gudicious utili+ation o resources. "here is no proportionate

relationship between the cost and &uality. (3! despite being the most epensive medical

care system! is not the leading nation in &uality o care. Cost eectiveness is epected to be

the natural allout o eicient care. "he beneit so accrued can either be shared with the

patients4 relatives by maintaining same &uality at reduced charges or enhancing oered

service level without reduction in charges.

conomic viability o the unit is Gudged by the income generated ater deduction o all

epenses. igher management always measures the success in terms o revenue loss or gain.

3nalysis o the epenses to identiy ependiture on vital ew and trivial many should be

done. easures should be directed at vital ew items to get maimum return. )hile doing this

eercise! Gudicious cost control should be done. Prevention o wasteul ependiture can

signiicantly reduce running cost o the unit.

,esource tili)ation:6ecause IC( care is epensive! resource utili+ation should be

optimum. 3ssessment o resource utili+ation should be relected in selection o &uality
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indicators.L2M Aptimum utili+ation o beds is essential to make the unit economically viable.

Dumber o patients managed! percentage occupancy! average length o stay /KA0 and

occupied bed days /KA o each patient added in a predeined duration0 etc. help in

&uantiying resource utili+ation and Gustiying the need o uture epansion. *eserving

patients denied IC( care due to paucity o bed or e&uipment! percentage o patientsremaining in IC( who could have been managed elsewhere and patients getting IC( care

where intensive care is epected to be utile should be taken into consideration while

assessing Gudicious utili+ation o resources.L1=,15M 3dherence to written or published IC(

admission and discharge standards can be used to measure the &uality o IC( bed utili+ation!

but such standards have not been subGected to the scientiic validation and thereore are not

endorsed or this purpose.L2M Proprietary systems such as 3P3C III can be used to match

unit data with the predicted IC( length o stay! days spent receiving mechanical ventilation!

and the likelihood o receiving active intervention. "his approach is limited by the act that

3P3C III has been validated only or the length o stay.L1?M *espite the limitations inaddressing this issue! local protocol should be developed based on the scientiic background

and local actors.

&uipment utili+ation is an e&ually important dimension o resource utili+ation to Gustiy

uture procurement. *owntime in hours! revenue loss due to e&uipment remaining down!

ependiture on overall maintenance o e&uipment and e&uipment wise revenue generation

/return on investment or 7AI0 indicate the eiciency o maintenance support and skilled

utili+ation o e&uipment by the IC( team. Check list o all e&uipment should be updated in

the unit on a daily basis to monitor e&uipment utili+ation and downtime.

.rrors and Patient (a3ety:Focus should be both on saety o patients and care providers.

"he 2

physicians denied having erred in the IC(! whereas at the same time they said that manyerrors are neither acknowledged nor discussed.L5!12M
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rrors could be due to various reasons. hortage o man power! deiciency o trained

manpower! inGudicious work pressure! inade&uate inrastructural and e&uipment support! lack

o protocol! and personal issues are the ew important causes o errors. "hese actors should

be addressed beore blaming a person. Complacent attitude and lack o commitment could

also be responsible or certain errors though it is inre&uently observed in a sensible unit. L2=!2EMost o the errors are not caused by individual inade&uacies but are a product o deects in

the system o care.L>M "hereore! beore conducting an error surveillance! ambiguity o

practice in oering various services should be eliminated. Care providers must know what is

epected rom them. uidelines! protocols! systems and processes developed locally with

reerence to national4international guidelines and recommendations should be in place.L2=MProtocols should be in written orm and ade&uate training should be given to the people

who are epected to ollow the protocol.L2@M*evelopment o local guidelines4processes etc.

should be done in consultation with the stake holders to break the resistance and to create a

sense o ownership. "his eercise should be done in piecemeal and training should beimparted as the systems and processes are being developed and implemented. Doncompliance

to monitoring and record keeping should be done regularly to ind out the magnitude o

problem and area o concern.L29M)riting protocols is relatively easy but implementation o the

same and to conduct compliance monitoring are diicult to accomplish. Don'adherence to

established standards o care have been related to poor outcome.L>M Anly 5< to E


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"he satisaction level o sta is very important. igher turnover due to dissatisaction causes

wastage o time and money on sta training. -uality o care goes down due to higher

turnover. 7eplacement o trained and motivated manpower is not good or the unit.

atisaction level and sta turnover should thereore be taken as perormance parameter o

the IC(.L2M any survey tools are available to assess this aspect.

Customer Focus:Care provided should be perceived and appreciated by the patients and

relatives. Concern and empathy should be ehibited by the natural action o the care provider.

IC( patients or their surrogates are oten dissatisied with the amount! nature! and clarity o

communications by care givers. "hese contacts! which are oten delayed and too brie! lead to

conusion! conlict! and uncertainty about the goals o therapy.L2M Communication protocol

and complain capturing and handling system prevents conusion and conlict. Patients and

their relatives should be encouraged to give suggestions and to epress their eelings. Dumber

o complains4suggestions lodged and addressed could be taken as parameters. "he mere

distribution o eed back orm! though! is easier and oten does not serve the purpose i the

educational background o eedback givers does not match the epectations o the

surveillance team. Instead o routine ritual o passive surveillance! eort should be made to

eplain and assist the relatives o patients or patients beore giving them eed back orms.

"hey should also appreciate the need and importance o surveillance otherwise they might

ignore such re&uest. "hey should also be encouraged to give eed back without hesitation and

ear. uch active surveillance is epected to be a better alternative and helps in identiying

actual diiculties and epectations o the target population. (ninhibited eed back is possible

i care providers are not part o such surveillance. "rained third party involvement or

conducting the survey and analysis is a better but a costlier alternative. Care providers can

help in designing the eedback ormat based on the past eed backs and area needing more

attention. icient customer eed back system also helps in identiying epectations o the

community. -uality indicators should be selected keeping these concepts in mind. Fre&uency!

method o surveillance and analysis should be predeined. IC( management should do

compliance monitoring and keep the necessary documents or review. Corrective action taken

should get relected in the subse&uent satisaction survey provided methodology remains the

same.

8ariation in standard o3 care:ariation in care is mostly due to geographical location! typeo hospital! and physiciansJ preerence. "hese variations can be tackled to a great etent by

protocols developed based on international guidelines and evidence based medical approach.

7esistance oered by individual clinician or group o clinicians could be the road blocks

while implementing the protocols and systems. Protocol'based approach might be viewed or

proGected as restriction in the authority and autonomy o individual clinician but keeping

obGective o evidence based medicine in view such variability should be curbed. upportive

administration can help in overcoming such resistance. )hile developing local protocols!

individualsJ or groupsJ opinion should be honored as much as possible. Ance protocol is
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developed! compliance o these is epected rom them. onitoring o compliance and need

based action is the responsibility o IC( management with the help o hospital authority.

ariation in care due to inancial status! and insurance coverage could be diicult to address.

In one study! 2


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Go to'

4ction Plan

"> arget (etting and Benchmarking:Current level o perormance and bench mark data

help in deciding the uture targets. For eample! i reintubation rate is considered the

perceived problem and needs attention! the gap between the current level o reintubation in

the unit and bench mark should be identiied. Kiterature background o bench mark and

method adopted or collecting the data should also be noted or uture reerence. 7eported

reintubation rate in patients receiving mechanical ventilation is 12.2 within >@ hours o

etubation based on the published data o large international survey conducted by steban et

al.in 2 Data Collection:ospital anagement ystem /0 should be robust enough to

generate data and analy+e the same based on the ed inormation to minimi+e man power

utili+ation and errors.L>M Inormation collected by the computeri+ed system is superior to that

collected by humans! especially i the system is speciically programmed to ac&uire the

desired inormation. IC( team should remain involved i a tailor'made sot ware is being

used. peciic need should be identiied and introduced by IC( proessionals while the

sotware is being developed.
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anual data collection is possible but computeri+ed physician order entry /CPA0 system

automatically detects errors in unbiased manner and thus improves &uality care by reducing

costs and errors.L2!2=M In the absence o this! data collection and incidence reporting by

individuals is the only viable alternative. Predeined criteria or data collection should be

established with least dependency on human Gudgment. It is always better i IC( personnelcollect data rather than relying on the health'care workers.L2M Awnership and accountability

should be ied or data collection! monitoring and maintenance o score board.

$> rend Analysis:core Card should be prepared to accommodate vital parameters based on

the monitored parameters. core 6oard should depict overall perormance o the IC(. "his

helps in the systematic collection o data! monitoring o important parameters at a glance and

also conduct trend analysis. )hile selecting the parameter! whenever possible correlate the

desired parameter /numerator0 with another parameter /denominator0 to make it more

meaningul. For eample number o adverse events /numerator0 can be epressed as the rate

o events by dividing the absolute number with a denominator like aggregate number o at'

risk patients! patient'days etc.L2M

Irrespective o the data type! care must be taken to collect a sample si+e that is large enough

to allow reliable statistical comparisons.L2M uppose monthly tracking shows that a particular

parameter luctuates between < and ?! then while doing the trend analysis over a period o

time a dierence in the parameter within the acceptable limit should not be considered as

deterioration in service. "hus! it is important not to over'interpret short'term changes in

perormance measurements while evaluating the same.L2M Fre&uency o data analysis is

thereore important. hort term analysis can show wide variation in the parameters.

tandardi+ation and accuracy o data collection is also important or subse&uent analysis and

comparison. For eample measuring the number o calendar days a patient spends in the IC(

is likely to overestimate KA. 3ccuracy will be better i eact number o hours occupied or

the number o days with midnight bed occupancy is taken into account or KA calculation.L=9M3 proper statistical analysis is also important or avoiding misrepresentation o data. I the

arithmetic mean is used to calculate KA in the IC(! it will oten misrepresent the population

because KA data are skewed by atypical stays o ew patients. 7eporting the median! mode!

or geometric mean will more accurately relect the central tendency o the data. L>1MCommon tools used whileollowing the P*3 cycle are8 brain storming! cause and eect diagram! prioriti+ation o
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#vital ew$ causes! corrective action! and monitoring o impact. Process improvement is

needed even or data collection to prevent it rom becoming burdensome.L>M

&> eam Building:Contribution o IC( team and involvement o each member is vital or

&ualitative and sustained change in the unit. It is also important to appreciate that a close

working group o dedicated healthcare providers can be as! i not more! important than the

written protocol.L>M IC(s oering a Hclosed model o care /IC( care and admission and

discharge decisions made eclusively by intensivists or in consultation with intensivists0!

have shown better outcome parameters and shortened KA. L>2M3n association o leaders o

industry rom the 6usiness 7oundtable! the 4eap3rog =roup! has advocated or the

widespread implementation o the intensivist model o care in the IC(. L>=M"he same

recommendation had subse&uently been given by the 7ational M

Conclusion:-uality indicators act as the yard stick to measure the level o care oered in a

unit over a period o time. ariation in care in the unit and among dierent units with similarcase mi can only be done i indicators are compared on regular basis. -uality o care in IC(

depends on the comple interaction between patient! machine and care providers. Process

driven and protocol based management should eliminate ambiguity and ensure better

outcome. uch approach is not possible unless care provided is &uantiied and gap between

current level and desired level is assessed ollowed by improvement initiatives taken to

bridge the gap. election o indicators and monitoring the same should! thereore! be

considered the most vital and challenging task to bring continuous improvement in the

perormance level o the unit.

Go to'

eferences

1. Parker . 3 letter rom the president. CC President! 2


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?. oldrad C! 7owan B. Conse&uences o discharges rom intensive care at night.

Kancet 2


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2


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=2. Chassin 7! Boseco :! Park 7! )inslow C! Bahn BK! errick D:! et al. *oes

inappropriate use eplain geographic variations in the use o health care servicesY

:33 19@E%25@825==,E.

==. cDeil 6:. hattuck lecture8 idden barriers to improvement in the &uality o care. Dngl : ed 2


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Introduction

H"o err is human! a seminal paper rom Institute o edicine /(30 in 1999! citing >>!


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Incident:(nepected or unanticipated events or circumstances not consistent with the

routine care o a particular patient! which could have! or did lead to! an unintended or

unnecessary harm to a person! or a complaint! loss! or damage.

7ear +iss:3n occurrence o an error that did not result in harm.

Adverse .vent:3n inGury resulting rom a medical intervention.

Preventable Adverse .vent:arm that could be avoided through reasonable planning or

proper eecution o an action.

Measurement

3s patient saety is a concept and an abstract term! converting it into numerical terms or

research and audit purposes is diicult. Ane also has to consider many dimensions o sae

patient care. )e all try to practice sae patient care but when it comes to &uantiying it!certain basic principles need to be ollowed.

Principles o management rom industry are being increasingly incorporated in medicine and

this is most evident in regards to patient saety. ae industries /e.g. aviation0 report deect

rate in terms o sigma or deects Per 1

deect rate and si sigma e&uals three deects per million. ealthcare industryJs record is

abysmal in this regard which runs at one or two sigmas.

3ny &uantiication tool will be meaningul i it consists o a numerator /number o events

observed0 and denominator /number at risk0 so that a rate can be calculated. It is laborintensive to keep a tab on rates o adverse events! and a more subGective approach may be

appropriate some time! which acts to highlight problem areas to be speciically addressed in a

more obGective way.

amples o such a subGective approach will be peer review! morbidity and mortality

conerences! investigation o liability claims! and incident reports. In all these! a single event

is analy+ed! which is not linked to a denominator which limits the ability to estimate rates.

Donetheless! they help to identiy problem areas.

Incident ,eport:It evaluates how a single patient is harmed but can also be utili+ed to lookat near misses i.e. incidents that did not but could have caused harm. "he IC(7 proGect

pioneered by *r. Pronovost rom :ohns opkins is an eample o such incident reporting

system which is web based.

"o be successul! an incident reporting system should be voluntary! anonymous! and not

linked with any orm o punitive measure. "he IC(7 system is open to participating

hospitals and personnel can enter incidents and near misses conidentially! which is analy+ed

centrally and eedback is given. Aver 1E


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actor! "eam actor! "ask actor! "raining and ducation actor! IC( environment and

Institutional environment.

,oot Cause Analysis' "his is a more ocused en&uiry on certain incidents which are deemed

to be important or patient saety. 3 sentinel event is identiied! important preventive aspects

o this event are discussed by the Hsaety team and the saeguards are implemented.

Failure +ode and .33ects Analysis *F+.A-'6oth the incident report and root cause

analysis are post hoc analysis which tries to improve patient saety ater the incident has

occurred. 3 more proactive approach where a problem area is identiied prospectively! and all

possible preventable aspects are discussed and remediable measures are taken. "his approach

takes away the primary burden rom an individual and ocuses more on system ailure. In an

F3! an error'prone process is identiied and a multi'disciplinary team is ormed to

analy+e the process rom multiple perspectives. "he team systematically assesses ailure

modes and the urgency with which each ailure mode should be addressed. )here 7C3 canbe thought o as an epanding circle o in&uiry that is ocused on a sentinel event! F3 is a

linear process that eamines a selected process rom start to inish. Conducting F3 is

highly time consuming and labor intensive! so its use should be restricted to areas prone to

serious adverse events. 7egulatory authorities are now making it mandatory in (3 and (B

or medical and nursing directors o IC(s to conduct at least one F3 annually.

Im!lementation

Implementing Hsaety culture in the IC( has to come rom a strong leadership primarily

rom the IC( director! backed by a willing management.

"he irst step in our country is to ensure that the healthcare providers are assured that no

punitive actions will be taken against them i an adverse event is identiied or reported. In

act some institutions in India have started rewarding such bold steps o revealing errors to

the authority. "he concept o #system ailure$ rather than Hindividual ailure needs to be

enorced.

econdly! a system o reporting adverse events has to be in place or audit or root cause

analysis. "his system should be discreet and could be paper or computer based.

"hirdly! an audit o incident report! root cause analysis or F3 should be perormed

periodically by a multidisciplinary team consisting o IC( director! Dursing director! -uality

control personnel! and hospital administrator. Corrective measures should be identiied and

eedback given to healthcare providers.

Finally! established practices or decreasing errors like computeri+ed physician order entry

/CPA0 system! patient identiication tags! check list or blood transusion should be in place

and checked periodically or compliance.

"here is a great need or research in this ield in our country to identiy areas o vulnerability!and inding cost eective solutions to problems o patient saety.


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Further reading

1. 7othschild :! Kandrigan CP! Cronin :)! Baushal 7! Kockley )! 6urdick ! et al.

"he Critical Care aety tudy8 "he incidence and nature o adverse events and

serious medical errors in intensive care. Crit Care ed 2


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IC( personnel development and &uality initiatives ocusing to personnel development. "his

will be discussed under the ollowing headings8

1. *einition o ta in IC(

2. "raining re&uirement

=. taing logistics

>. -uality measures

Staff in ICU

Irrespective o the model o critical care delivery in an IC(! a multidisciplinary approach is

recommended by the CC. 3s an eample! medication errors are reduced signiicantly in

hospital with intensivist staing and multidisciplinary rounds. "his involves the presence o

dedicated IC( personnel! especially the intensivist! IC( nurse! IC( pharmacist and

respiratory therapist.

Intensivist is a physician who is trained in a primary specialty such as

edicine43nesthesia4urgery4Chest edicine0 and has a certiicate o special &ualiication in

critical care. e diagnoses! manages! monitors! intervenes! arbitrates and individuali+es the

care to each patient at risk! in the midst o or recovering rom critical illness. e4she should

be immediately and physically available to patients in the IC(. "he credentials should

include both cognitive and procedural skills.

IC( ouse sta members are either physicians in training or otherwise who are ully

dedicated to the IC( and have no other responsibility and are on site to provide all

emergency care to the patient.

3n IC( nurse should be a licensed nurse with preerably added certiication in critical care.

3lthough certiication is not mandatory! certiication validates to patients and employers that

a nurse is &ualiied and has gone through rigorous training re&uirements to achieve the

additional credential.

IC( pharmacist is deined as a practitioner who is a &ualiied pharmacist and has speciali+ed

training or practice eperience providing pharmaceutical care or the critically ill patient.

"he presence o an IC( pharmacist as part o the IC( team improves &uality o care in the

IC( by reducing medication error by as much as ??.

3nother important personnel o the IC( is the respiratory therapist who provides cardio'

respiratory care to critically ill patients. "he absence o trained therapist should lead to

establishment o training programs or 7espiratory therapist

?raining


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"raining is must or maintaining and urther up gradating o skills o the IC( personnel.

Imparting training based on the identiied need is essential or any sensible unit. In the

absence o any certiication! nurses working in the IC( should have periodic assessment o

competence by the nursing director with provision or eedback and need based education

curriculum. "his competency assessment should be standardi+ed according to nursingguidelines o 33CD.

ouse sta should have had training in advanced airway management and 3CK.

FCC463IC critical course training is recommended but not mandatory or IC( ouse

sta.

Staffing 6ogistics

IC( staing pattern can be classiied as low intensity /no intensivist or elective intensivist

consultation0 or high'intensity /mandatory intensivist consultation or closed IC( /all caredirected by intensivist0 groups. igh'intensity staing is associated with lower hospital

mortality! lower IC( mortality! reduced hospital KA! and reduced IC( KA.

"he lack o ade&uate staing o nurses leads to delays in weaning patients! higher inection

rates! increased readmission rates! increased medication errors and increased length o stay.

cessive nursing workload as deined by Hhours per patient days or Hnurse4patient ratios is

associated with increased mortality in critically ill patients. taing pattern or nurses should

take into account patient load and case mi. "he gold standard or staing should be one

nurse or each critically ill patient.

Inade&uate house sta leads to poor emergency care and poor continuity o care% ade&uate

staing pattern should be taking into account patient load and acuity o care.

Quality Measures

-uality measures in the IC( are predominantly medical outcomes related but since the IC(

provides service to relatives and riends! IC( personnel! the hospital and the society! other

parameters must also be used. "hese include economic outcomes! psychosocial and ethical

outcomes and Institutional outcomes.

Institutional outcomes like sta satisaction and turnover rate are important measure o

&uality in the IC( related to personnel. igher rates o sta turnover leads to increased costs!

increased training time! decreased morale and increased stress on remaining sta! leading to

decreased &uality o perormance and worse patient outcomes.

ach IC( should measure and control regularly the eiciency o the use o nursing

manpower evaluating the work utili+ation ratio /)(70 by recommended scoring tools.

easuring sta satisaction is an important &uality initiative. ta retention rates should be

obtained rom personnel records and data o Gob satisaction should be obtained rom

&uestionnaires or eit interviews. *ays or hours o training should be monitored to ensure&uality o personnel development


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Conclusion:3 multidisciplinary approach with ade&uate IC( personnel and staing pattern

combined with ongoing training and need based skill development and measurement o

institutional outcomes is necessary to provide &uality critical care.

Further ,eading

1. 6rilli 7:! pevet+ 3! 6ranson 7*! Campbell ! Cohen ! *asta :F! et al. Critical

care delivery in the intensive care unit8 *eining clinical roles and the best practice

model. Crit Care ed 2


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. Continuity o care and acilities are important throughout the patientJs care period but

especially when stepping down to lower levels o care! to general wards or home.

"he 2< undamental &uality indicators or critical care developed by the panish ociety o

Intensive and Critical Care and Coronary (nits /ICR(C0 are8

1. Compliance with hand hygiene protocols

2. Providing inormation to amilies o patients in the IC(

=. 3ppropriate sedation


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>. 3ppropriate pain management

5. *" in sepsis

?. arly enteral nutrition

E. Prophylais or I bleed in those undergoing invasive mechanical ventilation

@. Inappropriate transusion o packed cells

9. emirecumbent position or patients on invasive mechanical ventilation

1


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only the tip o the iceberg. aGor adverse events comprise the visible portion below the tip.

"he submerged section is divided into two layers. "he minor adverse events are Gust below

the surace o water and the bottom layer is the near misses.

ore than ?< years ago! einrich proposed a =9@

Haccidents reported by 29E companies. "he result was a new ratio8 For every ?


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likely the base number is much larger than ?


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solutions implemented will not s&uander resources or blind us to the adverse eects o

interventions.

Protocols= chec%lists= bundles and guidelines

*elivery o healthcare is a science in three domains8 the irst is to understand disease biology4dynamics% the second is to ind eective interventions% the third is to ind strategies to deliver

the most appropriate intervention eectively by incorporating relevant research indings into

daily practice. "he inability to translate top &uality research into medical practice is a maGor

problem in healthcare. Published best practice guidelines do not by themselves reliably

improve patient care. Continuing educational programs! use o &uality indicators and

eedbacks are important elements o the strategy to deliver the best evidence based care to the

bedside. Checlistshave been ound to be eective in implementing evidence based

management bundles. "hey help in two ways8 with memory recall and with making eplicit

the minimum epected steps in comple processes. 3n average IC( patient re&uires multipleindividual interventions per day and checklists help in establishing higher standards o

baseline perormance. ven the simple strategy o having doctors4 nurses make their own

checklists or what they thought should be done each day improves consistency and &uality o

care.

Clinical Management $undles:

"here are more opportunities or clinicians to modiy their care in an eort to improve patient

outcome as more high'level evidence in critical care medicine becomes increasingly

available. 7ecent eamples o some o the evidence that should have triggered reevaluationo cliniciansJ approaches to patients include the use o steroids in septic shock! early goal'

oriented resuscitation in sepsis! hypothermia or out o hospital cardiac arrests! tight blood

glucose control! use o spontaneous breathing trials! and lung'protective ventilation. In these

scenarios! it is tempting to locally implement the eact protocol used in the study. 3s with

any change initiative! this implementation process can be comple in order to improve the

delivery o scientiically proven therapies! the concept o Hbundles is useul.

3 Hbundle is a group o interventions related to a disease process that! when eecuted

together! result in better outcomes than when implemented individually. "he science behind

the bundle is so well established that it should be considered standard o care. 6undle

elements should be dichotomous and compliance should be measurable as yes4no answers.

6undles avoid the piecemeal application o proven therapies in avor o an Hall or none

approach. "his strategy provides a simple but rigorous check list and documentation. It

acilitates easy perormance monitoring.

"# $asic $undle for all ICU !atients: 4 chec%listRemember: Fast hug

Feed! 3nalgesia! edation! "hroboprophylais! ead o bed elevation! (lcer prophylais!

lucose Control Se!sis esuscitation $undle


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erum lactate to be measured

6lood cultures obtained prior to antibiotic administration

From the time o presentation! broad'spectrum antibiotics administered within = hours or

mergency *epartment admissions and 1 hour or non'* IC( admissions

In the event of hypotension and/or lactate > 4 mmol/ !"# mg/dl$

*eliver an initial minimum o 2 4mmol/ !"# mg/dl$

3chieve central venous pressure o @mm g

3chieve central venous oygen saturation o T E. Inspiratory plateau pressure maintained S =< cm 2A or mechanically ventilated

patients

+# ?he A4ntibiotic Care $undleB

1. Clinical criteria or initiation o antimicrobial therapy

2. 3ctively get specimens or microbiology

=. Initial empiric antibiotic choice based on local policy

>. 7emove inected source8 oreign body! drain collections

5. odiy when microbiology results are available

?. *aily review o antibiotic choice and continuation

E. 7egular epert input


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.# 8entilator Care $undlea& 'eneral:

*" prophylais8 (nractionated heparin 5


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' I p S E.=< ' use CA= inusion

easures to decrease CA2 production /sedation! decrease temperature0

Intermittent interruption o sedation i there is 181 nursing care

/# $undle for !re)ention of 8entilator 4ssociated Pneumonia is %nown as94P

arly eaning

and ygiene

Aspiration Precautions

Prevention o contamination

Caution regarding bundles

First! it cannot be emphasi+ed ade&uately that the time-consuming process of protocol

implementation could negatively impact the acquisition and maintenance of high-level

clinical skills. n other !ords, the protocol can "ecome a priority and patient care can

"ecome uncoupled from skillful clinical decision making. Clinicians should al!ays "e a!are

that !hen implementing an evidence-"ased approach, the importance of "eing good

clinicians should al!ays "e kept in mind.

econd! the development o bundles is also potentially vulnerable to manipulation or

inappropriate ends. eeing in these bundles a potentially powerul vehicle or promoting theirproducts! some pharmaceutical and medical'device companies have begun to invest in

inluencing the adoption o guidelines that serve their own inancial goals. "here is thus a

&uestion o whether these bundles are Hevidence based or Hevidence biased. "he

relationship between scientiic societies and industry is comple and raught with problems.

"heoretically! each group eists to improve patient care and outcome. In practice! the primary

obGective o any industry is to sell its products and make a proit while the scientiic society

eists to represent its members! to impartially Gudge available evidence and provide advice

and support to its members in the best interest o patient care. "he process o developing

guidelines should not be perceived as a marketing vehicle or any particular industry.

Further ,eading

1. *onchin R! opher *! Alin ! 6adihi R! 6iesky ! prung CK! et al. 3 look into the

nature and causes o human error in the intensive care unit. -ual a ealth Care

2


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>. arland 3. Improving the IC(8 Part 2. Chest 2


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he cost o3 non/uality in any enterprise is more e!pensive than investing in /uality>

"he dierence is magniied in settings such as the IC(! where the baseline costs are among

the highest in the health care domain.

In order to choose outcomeparameters in any enterprise! the mission goals must be clearlydeined. In the critical care setting! the goals are as ollows8

1. "o preserve meaningul lie8 In this contet Hmeaningul lie reers to a &uality o lie

valued by the patient.

2. "o provide speciali+ed care to patients in order to sustain! protect and rehabilitate

them during their treatment or a critical illness or inGury8 Hpeciali+ed care implies

care in an environment where it is possible to provide real time monitoring o vital

parameters along with the ability to intervene rapidly when necessary.

=. "o provide compassionate palliative care to those who are dying rom irreversible

diseases in order to alleviate suering during their inal hours.

>. "o ensure the viability and sustainability /economic and human resources0 o the unit

in order to deliver the above modes o care proessionally as a team.

entinel events are measurable events which indicate the achievement /or non achievement0

o a goal. "he sentinel events in the corresponding domains would be as ollows8

Preser)ation of 6ife

"he marker o a negative outcome in this domain would be mortality. "he mortality can be

measured as8

Crude mortality:Crude mortality rates cannotbe used to measure &uality o IC( care

because they do not adGust or dierences in diagnosis and severity o disease.

!tandardi"ed #ortality $atio:*isease based4everity core adGusted8 "he tandardi+ed

ortality 7atio /70 is deined as the ratio of the o"served mortality rate to the expected

mortality rate. "his permits perormance'based comparisons o IC(s by adGusting or disease

category and severity o physiological derangement. "he reerence values or the epected

mortality rates are obtained by documenting mortality rates o patients rom a large number

o IC(s in a speciic population. "hese are then stratiied based on disease categories and

within multiple outcome score bands o standard IC( scoring systems. I the 7 or an

IC( is S1! then the outcomes or that unit are interpreted to be better than the overall

outcomes o the reerence set used to develop the scoring system. 3lternatively! an 7 o

T1 signiies that the observed mortality rate is higher than the epected mortality rate!

suggesting that the &uality o care needs to be improved.

S!eciali0ed Care During Critical Illness


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"he markers or this domain would be8

orbidity and post discharge events

#orbidity:orbidity could be due to three broad reasons8 chance, faults in the system orhuman error.ystem aults and human errors are appropriate targets or &uality improvement.

Faults in the system include overutili+ation! underutili+ation and misutili+ation o resources.

easures o morbidity during IC( stay are8

,esource utili)ation availability =eneral Complications:

Dew admissions! Patient #ates for$

*ays! entilator *ays 3irway "ube block /endotracheal! tracheostomy0

*evice *ays /airway! CC! D tube!

urinary0

7eintubation! (nplanned etubation

Durse8 Patient ratio

*octor8 Patient ratio

Don availability o IC( bed /denied

re&uest0

Don availability o entilator /denied

re&uest0


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Kength o tay

(nplanned 7eadmission

7ate

&uipment downtime

In3ection ,elated Complications: +edication 6 rans3usion ,elated:

and hygiene compliance edication rrors

Dosocomial Inection 7ate Prescription o a wrong medication

C76I

3P Inade&uate prescription , wrong dose! time schedule

)ound 4 ot tissue


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(rinary

Athers , Para nasal sinus! ye )rong administration , dilution solution! strength! inusion

rate

*7 Inections8 6K! 73 3dverse *rug 7eaction 6lood 4 Component transusion

reaction

Fungal Inections

3ntibiotic *e'escalation rate

Palliati)e Care

"he sentinel events to track are8

Futility8 number o patients being admitted or utile care to the IC(% there is! as yet!no universally accepted deinition o utility.

Dumber o counseling sessions or amily members

Family satisaction

8iability and Sustainability of the ICU as a 9ealing Unit

It is obvious that intensive care is based on team work and the markers o &uality should not

be restricted to a reductionist view o intensive care. "he ollowing are important8a# (conomic Issues:


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"his is important in our Indian setting where the public unding or the tertiary level o care is

inade&uate! the level o health insurance cover is low and health care bills drive amilies into

debt.

It has to be looked at rom the

ealth providers viewpoint ' capital 4 running epenses versus income

PatientsJ4 FamiliesJ viewpoint ' cost per person who has not survived% debt the amily 4

person has incurred per person alive 4 epired. "his is not an issue covered in )estern

literature and we need to have our own data.

b# (ducation and Safety issues

i. Patient saety8 error detection! reporting and error resilience%

ii. ta saety8 needle stick inGuries% 6s3g immuni+ation rate in IC( personnel% I

prophylais given% sta 6urn'out

iii. ducation and "raining8 Personnel trained , medical! nursing! technical% continuing

medical! nursing and technical education

(rrors in Medical Practice

It is very important to have a pragmatic perspective o error in the IC(. rrors increase as a

unction o compleity. In a study in which engineers observed patient care in IC(s or

twenty our hour periods! the average IC( patient re&uired 178 individual interactions per

day. "hese included a range o interventions rom physical maneuvers /positioning the

patient! physiotherapy0 to medication administration.

(rror Detection

Clinicians in the IC( make decisions in a highly comple environment by negotiations and

compromises as they trade o between competing goals. In order to characteri+e the systemic

causes o error in such environments! we need to identiy the pressures /e.g. atigue!

workload! policy and 4 or lack o resources0 that push people towards these boundaries and

then make eorts to counteract these pressures.

"he phrase %error in evolution&denotes the progression o a series o small mistakes towards

a cumulative adverse event. rroneous decisions undergo a selection process based on their

anticipated conse&uences. "he igure below illustrates the progression o error in critical care!

where personnel /clinicians! nurses! technicians and others0 conducting routine work hit a

boundary and where they come close to making an error /near miss0. HDear miss is a breach

o the irst boundary and is a violation o the bounds o safe practice. 3t this stage! the error

can still be detected and corrected beore the second boundary is crossed. "his is a window oopportunity to detect and prevent a potentially adverse event. I only adverse events are


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reported! the Hnear misses will continue to remain undetected. ince Hnear misses are an

integral component o the chain o events leading to an adverse event! detection! reporting

and reducing these should be an integral component o any strategy to reduce errors in any

system.

I undetected 4 uncorrected! it can proceed to the net stage ' an adverse eventwhich occurs

when the second boundary is crossed.

"he traditional culture in edicine pins errors on to individuals. In reality! errors occurbecause there are multiple Hmini'errors distributed across non living obGects /monitoring!

hand over notes! computers etc.0 as well as in the minds o technicians! nurses and

clinicians.t is essential to internali%e the perspective that faulty action is a product of fla!ed

thinking across the system - this is the concept of 'distributed cognition(."he perspective

that distributed cognition is responsible or any error shits the ocus o analysis rom the

study o individuals in controlled settings to the study o groups o individuals in their real'

world contet. (sing this ramework! a collective worklow can be reconstructed rom events

o critical importance that are spatially or temporally correlated. "his mode o analysis

ocuses on the identiication o vulnera"ilities and fla!s in the system/as opposed to theaction o a single individual0. In contrast! retrospective analysis o individual error is

vulnerable to the bias o 2


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)orload* )ith the least number of errors at a high )orload. +o)ever* at high )orload*

error detection )as reduced* leading to a much higher rate of adverse events. ,he rate of

error detection improves )ith practice.

(rror esilience

3 realistic approach is to recogni+e that error cannot be completely eliminated! but that the

negative conse&uences o an error can be controlled. "hus! an error resilient system should

have the ollowing targets8

control the propagation o error towards occurrence o adverse events

redmuce adverse events

have a strategy or error correction 4 recovery

rror correction and recovery should orm an integral part o the cognitive system underlying

&uality in critical care. "he critical role o error resilience in the maintenance o saety in any

system is neglected by approaches that ocus eclusively on completed errors.

7esearch indings challenge the common perception that eperts are somehow inallible.

"hey are consistent with error research in other domains which show a constant rate o error

regardless o epertise /with the eception o absolute beginners who make signiicantly

more errors at the beginning o their learning curve0.Clinicians at all levels of expertise

mae errors ho)ever* experts mae errors from )hich it is easier to recover.

he cost o3 non/uality in any enterprise is more e!pensive than investing in /uality>

Further ,eadings

1. *onchin R! opher *! Alin ! 6adihi R! 6iesky R! prung CK! Pi+ov 7! Cotel . 3

look into the nature and causes o human error in the intensive care unit. -ual a

ealth Care 2


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?. allesio 3A. Improving &uality and saety in the IC(8 a challenge or the net years.

Curr Apin Crit Care 22 .L=M 3I also

causes increased length o stay! nonavailability o beds due to unacceptable bed occupancy.

"he reported average prolonged stay or urinary inection is =.@ days! E.> days or surgical'

site inection! 5.9 days or pneumonia and seven to 2> days or primary bloodstream

inection.L=M

"he emergence and spread o antimicrobial'resistant organisms is a maGor concern. 3I also

is an important issue because =< to 5< reduction in 3I is possible by running an eicient

inection control program.L=M

,b-ecti)e

7eduction in the incidence o nosocomial inection is the main obGective but it is a broad

based and less speciic outcome parameter. Persuing this parameter in isolation could be a

utile eercise unless it is linked to the inluencing variables such as patient sub groups!

device! intervention! process and protocols. It is also important to understand that

improvement in incidence o nosocomial inection does not necessarily mean improvement in

&uality unless it is linked to other parameters such as mortality outcome! length o stay!

antibiotic consumption! cost implications etc. ere reduction in the incidence o 3I rate

without desired impact on the parameters mentioned earlier might not indicate &ualitativeimprovement because such reduction is possible rom change in the case mi.L5M
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT5http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT1http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT4http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT3http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT5


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*# Factors Influencing Infection ate

$>"> (ub groups:Averall inection loses its importance unless it is linked to patient sub

groups such as% age! pre'morbid conditions! immunocompetence level. "hereore! inection

rate could be dierent in a neonatal! pediatric! trauma! medical! surgical! burn and mied

IC(s. Inection rate will also be dierent in institution with predominance o a particular sub

group o patients. Incidence in the institutions or units primarily managing cancer patients

will be dierent than unit managing non cancer patients. imilarly result o a closed unit

could be dierent as compared to an open unit.

$>#> Device and Intervention ,elated:entilator associated pneumonia! urinary catheter

and invasive catheter or line related inection are device related parameters. Percentage o

patients being maintained on dierent devices will inluence the inection rate.

$>$> Processes and Protocols:Compliance to protocols! processes! guidelines! work

instructions are also important determinants o inection rate. Process and protocol could be

linked to antibiotic usage! investigations done! implementations o dierent treatment

bundles! nursing care /line care! tracheostomy care0! and hand hygiene.L?M (niormity o

practice through continuous training should be ensured and then compliance monitoring

should be done.

$>%> In3rastructure and (upport (ervice:*esign o IC(! &uality o water! laundry

management! ood handling! waste disposal! sterili+ation and other reprocessing and

maintenance procedures! as well as microbiology support inluence inection rate.

$>&> Organi)ational; uman ,esource and (ystem (upport:Inection rate is also related

to the organi+ational and human resource. Comparison o inection rate is possible i support

level is similar in participating institution. ervice provider related /nurse vs. patient! doctor

vs. patient ratio0 parameters should thereore be taken into consideration.

$>' (urveillance (ystem:urveillance system available in the unit also makes a dierence.

7eliability o data is an important consideration! particularly i ade&uate staing has not been

ensured. enerating and stratiying voluminous data is labor intensive. ariability in

reporting is possible in absence o electronic surveillance.LE!@M

+# Prioriti0ation of !arameter

*espite the availability o multiple parameters! it is practically not possible or logical to

monitor all the possible parameters on long term basis. Prioriti+ation o parameters thereore

is essential to select those with maimum out put potential. election o limited ew

parameters! while the unit is getting &uality'oriented! is also an alternative and easier

approach. 3s the unit matures! need based addition and deletion can be done or the optional

parameters but mandatory parameters should always be monitored. For eample! i use o

vancomycin is very limited in a particular unit then monitoring vancomycin resistant

enteroccoci /70 is not logical on routine basis and can be taken as an optional parameterwhereas line related inection could be a mandatory parameter. Certain key indicators should


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also be common and mandatory or inter institution! national or international comparison!

accreditation and public reporting.

For prioriti+ation! importance o parameters can be Gudged on a matri where the R ais

represents determinants o importance and O ais represents a score o the determinants.

6ased on the overall score! prioriti+ation can be done to select parameters. ample o such

matri is given below.

Quality Indicators Matri3

Determinants 8AP B(I I ((I

ase o data collection

ase o deinition

Fre&uency o events

Impact on mortality! morbidity! KA

Financial implications

ase o stratiication

"otal score

core 1 to 5 /where 1N least important! 5N most important0! 3P N ventilator associated

pneumonia! 6I N 6lood stream inection! ("I N (rinary tract inection! I N surgical site

inection

.# Defining Parameter and $ench Mar%ing


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)henever possible! parameter /numerator0 should be linked to a denominator to make it more

meaningul. Parameters used as denominator are8 number o patients! bed occupancy days!

number ventilated etc.L9M

3lthough international bench marks can be used or comparison o data! inluence o

geographical variation! nutritional and economical status etc. should be considered beore

comparing the result. It is thereore advisable to have national bench marks.

/# Common Quality Indicators elated to Infection:

'>"> Device related In3ection:entilator associated pneumonia /3P0! Central line

associated blood stream inection /6I0 and indwelling catheter related urinary tract inection

/("I0 are commonly monitored parameters. 3lthough 3P is being monitored very

re&uently wide variation in incidence is possible based on the diagnostic criteria used. *ue

to wide variation in surveillance deinition! it is diicult to ac&uire! interpret and compareintra and inter institutional data.L1.2= and @.1> respectively had been reported insurgical IC(.L15M

ospital'ac&uired bloodstream inection /6I0 alone has been estimated to be responsible or

2?!25< deaths per year and ranks as the eighth leading cause o death in the (nited tates.

=.55 cases o 6I per 1#> In3ection 3rom (peci3ic Organism:Inection due to C. difficileand methicillin'resistant 'taphylococcus aureusetended spectrum beta lactamase producers /6K0!
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856147/#CIT9http://www.ncbi.nlm.ni

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