Chapter 88 Quality Assurance and Patient Safety in The Intensive Care Unit
1 How is quality assessed?
The definition of quality encompasses many things but clearly involves meeting the expectations of the consumer. In health care, this standard usually involves the satisfaction of patients, physicians, and payers, as well as good clinical outcomes, appropriate resource use, cost containment, and attention to patient safety.
2 What is benchmarking?
To benchmark means to compare one’s own performance-related data with similar data from another institution. The Joint Commission requires that hospitals benchmark with other hospitals. This process has grown tremendously, and numerous quality indicators are now reported and available to the public. The Surgical Care Improvement Project was a benchmarking process with a goal to reduce the incidence of surgical complications by 25% by 2010. The appropriate use of deep vein thrombosis prophylaxis is an example of a quality indicator that when compared among different hospitals gave insight into the quality of care they provided.
3 What is the relationship between the intensive care unit (ICU) organization and quality of care?
Evidence indicates that the structure and organization of an ICU can influence outcome. A collaborative relationship among members of the health care team is critical. A multidisciplinary approach with the addition of a full-time intensivist greatly improves the quality of patient care in the ICU, as does the presence of critical care nurses with appropriate staffing ratios and clinical pharmacists on the unit. The use of clinical protocols continues to expand, with reliable data about their use leading to an improvement of care in critically ill patients. The use of spontaneous breathing trials has been validated in multiple studies, but worldwide its use remains stagnant at best. Not using a protocolized weaning system is an example of the need for organizational improvement in an ICU to improve care. Resistance to protocol use has come in many forms, but one of the primary arguments has been the unwillingness of physicians to reduce medicine to a cookbook profession and the need for individual tailored care for each patient. An inherent mistake in this argument is a lack of recognition of the individualized clinical data from each patient that is analyzed and used to treat the patient in a logical manner.
Resistance to change in the practice of critical care medicine is reflective of a broader problem in medicine in which studies suggest that 30% to 40% of patients do not receive care consistent with current medical knowledge.
4 List the uses to which severity of illness scoring systems are commonly applied
Stratification: Multiple scoring systems exist to stratify the severity or acuity of illness of critically ill patients. Examples of such classification systems are the:
These systems allow comparison of outcomes related to differing therapeutic approaches and attempt to match patients for severity of illness. The multiple scoring systems have not been compared in a prospective manner. Scoring systems for specific disease processes in critically ill patients exist, such as the risk, injury, failure, loss (complete loss of kidney function × 4 weeks) and end-stage kidney disease (complete loss of kidney function × 3 months) (RIFLE) criteria for kidney injury. Disease-specific scoring systems allow for standardized assessment enabling uniformity for research.
Efficiency of care delivery: Efficiency can be measured only if objective measures of resources are used together with models that define a population’s acuity of illness. It is important that the stratification of illness models have some validity in predicting outcome. These may be provided by the APACHE system and the Therapeutic Intervention Scoring System, among others.
Decision making in clinical management: Decision making may be aided by considering the information provided by scoring systems as these models allow physicians to stratify patients into cohorts. However, clinicians must be cognizant that scoring systems provide population illness overview, not specific patient prognosis. Individual patient data must be used when providing prognostic information for patients and their families.
Economics: Scoring of patients can assist in appropriate billing and reimbursement code application.
5 How is performance improvement carried out in the ICU?
The unit director in collaboration with the nurse manager and other members of the health care team should identify areas for improvements in care delivery. Performance improvement committees exist for monitoring performance indicators in ICUs and noting deficiencies. A formal process to address problems should exist. Common systems used are the PDSA process (plan, do, study, act) or PDCA process (plan, do, check, act). One proposed method for creating solutions for quality improvement in ICU is the barrier identification and creating solutions tool. It involves the creation of an interdisciplinary team that is given the authority to observe, interview, and simulate process in the ICU. The team is responsible for compiling the data and developing an action plan to create solutions to barriers to improvement in critically ill patients. This process is an example of a performance improvement method that can be generalized to solve many quality deficiencies in ICUs.
6 List a number of observations on which to base assessment of outcome
Although a variety of indicators can be used to assess outcome, the following usually provide a reasonable database and can be used for benchmarking when similar data are available from other institutions:
Patient satisfaction: This should include not only the patient’s subjective opinions but also some objective observations of outcome such as activities of daily living scores. A significantly understudied aspect of this parameter is the posthospital status of the patient.
Length of stay: The length of stay both in the hospital and in the ICU for patients who have been stratified by diagnosis, acuity, and comorbidities on admission provides valuable insight into outcomes and an excellent database for benchmarking, if studied consistently over a reasonable period.
Mortality indexed to severity of illness: Although this information can provide a simple benchmarking tool, the data should be critically reviewed because death cannot always be equated with a bad outcome.
Incidence of unanticipated returns to the ICU during the same hospital stay: This indicator may yield important information if examined in some detail. In addition to the actual incidence (which can be used for benchmarking), the individual cases should be reviewed. This may reveal a need to review the criteria for transferring patients from the unit or the compliance with the same. Alternatively, it may stimulate consideration of the adequacy of the care capabilities of the environments receiving the patients on discharge from the unit.
Incidence of complications: Complications may be linked to procedures (e.g., line placement, endotracheal intubation) or to general management (e.g., nosocomial infection, medication errors). Of major importance are those that have a clear impact on patient welfare. The criteria for identifying these and the methodology for data collection and analysis should be defined and consistently applied.
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