Wessex Intensive Care Society Meeting 2014 (#WICS2014)!

Are we as good as they tell us to be?!

Adrian VK Wong!ST7 ICM/Anaesthesia!

Wessex!

Quality, Standards and Guidelines on the ICU!

Follow and discuss!

#WICS2014!@avkwong!@wessexics!www.wessexics.com!

Declaration of interest!

❖  Wessex Trainee!

❖  ICS Trainee Committee!

❖  Standards, Safety and Quality Committee!

❖  ICM National Audit Recipe Book!

❖  Why!

❖  The tools!

❖  Standards!

❖  Guidelines/SOP/Protocols!

❖  Audits/Quality Improvement Projects!

❖  ICS/FICM!

❖  Documents in development!

Should we be doing what we are told?! Why should we?!

WHAT MAKES YOU A GOOD UNIT?!

– Henry FORD!

“Quality means doing it right when no one is looking”

ICU as a focus for quality improvement!

❖  Enormous costs!

❖  Staffing!

❖  Equipment!

❖  Medication!

❖  Big numbers ( ± 200 activities/patient/day)!

❖  Complex conditions and time pressure!

❖  Increased demand for Intensive Care Services!

ESICM Quality Indicators!❖  ICU fulfils national requirements to provide intensive care!

❖  24 hour availability of a consultant level Intensivist!

❖  Presence of adverse incident reporting system!

❖  Presence of routine multi-disciplinary clinical ward rounds!

❖  Standardised handover procedure for discharging patients!

❖  Reporting and analysis of Standardised Mortality Ratio!

❖  Intensive Care readmission rate within 48hrs of ICU discharge!

❖  The rate of unplanned endotracheal extubations!

❖  Rate of central venous catheter related blood stream infection!

–GR Dunstan, 1995!

“The success of intensive care is not to be measured only by the statistics of survival, as though each

death were a medical failure. It is to be measured by the quality of lives preserved or restored; and by the quality of the dying of those in whose interest it

is to die”!

Care and Quality Commission!Are services!

❖  safe?!

❖  effective?!

❖  caring?!

❖  responsive to people’s needs?!

❖  well-led?!

Good Medical Practice (2013)!❖  Domain 1: Knowledge, skills

and performance!

❖  Domain 2: Safety and Quality!

❖  Domain 3: Communication, partnership and teamwork!

❖  Domain 4: Maintaining trust!

The Tools!❖  Checklists/SOP/Protocols!❖  Audits/Quality Improvements!❖  Checklists!❖  Peer Review!

Guidelines/Protocols/SOP!Improving care is not about being better but rather to be at

our best all the time with every single patient.!

Too many guidelines!❖  UK’s NHS Library has got 169 guidelines!

❖  17 of which are on how to write guidelines!

❖  London acute NHS intranet has over 500!

❖  NICE > 1000 guidelines!

Checklists!

Audits/Quality Improvement!

Plan

Do

Study

Act

Audits/Quality Improvement!❖  Provides the mechanisms for reviewing the quality of

care.!

❖  Addresses quality issues systematically and explicitly, providing reliable information.!

❖  Confirm the quality of clinical services and highlight the need for improvement.!

“In God we trust. All others bring data”!

❖  Estimation of demand for intensive care beds!

❖  Discharges and follow up of patients from intensive care between 22:00 and 06:59 hrs!

❖  Quality and safety of handover in intensive care!

❖  Audit of end of life decisions in intensive care!

❖  Perceived benefits of intensive care follow up clinic!

❖  Compliance with best practice guidelines for the insertion and care of central venous catheters!

❖  Timeliness of antibiotic administration in septic shock!

❖  Ensuring best practice in patients with severe traumatic brain injury!

❖  Audit of inadvertent hypothermia in intensive care patient!

❖  Audit of tracheal tube length and tip position in ventilated patients!

❖  Incidence and management of new onset atrial fibrillation in patients admitted to intensive care!

❖  Therapeutic hypothermia after cardiac arrest!

❖  Dose of haemofiltration prescribed and administered in critically ill patients!

❖  Reducing volume of blood lost through sampling!

❖  Compliance with the Department of Health guideline on taking blood cultures!

❖  Time taken to insert an arterial line!

Peer review!

Anaesthesia Clinical Services Accreditation!

Peer review!

Anaesthesia Clinical Services Accreditation!

❖  A voluntary scheme for NHS and independent sector organisations!

❖  Quality improvement through peer review!

❖  A period of self-assessment and then improvement, with support from the College!

❖  Working towards the goal of becoming an accredited department!

Core standards for ICU!

❖  Staffing!

❖  Medical!

❖  Nursing!

❖  Therapy!

❖  Pharmacy!

❖  Dietitian!

❖  Operational!

❖  Equipment!

❖  Data Collection!

GPICS! Intensive Care Medicine!UK edition!

Guidelines for the provision of intensive care services!

GPICS Template!

1. Introduction!

2. Structure!

3. Process!

4. Activity!

5. Additional key components!

6. ICS/FICM Core Standards 2013!

National guidelines!

ICM National Audit Recipe Book!

Audit pack!❖  Background information!

❖  Methodology!

❖  Data collection pro forma!

❖  References!

❖  Excel spreadsheet!

❖  Data analysis tool!

Audit Recipe Survey - Top 5!

❖  ARDSnet ventilation compliance!

❖  Intubation and capnography!

❖  Tracheostomy care!

❖  CVC bundle!

❖  Renal replacement therapy dose!

General Comments/Themes!

❖  Keep it simple and the list small!

❖  Prioritisation!

❖  Evidence-based/Improved patient outcome!

❖  Objective and outcome based!

❖  Quality indicators!

@jasonleitch!

@jasonleitch!

REVALIDATION!

Future works…..!❖  Checklists!

❖  Safety reporting system!

–Ron D Burton!

“We all know that change is inevitable. It provides us with a challenge and an opportunity to grow

and improve.” !

@jasonleitch!

References!❖  ICU Core Standards -

http://ficm.ac.uk/sites/default/files/Core%20Standards%20for%20ICUs%20Ed.1%20%282013%29.pdf!

❖  Guidelines for the provision of anaesthetics services - http://www.rcoa.ac.uk/system/files/GPAS-FULL-2014_3.pdf!

❖  Thomas and Taylor. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Anaesthesia 2012; 67: 706-713.!

❖  National Patient Safety and Quality Improvement March 2014 - the value of widespread clinical engagement. (RCoA Webcast http://www.rcoa.ac.uk/webcast-catalogue)!

❖  FICM Guide to Revalidation (http://www.ficm.ac.uk/cpd-and-revalidation)!

❖  GMC Guide to Revalidation (http://www.gmc-uk.org/doctors/revalidation.asp)!

❖  RCoA Audit Recipe Book (http://www.rcoa.ac.uk/system/files/CSQ-ARB-2012_1.pdf)!

❖  Institute of Medicine: Crossing the Chiasm (http://www.iom.edu/Global/News%20Announcements/Crossing-the-Quality-Chasm-The-IOM-Health-Care-Quality-Initiative.aspx)!

❖  Urbach et al. Introduction of Surgical Safety Checklists in Ontario, Canada. NEJM 2014; 370: 1029-1038.!