Approach of ICCMU to Quality and KPI Development

8/11/2019 Approach of ICCMU to Quality and KPI Development

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Approach of ICCMU to Quality and KPIDevelopment

ADMC Intensive Care Intermediate Indicator and KPI Development Workshop

16/6/2005


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Government Action Plan IC Services Plan 2001

At a state level:

43 public ICUs

Did not know how many beds Did/do not have an informed position on role of

intensive care in acute hospital

No forum to interpret health services research Patient safety

Evidence-based practice

Hence Intensive Care Coordination & Monitoring Unit

(ICCMU)


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Quality Activities

In NSW ICUs

M&M meetings 86% (not all multidisciplinary) Regular Quality Meetings 72.4%

Journal Club 34.88%

Level 1 units:

3 no education

Remainder 1-5 hours per week (except for one

with 20 hours per week)


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ICCMU

Foster communication across all key stakeholders including NSW

Health, expert groups, clinicians and consumers at state, national and

international level

Facilitate an understanding of IC service provision including

workforce, patterns of demand including access issues, and other

factors that may impact on effective delivery of IC service in NSW

Promoting excellence in the standard of care of all NSW ICUs by: Clinical networking, promotion and dissemination of evidence-

based practice

Providing a forum for systematic analysis and assessment of

information regarding the quality of care in NSW ICUs


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In practical terms

Monitoring intensive care resources

Developing clinical communication networks ICUConnect facilitate sharing of information

Website

Community information

Clinician pages

evidence-based practice repository for Ps & Ps

Guideline development network

Collaborative approach to guideline development

Meeting 14/6/2005 38 nurse educators registered

Groups set up to provide care bundles hygiene, haemodynamicmonitoring, ventilation


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ICCMU Quality Group

Provide a forum for the systematic analysis and

assessment of information regarding the quality ofcare in NSW ICUs

Promote collection and interpretation of data on

quality

In conjunction with other ICCMU committees

promote quality improvement and evidence-basedpractice

Both promote and measure quality


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Multi-faceted approach to quality

Risk adjusted outcomes APD VicDRC

Access

MRU data

ICCIS vs white board Incident monitoring

Process indicators


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Incident Monitoring

NSW Patient Safety & Clinical Quality Program

Implementation of Advanced Incident MonitoringSystem (AIMS) in every health service

IIMS will provide a consistent means of

identifying, tracking & managing clinical,workforce and corporate incident information

across NSW

ICCMUQG input into statewide reports


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Process Indicators

Emphasis on appropriateness of care -

housekeeping

Growing body of evidence linking process of

care with better outcomes Pick up omissions

Checklist?


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Process indicators

Pronovost used process measures to assess quality

of care in 13 intensive care units wide variation

in results many patients not receiving

appropriate therapyPronovost, Berenholtz et al J Crit Care 2003

Pronovost - used daily goals form to improve

effectiveness of communication significant

improvement in understanding of daily goals by staff

decreased LOS

Pronovost, Berenholtz, Dorman et al J Crit Care 2003


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Checklist

In Hartford ICU used daily goals form as a

checklist or check-off rather than to do list Claimed:

Marked improvement in understanding of goals

of therapy

Reduction in LOS by av. 1.5 days

Reduction in ventilator days by av. 1 day Decrease of in unit mortality from 11.5% to

8.3%


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JL Vincent

for effective bedside rounds, a battery of questionsshould be raised systematically in front of each

patient Can he/she be weaned?

Is pain controlled, is sedation well tolerated, does

patient need restraints? Is nutrition adequate?

Is the head of the bed elevated?

Is DVT prophylaxis implemented? Is ulcer prophylaxis implemented?

Vincent Chest 2004


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Aim

To test the use of a checklist in a tertiaryintensive care unit as a method of ensuring

evidence-based quality processes of care are

performed routinely and systematically


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Method

Checklist completed for all adult patients once a day for

approximately one month

Checklist used allowed for recording of demographic data,

information regarding clinical condition (to give context to

answers) and actual checklist questions

Yes, no or not applicable

Intended as a challenge and answer process at the end of

each patient visit

Paper-based data collection

Baseline survey and impact evaluation done


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Questions chosen

Pain/sedation

Pain at rest?

Pain with relevant movement?

Pain addressed?

Sedation appropriate response?

Ventilation

If ventilated head of bed raised 300

Is patient being weaned?

If not ventilated, sitting out of bed?


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Questions chosen

Lines and drugs

Has the age of all lines been checked?

Is the patient being fed ( E, parenteral, oral)

Thromboprophylaxis?

Stress ulcer prophylaxis

Have antibiotics been reviewed?

Path/Micro/Other

Was blood sugar recorded in last 12 hours?

If so was it


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Results

Figures are after not applicables removed

Sedation - >30% oversedated Pain approx 30% had pain (nearly all treated)

VAP >90% head of bed raised - ?300

Weaning - 60%


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Results

Sitting out of bed daily (non-ventilated) 63.3%

Age of lines 100%

Nutrition 87.5%

DVT prophylaxis 89.6%

Stress ulcer prophylaxis 84.2%


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Results

Antibiotics reviewed 96.9%

BSLs Most checked in last 12 hours

85.5% 3days


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Check list daily goals

A checklist in the intensive care environment could have the

following advantages:

Embeds quality into routine care Immediate patient safety ie ensuring that the patient gets

what he/she needs immediately safety lesson from

aviation Educational tool constant repetition reinforces the

principle eg BSL


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Indicators?

Evidence-based with:

Common acceptance of evidence Clear definitions of yes, no or N/A ie clear unit

protocol

Ie meaningful numerator and denominator thromboprophylaxis, elevated head of bed, stress ulcer

prophylaxis (NB JCAHO)

If there is a clear unit policy then close to 100%compliance should be possible


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Discussion

Well accepted by all staff more interest in process ofcare

Has changed practice:

More attention to pain scores and pain in general

Talk about collecting process indications PDA etc

Prompts asked on morning round: Can central line be removed?

Bowels open last 24 hours?

If no is faecal impaction present?

Has micro been checked? Can patient sit out of bed?

Can any antibiotics be stopped?


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Approach of ICCMU to Quality and KPI Development

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