examples of quality improvement projects in icu

To cite: Jones AS, Isaac RE, Price KL, Plunkett AC. management of analgesia, sedation, and delirium. Mechanical ventilation days were partially missing from 3 units (23 months, 3% of the data) and occupancy data from one unit (2 months, 0.3% of the data) was missing and was treated as missing. Some of the proven quality improvement initiatives to improve the neonatal care outcomes in NICU include measures such as maintaining hand hygiene, maintenance and optimization of the central line, improving mother-infant interaction, reducing the risk of bronchopulmonary dysplasia and hypothermia, reducing the exposure of infants to various stressors, and implementing the family … Have any of you partipated in QI, what were the projects. An approach to monitor and compare the function of different intensive care units (ICUs) is needed to optimize outcomes for patients and the health system as a whole. The participating units had an average occupancy of %. The six domains of a critical care unit care and function selected were safe, timely, effective, efficient, patient/family satisfaction, and staff work life. Over the 3.5-year study period, there were 49,762 admissions with 275,173 patient days. We have explored the use of statistical process control charts and have found them to be a useful and acceptable way to display the data to our intended audience. Hospital Mortality Number of patients that died while under the care of the ICU team or following discharge from ICU during the same hospitalization, calculated as percent of all ICU discharges. ; Carla A. Chrusch, M.D., M.S. 0000038139 00000 n TE�A�ض��EX��7V+-��G �{�!YZ��4kR��:y��A�܎1O�*=V�m ��#�Ma�|�'\� Cardiovascular ICUs admitted postcardiovascular surgery patients exclusively. Abbreviated definitions are shown for all quality indicators in Appendix A and an example of a detailed operational definition is shown in Appendix B. The second round used cumulative voting. Not all units collected data on the selected quarterly indicators prior to 2009. Each institution is responsible for maintaining a process for recognizing and documenting all unplanned extubations. The last major revision to the operational definitions was at a conference in June 2011. Graphs were created using OriginPro 7 (OriginLab Corporation, Northampton, MA). Figure 3 is an example of a composite measure showing the number of wasted ICU beds versus average monthly occupancy by unit. 0000003238 00000 n 5, pp. There were 20 responses as to how the system could be improved: offer training in interpretation of the data (40%), ensure data quality and consistent definitions (25%), and add more measures (20%) and more benchmarking (15%). The stresses placed on critical care services continue to escalate from increases in both the numbers of patients and expectations regarding the provision of safe, quality care. On behalf of all authors, the corresponding author states that there are no competing interests. Unit characteristics and average performance. Plan, Do, Study, Act (PDSA) methodology was used. Participating ICUs were “closed” with all patients cared for by a consultant intensivist with 24-hour availability and daily multidisciplinary rounds. Sound management decisions need to be based on an understanding of past performance, current need and utilization, and anticipated population needs. Although we developed and implemented a web-based data submission and reporting system, this was on a demonstration platform and did not have integrated data checking or validation tools. 2016: Projects [PDF]. Fleck, Mojica, Priestap, and Shahpori performed acquisition of data. 0000031210 00000 n Vertical dashed line is at 80% occupancy and horizontal dashed line at 1 wasted bed per day. Each year at IHI’s National Forum, we encourage students and residents to display storyboards about their Chapter successes, quality improvement projects, and personal improvement projects. For purposes of this paper, all sites resubmitted data consistent with the latest operational definitions to a central office as either Excel spreadsheets (Microsoft Corporation, Redmond, WA) or SAS data files (SAS Institute, Cary, NC) which were merged into a primary dataset. Unplanned extubation may result in patient harm and prolonged length of stay due to loss of the airway and the risks associated with recapture. Postextubation respiratory failure was added unanimously during a June 2007 team conference call based on previous discussions. A Health Foundation Innovating for Improvement grant (Innovating for Improvement Round 5) supported all phases of this study. 1912–1916, 2000. endstream endobj 73 0 obj <� �l��ʄ�� )/V 2>> endobj 74 0 obj <> endobj 75 0 obj <> endobj 76 0 obj [77 0 R 79 0 R] endobj 77 0 obj <>>> endobj 78 0 obj <>/Type/XObject/BBox[231.21 758.118 363.774 785.955]/FormType 1>>stream 1131–1137, 1998. The average therefore is expressed as the mean for the last 4 quarters of the study period (fourth calendar quarter of 2009 to third calendar quarter of 2010). Number of unplanned extubations per 1000 invasive mechanical ventilation days. Number of patients who were MRSA negative on admission with subsequent isolation of MRSA from any sample obtained 24 hours or more after ICU admission, calculated as cases per 1000 ICU discharges. be chosen based on usefulness, feasibility, and reliability. If not recognised early, delirium can lead to increased length of stay, hospital and societal costs, ventilator days and risk of mortality. Ratio of ventilator days (invasive or noninvasive for an acute indication) to total patient days corrected for avoidable days. A significant and/or sustained increase in unplanned extubations should lead to the review of these factors. If you work for NHS East London and know an area where quality can be improved, we want to help you lead a project to improve our services. ! However, a more global description and balanced assessment of critical care performance is needed in order to understand how to make it better. Bouza, E. Garcia, M. Diaz, E. Segovia, and I. Rodriguez, “Unplanned extubation in orally intubated medical patients in the intensive care unit: a prospective cohort study,” Heart & Lung, vol. Similar process control charts, using either x-bar or p-charts, were used to report all indicators on a regular basis. 0000003990 00000 n SPC charts can also be used to compare average performance between units. Mechanical ventilation is the primary characteristic that distinguishes a patient requiring full critical care services from one requiring only high dependency or an intermediate level of care. endstream endobj 79 0 obj <> endobj 80 0 obj <>/ColorSpace<>/Font<>/ProcSet[/PDF/Text/ImageB]/ExtGState<>>> endobj 81 0 obj <> endobj 82 0 obj <> endobj 83 0 obj <> endobj 84 0 obj [/Separation/Black 98 0 R 100 0 R] endobj 85 0 obj <> endobj 86 0 obj <>stream 2016, Article ID 2516765, 11 pages, 2016. https://doi.org/10.1155/2016/2516765, 1Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada, 2Department of Medicine, University of Western Ontario, London, ON, Canada, 3The Quality Improvement in Critical Care Project, Canada. 7, pp. The European Society of Intensive Care Medicine recently agreed upon 9 quality indicators of which approximately half are related to ICU organization and structure [9]. reflect present performance with a mix of lead and lag indicators. For example, even something as fundamental as what constitutes an ICU bed required significant discussion. 36, no. 161, no. For example, rather than sites submitting the rate of unplanned extubations, they instead submitted the number of unplanned extubations and the sum of invasive mechanical ventilation and the rate was calculated centrally. A major challenge surrounding the development of such measures for critical care was the lack of standardized definitions that included specification of the population at risk and the period of exposure to risk, such as device days, for example. We have demonstrated the feasibility of such a reporting system. Emergency Department quality improvement is a journey that takes time and improving ED performance is much more than an emergency department initiative–it must involve the entire system of care. We use examples of successful neonatal networks from across North America to explore continuous quality improvement in the neonatal intensive care unit, including the rationale for the formation of neonatal networks, the role of networks in continuous quality improvement, quality improvement methods and outcomes, and barriers to and facilitators of quality improvement. Results also confirmed and reinforced that there was a desire for measures and methodology that would allow for comparisons with others. One of the initial articles published by ALCCM was “Critical Care Organizations: Business of Critical Care and Value/Performance Building,” which provided a road map and key features to be considered when planning a value-based care program. (See also Appendix. 4, pp. 0000002178 00000 n The mean is shown as a solid line and the upper control limit (3, Percent of patients discharged at night. “Kangaroo Care in the Neonatal Intensive Care Unit: A Quality Improvement Project” [view Project] Julie Lewis BSN, RN, DNP Student “using an Evidence-Based Ventilator-Associated Pneumonia Prevention Bundle with a Compliance Checklist to Reduce VAP Rates” [view Project] Jessica Libla BSN, RN, … The current lack of severity adjustment is less of a limitation when monitoring these quality indicators over time since illness severity will be relatively stable within individual ICUs. An example of the type of SPC charts used is shown in Figures 1 and 2. We administered four questions, focusing on the components of content and format. All critical care admissions were captured in local data sets that contain patient demographic information, admission diagnoses, a severity of illness measure, admission and discharge times, ventilation days, and mortality. 1, no. Revision Notes Current version was in May 2012. The first round identified any undisputed quality indicators. How important adjusting for severity of illness is in the interpretation and use of indicators such as mortality, patient flow, length of stay, and readmission for purposes of quality improvement is unclear and the subject of future work. 0000001441 00000 n They are also very active with patient flow ranging from patients/bed/year in trauma units to patients/bed/year in cardiovascular units. �Tw�&��ױ6PtY��0'����.�:�Z~i�(L��'��QCC�� Using factor analysis, Doll and Torkzadech [13] identified and validated five components of end-user computing satisfaction: content, accuracy, format, ease of use, and timeliness. To achieve this, Nationwide launched an initiative to prevent hospital-acquired harm—a serious issue impacting every hospital—and expanded its quality improvement infrastructure to accommodate more than 150 harm-related projects. The process was led by a certified facilitator using established techniques for consensus building and prioritization that occurred over several rounds [10]. 0000028005 00000 n A national ICU database with consistent definitions and nomenclature would provide a mechanism for comparing characteristics and performance between units and regions over time. B. Sexton, J. C. Pham, C. Goeschel, B. D. Winters, and M. R. Miller, “Measurement of quality and assurance of safety in the critically Ill,”, A. D. Slonim and M. M. Pollack, “Integrating the Institute of Medicine's six quality aims into pediatric critical care: relevance and applications,”, M. C. Scanlon, K. P. Mistry, and H. E. Jeffries, “Determining pediatric intensive care unit quality indicators for measuring pediatric intensive care unit safety,”, P. J. Pronovost, S. M. Berenholtz, K. Ngo et al., “Developing and pilot testing quality indicators in the intensive care unit,”, A. Rhodes, R. P. Moreno, E. Azoulay et al., “Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the task force of Safety and Quality of the European Society of Intensive Care Medicine (ESICM),”, C. R. Nicolay, S. Purkayastha, A. Greenhalgh et al., “Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare,”, J. Thor, J. Lundberg, J. The resulting prioritization matrix led to the selection of nine more indicators. One limitation was the lack of severity of illness adjustment. The project was funded by the Canadian Patient Safety Institute and the Program of Experimental Medicine (POEM), Department of Medicine, Schulich School of Medicine and Dentistry. The objective of this project was to select and refine indicators for a critical care scorecard encompassing multiple domains of intensive care unit function as well as a mechanism for comparing the characteristics and performance between and within units, health care systems, and regions over time. Calculated as a percent of eligible neurologic determination of death (NDD) patients. Putative factors in unplanned extubation include inadequate/inappropriate:(i)positioning, length, or fastening of artificial airways,(ii)management of analgesia, sedation, and delirium,(iii)vigilance, nurse : patient ratio, and the use of physical restraints. Hi all,Im trying to figure out some ideas for a quality improvement/ performance improvement project on our unit. P. M. Atkins, L. C. Mion, W. Mendelson, R. M. Palmer, J. Slomka, and T. Franko, “Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study,” Chest, vol. 2018: Projects [PDF]. Calculated from the date/time of ICU admission and discharge. 0000036292 00000 n This was reiterated at the PrOMIS (Prioritizing the Organization and Management of Intensive care Services in the United States) Conference that identified the lack of a standardized, national performance measurement of critical care services as a major problem [4]. Continuous variables were expressed as the mean and standard deviation, with the exception of the number of beds which was expressed as the median and range. Occupancy Average occupancy is calculated as the sum of the average maximum census and average minimum census divided by twice the number of ICU beds. Avoidable days were missing from one cardiovascular unit for the entire study period; therefore wasted bed days could not be calculated. %%EOF 4, pp. There were five candidate indicators that all participants agreed met all the selection criteria. The most common question raised by the new reporting system was how to interpret the data (45% of respondents). Refers to transfers to another hospital that occur during an ICU admission. The number of cases with a laboratory confirmed bloodstream infection associated with a central venous catheter expressed per 1000 line days. A collaborative evidence-based quality improvement project was therefore undertaken by the iMobile team at KCH in conjunction with researchers from King's Improvement Science (KIS). Quality Indicators such as ventilator utilization ratio and ICU mortality can be used to help guide the selection of appropriate peer groups for interunit comparisons. 1.4 It is essential that senior ICU staff promote a culture of quality improvement within the ICU, whatever its size and role. Staff Turnover Number of nurses leaving ICU, calculated as percent of total number of nurses working in the ICU. Inclusion of equity as a domain was beyond the scope of this initial project. Candidate quality indicators were proposed, developed, and refined using the principles developed at the original conference. Percent readmissions per month as p-charts in small multiples. be based on available evidence, or in the absence of high-level evidence on benchmarks; when using a benchmark, the target will be set at a high level as opposed to an average or median target. Consent Rate for Solid Organ Donation The number of neurologic determination of death (NDD) patients for whom consent was obtained for solid organ donation. Delirium is a key quality metric identified by The Society of Critical Care Medicine for intensive care unit (ICU) patients. The upper and lower control limits are set at 3. Caring for critically ill patients is complex and resource intensive. Conclusions. 5, pp. 0000031069 00000 n Statistical analysis was performed using SAS 9.3 (SAS Institute, Cary, NC). The types of control charts available for data display included p-charts for individual units over time and x-bar charts for comparisons between units. T. Boulain, G. Bouachour, J. P. Gouello et al., “Unplanned extubations in the adult intensive care unit: a prospective multicenter study,” American Journal of Respiratory and Critical Care Medicine, vol. A meeting in November 2008 was used to further review the operational definitions, data submission, and data display. T. Boulain, G. Bouachour, J. P. Gouello et al., “Unplanned extubations in the adult intensive care unit: a prospective multicenter study,” American Journal of Respiratory and Critical Care Medicine, vol. 0000000016 00000 n 0000002528 00000 n An approach to monitor and compare the function of different intensive care units (ICUs) is needed to optimize outcomes for patients and the health system as a whole.Objective. Poster Presentations: Sara L Bauer, "Evidence Based Care of Homeless Women: A Protocol for Depression" Regina Cole, "Academic Electronic Health Record System Criteria Relevance and Attitudes toward Adoption in Accredited Schools of Nursing" Number of nurses leaving ICU, calculated as percent of total number of nurses working in the ICU. Previous versions were in June 2011. Data on nosocomial infections was obtained from the local infection control service and data on nursing work hours from each institution’s financial office. Pediatric [6, 7] and adult critical care [8, 9] have begun the process of developing quality indicators. 1912–1916, 2000. 0 The perspective is for management and quality improvement. Institute of MedicineInstitute of Medicine Report, A. E. Barnato, J. M. Kahn, G. D. Rubenfeld et al., “Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference,”, P. J. Pronovost, J.
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