2020: Projects [PDF]. 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. 71–75, 2006. Transfers may be required for medical reasons (need for a medical service/intervention not available at the initial hospital) or as part of ICU bed management, calculated at percent of live ICU discharges. Quality improvement in critical care project contributors are the following: Department of Critical Care Medicine, University of Calgary, Calgary, AB: Paul J. E. Boiteau, M.D. Examples of Quality Improvement Projects in Managing and Increasing Efficiencies for Patient Service: Appointments, Discharges, Follow-Up Care, and Emergency Department Service Examples of Quality Improvement Projects in Operational Efficiencies in a Medical Facility Number of nurses leaving ICU, calculated as percent of total number of nurses working in the ICU. The resulting prioritization matrix led to the selection of nine more indicators. However, a more global description and balanced assessment of critical care performance is needed in order to understand how to make it better. 270–276, 2007. 72 0 obj <> endobj Drafting of the paper was managed by Carla A. Chrusch and Claudio M. Martin. Less than half of the units were able to submit data on patient and family satisfaction and staff turnover, overtime, and absenteeism, and results for these indicators will not be described. 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" S. K. Epstein, M. L. Nevins, and J. Chung, “Effect of unplanned extubation on outcome of mechanical ventilation,” American Journal of Respiratory and Critical Care Medicine, vol. Unplanned extubation may result in patient harm and prolonged length of stay due to loss of the airway and the risks associated with recapture. Trauma ICUs admitted trauma and neurosurgical patients in addition to general medical and/or surgical patients. Fellowship training in gastroenterology offers a unique opportunity to develop these skills in preparation for practice. Some potential indicators that were considered but not ultimately chosen included delay in emergency admission, cancelled surgery, elevation of the head of the bed, deep venous thrombosis prophylaxis, use of sedation and restraints, appropriateness of blood transfusions, nutrition, treatment of sepsis, nutrition, use of a pain scale, procedure related complications, ICU acquired C. difficile infection, decubitus ulcers, length of stay of ICU decedents, admissions from other hospitals, and repatriation rate. %%EOF The number of neurologic determination of death (NDD) patients for whom consent was obtained for solid organ donation. 4, pp. For example, wasted bed days were derived by dividing the number of avoidable days by the number of days in the month. Detailed operational definitions were developed for 22 quality indicators. Abbreviated definitions are shown for all quality indicators in Appendix A and an example of a detailed operational definition is shown in Appendix B. A meeting in November 2008 was used to further review the operational definitions, data submission, and data display. 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. 0000038139 00000 n It is a combined med & surg ICU. The first round identified any undisputed quality indicators. startxref 0 Calculated as a percent of eligible neurologic determination of death (NDD) patients. Thanks so much!! While this will lead to an overestimate of the rate of unplanned extubation, the magnitude is expected to be small. Number of nursing overtime hours, calculated as a percent of total hours worked. 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. Number of nurses sick hours, calculated as percent of total number of hours. Copyright © 2016 Carla A. Chrusch et al. Ratio of ventilator days (invasive or noninvasive for an acute indication) to total patient days corrected for avoidable days. Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. Detailed operational definitions were developed for each quality indicator that included the domain represented, how it is reported, the reporting period, significance of the indicator, derivation, details of data collection, considerations and assumptions in its measurement or derivation, data display, benchmark or goal, revision notes, and references. 0000000016 00000 n Potassium Replacement Protocol. 0000037007 00000 n 1348–1355, 2004. 9.3. Objectives: To examine the impact of an ICU bundle on delirium screening and prevalence and describe characteristics of delirium cases. 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]. The process was led by a certified facilitator using established techniques for consensus building and prioritization that occurred over several rounds [10]. %PDF-1.6 %���� 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]. 4,pp. Incidence of ICU Acquired Methicillin-Resistant S. aureus (MRSA) 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. Krayem, R. Butler, and C.Martin, “Unplanned extubation in the ICU: impact on outcome and nursing workload,” Annals of Thoracic Medicine, vol. 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. We attribute our success with this selection process to being a relatively homogeneous group (academic institutions in a public funded health care system with physician specialty training under a single national specialty organization), the agreement on principles for quality indicator selection, and a pilot phase that demonstrated the initial feasibility of our approach. Results also confirmed and reinforced that there was a desire for measures and methodology that would allow for comparisons with others. 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. Critically ill patients experience a high burden of disease and providing care for these patients is expensive and complex. 1348–1355, 2004. For example, even something as fundamental as what constitutes an ICU bed required significant discussion. 0000003238 00000 n 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. Quality Improvement in our Unit . To cite: Jones AS, Isaac RE, Price KL, Plunkett AC. 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. ICU Discharges That Occur at Night Number of patients discharged alive to a ward, step-down, high-dependency, high observation, or another non-ICU patient area in the same hospital, between the hours of 22:00 and 06:59, calculated as a percent of all live ICU discharges. 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. Features include: early mobilization, cycling (cycle ergometer), Wii therapy, biomedical … 6, pp. Also, severity of illness is only one of many factors that might need to be considered when exploring any signal produced by the data. 71–75, 2006. 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. Quality Improvement (QI) initiatives in the ICU to decrease nosocomial infections and maintenance of normoglycemia have been shown to improve outcomes as well as decrease costs. Total score and decision-making and care subscales from the Family Satisfaction-24 survey. The amount of time that patients occupy an ICU bed for more than 4 hours after a transfer order is written is considered avoidable. We recognize that socioeconomic status, geographic distance from an urban centre, and gender are important possible sources of inequity even in a publicly funded health care system such as Canada’s. Our process resulted in the selection and development of 22 indicators representing 6 domains of ICU function. x-bar statistical process control chart with rational subgrouping by unit type (from left to right: mixed medical surgical (MS), trauma (T), and cardiovascular (CV)). In comparison to the programs above, the following are examples of quality improvement projects in hospitals. Data submission, review, and revision continued with an ongoing iterative process. Ventilated patient flow was added to complement patient flow in October 2008 bringing the total to 22 quality indicators (Table 1). 8, no. Benchmark/Goal Best reported rates in the literature are <5%. Strengths of this study include the participation of multiple institutions and regions from across the country; participation of knowledge users, clinicians, and improvement experts; and the demonstration that existing data sources can be effectively combined in statistical control charts that users judged to be superior to previously available reports. Statistical process control (SPC) charts were used as the primary mode of data sharing and display. 112, no. 4,pp. Intensive care unit occupancy versus wasted ICU beds per day. 104 0 obj <>stream 0000004413 00000 n 0000002178 00000 n 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. High-quality care is consistent with evidence base and professional knowledge, and it is characterised by an increased likelihood of achieving desired outcomes (IOM 2001). SPC charts have been used extensively by industry for quality control and are becoming increasingly common in medical quality improvement applications [11, 12]. Part of the recommendations in To Err Is Human: Building a Safer Health System [3] was the setting of performance standards and consistency across organizations. Inclusion of equity as a domain was beyond the scope of this initial project. Transfers may be required for medical reasons (need for a medical service/intervention not available at the initial hospital) or as part of ICU bed management, calculated at percent of live ICU discharges. Number of pneumonias occurring in patients requiring a device to assist respiration through a tracheostomy or endotracheal tube. Objective. ; Department of Medicine, McGill University, Montreal, QC: Denny Laporta, M.D. They are also very active with patient flow ranging from patients/bed/year in trauma units to patients/bed/year in cardiovascular units. 0000000975 00000 n Quality Management Plan. Sign up here as a reviewer to help fast-track new submissions. Unplanned Extubation Number of unplanned extubations per 1000 invasive mechanical ventilation days. Quality Improvement in Critical Care: Selection and Development of Quality Indicators, The Quality Improvement in Critical Care Project, Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada, Department of Medicine, University of Western Ontario, London, ON, Canada, The Quality Improvement in Critical Care Project, Canada. The number of days when a patient has an artificial airway but is not on invasive mechanical ventilation is not readily available and is not included. Fortunately, falls are a public health problem that is largely preventable. ; Carla A. Chrusch, M.D., M.S. New variables were derived from submitted data as defined in the operational definitions. The feasibility was demonstrated with the collection of 3.5 years of data. Hi all,Im trying to figure out some ideas for a quality improvement/ performance improvement project on our unit. XmR statistical process control run chart with 3 sigma limits. Similar process control charts, using either x-bar or p-charts, were used to report all indicators on a regular basis. Additional Resources 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. This project has demonstrated that a network-wide quality improvement project can produce sustained improvements in delirium care in multiple critical care units across a city-wide area. 366–371, 2007. One mixed ICU also admitted postoperative cardiovascular surgery patients. R. S. Ream, K. Mackey, T. Leet et al., “Association of nursing workload and unplanned extubations in a pediatric intensive care unit,” Pediatric Critical CareMedicine, vol. Explicit operational definitions are essential. Methods. Following the conference, the group maintained discussions on a regular basis through a combination of email, teleconference calls, webinars, and internet groups. 161, no. 366–371, 2007. Individual patients were not identifiable. 2014: Projects [PDF]. Bubble size is proportional of patient flow (patients/bed/year). Best reported rates in the literature are <5%. Saline Flush Charting In An Intensive Care Unit: A Quality Improvement Project Russell R. Miller , Nathan B. Grossman , Jia S. Milam , and Justin B. Dickerson Barriers To Early Mobility In The Intensive Care Unit (ICU): Assessing The Rehabilitation Specialist's Perspective Additionally, using a data-driven approach can help engage stakeholders and … Incidence of Central Line-Related Bloodstream Infections (CLBSI) The number of cases with a laboratory confirmed bloodstream infection associated with a central venous catheter expressed per 1000 line days. Experts interviewed for this article cited two nursing-related quality improvement projects they were involved with that were simple, but very beneficial. Results. Revision Notes Current version was in May 2012. Dr. Carla A. Chrusch had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Display different slices of a common target for ICUs need not be ventilated at the conference! 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