training of medical personnel and ensuring their quality assessment system for medical practice . how to achieve accreditation nationally and international

1. Training and Accreditation of
icu physician ..Evaluation of staff
performance
BY / Ashraf Magdy Elshaer

3. •An Intensive Care Unit is a specially staffed and
equipped, separate area of the hospital dedicated to the
management of patients with life-threatening illnesses,
injuries and complications, and monitoring of potentially
life-threatening conditions, operating in cooperation with
other departments integrated in a hospital.

4. Accreditation
Evaluation
Quality + Training

5. Determine minimal training requirements for
physician.
Determine minimal training requirements for
nurses.
Determine duration of training.
Develop continuous education program.
In services education for new equipments and
procedures.
TRAINING

7. •
State or quality of being adequately or “well qualified” to
perform a specific role.
1) Training/Education
• Medical School
• Residency/Fellowship
• Continuing Medical
Education
2) Certification
• Board Certification
• Maintenance of
Certification
3) Public Reporting of
Outcomes
Assessing Clinical Competence:
CLINICAL COMPETENCE

8. Airway
• Assessment and maintenance of the
airway including an unexpected
difficult intubation
• Endotracheal intubation
• Replacement of a preexisting
tracheostomy tube
Breathing
• Ventilation by bag and mask
• Application of conventional positive
pressure mechanical ventilation
• Application of non-invasive ventilation
• Use of advanced ventilation
techniques excluding those listed as
non-core
• Special gas admixture administration
(heliox, NO)
• Fiberoptic bronchoscopy in the
intubated patient
• Thoracocentesis
• Thoracostomy tube insertion
 Circulation
• Placement of arterial lines
Placement of central venous lines
• Utilization, zeroing and calibration of
transducers
• Application and maintenance of pulmonary
artery catheter
• Cardiac output measurements and other
derived calculations from pulmonary artery
catheter
• Electrocardiogram (ECG) interpretation
• Defibrillation
• Elective cardioversion
• Cardiac overdrive pacing
• Temporary transvenous pacemaker
• Temporary transcutaneous pacemaker
• Pericardiocentesis

9. Central Nervous System (CNS)
Declaration of brain death
Lumbar puncture
Monitoring the degree of neuromuscular
blockade with peripheral nerve stimulation
Renal
Insertion of a temporary hemodialysis
catheter
Management of continuous renal
replacement therapy
Gastrointestinal
•Intra-abdominal pressure monitoring
•Peritoneal tap
Nutrition
Determination of a nutrition plan including
TPN Transport
Transport
Organization and supervision of the
transport of critically ill patients
Neurocritical core privileges:
• Management of thrombolytic therapy.
• Management of patients after peripheral
and cerebral endovascular procedures.
• Management of cerebral perfusion
pressure.

10. Effectiveness: the effect of
care on Mortality and Health.
QUALITY
Efficiency: The effect per unit
cost.
Satisfaction: Acceptability of the
patients, their relatives and staff,
including the ability to meet external
demand.
Continuity
Staff satisfaction
Safety
Availability
(Access to
service)
Customer satisfaction
Time
management

11. • Accreditation is an integral part of quality and it is not a one time
process.
• Quality team was found to allow management towards quality and
accreditation.
• Necessity of maintaining continous quality after accreditation:
If the standards are not maintained as they were at time of
accreditation, the quality care will suffer and the license will be
cancelled by the accreditation agency.

12. • Patient care in the icu is related to patient satisfaction so
questionnaire on satisfaction was filled by patients/ relatives.
• Prepared checklist for surprise check for the icu and the staff
whether they are following the criteria of care or not.

14. A CHECKLIST is prepared for surprise check of the icu to check whether the staff were
following the criteria or not:
• The standards of checklist are:
Documented polices and procedures guide the care of patients requiring cardiopulmonary
resuscitation.
Documented procedure guides the performance of various procedures.
Documented polices and procedures guide the care of patients in the icu and high dependency
units.
Documented polices and procedures guide the care of patients requiring appropriate pain
management.
Documented polices and procedures guide the end of life care.
Hospital infection protocol: the infection control program is supported by the management and
includes training of the staff.

16. • Quality indicators- quality assurance in
the icu:
1. To maintain high standard of hygiene and
cleanliness.
2. To prevent hospital acquired infection.
3. Morbidity and Mortality.
4. Incidence Reporting.
5. Daily maintenance/ checking of vital
equipment.
6. Priority of patient comfort and home
feeling.
7. Staff professionalism and looking.
• Quality indicators examples in the icu:
1. Needle stick injury (NSI).
2. Central line associated blood stream
infection (CRBSTI).
3. Incidence of pressure sores.
4. Catheter associated urinary tract infection
(CAUTI).
5. Ventilator associated pneumonia (VAP)
6. Surgical site infection (SSI).
7. Fall rate.
8. Reintubation rate within 48 hours of
intubation.
9. Return to the icu within 48 hours of
discharge.

17. • Needle stick injury:
No of NSIs reported in a month / total no of inpatients days in a
month ☓ 100
• Central line associated blood stream infection (CRBSTI):
No of central line associated blood stream infections in a month / no
of central line days in a month ☓ 100
• Incidence of pressure sores:
No of incidence of pressure sores developed after admission to the
hospital / patient days ☓ 100

18. • Catheter associated urinary tract infection:
No of CAUTI / no of catheter days ☓ 100
• Ventilator associated pneumonia:
No of VAP / no of ventilator days ☓ 100
• Fall rate:
No of episodes of fall of patients without injury / total no of patients
discharged-death ☓ 100

19. • Reintubation rate:
Reintubation leads to prolonged stay, longer ventilation and higher
nosocomial infection.
No of patients reintubated / no of patients extubated ☓ 100
• Rate of return to icu within 48 hours:
No of cases returning to icu within 48 hours / no of patients shifted
out from the icu in a month ☓ 100
• Surgical site infection (SSI)
• No of SSI cases / total no of surgeries ☓ 100

20. • An clinical quality
SCORECARD
(specifically designed
for utilization in the
ICU) is designed to
see the impact on
various performance
metrics for ICU
attending physicians
and nurses.

21. Accreditation
Evaluation
Quality + Training

22. =
EVALUATION OF ICU PERFORMANCE
EVALUATION OF ICU QUALITY
Staff
performance
Icu place
performance
Equipment, infection control

23. Is a process of validation and
judgement in which colleges,
universities and other
institutions of higher learning
are evaluated.
ACCREDITATION

25. GAHAR

36. • Teamwork in the intensive care unit (ICU) refers to the
leadership, decision-making, communication, and
coordination behaviors used by multidisciplinary team
members to provide patient care.
PLANNING TEAM

37. • The planning phase of a new ICU is organized by a multidisciplinary team
including, at least:
✻The director of the future ICU.
✻A representative of the medical staff.
✻The head nurse.
✻The architect.
✻A representative of the hospital management.
✻An engineer.
✻Safety officer.
✻The hospital infection control specialist.
✻Representatives of referring medical and surgical departments in the hospital.
✻A representative of a patients’ association participation should be considered.
PLANNING TEAM

38. Organization and responsibilities:
• Intensive care medicine is the result of close cooperation among doctors,
nurses, and allied health care professionals (AHCP).
• An efficient process of communication has to be organized between the
medical and nursing staff of the ICU.
o Poor communication during rounds and handovers (or handoffs) is a cause of medical error.
o Units with high levels of nurse-doctor collaboration have improved patient mortality rates and
reduced average patient length of stay.
• Tasks and responsibilities have to be clearly defined.
PLANNING TEAM

39. • Staff meetings together with physicians, nurses, and AHCP must be
regularly organized in order to carry out the following:
– Discuss difficult cases and address ethical issues.
– Present new equipment.
– Discuss protocols.
– Share information and discuss organization of the ICU.
– Provide continuous education.
PLANNING TEAM

40. Polices and procedures
• Standard treatment protocol to be followed.
• Silence to be observed
• All new admission/ discharge to be informed to the icu in charge
• All admissions/ discharge to be registered.
Staff standing order
• Proper joining at the time of the shifts.
• Daily round of the physician and icu team to take decision for change of
plan or treatment.
• Instructions and maintenance of input and output chart.
• Cleaning and maintenance of equipments.
• Checking and replacement of essential drugs.

41. • Daily rounds
Formal daily rounds are organized to give information and
plan therapy.
All ICU health professionals involved in direct patient care
should participate in these rounds.

42. Treatment policy
• Responsibility lies with the charge of unit admitting the case.
• No direct admission to icu but transferred from unit.
• 20% of icu beds to be vacant for emergency admission.
• Admission only on recommendation of the icu director subjected
to available bed.
• A vacant bed is allocated in original ward for patient return.
• Continuity of treatment is per view of icu in charge in consultation
with unit in charge.

43. Medical staff

44. MEDICAL
DIRECTOR

45. • Each ICU must have a MEDICAL DIRECTOR= SPECIALIST STAFF
• Who takes overall responsibility for the operation of the Unit.
• Has the sole administrative and medical responsibility for this unit and cannot hold
top-level responsibilities in other departments or facilities of the hospital.
• The specialist provides patient management, administration, teaching, research, audit and ICU
based activities inside and outside of the ICU as required.

46. • The head of the ICU should be a Fellow of the College and a senior accredited
specialist in intensive care medicine as defined at country level, usually with a
prior degree in anesthesiology, internal medicine, or surgery and have had a
formal education, training, and experience in intensive care medicine.
• The director-specialist professional activities (administrative and medical
management of the unit) are devoted full-time (full time comitment) or at least
75% of the time to intensive care.
• The consultant should provide reasonable working hours and leave.
(The ICU roster must allow reasonable working hours and leave.)

47. • In smaller ICUs, there must be at least one specialist rostered to the
unit at all times.
• In larger ICUs, more than one specialist should be rostered to the Unit
(one per pod of 8-15 beds).

48. MEDICAL
STAFF
MEMBERS

49. MEDICAL STAFF MEMBERS:
• They assist the head of the ICU.
• Are experienced physicians certified and qualified in intensive care
medicine.
• They define admission and discharge criteria and carry the
responsibility for diagnostic and therapeutic protocols in the ICU.
• The regular medical staff members of the ICU treat patients with
consultation of the specialists in different medical, surgical, or
diagnostic disciplines whenever necessary.

50. • An important task is to supervise and teach the doctors in training
in training centers.
• The number of staff required will be calculated according to the
number of beds in the unit, number of shifts per day, desired
occupancy rate, extra manpower for holidays and illness, number
of days each professional is working per week, and the level of
care and as a function of clinical, research, and teaching workload.
• Extended work shifts have been shown to negatively impact the
safety of patients as well as medical staff.

51. • Duties and services outside of the ICU:
Such as emergency response (e.g. rapid response teams) and
outreach services.
Must be staffed by personnel additional to those required for
managing patients within the ICU.
Must not compromise care of patients within the ICU.
Resources for these activities must be provided.

52. • There must be at least one other REGISTERED MEDICAL
PRACTITIONER with an appropriate level of experience rostered to
the ICU at all times.
• These medical practitioners must have appropriate orientation and
training and be competent in providing advanced life support.

53. Nursing
staff

54. NURSING STAFF:
• Should be formally trained in intensive care medicine and
emergency medicine.
• The head nurse has experience and is in charge of education and
evaluation of the competencies of the nurses.
• Division 1 registered nurses (RN) are responsible for direct patient
care. any activities that involve direct contact with the patient.
• Enrolled nurses (Division 2 RNs) (PRN) may be allocated duties to
assist registered nurses.

55. • There should be a designated senior nurse in charge of each ICU with
a post-registration qualification in intensive care.
• All registered nurses must be competent in providing advanced life
support and undertake refresher training annually.
• In addition to clinical expertise, some nurses may develop specific
skills (e.g., human resource management, equipment, research,
teaching new nurses).

56. • The appropriate nursing staff: patient ratio and the total number of
nursing staff required by each unit depends on: many variables such
as the total number of patients, severity of illness of patients,
methods of rostering, as well as individual policies for support and
monitoring in each unit.
• In morning administrative shifts, there should be an increase of 25-
30% in the nursing number.

57. • The Australian College of Critical Care Nurses (ACCCN) guidelines
require a minimum of 1:1 for ventilated and other critically ill
patients, and 1:2 nursing staff for lower acuity patients (clinically
determined).
• 1:3 and 1:4 in intermediate care units.
• Greater ratios may be required for patients requiring complex
management.

58. HEAD NURSE:
• A dedicated, full-time experienced nurse with post registration qualification,
who is responsible for the functioning and quality of the nursing care.
• Should be supported by at least one deputy head nurse able to replace him
(her).
• The head nurse should ensure the continuing education of the nursing staff.
• Head nurses and deputy head nurses should not normally be expected to
participate in routine nursing activities.
• The head nurse works in collaboration with the medical director, and together
they provide policies and protocols, and directives and support to the team.

59. NURSES IN TRAINING:
• Nurses in specialty training for intensive care and emergency
nursing must be trained in ICUs under the supervision of sufficient
training personnel.
• They should not be seen as substitute for regular intensive care
nursing staff but may be gradually assigned to patient care
according to their actual level of training.

60. ALLIED HEALTH CARE PERSONNEL:
• PHYSIOTHERAPISTS:
One physiotherapist with dedicated training and expertise in critically ill patients
should be available per five beds for level III care on a 7 day/week basis.
• TECHNICIANS:
Maintenance, calibration, and repair of technical equipment in the ICU must to
be organized. This facility can be shared with other departments of the hospital
but a 24-h availability has to be organized with priority for the ICU.
• INFECTION CONTROL SPECIALIST.

61. • RADIOLOGY TECHNICIAN:
Should be on call around the clock. Interpretation of the medical imaging by the
radiologist must be available at all times.
• CLINICAL PHARMACIST:
Should be available to consult during normal working hours.
A sufficient collaboration with pharmacy is of particular importance with respect
to patient safety.
• EQUIPMENT- SAFETY OFFICER:
Larger ICUs should have an equipment officer to coordinate and oversee the
selection, maintenance of equipment and disposables for the Unit.

62. • DIETICIAN:
Should be on call during normal working hours.
• SPEECH AND LANGUAGE THERAPIST:
Should be available to consult during normal working hours.
• PSYCHOLOGIST:
Should be available to consult during normal working hours.
• OCCUPATIONAL THERAPIST:
Should be available to consult during normal working hours.

63. • CLEANING PERSONNEL:
- A specialized group of cleaning personnel familiar with the ICU environment
should be available for the ICU.
- They should be familiar with infection control, prevention protocols, and hazards
of medical equipment.
- Cleaning and disinfection of the patient areas are performed under the nurse’s
supervision.
- A checklist of the cleaning status must be kept.
- Regular updates should be provided to ensure cleaning protocols reflect best
practice.