quality in ICU

1. Quality in Critical Care
Material Adapted from the WHO Clinical Care SARI course

2. Learning objectives
 Define quality care.
 Describe global variation in critical care.
 Discuss quality indicators for structure,
process and outcomes in critical care.
 Describe quality improvement (QI) work and
its benefits.
 Identify practical quality tools that can be
applied.

3. What is quality care?
 Quality is multi-
dimensional.
(Institute of Medicine, Washington DC, 2001) https://www.who.int/servicedeliverysafety/quality-report/en/
Elements of health care quality

4. Why is quality important?
 Access to care means little if services are not
delivered with quality in mind.
 Between 5.7 and 8.4 millions deaths occur
annually from poor quality care in LMICs.
 Substandard care wastes significant resources,
fails to turn investments into better health,
harms the health of populations, and destroys
human capital.
Ref: Crossing the global quality chasm. The National Academies
of Sciences, Engineering, Medicine; 2018

5. What is quality care?
 Safe
 Avoids harm to patients with care intended to help them
 Timely
 Reduces waiting for patients and those giving care
 Efficient
 Reduces waste
 Equitable
 Reduces gaps or disparities in care
 Effective
 Matches care to science, adheres to standards of care
 Patient-centred
 Respects the individual patient
(Institute of Medicine, Washington DC, 2001)
Quality element Description
Safe Avoiding harm to people for whom the care is intended.
Timely Reducing waiting times and sometimes harmful delays for both those who
receive and those who give care.
Effective Providing evidence-based health care services to those who need them.
Equitable Providing care that does not vary because of age, sex, gender, race, ethnicity,
geography, religion, socio-economic status, linguistic or political affiliation.
Efficient Maximizing the benefit of available resources and avoiding waste.
Patient-centered Providing care that responds to individual preferences, needs and values in
health services that are organized around the needs of people.
Integrated Providing care that is coordinated across levels and providers and makes
available the full range of health services throughout the life course.

6. What’s special about a critical care
system?
 Frequent monitoring, lots of information
processing required.
 Complex, expensive technology and equipment.
 Rapid clinical-decision making.
 Complex risk-benefit analysis.
 Invasive (risky) interventions.
 Requires interdisciplinary team of healthcare
workers.

7. Health delivery system

8. Critical care as a system
 I
Resources Processes Outcomes
ICU organization
•number of beds
•architecture/location
•integration into health
care system
.
Availability of equipment
and supplies
•medicines, ventilators, etc.
Availability of staffing
•intensivists, physician,
specialists
•ICU nurses, patient ratio
•pharmacists, dieticians,
respiratory therapists,
physiotherapists, biomedical
technicians, etc.
Refer to any interventions
done for patients, i.e.
procedures, medications,
etc.
• Administering
appropriate antimicrobial
therapy for patients with
sepsis.
• Application of LPV for
patients with ARDS.
• Implementing ABCDE
bundle for patients
• Mortality: adjusted for
patient diagnosis,
severity of illness at
admission.
• ICU length of stay.
• Re-intubation rate.
• Re-intubation rate.
• Quality of life in ICU
survivors.

9. Example of Quality Indicators
Scales Organization of Critical Care 2014

10. Global Variation in ICU
Substantial variation exists
globally and within countries,
some of which may influence
patient outcomes:
- e.g. # ICU beds per
population
- e.g. physician staffing (low
vs high intensity)
- e.g. availability of
medicines, technology and
supplies.

11. International Comparisons
 Outcomes comparisons challenging
 Problem of comparing outcome:
 Population (age distribution, comorbidities)
 Patient selection (admission criteria)
 Delayed admissions (ICU bed availability)
 Other care locations (step-down, recovery rm)
 Discharges (long-term vent facilities)
 End-of-life care (Palliative care practices)
Scales Organization of Critical Care 2014

12. Global Variation in ICU
African countries High income countries P value
64 (24.3) 43 (97.7) < 0.001
188 (71.5) 44 (100) < 0.001
204 (77.6) 44 (100) < 0.001
238 (90.5) 44 (100) 0.03
70 (26.6) 41 (93.2) < 0.001
Possibility to implement all sepsis resuscitation bundles
- Lactate
- Cultures
- Antibiotics
- Hypotension
- CVP/ScvO2
Baelani et al Crit Care 2011

13. International Comparisons
 Outcomes comparisons very difficult
 Many issues comparing outcomes:
 1. Population (age distribution, comorbidities)
 2. Patient selection (admission criteria)
 3. Delayed admissions (ICU bed availability)
 4. Other care locations (step-down, recovery
room)
 5. Discharges (long-term ventilator facilities)
 6. End-of-life care (Palliative care practices)
Scales Organization of Critical Care 2014

14. ICU characteristics
 ICU characteristics World*
 University based 59.8%
 Closed ICU 82.9%
 Surgical ICU 18.8%
 RN AM 1.5
 RN PM 1.8
*Sakr Crit Care Med 2015; 43:519

15. Structure
 Closed ICU = Intensivist responsibility
 Open ICU = other specialist
 Collaborative ICU
 High-intensity
 Low-intensity
 Meta-analysis of 27,000 patients in 27 ICUs found
“high-intensity staffing associated with:
 Shorter LOS (hospital and ICU)
 Lower mortality
Pronovost JAMA 2002; 288:2151

16. Elements of Success
 Practice Pattern
 Safety
 Efficacy
 Efficiency
 Service Philosophy
 Consistency
 Continuity
 Communication
St Andre Crit Care Med 2015; 43:874

17. ICU Leader Characteristics
 Listener & Learner
 Integrity
 Adaptive
 Manage $
 Decisive
 Truth
 Anticipate
 Mentor
St Andre Crit Care Med 2015

18. Does Unit Designation Matter?
 Dedicated TICU vs mixed ICU
 Acute respiratory failure, Pneumonia, Acute renal
failure N=3822
 Outcomes:
 Any complication AOR 0.46
 Failure to rescue AOR 0.35
 Mortality AOR 0.34
 Older pts, sicker pts, more comorbidities in TICU
but **RN yrs +2yrs (same doctors)
Bukar J Trauma Acute Care Surg 2015; 78:920

19. Nursing staff ratio
 1:1 Nursing
 Improves job satisfaction
 Improves some objective outcomes
 Challenges
 Availability, Cost
 Aging workforce
 Qualified and competent
Penoyer Crit Care Med 2010; 38:1521

20. Pharmacists
 Critical care consultant, steward of resources,
and safety officer.
 US study 1999 – presence of critical care
pharmacist reduced adverse drug events by
two thirds.
 European study 2010 – showed similar
reduction in preventable ADEs.
Leape JAMA 1999; 282:267
Klopotowska Crit Care Med 2010; 14:R174

21. Select a QI project

22. Create a QI culture and team
 A large inclusive quality team to prioritize
projects:
 Clinical leaders, technical experts, day-to-day leaders,
interdisciplinary team members, sponsors
 Smaller teams to focus on implementation and
measurement for each project selected.
 A culture of quality and safety:
 This is everyone’s responsibility and opportunity
 The objective is to improve care, not to punish
workers

23. Selected WHO tools for improving
quality in the ICU
 Checklist for best daily
practices
 Checklists for high-
quality use of invasive
mechanical ventilation
for ARDS
 Checklist for initiating,
improving, evaluating
and sustaining a quality
improvement
programme

24. Checklist for daily best practices
 Aids providers in daily care
of patients
 For use in the ICUs by
multiple cadres of
providers involved in
patient care
 Improves quality:
 Effectiveness – reinforces
key diagnostic and
management considerations

25. Checklist of invasive mechanical
ventilation for ARDS
 Provides guidance to
providers caring for patients
with ARDS
 Improves quality:
 Effectiveness – reinforces
key diagnostic and
management
considerations
 Efficiency – gives guidance
on reorganization of
resources to optimize
workflow

26. Many other quality tools exist
 A compendium of tools and resources for
improving the quality of health services

27. Summary
 Quality care is the provision of safe, timely,
effective, efficient, equitable, and patient-centred
care.
 Systematic and continuous quality improvement
is essential because critical care is complex and
imperfect, even with the best efforts.
 Quality measures are related to ICU
resources/structure, processes of care and
patient outcomes.
 Consider to initially focus on processes of care
instead of hard-to-measure outcomes.