Quality in critical care aims to provide care that is safe, effective, patient-centered and improves outcomes. There is global variation in critical care resources and processes. Quality improvement is important as substandard critical care can harm patients and waste resources. Quality can be measured through indicators related to ICU structure, care processes and patient outcomes. Checklists and tools from WHO help standardize processes and improve quality.
What can a Clinical Nurse Leader do for your critical care nursing unit? Plenty! Consider this new nursing role as one that can improve patient outcomes and increase satisfaction for both clients and staff. Successful microsystems begin with empowering patients, families and front line nurses.
Using Implementation Science to transform patient care (Knowledge to Action C...NEQOS
Master Class presentation and workshop materials from the NENC AHSN Collaborating for Better Care Partnership's Master Class, led by Professor Jeremy Grimshaw' on 1st September 2014
Accountable care organizations are incented to provide higher quality care at a lower total cost. This represents a big change compared to the old system that encouraged hospitals to increase revenues by performing a high volume of procedures.
Hospitals are no longer reimbursed for treatment of most healthcare-associated infections. Value-based purchasing rewards hospitals that achieve clinical and patient satisfaction metrics—at the expense of those that do not.
Regulatory pressures, such as ventilator-associated event reporting and meaningful use, also create new work and may result in lower revenues.
Frontline clinicians are spending more and more time documenting their work and have less time left to focus on patients.
The result? Hospitals and health systems have an increasing urgency to eliminate waste and inefficiency from the care delivery process in order to improve outcomes and lower the cost of care.
So that’s a financial problem. Let’s talk a little bit about how that relates to the clinical problem and the clinical goals that hospitals have. One of the opportunities, one of the neat things about this analytics and mechanical ventilation is that the clinical goals and the financial goals in ventilation are perfectly aligned. The best clinical thing to do for a patient is to get them off the vent breathing on their own as quickly as possible. The best financial thing to do is to get them off the vent breathing on their own as quickly as possible. And there are really only three goals in mechanical ventilation, it’s a complex clinical therapy with complex patients but the goals are simple. It’s to provide life support, prevent or at least reduce patient harm, and minimize time on vent.
Quality and safety, Vision 2025, Specific challenges of Nursing on quality, Quality improvement division, Fish bone technique,QI model, PDCA, Role of Nurse, Empowerment, Nursing positioning and policies,
What can a Clinical Nurse Leader do for your critical care nursing unit? Plenty! Consider this new nursing role as one that can improve patient outcomes and increase satisfaction for both clients and staff. Successful microsystems begin with empowering patients, families and front line nurses.
Using Implementation Science to transform patient care (Knowledge to Action C...NEQOS
Master Class presentation and workshop materials from the NENC AHSN Collaborating for Better Care Partnership's Master Class, led by Professor Jeremy Grimshaw' on 1st September 2014
Accountable care organizations are incented to provide higher quality care at a lower total cost. This represents a big change compared to the old system that encouraged hospitals to increase revenues by performing a high volume of procedures.
Hospitals are no longer reimbursed for treatment of most healthcare-associated infections. Value-based purchasing rewards hospitals that achieve clinical and patient satisfaction metrics—at the expense of those that do not.
Regulatory pressures, such as ventilator-associated event reporting and meaningful use, also create new work and may result in lower revenues.
Frontline clinicians are spending more and more time documenting their work and have less time left to focus on patients.
The result? Hospitals and health systems have an increasing urgency to eliminate waste and inefficiency from the care delivery process in order to improve outcomes and lower the cost of care.
So that’s a financial problem. Let’s talk a little bit about how that relates to the clinical problem and the clinical goals that hospitals have. One of the opportunities, one of the neat things about this analytics and mechanical ventilation is that the clinical goals and the financial goals in ventilation are perfectly aligned. The best clinical thing to do for a patient is to get them off the vent breathing on their own as quickly as possible. The best financial thing to do is to get them off the vent breathing on their own as quickly as possible. And there are really only three goals in mechanical ventilation, it’s a complex clinical therapy with complex patients but the goals are simple. It’s to provide life support, prevent or at least reduce patient harm, and minimize time on vent.
Quality and safety, Vision 2025, Specific challenges of Nursing on quality, Quality improvement division, Fish bone technique,QI model, PDCA, Role of Nurse, Empowerment, Nursing positioning and policies,
MicroGuide app, pop up uni, 1pm, 3 september 2015NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Literature Evaluation TableStudent Name Joyce NwakorPIC.docxcroysierkathey
Literature Evaluation Table
Student Name: Joyce Nwakor
PICOT Question: For patients and healthcare workers in the hospital (p) does hand washing protocol (I) compared to an alcohol-based solution (C) reduce hospital-acquired infection (O) within a period of stay in the hospital (T)
Criteria
Article 1
QUANT
Article 2
QUANT
Article 3
QUANT
Article 4
REVIEW
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Daisy, V. T., & Sreedevi, T. R.
Link:
http://eds.a.ebscohost.com.lopes.idm.oclc.org/eds/detail/detail?vid=4&sid=72619044-c224-4bc5-9982-cf6c3953f7d2%40sessionmgr4007&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=110819455&db=ccm
Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C., … Bader, M. K. (2015). Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing. American Journal of Critical Care, 24(3), 216-224. doi:10.4037/ajcc2015898
Knighton, S. (2017). The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases, 4(suppl_1), S411-S412. doi:10.1093/ofid/ofx163.1029
João Manuel Garcia do Nascimento Graveto, Rita Isabel Figueira Rebola, Elisabete Amado Fernandes, & Paulo Jorge dos Santos Costa. Link:
https://doi-org.lopes.idm.oclc.org/10.1590/0034-7167-2017-0239
Article Title and Year Published
Effectiveness of a Multi-Component Educational Intervention on Knowledge and Compliance with Hand Hygiene among Nurses in Neonatal Intensive Care Units. 2015Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing
Published May 2015
The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases.
Published in 2017
Hand hygiene: nurses’ adherence after training.
2018
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study
The study was aimed to assess the effectiveness of a multi-component educational intervention on the knowledge and compliance with handhygiene guidelines among nurses working in Neonatal Intensive Care Units.
The research investigated the reduction of infections in the hospital through observation of hand hygiene.
What handwashing procedures were performed by the medical personnel before patient contact part 1.
What is the level of effectiveness of training (I) in improving nurses’(P) adherence to hand hygiene(O)?”.
Design (Type of Quantitative, or Type of Qualitative)
A pre-experimental pre-test post-test design was adopted for the study. QUANT
Pre-experimental study design
. QUANT
A quantitative study was done using quasi observational data
Qualitative/ quantitative studies
This is a review
Setting/Sample
This study was conducted in 3 level III NICUs of selected private hospitals in Kerala
Total sample compri ...
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
MicroGuide app, pop up uni, 1pm, 3 september 2015NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
International Patient Safety Goals (IPSG) help accredited organizations address specific areas of concern in some of the most problematic areas of patient safety.
International-Patient-Safety-GoalsGoal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Literature Evaluation TableStudent Name Joyce NwakorPIC.docxcroysierkathey
Literature Evaluation Table
Student Name: Joyce Nwakor
PICOT Question: For patients and healthcare workers in the hospital (p) does hand washing protocol (I) compared to an alcohol-based solution (C) reduce hospital-acquired infection (O) within a period of stay in the hospital (T)
Criteria
Article 1
QUANT
Article 2
QUANT
Article 3
QUANT
Article 4
REVIEW
Author, Journal (Peer-Reviewed), and
Permalink or Working Link to Access Article
Daisy, V. T., & Sreedevi, T. R.
Link:
http://eds.a.ebscohost.com.lopes.idm.oclc.org/eds/detail/detail?vid=4&sid=72619044-c224-4bc5-9982-cf6c3953f7d2%40sessionmgr4007&bdata=JnNpdGU9ZWRzLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#AN=110819455&db=ccm
Fox, C., Wavra, T., Drake, D. A., Mulligan, D., Bennett, Y. P., Nelson, C., … Bader, M. K. (2015). Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing. American Journal of Critical Care, 24(3), 216-224. doi:10.4037/ajcc2015898
Knighton, S. (2017). The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases, 4(suppl_1), S411-S412. doi:10.1093/ofid/ofx163.1029
João Manuel Garcia do Nascimento Graveto, Rita Isabel Figueira Rebola, Elisabete Amado Fernandes, & Paulo Jorge dos Santos Costa. Link:
https://doi-org.lopes.idm.oclc.org/10.1590/0034-7167-2017-0239
Article Title and Year Published
Effectiveness of a Multi-Component Educational Intervention on Knowledge and Compliance with Hand Hygiene among Nurses in Neonatal Intensive Care Units. 2015Use of a Patient Hand Hygiene Protocol to Reduce Hospital-Acquired Infections and Improve Nurses' Hand Washing
Published May 2015
The Use of Instructional Technology to Increase Independent Patient Hand Hygiene Practice of Hospitalized Adults in an Acute Care Setting. Open Forum Infectious Diseases.
Published in 2017
Hand hygiene: nurses’ adherence after training.
2018
Research Questions (Qualitative)/Hypothesis (Quantitative), and Purposes/Aim of Study
The study was aimed to assess the effectiveness of a multi-component educational intervention on the knowledge and compliance with handhygiene guidelines among nurses working in Neonatal Intensive Care Units.
The research investigated the reduction of infections in the hospital through observation of hand hygiene.
What handwashing procedures were performed by the medical personnel before patient contact part 1.
What is the level of effectiveness of training (I) in improving nurses’(P) adherence to hand hygiene(O)?”.
Design (Type of Quantitative, or Type of Qualitative)
A pre-experimental pre-test post-test design was adopted for the study. QUANT
Pre-experimental study design
. QUANT
A quantitative study was done using quasi observational data
Qualitative/ quantitative studies
This is a review
Setting/Sample
This study was conducted in 3 level III NICUs of selected private hospitals in Kerala
Total sample compri ...
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TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
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is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
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and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
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the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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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.
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.
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
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.
Editor's Notes
Not all entirely, open or closed but combination
At the top of this heap is someone who is a good listener and willing to learn