An audit examines processes and outcomes in intensive care to identify opportunities for quality improvement. It involves comparing objectives and reality by assessing structure, process, and outcomes. Auditing an ICU's performance is important for patient safety, professional development of staff, and efficient use of resources. Key indicators that should be audited include adherence to evidence-based practices for conditions like sepsis, ventilation protocols to prevent pneumonia, and checklists for procedures like central line insertion. Collecting data on adverse events through confidential reporting allows teams to learn from mistakes and standardize care processes. Implementing care "bundles" that group several evidence-based practices for a given condition can help improve outcomes more than single interventions alone. Regular auditing is essential for ongoing assessment and

1. QUALITY IN ICU
Maged Abulmagd,MD,EDIC

4. What is Quality ?
“the degree to which health services increase
the likelihood of desired health outcomes
and are consistent with current professional
knowledge”
Institute of Medicine, 1990
ResultsQuality = Objectives
Quality is defined byQuality is defined by
goalsgoals

5. ICU and Aircraft
Safety is primary
goal
Technological
innovation
Multiple sources of
threat
Teamwork is
essential

6. ICU versus aircraft
•Patients more varied than aircraft
•Patients more complex than aircraft
•Many more staff to coordinate
•Many more possible complications
•An ICU stay is far longer than any flight

7. The science of safety
Understand system performance
Use strategies to improve system performance

Standardize

Create Independent checks for key process

Learn from Mistakes
Apply strategies to both technical work and team work.
Recognize that teams make wise decisions

8. Adverse Events inAdverse Events in
Hospitalized PatientsHospitalized Patients

13.5% of Medicare patients experience a serious13.5% of Medicare patients experience a serious
adverse event during hospitalizationadverse event during hospitalization
(134,000 pts/month)(134,000 pts/month)

Most common causes:Most common causes:

Medications (31%)Medications (31%)

Ongoing patient care (28%)Ongoing patient care (28%)

Surgery (26%)Surgery (26%)

Infection (15%)Infection (15%)
Office of Inspector General. Adverse events in hospitals:
National incidence among Medicare beneficiaries. November 2010.

9. Audit
• from Latin auditus = act of hearing
• Synonyms: examination, analysis,
checkup, inspection,
perlustration, review, scan,
scrutiny, survey, view
• Related: investigation, probe, check,
control, corrective

10. Reasons for auditing your ICU
Audit is an essential tool for quality improvement
you only manage what you measure
Audit is in the interest of your patients
to ensure safe and evidence-based care
Audit is in the interest of your ICU team
to enhance team culture, professionalism, job satisfaction
Audit is in the interest of health systems
to ensure efficient and fair use of resources
Audit is an essential tool for quality improvement
you only manage what you measure
Audit is in the interest of your patients
to ensure safe and evidence-based care
Audit is in the interest of your ICU team
to enhance team culture, professionalism, job satisfaction
Audit is in the interest of health systems
to ensure efficient and fair use of resources

11. A. Valentin 10/2004
Tidalvolume ≤ 6ml PBW in ARDS/ALI:
Lungprotective Ventilation in Reality
Brunckhorst F, Crit Care Med 2008
Perceived adherence:Perceived adherence: 80%80%
Real adherence:Real adherence: 3%3%
Perceived adherence:Perceived adherence: 80%80%
Real adherence:Real adherence: 3%3%

12. A thorough, systematic examination of the
processes and results of a health care service.
External
Audit
External
Audit
Internal
Audit
Internal
Audit
Benchmarking
Internal
Benchmarking
Internal
Quality
Indicators
Quality
Indicators
Benchmarking
External
Benchmarking
External

13. Paradigm of Quality
Good-Bad
+
-
t
good
bad
Q
+
-
t
Q
Good-Better

14. A. Valentin 10/2004
Another reason for auditing your ICUAnother reason for auditing your ICU
If you don‘t compare your ICU with others
someone else will do it !
If you don‘t compare your ICU with others
someone else will do it !

15. Purpose of an audit
• to blame
• to improve
• to enhance
• to ensure
• to change
ASSESSMENT AND IMPROVEMENTASSESSMENT AND IMPROVEMENT
OF QUALITYOF QUALITY

16. To audit means
to compare Objectives and Reality
• Structure
what you need vs what is provided
• Process
what you should do vs. what you do
• Outcome
what you expect vs. what you find

17. Time
Indicator Single ICU
Internal comparisonInternal comparison

18. External comparisonExternal comparison
ICUs
Indicator

19. • Audit
– What is it?
A search for opportunities to improveA search for opportunities to improve
– Who should do it?
Yourself with the help of experts & networksYourself with the help of experts & networks
• Can we identify high quality ICUs?
Probably, but not at a quick glanceProbably, but not at a quick glance
• Combining measures
May be helpful, but models need to be developedMay be helpful, but models need to be developed
•
• Audit
– What is it?
A search for opportunities to improveA search for opportunities to improve
– Who should do it?
Yourself with the help of experts & networksYourself with the help of experts & networks
• Can we identify high quality ICUs?
Probably, but not at a quick glanceProbably, but not at a quick glance
• Combining measures
May be helpful, but models need to be developedMay be helpful, but models need to be developed
•

20. Quality Areas and Management Tools

21. Quality Indicator (QI)

This is a measure of a structure, process or
outcome that could be used by local teams to
improve care.

A QI helps to understand a system, compare it
and improve it but they all will have limitations.

They can only serve as flags or pointers

22. List of indicators
• Presence of an intensivist in the ICU 24h/365d
• Critical incident reporting system in use
• Early enteral nutrition
• Mild therapeutic hypothermia after CPR
• Reintubation
• Ventilator associated pneumonia
• Unplanned readmission
• Mortality after severe brain trauma
• Standardised mortality ratio
StructureProcessOutcome
Ö STER RE ICH ISC HES ZEN TRU M FÜR
D OK UM EN TA TION U ND QU ALIT ÄTS-
SIC HERU NG IN DE R INTE NSIVMED IZIN
ASDI

23. Ffundamental Quality Indicators !!!!Ffundamental Quality Indicators !!!!
• Early ASS in ACSEarly ASS in ACS
• Early reperfusion in STEMIEarly reperfusion in STEMI
• Semirecumbent position in MVSemirecumbent position in MV
• Surgical intervention in TBISurgical intervention in TBI
with SDH of EDHwith SDH of EDH
• ICP in severeTBI withICP in severeTBI with
pathologic CTpathologic CT
• Early management of severeEarly management of severe
sepsis/septic shocksepsis/septic shock
• Early enteral nutritionEarly enteral nutrition
• GI-bleeding prophylaxis in MVGI-bleeding prophylaxis in MV
• Appropriate sedationAppropriate sedation
• Early ASS in ACSEarly ASS in ACS
• Early reperfusion in STEMIEarly reperfusion in STEMI
• Semirecumbent position in MVSemirecumbent position in MV
• Surgical intervention in TBISurgical intervention in TBI
with SDH of EDHwith SDH of EDH
• ICP in severeTBI withICP in severeTBI with
pathologic CTpathologic CT
• Early management of severeEarly management of severe
sepsis/septic shocksepsis/septic shock
• Early enteral nutritionEarly enteral nutrition
• GI-bleeding prophylaxis in MVGI-bleeding prophylaxis in MV
• Appropriate sedationAppropriate sedation
• Pain management in unsedatedPain management in unsedated
ptspts
• Inappropriate transfusion of RBCInappropriate transfusion of RBC
• Organ donorsOrgan donors
• Compliance with hand-washingCompliance with hand-washing
protocolsprotocols
• Information to familiesInformation to families
• Withholding/Withdrawing lifeWithholding/Withdrawing life
supportsupport
• Quality survey at ICU dischargeQuality survey at ICU discharge
• Presence of intensivist 24h/dayPresence of intensivist 24h/day
• Adverse event registerAdverse event register
• Pain management in unsedatedPain management in unsedated
ptspts
• Inappropriate transfusion of RBCInappropriate transfusion of RBC
• Organ donorsOrgan donors
• Compliance with hand-washingCompliance with hand-washing
protocolsprotocols
• Information to familiesInformation to families
• Withholding/Withdrawing lifeWithholding/Withdrawing life
supportsupport
• Quality survey at ICU dischargeQuality survey at ICU discharge
• Presence of intensivist 24h/dayPresence of intensivist 24h/day
• Adverse event registerAdverse event register

24. Unintended Event :
An occurrence that harmed or could have harmed
a patient
SEE: multicenter, multinational, single day study in
ICU
Reporting by all ICU staff members :
Voluntarily – Anonymously - Confidential

25. Selected Events
• Medication wrong drug, dose, or route
• Airway unplanned extubation
artificial airway obstruction
cuff leakage
• Lines, Drains dislodgement
Catheters inappropriate opening/disconnection
• Equipment power supply, oxygen supply,
failure ventilator, infusion pump
• Alarms inappropriate turn off
SEE STUDYSEE STUDY

26. SEE Study – participating Countries
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
3
6
7
7
8
11
12
14
19
22
27
28
35
0 5 10 15 20 25 30 35 40
Australia
USA
Estonia
Indonesia
Macedonia
Norway
Poland
Romania
Singapore
Latvia
Slovakia
Albania
Finland
Brasil
Belgium
Netherlands
Slovenia
Hongkong
Greece
Denmark
India
France
Switzerland
Germany
Czech Republic
Spain
Portugal
UK
Austria
Italy
Number of ICUs
220 ICUs in 29 countries
2090 patients

27. Adverse events in ICU

Frequent and in relation with

Severity of the patients

Procedures

Impact on :

Morbidity and mortality

Finance :
− Iatrogenic pneumothorax : 17,312 US$
− DVP and post operative pulmonary emboli : 21,709 US$

Legal issues

Psychology and competency of the team

Preventability ?

28. You should conclude that
this is a very dangerous ICU

No documentation of events

No evaluation

No corrective action

29. If you hear this
“I am proud to say that
I have no adverse event
in my ICU”
May be even no patient in that ICU……

30. Critical Care Bundles

Ventilator Bundle

Central Line Bundle

Severe Sepsis Bundles

31. Bundles

A "bundle" is a group of evidence-based
care components for a given disease that,
when executed together, may result in
better outcomes than if implemented
individually.

32. Bundle Design Guidelines
• The bundle has three to five interventions (elements),
with strong clinician agreement.
• Each bundle element is relatively independent.
• The bundle is used with a defined patient population in
one location.
• The multidisciplinary care team develops the bundle.
• Bundle elements should be descriptive.
• Compliance with bundles is measured using all-or-none
measurement, with a goal of 95 percent or greater.

33. VAP BUNDLE

34. Ventilator-Associated Pneumonia (VAP)Bundle

DVT prophylaxis

GI prophylaxis

Head of bed (HOB) elevated to 30-45°

Daily Sedation Vacation

Daily Spontaneous Breathing Trial

35. DVT prophylaxis

Include deep venous prophylaxis as part of your ICU order
admission set and ventilator order set.

Include deep venous prophylaxis as an item for discussion on daily
multidisciplinary rounds.

Empower pharmacy to review orders for patients in the ICU.

Post compliance with the intervention in a prominent place in your
ICU to encourage change and motivate staff.

36. Head of Bed elevation

Implement a mechanism to ensure
head-of-the-bed elevation, such as
including this intervention on nursing
flow sheets and as a topic at
multidisciplinary rounds.

Create an environment where
respiratory therapists work
collaboratively with nursing to maintain
head-of-the-bed elevation.

Involve families in the process by
educating them about the importance
of head-of-the-bed elevation.

37. Daily sedation vacation/
Spontaneous Breathing Trials

Assess that compliance is occurring each
day on multidisciplinary rounds.

Consider implementation of a sedation
scale such as the Riker scale to avoid
oversedation.

Post compliance with the intervention in a
prominent place in your ICU to encourage
change and motivate staff.

38. Central line bundle
Hand Hygiene

Maximal Barrier Precautions Upon Insertion

Chlorhexidine Skin Antisepsis

Optimal Catheter Site Selection, with
Avoidance of the Femoral Vein

Daily Review of Line Necessity with Prompt
Removal of Unnecessary Lines

39. Hand Hygiene

Include hand hygiene as part of your
checklist for central line placement.

Keep soap/alcohol-based hand washing
dispensers prominently placed and make
universal precautions equipment, such as
gloves, only available near hand sanitation
equipment.

40. Hand Hygiene

Post signs at the entry and exits to the patient room as
reminders.

Initiate a campaign using posters including photos of
celebrated hospital doctors/employees recommending
hand washing.

Create an environment where reminding each other
about hand washing is encouraged.

Signs often become "invisible" after just a few days. Try
to alter them weekly or monthly (color, shape size).

41. Maximal Barrier Precautions
Upon Insertion

Include maximal barrier precautions as
part of your checklist for central line
placement.

Keep equipment ready stocked in a cart
for central line placement to institute
maximal barrier precautions.

42. Chlorhexidine skin antisepsis:

Include Chlorhexidine antisepsis as part of your
checklist for central line placement.

Include Chlorhexidine antisepsis kits in carts storing
central line equipment. Many central line kits include
povidone-iodine kits and these must be avoided.

Ensure that solution dries completely before an
attempted line insertion.

43. Daily review of Lines/
Prompt removal

Include daily review of line necessity as part of your
multidisciplinary rounds.

Include assessment for removal of central lines as
part of your daily goal sheets.

Record time and date of line placement for record
keeping purposes and evaluation by staff to aid in
decision making.

44. SEVERE SEPSIS BUNDLES

45. severe sepsis bundles

The sepsis resuscitation bundle

The sepsis management bundle

46. Sepsis resuscitation bundle

describes seven tasks that should begin immediately,
but must be accomplished within the first 6 hours of
presentation for patients with severe sepsis or septic
shock.

Some items may not be completed if the clinical
conditions described in the bundle do not prevail in a
particular case, but clinicians should assess for them.

The goal is to perform all indicated tasks 100 percent of
the time within the first 6 hours of identification of severe
sepsis.

47. SURVIVING SEPSIS CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN 3 HOURS
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate
4mmol/L
TO BE COMPLETED WITHIN 6 HOURS
5) Apply vasopressors (for hypotension that does not respond to
initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume
resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
-Measure central venous pressure (CVP)
-Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated

48. Quality is not about individual performanceQuality is not about individual performance
Structures and processes in the ICU
that ensure
that every patient, every time,
receives
every applicable evidence-based best practice
Structures and processes in the ICU
that ensure
that every patient, every time,
receives
every applicable evidence-based best practice

49. What a team needs to knowWhat a team needs to know
•What are our goals ?
•Do we reach our goals ?
•What are our strengths ?
•What are our weak points ?
•Are we getting better ?
•What are our goals ?
•Do we reach our goals ?
•What are our strengths ?
•What are our weak points ?
•Are we getting better ?