Objective: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a “how-to” guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. Data Sources and Methods: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on “quality improvement” and “critical care or intensive care” and searched online for additional resources. Data Synthesis and Overview: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. Conclusions: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families. (Crit Care Med 2006; 34:211–218)

http://www.china-ccqc.com/upload/2015-03-12/33fa8a71-12f9-4608-a002-47356efc890f.pdf

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

Care bundles or protocols that combine several medical practices have been proposed as tools to promote rapid adoption of proven therapies, benchmark performance, and improve patient outcomes (1). Reports that several practices instituted together could reduce the prevalence of catheter-related infection or mortality in mechanically ventilated patients supported this approach (2, 3). Care bundles have also been proposed based on the holistic principle that the whole is greater than the sum of its parts (4). Based on this therapeutic approach, the Institute for Healthcare Improvement and the Centers for Medicare and Medicaid Services recently proposed instituting “all or none” performance measures (5, 6). Hospital performance, and possibly re-imbursement in the future, may be based on the frequency with which all elements of a care bundle were administered together (7, 8).

The Joint Commission and Institute for Healthcare Improvement have recommended that components of a bundle should individually have proven benefit and wide acceptance, and together have even greater benefit (1, 9, 10). Importantly, bundle proponents encourage determination that individual components add to aggregate beneficial effects on outcome (6). However, there is currently no consensus on methods and standards for the development and testing of valid care bundles.

Although promising, care bundles pose challenges. Several care bundles posted on the Internet have not undergone rigorous peer review (11, 12). Some bundles addressing the same problem—sepsis—differ in content and compliance rates (13). Many bundles lack strong evidence for the efficacy of one or more of their individual components (14). Importantly, adoption of all bundle elements as a single intervention limits the ability to test the interdependent and independent efficacy of individual components (15). Therefore, the introduction of care bundles may mandate changes in standard care without the ability to fully monitor the impact of component parts. Resolving these issues has become critical as care bundles have evolved from preventing complications (e.g., catheter-related infections) to treating life-threatening conditions (e.g., sepsis).

As bundle development and application lack clear standards but are increasing in frequency, we examined this approach for the treatment of sepsis. We performed a meta-analysis of clinical trials, testing the impact of sepsis bundles compared with nonprotocolized care. Component therapies of interest were adopted from two widely instituted sepsis bundles, i.e., a 6-hr acute bundle and a 24-hr management bundle (Table 1) that were based on guidelines originally developed by the Surviving Sepsis Campaign and available at the time of these clinical trials (12, 16). Our goals were to examine the effect of bundle institution on survival and the application of individual bundle components.



Table 1

Components in two sepsis bundles formulated by the Surviving Sepsis Campaign (12, 16)

/pdf/bundled-care-for-septic-shock-an-analysis-of-clinical-trials-36mrdcls5o.pdf

Bundled care for septic shock: An analysis of clinical trials

Ensuring patient safety through effective leadership behaviour: A literature review

objective. To evaluate the impact of a multifaceted intervention on compliance with evidence-based therapies and ventilator-associated pneumonia (VAP) rates. design. Collaborative cohort before-after study. setting. Intensive care units (ICUs) predominantly in Michigan. interventions. We implemented a multifaceted intervention to improve compliance with 5 evidence-based recommendations for mechanically ventilated patients and to prevent VAP. A standardized CDC definition of VAP was used and maintained at each site, and data on the number of VAPs and ventilator-days were obtained from the hospital’s infection preventionists. Baseline data were reported and postimplementation data were reported for 30 months. VAP rates (in cases per 1,000 ventilator-days) were calculated as the proportion of ventilator-days per quarter in which patients received all 5 therapies in the ventilator care bundle. Two interventions to improve safety culture and communication were implemented first. results. One hundred twelve ICUs reporting 3,228 ICU-months and 550,800 ventilator-days were included. The overall median VAP rate decreased from 5.5 cases (mean, 6.9 cases) per 1,000 ventilator-days at baseline to 0 cases (mean, 3.4 cases) at 16‐18 months after implementation ( ) and 0 cases (mean, 2.4 cases) at 28‐30 months after implementation ( ). Compared to baseline, VAP P ! .001 P ! .001 rates decreased during all observation periods, with incidence rate ratios of 0.51 (95% confidence interval, 0.41‐0.64) at 16‐18 months after implementation and 0.29 (95% confidence interval, 0.24‐0.34) at 28‐30 months after implementation. Compliance with evidencebased therapies increased from 32% at baseline to 75% at 16‐18 months after implementation ( ) and 84% at 28‐30 months after P ! .001 implementation ( ). P ! .001 conclusions. A multifaceted intervention was associated with an increased use of evidence-based therapies and a substantial (up to 71%) and sustained (up to 2.5 years) decrease in VAP rates.

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/S0195941700040224

Collaborative Cohort Study of an Intervention to Reduce Ventilator-Associated Pneumonia in the Intensive Care Unit

Objective: To develop a practical set of measures for routine monitoring, performance feedback, and improvement in the quality of palliative care in the intensive care unit (ICU).

Design: Use of an interdisciplinary iterative process to create a prototype “bundle” of indicators within previously established domains of ICU palliative care quality; operationalization of indicators as specified measures; and pilot implementation to evaluate feasibility and baseline ICU performance.

Setting: The national Transformation of the Intensive Care Unit program developed in the United States by VHA Inc.

Patients: Critically ill patients in ICUs for 1, >3, and >5 days.

Measurements and main results: Palliative care processes including identification of patient preferences and decision making surrogates, communication between clinicians and patients/families, social and spiritual support, and pain assessment and management, as documented in medical records. Application is triggered by specified lengths of ICU stay. Pilot testing in 19 ICUs (review of >100 patients’ records) documented feasibility, while revealing opportunities for quality improvement in clinician-patient/family communication and other key components of ICU palliative care.

Conclusions: The new bundle of measures is a prototype for routine measurement of the quality of palliative care in the ICU. Further investigation is needed to confirm associations between measured processes and outcomes of importance to patients and families, as well as other aspects of validity.

/pdf/improving-comfort-and-communication-in-the-icu-a-practical-38bbl951e4.pdf

Tom Nolan

Papers

Developing and pilot testing quality indicators in the intensive care unit