Challenges and Solutions

James S. Krinsley, MD, FCCP
Ruth M. Kleinpell, PhD, RN, FCCM

In part, some of the increased attention to quality improvement practices has resulted from regulatory organizations. A number of recent guidelines specific to the care of acute and critically ill patients have given ICU clinicians specific measures to target. These include the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)’s work on ICU Core Measures,1 which focus on central-line-associated primary bloodstream infections, ventilator-associated pneumonia prevention through positioning of the patient's head of the bed 30 degrees or more, stress ulcer disease prophylaxis, deep vein thrombosis prophylaxis, ICU length of stay and risk adjusted mortality rates; and the National Quality Forum's endorsement of measures including urinary catheter-associated urinary tract infection, ventilator-associated pneumonia and central line catheter-associated blood stream infection rates for ICU patients.2 Other institutional efforts aimed at improving care in the ICU include the Institute for Healthcare Improvement’s breakthrough series for adult critical care, including reducing complications from ventilators and central lines3 and the Agency for Healthcare Research and Quality inpatient quality and patient safety indicators.4 The benefit of specific measures such as intensive glucose control5,6 targeted treatment for patients with sepsis,7-9 pneumonia prevention and management,10 intensivist-led care,11,12 adequate nurse staffing13 and facilitating family communication14,15 have also been substantiated and are advocated ICU initiatives.

Although an increasing number of strategies focused on promoting quality care exist, adopting and integrating various quality initiatives in the ICU continues to pose challenges. Several strategies are available to promote successful adoption of advocated quality initiatives in the ICU. These strategies include: 1) create a multiprofessional team to target adoption of an initiative, 2) outline a timeline for adoption, 3) designate leaders to champion the efforts, 4) plan and implement the initiative, 5) assess the impact, 6) monitor adherence, 7) report the results, 8) reinforce the goals of the initiative.
This process may be illustrated by examining the barriers to implementation of the intensive glucose management protocol promulgated in the Stamford Hospital Critical Care Unit, an initiative that earned Stamford Hospital the 2004 Codman Award, given by the Joint Commission on Accreditation of Healthcare Organizations.5 The publication of Dr. van den Berghe’s seminal work6 in a population of mechanically ventilated surgical ICU patients (63% following cardiac surgery) prompted review of the unit’s comprehensive database. This revealed a strong association between increasing glucose levels during ICU admission and the risk of hospital mortality.16 A group of nurses met with nursing and medical leadership in the unit to discuss the possibility of instituting a similar protocol. The initial glycemic treatment threshold—110 mg/dl—was resisted because of fears of hypoglycemia, the increased amount of work required that this strict goal would require, and the paradigm shift away from the longstanding tolerance of moderate levels of hyperglycemia in critically ill patients that this treatment represented. The compromise treatment “trigger” of 140 mg/dl facilitated “buy-in” by the staff. Frequent feedback of glucose data to the nursing staff following implementation of the protocol allowed constant reinforcement of the treatment goals and ongoing “fine-tuning” of the protocol. The keys to the success of the protocol included: the data- and protocol-driven culture that already existed in the unit, a shared vision for the unit’s direction by the medical and nursing leadership, the presence of a robust data management and outcomes analysis system, the choice of an achievable goal, and the flexibility to monitor and change the protocol as needed.

A variety of quality measures can be targeted to improve care in the ICU, including outcome, process, access or complication measures.17 While integrating quality improvement measures in the ICU can prove challenging, their realization can have a significant impact on improving patient care, targeting costs of care and promoting quality outcomes.

Examples of Quality Indicators for the ICU

• Catheter-related blood stream infections
• Catheter-related urinary tract infections
• Ventilator-associated pneumonia rates
• Stress ulcer prevention measures
• Deep vein thrombosis prevention measures
• Blood glucose control
• Appropriate sedation
  Pain assessment and management
• Appropriate blood transfusions
• Adherence to protocols/precautions—hand hygiene, contact precautions, etc.
• Length of stay—ICU and overall hospital
• ICU readmission rates
• ICU mortality rates
• Costs of care—ICU and overall hospital
• Review of necessity of frequently performed procedures—arterial blood gases, blood
  sampling, etc.
• Medication reconciliation outcomes
• Patient safety measures—e.g., appropriate use of restraints, medication safety measures
• Nutritional intake
• Adverse events (e.g., accidental extubation)
• Patient and family satisfaction ratings
• Rates of adherence to best practices
• Symptom management and comfort care measures for end-of-life care
  
  
  James S. Krinsley, MD is director of critical care at Stamford Hospital in Stamford, CT, and associate clinical professor of medicine at Columbia University College of Physicians and Surgeons. Ruth M. Kleinpell, PhD, RN-CS is an associate professor at Rush University College of Nursing and a nurse practitioner at Our Lady of the Resurrection Medical Center in Chicago, IL. Dr. Krinsley is serving as chair and Dr. Kleinpell as vice chair for the Society’s “Summit on ICU Cost and Quality: Tools for the Real Life ICU” to be held May 18-20, 2005, in Washington DC. This year’s Summit will focus on implementing performance improvement measures in the ICU. Strategies for success and ready-to-implement tools will be shared that can be used by participants to target ICU-focused initiatives. For further information, visit the SCCM Web site at www.sccm.org/education.