Post on 12-Feb-2016
description
A. ValentinVienna, Austria
andreas.valentin@meduniwien.ac.at
Audit of quality indicatorsin intensive care medicine
Ö STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
AS
DI
Topics
• Audit– What is it?– Who should do it?
• Can we identify high quality ICUs?
• Combining measures
• The role of intensive care in the whole chain of care
Intensive Care is about medicine, care, compassion and organisation
Are we doing a good job ?How could we do even better ?
A. Valentin 10/2004
Tidalvolume ≤ 6ml PBW in ARDS/ALI:Lungprotective Ventilation in Reality
Brunckhorst F, Crit Care Med 2008
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%
Audit
• from Latin auditus = act of hearing
• Synonyms: examination, analysis, checkup, inspection, perlustration, review, scan, scrutiny, survey, view
• Related: investigation, probe, check, control, corrective
A thorough, systematic examination of the processes and results of a health care service.
External Audit
Internal Audit
BenchmarkingInternal
Quality Indicators
BenchmarkingExternal
Patient safety in trauma: maximal impact management errors at a level I trauma center
Ivatury RR, J Trauma 2008
• Deaths 764• Potentially preventable: 7.8%• Preventable: 2.1%• Human factors: 97%
• Poor bleeding control and volume resuscitation 30• Inability to secure a proper airway 13• Missed injuries 9• Inadequate deep vein thrombosis prophylaxis 6• Delayed diagnosis of bowel gangrene 3• Miscellaneous 15
Summary of management errors among the 76 deaths
Patient safety in trauma: maximal impact management errors at a level I trauma center
Ivatury RR, J Trauma 2008
Purpose of an audit
• to blame
• to improve• to enhance• to ensure• to change
ASSESSMENT AND IMPROVEMENTASSESSMENT AND IMPROVEMENTOF QUALITYOF QUALITY
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 by Quality is defined by goalsgoals
Paradigm of Quality
Good-Bad
+
-t
good
bad
Q+
-t
QGood-Better
4 Reasons for auditing your ICU
1. Audit is an essential tool for quality improvement• you only manage what you measure
2. Audit is in the interest of your patients• to ensure safe and evidence-based care
3. Audit is in the interest of your ICU team• to enhance team culture, professionalism, job satisfaction
4. Audit is in the interest of health systems
1. to ensure efficient and fair use of resources
Another reason for auditing your ICU
If you don‘t compare your ICU with others
someone else will do it !
A. Valentin 10/2004
Intensive care: Why the differences?
An Audit Commission report has highlighted that some hospital intensive care services have higher death rates than others. BBC News Online examines the reasons behind this.
BBC News Online: HealthWednesday, October 27, 1999 Published at 13:40 GMT 14:40 UK
To audit meansto compare Objectives and Reality
• Structurewhat you need vs what is provided
• Processwhat you should do vs. what you do
• Outcomewhat you expect vs. what you find
Perception ?
Process Structure
Outcome
Quality Interactions
Environment
Quality interactions innosocomial infection
• Structure– Room design– Fixed installations– Medical equipment– Air conditioning– Staffing– Training level– Funding
• Process– Handwashing– Isolation/infection
precaution– Infection reporting– Room cleaning,
desinfection– Antibiotic use– Communication
Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit
Alcohol solution easily available
4 months later: 51.3 %
42.4 (621) 60.9 (905)
Maury E, AJRCCM 2000
Time
Indicator Single ICU
Internal comparison
External comparison
ICUs
Indicator
What do we need?
• A network of ICUs who collect data – Temporally limited – Temporally unlimited (benchmarking project)
• Standardization of data collection– Common data set
• A set of tools to compare institutions– Defined indicator variables
Clinical Audit
To determine• whether you have done what you set out to
do• whether you have achieved your objectives
Requirement• a standard or guidelines for intended care to
audit against.
Quality Areas and Management Tools
120 Quality Indicators
SEMICYUC20 fundamental Quality Indicators
• Early ASS in ACSEarly ASS in ACS• Early reperfusion in STEMI Early reperfusion in STEMI • Semirecumbent position in MVSemirecumbent position in MV• Surgical intervention in TBI Surgical intervention in TBI
with SDH of EDHwith SDH of EDH• ICP in severeTBI with ICP in severeTBI with
pathologic CTpathologic CT• Early management of severe Early 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 unsedated Pain management in unsedated ptspts
• Inappropriate transfusion of RBCInappropriate transfusion of RBC• Organ donorsOrgan donors• Compliance with hand-washing Compliance with hand-washing
protocolsprotocols• Information to familiesInformation to families• Withholding/Withdrawing life Withholding/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
Austrian Center for Documentation and Quality Assurance in Intensive Care Medicine
• Founded in 1994• Support of several multinational studies in
intensive care:– SAPS 3– SEE 1 & 2
• 130 ICUs in Austria use the documentation standard with the software ICdoc
• 70 ICUs take part in the ASDI benchmarking• Annual reports to participating ICUs
ASDI benchmarking
ICUs
Data cleaningAnalysisReport
Quality Indicators
Criteria for selection
•Already integrated in the ICU documentation•Cover specific problems of intensive care•Easy to review
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
StructureProcess
Outcom
eÖ STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Ö STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Ö STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Enteral NutritionStart within < 48h Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Reintubation:Proportion of all intubated pts Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Unplanned ReadmissionÖ STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Observed/ExpectedMortality Ratio Ö STER RE ICH ISC HES ZEN TRU M FÜR
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O/E ratio± transferred patients Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Can we identify high-quality ICUs ?
Enteral NutritionStart within < 48h Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Reintubation:Proportion of all intubated pts Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Unplanned ReadmissionÖ STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Observed/ExpectedMortality Ratio Ö STER RE ICH ISC HES ZEN TRU M FÜR
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O/E ratio± transferred patients Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Quality report for ICUsÖ STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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SMR by reasons for admission
WomenMen
-0,2 -0,1 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 1,1 1,2 1,3 1,4 1,5 1,6
Metabolic disease
Surgery, non specif ied
Trauma surgery
Renal disease
Transplant surgery
Cardiovascular disease
Neurologic disease
Neurosurgery
Cardiovascular surgery
Respiratory disease
Abdominal surgery
Sepsis
Shock
Trauma w ithout surgery
Gastrointestinal disease
Ö STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
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Valentin A, Crit Care Med 2003
Different relationships between the performance of the ICU and the severity of illness of the admitted patients
Moreno R, Curr Opin Crit Care 2010
Performance of the ICU and the severityof illness of the admitted patients Ö STER RE ICH ISC HES ZEN TRU M FÜR
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70 ICUs Single ICU
A. Valentin 10/2004
Interpreting results
Quality Quality indicators indicators should prompt should prompt a look into a look into detailsdetails
A. Valentin 10/2004
Nutrition & Glucose managament
• Enteral nutrition too late• Not enough caloric intake
• Inappropriate blood glucose management• Blood glucose variability too high• Frequency of hypoglycaemic episodes • Overreaction in case of hypoglycaemia
A. Valentin 10/2004
Energy deficit per day in ventilated patients and respective ICU survival
ED <1200 kcal/d
ED >1200 kcal/d
Faisy C, Brit J Nutr 2009
A. Valentin 10/2004
Glucose variabilityindependent predictor of mortality
Krinsley JS, Crit Care Med 2008
Combining measures
Standardized Mortality Ratiovs.
Standardized Severity Adjusted Resource Use
mostefficent
leastefficent
Rothen H, Int Care Med 2007
Standardized Mortality Ratiovs.
Standardized Severity Adjusted Resource Use
mostefficent
leastefficent
Ö STER RE ICH ISC HES ZEN TRU M FÜRD OK UM EN TA TION U ND QU ALIT ÄTS-SIC HERU NG IN DE R INTE NSIVM ED IZIN
ASDI
Quality assessment in ICUs: a proposal for a scoring system in terms of structure and process
Najjar-Pellet J et al, Int Care Med 2007
Dimensions
• Human resources• Architecture• Safety and environment• Management of documentation• Patient care management• Risk management of infections• Evaluation and surveillance
95 variables
Quality assessment in ICUs: a proposal for a scoring system in terms of structure and process
Najjar-Pellet J et al, Int Care Med 2007
40 ICUs
Naj
jar-
Pelle
t J e
t al,
Int C
are
Med
200
7
Average
Maximum
Level of achievement
Najjar-Pellet J et al, Int Care Med 2007
Quality Indicatorsand
the continuum of care
Angus DC, adapted from Cook D; Intensive Care Med (2003)
The course of critical illness
Con
tinuu
m o
f car
e
n=23.097Patients at risk ?
Advanced Life support
Died 2.7%
MET38/1000 Admissions
Left on ward 75% Died 1.6% ICU 15%
Young L,Resuscitation 2008
23% within 24hafter ICU discharge
SAPS 3 CohortICU discharge destination
SAPS 3 hospital outcome cohortn=16784
ICU outcome: aliven=13809
Cohortn=12911
IMC/HDUn=2620
20.3%
WARDn=10291
79.7%
ER, RR, ICUn=898
A. Valentin 10/2004
SAPS 3 Cohort
Metnitz & Moreno, Int Care Med 2005
Proportional Post-ICU MortalitySample of 75 Austrian ICUs Ö STER RE ICH ISC HES ZEN TRU M FÜR
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ICU vs. Post ICU Mortality:Distribution (%) by risk of death (SAPS II)
postICU
postICU
postICU
postICU
post ICU
ICUICU
ICUICU
ICU
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0,0-0,2 0,2-0,4 0,4-0,6 0,6-0,8 0,8-1,0SAPS II risk of death
% o
f all
deat
hs
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A. Valentin 10/2004
Multifactorial impact on post-ICU mortality
• Severity of disease• Age and comorbidities• Diagnosis• Treatment before admission to the ICU
eg:– First response emergency treatment– Surgery
• Performance of the ICU• ICU capacity + need for triage• Performance of post ICU institutions• Infrastructur
ICU - Discharges at Night Time(% of all ICU Discharges) Ö STER RE ICH ISC HES ZEN TRU M FÜR
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Intermediate care reduced the mortality of pts discharged „prematurely“ from ICU
Beck DH, Intensive Care Med (2002)
Severity adjustedRR 95%CI
• Discharge at night: - All 1.70 1.28-2.25 - Ward 1.87 1.36-2.56 - HDU 1.35 0.77-2.36
• Discharge with TISS >30Ward vs HDU 1.31 1.02-1.83
A. Valentin 10/2004
Appropriate level of care
Last ICUday
General ward
Wrong time or wrong destination ?
Quality is not about individual performance
Structures and processes in the ICUthat ensure
that every patient, every time,receives
every applicable evidence-based best practice
What 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 ?
Topics
• 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 measuresMay be helpful, but models need to be developedMay be helpful, but models need to be developed
• The role of intensive care in the whole chain of careNeeds to be an essential part of an ICU quality Needs to be an essential part of an ICU quality
assessment assessment
Congratulations to
the Swedish Intensive Care registry !!!