PATIENTS SAFETY in INTENSIVE CARE UNIT Assoc. Prof. Sait Karakurt Marmara University Medical School Pulmonary and Critical Care Medicine.

PATIENTS SAFETY PATIENTS SAFETY in INTENSIVE CARE UNITin INTENSIVE CARE UNIT

Assoc. Prof. Sait KarakurtAssoc. Prof. Sait KarakurtMarmara University Medical SchoolMarmara University Medical SchoolPulmonary and Critical Care MedicinePulmonary and Critical Care Medicine

Patients safety practice - Patients safety practice - definitiondefinition

A type of process or structure whose A type of process or structure whose application reduces probability of application reduces probability of adverse events resulting from exposure adverse events resulting from exposure to health care system across a range of to health care system across a range of diseases and procedures.diseases and procedures.

PATIENTS SAFETY-PATIENTS SAFETY-magnitude of problemmagnitude of problem

Medical-errors-releated deaths Medical-errors-releated deaths – 44.000 to 98.000/year 44.000 to 98.000/year

100 patients/day die from their care in USA100 patients/day die from their care in USA

Adverse drug eventsAdverse drug events– rates 2 to 7 per 100 admissionsrates 2 to 7 per 100 admissions

2 errors per patients per day in ICU2 errors per patients per day in ICU

Corrigan J et al. eds, For the Committee on Quality of Health Care of America Institute of Medicine To Err is Human: building a safer health system 2000

Prevalance of medical errors Prevalance of medical errors

1152 events during 6 years (JCAHO)1152 events during 6 years (JCAHO)– 62% in general hospitals62% in general hospitals– 2/3 self reported by the institutions2/3 self reported by the institutions– 1/3 patients complaints or media stories1/3 patients complaints or media stories

– 76% of events reported resulted in patients 76% of events reported resulted in patients deathdeath

ICUICU-treatment-treatment-monitorisation-monitorisation-continuous and same standart-continuous and same standart-24 hours-24 hours

PATIENT SAFETY-ICU definition

Low-intensity (no intensivist or elective Low-intensity (no intensivist or elective intensivist consultation) or high-intensity intensivist consultation) or high-intensity (mandatory intensivist consultation or closed (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups.ICU [all care directed by intensivist]) groups.

High-intensity staffing was associated with High-intensity staffing was associated with

lower hospital mortality of 0.71lower hospital mortality of 0.71

High-intensity staffing was associated with a High-intensity staffing was associated with a lower ICU mortality of 0.61lower ICU mortality of 0.61

PATIENTS SAFETY-PATIENTS SAFETY-closed vs open ICUclosed vs open ICU

Peter J. Pronovost et al. Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients A Systematic Review JAMA. 2002;288:2151-2162.

Intensivist

Doctors Nurses Respiratorytherapists

Clinicall pharmacy

Other

ICU teamICU team

The rate of preventable ordering ADEs decreased by The rate of preventable ordering ADEs decreased by 66%66% from 10.4 per 1000 patient-days before the from 10.4 per 1000 patient-days before the intervention to 3.5intervention to 3.5 after the intervention. after the intervention.

The presence of a pharmacist on rounds as a full member The presence of a pharmacist on rounds as a full member of the patient care team in a medical ICU was associated of the patient care team in a medical ICU was associated with a substantially lower rate of ADEs caused by with a substantially lower rate of ADEs caused by prescribing errors. prescribing errors.

PATIENT SAFETY-Pharmacist in ICU team

Lucian L. Leape et al Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit. JAMA. 1999;282:267-270.

The mean of the weighted incidence rate The mean of the weighted incidence rate detected by pharmacists was 0.33 ADE detected by pharmacists was 0.33 ADE per admission the mean was 0.16 ADE per admission the mean was 0.16 ADE per admission with detection by per admission with detection by nonpharmacists (nonpharmacists (pp = 0.003) = 0.003)

Shobha Phansalkar at al.Pharmacists versus nonpharmacists in adverse drug event detection: A meta-analysis and systematic review American Journal of Health-System Pharmacy 2007, Vol. 64, Issue 8, 842-849

PATIENT SAFETY-Pharmacist in ICU team

ICU-level of care and staff numberICU-level of care and staff number

Level of careLevel of care nurse/patientnurse/patient nurse /bed doctor/bednurse /bed doctor/bed

IIIIIIProvide care all Provide care all

critically ill patientscritically ill patients

1/11/1 6 56 5

IIIISome critically ill Some critically ill patients should be patients should be

transported suitable transported suitable centercenter

1/1.61/1.6 4 44 4

IIInitial stabilisation of Initial stabilisation of critically ill patientscritically ill patients

1/31/3 2 32 3

’’Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Intensive Care Med 1997;23:226-32.Intensive Care Med 1997;23:226-32.

2,492 patients 2,492 patients

Four time periods based on intensivist-to-ICU Four time periods based on intensivist-to-ICU bed ratios of 1:7.5, 1:9.5, 1:12, and 1:15.bed ratios of 1:7.5, 1:9.5, 1:12, and 1:15.

No differences in ICU or hospital mortality. No differences in ICU or hospital mortality. However, a ratio of 1:15 was associated with However, a ratio of 1:15 was associated with increased ICU LOS. (9.7 days vs 12.3 days increased ICU LOS. (9.7 days vs 12.3 days p<0.001)p<0.001)

Saqib I. Dara, Bekele Afessa, Intensivist-to-Bed Ratio Association With Outcomes in the Medical ICU Chest 2005;128:567-572.

PATIENTS SAFETY-PATIENTS SAFETY-Intensivist workloadIntensivist workload

PATIENTS SAFETY-PATIENTS SAFETY-Staff workloadStaff workload 1050 patients, 337 deaths, 49 more than predicted by 1050 patients, 337 deaths, 49 more than predicted by

the APACHE IIthe APACHE II

1·3 nurses per patient (requirement 1·6 per patient)1·3 nurses per patient (requirement 1·6 per patient)

Adjusted mortality was more than 2 times higher in Adjusted mortality was more than 2 times higher in patients exposed to high than in those exposed to low patients exposed to high than in those exposed to low ICU workload. ICU workload.

WO Tarnow-Mordi et al Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unitThe Lancet 2000; 355:1864-1868

Strategy for change: Strategy for change: 1-physician led multidisciplinary rounds 1-physician led multidisciplinary rounds 2- daily "flow" meeting to assess bed 2- daily "flow" meeting to assess bed availability availability 3- "bundles" (sets of evidence based 3- "bundles" (sets of evidence based best practices)best practices)4- culture changes with a focus on the 4- culture changes with a focus on the team decision making process team decision making process

Jain M,   Links Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006 Aug;15(4):235-9.

PATIENTS SAFETY-PATIENTS SAFETY-team workteam work

Ventilator associated pneumonia (from 7.5 to 3.2 per 1000 Ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) ventilator days, p = 0.04)

Bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = Bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), 0.03),

A downward trend in the rate of urinary tract infections (from A downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17).3.8 to 2.4 per 1000 catheter days, p = 0.17).

There was a strong downward trend in the rates of adverse There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per events in the ICU as well as the average length of stay per episode episode

Jain M,   Links Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006 Aug;15(4):235-9.

PATIENTS SAFETY-PATIENTS SAFETY-team workteam work

29.080 patients, Mayo Clinic, USA29.080 patients, Mayo Clinic, USA

weekdayweekday weekend weekend

mortalitymortality mortality mortality p p

Medical ICU Medical ICU 16.3% 16.3% 15.2% 15.2% NS NS

Multispeciality ICUMultispeciality ICU 10.1% 10.1% 17.2% 17.2% NS NS

Surgical ICU Surgical ICU 3.5% 3.5% 6.4% 6.4% p<0.01p<0.01

PATIENTS SAFETY-PATIENTS SAFETY-continuous standart carecontinuous standart care

S Allen Ensminger et al. The hospital mortality of patients admitted to the ICU on weekends. Chest 2004;126:1292-1298.

Medication errorsMedication errors

OrderingOrdering Transcribing Transcribing Dispensing Dispensing AdministratingAdministrating

– missing dosemissing dose– dosedose– routeroute– frequencyfrequency

Monitoring Monitoring

Adverse drug eventsAdverse drug events

Preventable adverse Preventable adverse drug eventsdrug events

OrderingOrdering 56%56% AdministrationAdministration 34%34% TranscribingTranscribing 6%6% DispendingDispending 4%4%

Drug ClassDrug Class

1.1. AnalgesicsAnalgesics

2.2. SedativesSedatives

3.3. AntibioticsAntibiotics

Adverse drug reactions in ICUAdverse drug reactions in ICU

29.7 per 100 admission29.7 per 100 admission

WHO Colloborating Center for International Drug Monitoring 2000

Medication errors-Medication errors-preventionprevention

Computerized physician order enteryComputerized physician order entery

Clinical decision support systemClinical decision support system

Computerized physician order enteryComputerized physician order entery

Standardized, legible, complete orders Standardized, legible, complete orders by only accepting typed orders in by only accepting typed orders in astandart and complete formatastandart and complete format

Clinical decision support systemClinical decision support system

Basic clinical decision support may include Basic clinical decision support may include suggestion or default values for drug doses, suggestion or default values for drug doses, routes and frequencies.routes and frequencies.

More sophisticated system can perform drug More sophisticated system can perform drug allergy checks, drud-laboratory value checks, allergy checks, drud-laboratory value checks, drug-drug interactions checks and in addition drug-drug interactions checks and in addition to providind reminders about corollary to providind reminders about corollary orders or drug guidelines.orders or drug guidelines.

Incorporate patient-spesific or pathogen-Incorporate patient-spesific or pathogen-spesific informationspesific information

Nosocomial infections occur in about 7-Nosocomial infections occur in about 7-10% hospitalized patients and account 10% hospitalized patients and account for 80.000 deaths per year in the US.for 80.000 deaths per year in the US.

The evidence in favor of 79 patients The evidence in favor of 79 patients safety practises of which 22 (28%) safety practises of which 22 (28%) involved infection controlinvolved infection control

ICU-patients safetyICU-patients safety

Making health care safer: a criticall analysis of patients safety practices Evid Rep Tecnol Assess SUmm 2001;43:1-668

PATIENTS SAFETY-PATIENTS SAFETY-prevention of nosocomial infectionsprevention of nosocomial infections

John P. Burke, M.D. NextInfection Control — A Problem for Patient Safety NEJM 2003 348:651-656

John P. Burke, M.D. NextInfection Control — A Problem for Patient Safety NEJM 2003 348:651-656

PATIENTS SAFETY-PATIENTS SAFETY-prevention of nosocomial infectionsprevention of nosocomial infections

PATIENTS SAFETY-PATIENTS SAFETY-Evidence-based approachEvidence-based approach

Practices with the strongest supporting Practices with the strongest supporting evidence are generally clinical evidence are generally clinical interventions that decrease the risks interventions that decrease the risks associated with hospitalization, critical associated with hospitalization, critical care or surgery.care or surgery.

Practices with the strongest Practices with the strongest supporting evidencesupporting evidence Appropriate use of prophylaxis to prevent Appropriate use of prophylaxis to prevent

thromboembolism in patients at riskthromboembolism in patients at risk

Use of perioperative beta-blockers in appropriate Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and patients to prevent perioperative morbidity and mortalitymortality

Use of steril barriers while placing central Use of steril barriers while placing central intravenous catheters to prevent infectionsintravenous catheters to prevent infections

Appropriate use of antibiotic prophylaxis in surgical Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infectionspatients to prevent postoperative infections

Practices with the strongest Practices with the strongest supporting evidencesupporting evidence Asking that patients recall and restate what they have Asking that patients recall and restate what they have

been told during informed consent processbeen told during informed consent process

Continuous aspiration of subglottic secretions to Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumoniaprevent ventilator-associated pneumonia

Use of pressure relieving materials to prevent Use of pressure relieving materials to prevent pressure ulcers pressure ulcers

Use of real time ultrasound guidance during cental Use of real time ultrasound guidance during cental line insertion to prevent complicationsline insertion to prevent complications

Practices with the strongest Practices with the strongest supporting evidencesupporting evidence Patient self management warfarin to achieve Patient self management warfarin to achieve

appropriate outpatient anticoagulation and prevent appropriate outpatient anticoagulation and prevent complicationscomplications

Appropriate provision of nutrition, with a particular Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill emphasis on early enteral nutrition in critically ill and surgical patientsand surgical patients

Use of antibiotic-impregnated central venous Use of antibiotic-impregnated central venous catheters to prevent catheter-releated infections.catheters to prevent catheter-releated infections.

ICU-patients safetyICU-patients safety

Standartization of ICUStandartization of ICU

Evidence-based approach can help identify Evidence-based approach can help identify practices that are likely to improve patient practices that are likely to improve patient safety.safety.

To reduce medication-releated errors by To reduce medication-releated errors by using computerized physician order entery using computerized physician order entery with clinical decision support systemwith clinical decision support system

Prevention of nosocomial infections. Prevention of nosocomial infections.