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Improving quality of intensive careOptimizing audit & feedback with actionable indicators and an action implementation toolboxBlom, M.J.

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Citation for published version (APA):Blom, M. J. (2019). Improving quality of intensive care: Optimizing audit & feedback with actionable indicatorsand an action implementation toolbox.

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Appendices

174 | Appendix A

Appendix A: Literature and guidelines selected for developing the actionable indicators of antibiotic use

Author Publication year

Title

LiteratureAlvarez-Lerma F. et al [1]

1996 Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit

D'Amico R. et al [2]

1998 Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomized controlled trials

Price J. et al [3]

1999 Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit

Kollef M. H. et al [4]

1999 Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients

Nardi G. et al [5]

2001 Reduction in gram-positive pneumonia and antibiotic consumption following the use of a SDD protocol including nasal and oral mupirocin

Trouillet J.L. et al [6]

2002 Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versuspiperacillin-susceptible organisms

Garbino J. et al [7]

2002 Prevention of severe candida infections in non-neutropenic, high-risk, critically ill patients: a randomized, double-blind, placebo-controlledtrial in patients treated by selective digestive decontamination

Eachempati S.R. et al [8]

2009 Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients?

Chastre J. et al [9]

2003 Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults

Houston S. et al [10]

2003 Reducing the incidence of nosocomial pneumonia in cardiovascular surgery patients

Jacobs S. et al [11]

2003 Fluconazole improves survival in septic shock: a randomized double-blind prospective study

Hughes M.G. et al [12]

2004 Effect of an intensive care unit rotating empiric antibiotic schedule on the development of hospital-acquired infections on the non–intensive care unit ward

Hartmann B. et al [13]

2004 Review of antibiotic drug use in a surgical ICU: management with a patient data management system for additional outcome analysis in patients staying more than 24 Hours

Shaw M.J. [14] 2005 Ventilator-associated pneumonia

Literature and guidelines used for developing the antibiotic indicators | 175

A

Bianco A. et al [15]

2005 Appropriateness of glycopeptide use in a hospital in Italy

Siempos I.I. et al [16]

2007 Carbapenems for the treatment of immunocompetent adult patients with nosocomial pneumonia

Bennett K.M. et al [17]

2007 Implementation of antibiotic rotation protocol improves antibiotic susceptibility profile in a surgical intensive care unit

Berenholtz S.M. et al [18]

2007 Developing quality measures for sepsis care in the ICU

Aarts M.W. et al [19]

2007 Antibiotic management of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome?

Roberts J.A. et al [20]

2008 Better outcomes through continuous infusion of time-dependentantibiotics to critically ill patients?

Lam S.W. et al [21]

2009 Evolving role of early antifungals in the adult intensive care unit

Garcin F. et al [22]

2010 Non-adherence to guidelines: an avoidable cause of failure of empirical antimicrobial therapy in the presence of difficult-to-treatbacteria

Zilberberg M.D. et al [23]

2010 Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study

Rajamani A. et al [24]

2011 The SCRIPT project: a knowledge translation approach to improve prescription practice in a general intensive care unit

Mangino J.E. et al [25]

2011 Development and implementation of a performance improvement project in adult intensive care units: overview of the ImprovingMedicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study

Zahar J. et al [26]

2011 Outcomes in severe sepsis and patients with septic shock: Pathogen species and infection sites are not associated with mortality

Joung M. et al [27]

2011 Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia

Chang H.J. et al [28]

2011 Risk factors and outcomes of carbapenem nonsusceptible Escherichia coli bacteremia: A matched case control study

van den Bosch C.M.A et al [29]

2014 Development of quality indicators for antimicrobial treatment in adults with sepsis

Leone M. et al [30]

2014 De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomizednoninferiority trial

176 | Appendix A

GuidelinesDellit T.H. et al [31]

2007 Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for developing an institutional program to enhance Antimicrobial Stewardship

Dutch Working Party on Antibiotic Policy [32]

2010 SWAB guidelines for antibacterial therapy of adult patients with sepsis

Dellinger R.P. et al [33]

2013 Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock

Oostdijk E.A.N. [34]

2014 SWAB guidelines for selective decontamination in patients admitted to the intensive care

National Institute for Health and Care Ex-cellence [35]

2015 Antimicrobial Stewardship: systems and processes for effective antimicrobial medicine use

Schuts E.C. et al [36]

2015 Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis


A

References

[1] Alvarez-Lerma F. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group. Intensive Care Med 1996;22(5):387-94.

[2] D’Amico R, Pifferi S, Leonetti C, Torri V, Tinazzi A, Liberati A. Effectiveness of antibiotic prophylaxis in critically ill adult patients: systematic review of randomised controlled trials. Bmj 1998;316(7140):1275-85.

[3] Price J, Ekleberry A, Grover A, Melendy S, Baddam K, McMahon J, et al. Evaluation of clinical practice guidelines on outcome of infection in patients in the surgical intensive care unit. Crit Care Med 1999;27(10):2118-24.

[4] Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest 1999;115(2):462-74.

[5] Nardi G, Di Silvestre AD, De Monte A, Massarutti D, Proietti A, Grazia Troncon M, et al. Reduction in gram-positive pneumonia and antibiotic consumption following the use of a SDD protocol including nasal and oral mupirocin. Eur J Emerg Med 2001;8(3):203-14.

[6] Trouillet JL, Vuagnat A, Combes A, Kassis N, Chastre J, Gibert C. Pseudomonas aeruginosa ventilator-associated pneumonia: comparison of episodes due to piperacillin-resistant versus piperacillin-susceptible organisms. Clin Infect Dis 2002;34(8):1047-54.

[7] Garbino J, Lew DP, Romand JA, Hugonnet S, Auckenthaler R, Pittet D. Prevention of severe Candida infections in nonneutropenic, high-risk, critically ill patients: a randomized, double-blind, placebo-controlled trial in patients treated by selective digestive decontamination. Intensive Care Med 2002;28(12):1708-17.

[8] Eachempati SR, Hydo LJ, Shou J, Barie PS. Does de-escalation of antibiotic therapy for ventilator-associated pneumonia affect the likelihood of recurrent pneumonia or mortality in critically ill surgical patients? J Trauma 2009;66(5):1343-8.

[9] Chastre J, Wolff M, Fagon JY, Chevret S, Thomas F, Wermert D, et al. Comparison of 8 vs 15 days of antibiotic therapy for ventilator-associated pneumonia in adults: a randomized trial. Jama 2003;290(19):2588-98.

[10] Houston S, Gentry LO, Pruitt V, Dao T, Zabaneh F, Sabo J. Reducing the incidence of nosocomial pneumonia in cardiovascular surgery patients. Qual Manag Health Care 2003;12(1):28-41.

[11] Jacobs S, Price Evans DA, Tariq M, Al Omar NF. Fluconazole improves survival in septic shock: a randomized double-blind prospective study. Crit Care Med 2003;31(7):1938-46.

178 | Appendix A

[12] Hughes MG, Evans HL, Chong TW, Smith RL, Raymond DP, Pelletier SJ, et al. Effect of an intensive care unit rotating empiric antibiotic schedule on the development of hospital-acquired infections on the non-intensive care unit ward. Crit Care Med 2004;32(1):53-60.

[13] Hartmann B, Junger A, Brammen D, Rohrig R, Klasen J, Quinzio L, et al. Review of antibiotic drug use in a surgical ICU: management with a patient data management system for additional outcome analysis in patients staying more than 24 hours. Clin Ther 2004;26(6):915-24; discussion 04.

[14] Shaw MJ. Ventilator-associated pneumonia. Curr Opin Pulm Med 2005;11(3):236-41.

[15] Bianco A, Rizza P, Scaramuzza G, Pavia M. Appropriateness of glycopeptide use in a hospital in Italy. Int J Antimicrob Agents 2006;27(2):113-9.

[16] Siempos, II, Vardakas KZ, Manta KG, Falagas ME. Carbapenems for the treatment of immunocompetent adult patients with nosocomial pneumonia. Eur Respir J 2007;29(3):548-60.

[17] Bennett KM, Scarborough JE, Sharpe M, Dodds-Ashley E, Kaye KS, Hayward TZ, 3rd, et al. Implementation of antibiotic rotation protocol improves antibiotic susceptibility profile in a surgical intensive care unit. J Trauma 2007;63(2):307-11.

[18] Berenholtz SM, Pronovost PJ, Ngo K, Barie PS, Hitt J, Kuti JL, et al. Developing quality measures for sepsis care in the ICU. Jt Comm J Qual Patient Saf 2007;33(9):559-68.

[19] Aarts MA, Brun-Buisson C, Cook DJ, Kumar A, Opal S, Rocker G, et al. Antibiotic management of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome? Intensive Care Med 2007;33(8):1369-78.

[20] Roberts JA, Lipman J, Blot S, Rello J. Better outcomes through continuous infusion of time-dependent antibiotics to critically ill patients? Curr Opin Crit Care 2008;14(4):390-6.

[21] Lam SW, Eschenauer GA, Carver PL. Evolving role of early antifungals in the adult intensive care unit. Crit Care Med 2009;37(5):1580-93.

[22] Garcin F, Leone M, Antonini F, Charvet A, Albanese J, Martin C. Non-adherence to guidelines: an avoidable cause of failure of empirical antimicrobial therapy in the presence of difficult-to-treat bacteria. Intensive Care Med 2010;36(1):75-82.

[23] Zilberberg MD, Kollef MH, Arnold H, Labelle A, Micek ST, Kothari S, et al. Inappropriate empiric antifungal therapy for candidemia in the ICU and hospital resource utilization: a retrospective cohort study. BMC Infect Dis 2010;10:150.

[24] Rajamani A, Suen S, Phillips D, Thomson M. The SCRIPT project: a knowledge translation approach to improve prescription practice in a general intensive care unit. Crit Care Resusc 2011;13(4):245-51.


A

[25] Mangino JE, Peyrani P, Ford KD, Kett DH, Zervos MJ, Welch VL, et al. Development and implementation of a performance improvement project in adult intensive care units: overview of the Improving Medicine Through Pathway Assessment of Critical Therapy in Hospital-Acquired Pneumonia (IMPACT-HAP) study. Crit Care 2011;15(1):R38.

[26] Zahar JR, Timsit JF, Garrouste-Orgeas M, Francais A, Vesin A, Descorps-Declere A, et al. Outcomes in severe sepsis and patients with septic shock: pathogen species and infection sites are not associated with mortality. Crit Care Med 2011;39(8):1886-95.

[27] Joung MK, Lee JA, Moon SY, Cheong HS, Joo EJ, Ha YE, et al. Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia. Crit Care 2011;15(2):R79.

[28] Chang HJ, Hsu PC, Yang CC, Kuo AJ, Chia JH, Wu TL, et al. Risk factors and outcomes of carbapenem-nonsusceptible Escherichia coli bacteremia: a matched case-control study. J Microbiol Immunol Infect 2011;44(2):125-30.

[29] van den Bosch CM, Hulscher ME, Natsch S, et al. Development of quality indicators for antimicrobial treatment in adults with sepsis. BMC Infect Dis 2014;14:345.

[30] Leone M, Bechis C, Baumstarck K, Lefrant JY, Albanese J, Jaber S, et al. De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomized noninferiority trial. Intensive Care Med 2014;40(10):1399-408.

[31] Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-77.

[32] Dutch Working Party on Antibiotic Policy (SWAB). Guidelines for Antibacterial therapy of adult patients with Sepsis: http://www.swab.nl/swab/cms3.nsf/uploads/65FB380648516FF2C125780F002C39E2/$FILE/swab_sepsis_guideline_december_2010.pdf. 2010.

[33] Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013;41(2):580-637.

[34] Oostdijk EAN. Selective decontamination in ICU patients: Dutch guideline. 2015.[35] Zhang Z, Chen L. The association between fluid balance and mortality in patients

with ARDS was modified by serum potassium levels: a retrospective study. PeerJ 2015;3:e752.

[36] Schuts EC, Hulscher ME, Mouton JW, Verduin CM, Stuart JW, Overdiek HW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016.

180 | Appendix B

Appendix B: Action implementation toolbox antibiotic use

Action implementation toolbox containing possible barriers and subsequent improvement actions on each quality indicator arranged by the determinants of practice from the checklist of Flottorp et al. (2013). The last row on each block e.g. ‘Actions 4+5’ refer to actions mentioned at another barrier which are also possible improvement strategies for the barrier in question.

A. Barriers relating to the guidelines

Barrier 1: Antibiotic guidelines are missingApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material1. Develop local

antibiotic guidelines* specified for the ICU

Empirical therapy according to the guidelines reduces mortality, duration of therapy and length of hospital stay. [1] Locally developed guidelines, based on (inter) national protocols, often have the best chance of being accepted by local health care providers and hence of being implemented [2, 3].

*Local antibiotic guidelines: facility-specific evidence- based treatment recommendations that assist professionals in their decision making

The Dutch Antibiotic Working Party (SWAB) offers national antibiotic guidelines, which can be adapted for each hospital based on local resistance patterns. http://www.swabid.nl.

SWAB offers Dutch protocols for sepsis and selective digestive or oropharyngeal decontamination. http://www.swab.nl/richtlijnen

The surviving sepsis campaign protocols offer recommendations for the care of severely septic patients [4].

The Infectious Diseases Society of America published many protocols, including the protocol for developing an institutional program to enhance Antimicrobial Stewardship [5].

Action implementation toolbox antibiotic use | 181

A

Barrier 2: Antibiotic guidelines are inadequate or unclearApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material2. Revise antibiotic

guidelines so that the recommendations are adequate and understandable

A Dutch study illustrated that adjusting local guidelines based on scientific evidence and consistency with other guidelines, ensuring a better distribution and education on these guidelines, and facilitating the logistics achieved a significant improvement in the quality of care [6].

3. Extend antibiotic guidelines by adding missing criteria or recommendations

Indicator 1: Blood cultures should be taken before the start of therapy, since the use of antibiotics lowers the positivity rates [7, 8].Indicator 2: Critically ill patients may have pathology that results in altered pharmacokinetics and renal clearance. Therapeutic drug monitoring (TDM) serves as an accurate method for dose adjustment in critically ill patients. The clinical outcome benefits of a systematic TDM program for antibiotics have mainly been demonstrated for aminoglycosides [9, 10].Indicator 3: Surveillance cultures are needed to determine whether SDD / SOD is effective. If not effective, the frequency of SDD/SOD should be increased or passage through the gastrointestinal tract should be improved.Controversy exists whether SDD and SOD increase the prevalence of antibiotic resistant bacteria. Therefore, it is advised to accompany the implementation of SDD and SOD with a stringent surveillance system to detect antibiotic resistant pathogens in the ICU. [11]Indicator 4: Up to 71% of patients at an ICU use antibiotics. [12] Extensive use of antibiotics is the main driving force in the emergence of resistant microorganisms. [13] Awareness of (trends) in resistance rates can lead to early detection and initiation of prevention policies.


The website http://www.A-teams.nl offers a list with restricted antibiotics.

SWAB offers Dutch protocols for selective digestive or oropharyngeal decontamination, among others http://www.swab.nl/richtlijnen

The Dutch Association for Hospital Pharmacists (NVZA) offers guidelines for TDM: http://tdm-monografie.org/

182 | Appendix B

Barrier 3: Local antibiotic guidelines are not consistent with the national guidelinesApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material4. Revise antibiotic

guidelines so that the recommendations are consistent with the national guidelines

A Dutch study illustrated that adjusting the local guidelines based on scientific evidence and consistency with other guidelines, ensuring a better distribution and education on these guidelines, and facilitating the logistics achieved a significant improvement in the quality of care [6].

The Dutch Antibiotic Working Party (SWAB) offers national guidelines, which can be adapted for each hospital based on local resistance patterns. http://www.swabid.nl.

SWAB offers Dutch guidelines for selective digestive or oropharyngeal decontamination, among others http://www.swab.nl/richtlijnen

5. Discuss the reasons for conflicting recommendations with the healthcare professionals

Interactive (thematic) meetings can result in more support [14, 15].

Barrier 4: The quality of evidence or source supporting antibiotic guidelines is unclear or weakApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material6. Evaluate

and discuss recommendations in antibiotic guidelines for which there is low quality evidence


7. Ensure that antibiotic guidelines are made or endorsed by an organization and people that have credibility with the targeted healthcare professionals

The Dutch Working Party on Antibiotic Policy (SWAB) consists of a multidisciplinary group of experts, consisting of infectious diseases specialists, medical microbiologists, hospital pharmacists, and, if indicated, other specialties. SWAB develops and updates national antibiotic guidelines.



A

Barrier 5: The antibiotic guidelines are not (easily) accessibleApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material8. Ensure that

antibiotic guidelines are electronically accessible

Antibiotic guidelines can be easily accessed when available electronically. For example, on a network or online, preferably linked to the electronic health record (EHR) or patient data management system (PDMS) [16].Use of a computerized system to guide antibiotic administration had shown to minimize adverse drug effects and to reduce inadequate administration of antibiotics [3].

9. Develop a flowchart or pocket card with the highlights of the antibiotic guidelines

Antibiotic guidelines can be easily applied, also in hospitals without EHRs, by offering a flowchart or pocket card covering essential information from the guidelines [16].

Standard format flowchart or pocket card

10. Spread a digital newsletter with details or updates of the antibiotic guidelines

Information spread by email is an effective way to introduce people to (updates of) the antibiotic guidelines [17].

Standard format digital newsletter

11. Distribute promotional posters on specific topics relating to antibiotic use

Promotional posters can stimulate familiarity with guidelines and serve as a reminder [18].

Standard format posters

Barrier 6: The recommendation to discontinue/switch/streamline antibiotics is not feasible for the healthcare professional Applicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material12. Ensure that the clinical action fits into daily practice

Clinical actions that fit into daily practice will be applied more easily.

13 + 14 + 15

Barrier 7: The recommendation to perform cultures (in time) is not feasible for the healthcare professional Applicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 12 + 13 + 14 + 15

184 | Appendix B

Barrier 8: The recommendation to plan annual meetings on antibiotic resistance trends is not feasible for the healthcare professional Applicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 12 + 13 + 14 + 15

B. Barriers relating to the individual health care professional

Barrier 9: Health care professionals are not (sufficiently) familiar with antibiotic guidelines Applicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material13. Academic detailing:

organize a tailored educational meeting on the contents and importance of appropriate antibiotic use

Education will help to raise awareness of antibiotic guidelines, and encourage discussion on the importance of diagnostics and therapy of infectious diseases [19].(Continuing) educational meetings or discussion groups for all professionals (specialists, residents, nurses) might help to optimize antibiotic prescribing [20].

It might be helpful to point out a coordinator responsible for the educational sessions [17, 21].

Standard format presentations on topics relating to appropriate antibiotic use at the ICU

14. Organize an interactive meeting or consensus process on specific topics relating to appropriate antibiotic use


It might be helpful to point out a coordinator responsible for the educational sessions [17, 21].

15. Distribute educational material on appropriate antibiotic use

A review on six interventions which evaluated the dissemination of educational materials in printed form or via educational meetings showed positive results on antibiotic prescribing and costs [20].

Actions 8 + 9 + 10 + 11


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Barrier 10: Health care professionals perceive guidelines in general as restricting their autonomy*The targeted healthcare professionals may interpret the quality of the evidence or its applicability differently, may not think the recommended intervention is cost-effective, or may lack confidence in the developer of guidelinesApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 13 + 14 + 15

Barrier 11: Health care professionals lack knowledge on the importance of using antibiotics appropriatelyApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material16. Engage leaders

or managers in designing and implementing the interventions regarding appropriate antibiotic use

Opinions and behaviour of others might reinforce desired practice [22].

17. Appoint a ‘role model’ for appropriate antibiotic use

A role model or opinion leader is able to point out the importance and responsibility for appropriate antibiotic use. Alone or in combination with other interventions they may successfully promote evidence-based practice [21].

18. Ensure there is structural audit and feedback on individual performance

If staff is fed back on their performance on antibiotic use, they will be more aware of the problem [17]. Interventions that included feedback were more effective than those that did not [23].

Actions 13 + 14 + 15

Barrier 12: Appropriate antibiotic use is not considered important/relevant on the ICUApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 13 + 14 + 15 + 16 + 17 + 18

Barrier 13: Health care professionals do not agree with the antibiotic guidelinesApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 13 + 14 + 15

186 | Appendix B

Barrier 14: Health care professionals do not believe that appropriate antibiotic use will lead to desired/better outcomes (lack of motivation)Applicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting materialActions 13 + 14 + 15 + 18

Barrier 15: Health care professionals forget to (routinely) perform specific actions regarding appropriate antibiotic useApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material19. Install a clinical

decision support system in the EHR or PDMS

Information from computer-based medical records can be used to help improve physicians' selection of empir-ic antibiotics or diagnostics [3, 23, 24].

20. Build in a notification or reminder system in the EHR or PDMS

A review on interventions using re-minders showed a reduction in antibi-otic prescribing and improvement of appropriate antibiotic use [20].

21. Build in a pre-or post-authorization system for restricted antibiotics in the EHR or PDMS

An infectious disease or microbiology specialist has to approve on a restricted antibiotic, notification of the reason for choosing the restricted antibiotic is mandatory [25].

22. Implement a checklist for actions to be taken along the antibiotic pathway

Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use [26, 27].

23. Give nurses more responsibility to perform actions regarding antibiotic therapy

If nurses have more independence or responsibility, cultures and TDM can be performed faster and more efficiently, because there is no need to wait for the doctor. The responsibilities of nurses can be detailed in antibiotic guidelines [28].

Actions 13 + 14 + 15 + 18


A

Barrier 16: Health care professionals lack skills to perform the actions regarding appropriate antibiotic use Applicable to indicator: 1 - 2 - 3 Improvement strategy Rationale or description Supporting material24. Organize training

sessions on skills needed to perform blood cultures or TDM adequately

Organize combined training sessions for specialists, residents, nurses, management coordinators. When training / consultation sessions are organized where the instruments are explained and discussed in difficult situations, the threshold to use the tools can be reduced or eliminated [19].It might help to point out a coordinator responsible for the educational sessions [17, 21].

Actions 13 + 14 + 15 + 18

C. Barriers relating to professional interactions

Barrier 17: There is inadequate communication or interaction within ICU teamsApplicable to indicator: 1 - 2 - 3 Improvement strategy Rationale or description Supporting material25. Organize an

educative team building event

Educational sessions will help to raise awareness of antibiotic policies, and encourage discussion on the importance of actions regarding the diagnostic process and treatment of infectious diseases [19].

It might help to point out a coordinator responsible for the educational sessions [17, 21].

26. Organize standard evaluation moments with the medical staff

If a team is fed back on their communication and actions regarding the diagnostic process and treatment of antibiotics, they will be more aware of the problem [17].

27. Organize professional teams in a way that roles are defined and members have a shared goal

Substitution of tasks and implementing a shared goal can be effective in attaining better communication [29].

188 | Appendix B

28. Ensure that antibiotic duration is communicated during daily rounds, multidisciplinary meetings, and shift change

A clear and sufficiently communicated treatment plan can lead to better patient outcomes such as a shorter treatment duration [29].

Actions 13 + 14 + 15 + 17 + 18 + 22 + 23 + 30 + 31

Barrier 18: There is no standard evaluation moment of ICU teams with the Microbiology department about the resistance ratesApplicable to indicator: 4Improvement strategy Rationale or description Supporting material29. Schedule

evaluation moments

An comfortable team climate is a determinant for success [30]. Discussing local epidemiology can guide the selection of empiric therapy [31].

Barrier 19: The action regarding antibiotic use is not documented in the patient recordApplicable to indicator: 1 - 2 - 3 - 4 Improvement strategy Rationale or description Supporting material30. Ensure that all

performed actions are recorded in the patient record

Ensure that actions regarding antibiotic therapy are always recorded. This gives insight and ensures better communication [19].

31. Build in a (mandatory) documentation area in the EHR or PDMS

A (mandatory) registration area ensures better communication, especially when different health care professionals work in shifts [17].


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D. Barriers relating to incentives and resources

Barrier 20: Resources for blood or site culture performance are not availableApplicable to indicator: 1 - 3Improvement strategy Rationale or description Supporting material32. Ensure that enough

culture media are available on the ICU

The availability of culture media can contribute to higher performance of blood or site cultures, which can improve the appropriateness of antibiotic therapy.

33. Ensure that the culture media can be found easily

Easy access to culture media can contribute to higher performance of blood or site cultures, which can improve the appropriateness of antibiotic therapy.

Barrier 21: There is delay in the routing (bottles with culture media arrive in the lab too late or not at all)Applicable to indicator: 1 - 3 Improvement strategy Rationale or description Supporting material34. Implement a

standard routing from ward to microbiology department

A standard routing, such as pneumatic tube transport might reduce delay in routing to the laboratory.

Actions 13 + 14 + 15 + 23

Barrier 22: Patient safety hinders performance of blood culture performance before start of antibiotic therapyApplicable to indicator: 1 Improvement strategy Rationale or description Supporting materialActions 13 + 14 + 15

Barrier 23: The PDMS / EHR hinders performance of the necessary actions for appropriate antibiotic useApplicable to indicator: 1 - 2 - 3 Improvement strategy Rationale or description Supporting material35. Adapt the PDMS

/ EHR Alert or reminder can increase appropriate antibiotic use, but be aware of alert fatigue [32].

Actions 19 + 20 + 21

190 | Appendix B

E. Capacity for organizational change

Barrier 24: there is a lack of capable leadershipApplicable to indicator: 1 - 2 - 3 Improvement strategy Rationale or description Supporting material36. Provide external

support or training for managers and leaders

It might be helpful to share knowledge with external contacts, because they might have another opinion or new perspective about certain topics.

37. Shift or allocate leadership or management responsibilities to someone with a suitable style

Adequate leadership can lead to a more efficient and effective workflow.

Actions 16 + 17


A

References

[1] Schuts EC, Hulscher ME, Mouton JW, Verduin CM, Stuart JW, Overdiek HW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016.

[2] Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318(7182):527-30.

[3] Kollef MH. Optimizing antibiotic therapy in the intensive care unit setting. Crit Care 2001;5(4):189-95.

[4] Lehman KD, Thiessen K. Sepsis guidelines: Clinical practice implications. Nurse Pract 2015;40(6):1-6.

[5] Barlam TF, Cosgrove SE, Abbo LM, MacDougall C, Schuetz AN, Septimus EJ, et al. Implementing an Antibiotic Stewardship Program: Guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016;62(10):e51-77.

[6] van Kasteren ME, Mannien J, Ott A, Kullberg BJ, de Boer AS, Gyssens IC. Antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. Clin Infect Dis 2007;44(7):921-7.

[7] Cohen J, Brun-Buisson C, Torres A, Jorgensen J. Diagnosis of infection in sepsis: an evidence-based review. 2004.

[8] Cockerill FR, 3rd, Wilson JW, Vetter EA, Goodman KM, Torgerson CA, Harmsen WS, et al. Optimal testing parameters for blood cultures. Clin Infect Dis 2004;38(12):1724-30.

[9] Roberts JA, Norris R, Paterson DL, Martin JH. Therapeutic drug monitoring of antimicrobials. 2012.

[10] Udy AA, Roberts JA, Boots RJ, Paterson DL, Lipman J. Augmented renal clearance: implications for antibacterial dosing in the critically ill. Clin Pharmacokinet 2010;49(1):1-16.

[11] Oostdijk EAN. Selective decontamination in ICU patients: Dutch guideline. 2015.[12] Vincent JL, Rello J, Marshall J, Silva E, Anzueto A, Martin CD, et al. International

study of the prevalence and outcomes of infection in intensive care units. JAMA 2009;302(21):2323-9.

[13] van der Veer SN, de Vos ML, de Keizer NF. Van meten naar verbeteren: kwaliteitsindicatoren op de Intensive Care. Ervaringen en aanbevelingen uit de InFoQI studie. 2013.

[14] Lewis CP, Corley DJ, Lake N, Brockopp D, Moe K. Overcoming Barriers to Effective Pain Management: The Use of Professionally Directed Small Group Discussions.

192 | Appendix B

Pain Manag Nurs 2014.[15] Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the gap

between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. The Cochrane Effective Practice and Organization of Care Review Group. BMJ 1998;317(7156):465-8.

[16] Jun J, Kovner CT, Stimpfel AW. Barriers and facilitators of nurses’ use of clinical practice guidelines: An integrative review. Int J Nurs Stud 2016;60:54-68.

[17] Fischer F, Lange K, Klose K, Greiner W, Kraemer A. Barriers and Strategies in Guideline Implementation-A Scoping Review. Healthcare (Basel) 2016;4(3).

[18] Scales DC, Dainty K, Hales B, Pinto R, Fowler RA, Adhikari NK, et al. A multifaceted intervention for quality improvement in a network of intensive care units: a cluster randomized trial. JAMA 2011;305(4):363-72.

[19] Erdek MA, Pronovost PJ. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care 2004;16(1):59-64.

[20] Davey P, Brown E, Charani E, Fenelon L, Gould IM, Holmes A, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2013(4):CD003543.

[21] Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2011(8):CD000125.

[22] Grol R, Wensing M. What drives change? Barriers to and incentives for achieving evidence-based practice. Med J Aust 2004;180(6 Suppl):S57-60.

[23] Davey P, Marwick CA, Scott CL, Charani E, McNeil K, Brown E, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev 2017;2:CD003543.

[24] Evans RS, Classen DC, Pestotnik SL, Lundsgaarde HP, Burke JP. Improving empiric antibiotic selection using computer decision support. Arch Intern Med 1994;154(8):878-84.

[25] Reed EE, Stevenson KB, West JE, Bauer KA, Goff DA. Impact of formulary restriction with prior authorization by an antimicrobial stewardship program. Virulence 2013;4(2):158-62.

[26] Conroy KM, Elliott D, Burrell AR. Testing the implementation of an electronic process-of-care checklist for use during morning medical rounds in a tertiary intensive care unit: a prospective before-after study. Ann Intensive Care 2015;5(1):60.

[27] van Daalen FV, Prins JM, Opmeer BC, Boermeester MA, Visser CE, van Hest RM, et al. Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial. Clin Microbiol Infect 2017;23(7):485 e1- e8.


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[28] Hatherley C, Jennings N, Cross R. Time to analgesia and pain score documentation best practice standards for the Emergency Department - A literature review. Australas Emerg Nurs J 2016;19(1):26-36.

[29] Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5.

[30] Hulscher ME, Schouten LM, Grol RP, Buchan H. Determinants of success of quality improvement collaboratives: what does the literature show? BMJ Qual Saf 2013;22(1):19-31.

[31] Patel SJ, Saiman L. Principles and strategies of antimicrobial stewardship in the neonatal intensive care unit. Semin Perinatol 2012;36(6):431-6.

[32] Thursky KA, Buising KL, Bak N, Macgregor L, Street AC, Macintyre CR, et al. Reduction of broad-spectrum antibiotic use with computerized decision support in an intensive care unit. Int J Qual Health Care 2006;18(3):224-31.

194 | Appendix C

Appendix C: Detailed description of the quality indicator development process for pain management

We developed quality indicators using a modified RAND method[1, 2]. We modified the RAND method by asking experts at the beginning of the process to propose indicators reflecting sufficient pain management without providing them a predefined list of potential indicators from the literature.

Round 1: Identification of potential indicatorsIn the first round we made an inventory of potential indicators from the panel’s expert opinion, literature and national and international clinical practice guidelines. We asked all panel members by e-mail to list aspects that reflect adequate pain management and what information they would need to assess the quality of pain management in an ICU. We searched Medline to extract available indicators in the literature published up to March 2016. Based on work of Kotter et al. [3] we developed a search strategy containing several synonyms for the following domains of interest: quality indicator, critical care, pain, and development (see Table C.1 for the full search strategy). We screened titles and abstracts to assess eligibility for inclusion. Relevant articles were then subjected to full-text review. Articles were excluded if they did not concern pain management, critical care, adults or performance measures, were case reports, not written in English or Dutch, or only concerned specific patient-subgroups. We made an expert-based selection of national and international guidelines regarding ICU pain management and extracted all potential indicators [4-6]. The indicators proposed by the experts and those selected from literature and guidelines were combined and duplicates were removed.

Round 2: Rating of indicatorsIn round 2 all ten experts independently rated the potential indicators identified in round 1 on two aspects: relevance (i.e. the relation with quality of care or health costs) and actionability (i.e. if performance is low it is clear how to improve). Rating was done on a 9-point Likert scale (1=totally disagree, 9=totally agree) using an online survey tool. The indicators with a median score of seven or higher for relevance and actionability were considered appropriate. Indicators with a median score of 4-9 on either relevance or actionability were uncertain and indicators with a median score of 1-3 on one of the criteria were defined as inappropriate [1]. We selected all appropriate and uncertain indicators to discuss during the expert panel consensus meeting.

Description of the quality indicator development process for pain management | 195

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Table C.1 Full search strategy in Medline.Quality indicator Domain Critical care Development1. quality indicator[Mesh] 11. pain[Mesh] 19. critical

care[Mesh]23. develop*

2. quality criterion[tw] 12. distress 20. intensive care units[Mesh]

3. quality measure[tw] 13. comfort 21. intensive care medicine[tw]

4. performance indicator[tw] 14. pain management[Mesh]

22. critical illness[Mesh]

5. performance measure[tw] 15. “pain service”6. outcome measure[tw] 16. discomfort7. outcome indicator[tw] 17. “pain score”8. audit 18. visual analog

scale[Mesh]9. outcome assessment[Mesh]10. process assessment[Mesh]

1-10(or) AND 11-28(or) AND 19-22(or) AND 23 excluded: children, infants & adolescents.

Round 3: Expert panel consensus meetingIn round 3 the results of the second round were presented to and discussed within the expert panel during a face-to-face consensus meeting. All experts from round 2 were invited; six out of ten were able to attend the meeting. During the discussion indicators were merged and rephrased, or definitions were refined to describe indicators unambiguously. After the discussion, the experts independently rated the indicators again on a 9-point Likert scale on relevance and actionability. In addition, the panel members gave each indicator a validity score, reflecting if the indicator is associated with and appears to measure quality of pain management in clinical practice (i.e. face and content validity). According to the RAND method [1] indicators with median scores of 7-9 on relevance and actionability without disagreement (i.e. 80% of the assessment rates were within the range of the median scores of 7-9), together with a validity score in the highest quartile of all validity scores, were selected. After the expert meeting the selected indicators were fully described in factsheets according to the AIRE instrument [7], including their operationalization, goal, relation to quality, type (process or outcome), definition, inclusion and exclusion criteria, unit of observation, and relevant subgroups. The factsheets were sent to the expert panel members for final approval.

196 | Appendix C

We presented the pain management indicators and discussed their definitions at a field consultation meeting with 22 ICU professionals representing ICUs participating in the NICE registry. Feedback received during the discussion was used to further refine indicator definitions in terms of clarity and unambiguousness.

Description of the quality indicator development process for pain management | 197

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References

[1] Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lázaro P, et al. The Rand/UCLA appropriateness method user’s manual. Santa Monica: RAND Corporation; 2001.

[2] Van Engen-Verheul M, Kemps H, Kraaijenhagen R, De Keizer N, Peek N. Modified Rand method to derive quality indicators: a case study in cardiac rehabilitation. Stud Health Technol Inform 2011;169:88-92.

[3] Kotter T, Blozik E, Scherer M. Methods for the guideline-based development of quality indicators-a systematic review. Implement Sci 2012;7:21.

[4] Spijkstra JJ, Horn J, Gielen-Wijffels SEMJ, Burger D, van den Berg B, Snellen FTF. Herziene richtlijn analgesie en sedatie voor volwassenen op de intensive care. Utrecht: Dutch Society of Intensive Care (NVIC); 2013.

[5] Barr J, Fraser GL, Puntillo K, Ely EW, Gelinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1):263-306.

[6] Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, et al. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(1):119-41.

[7] de Koning J, Smulders A, Klazinga NS. Appraisal of Indicators through Research and Evaluation (AIRE). Amsterdam: Academisch Medisch Centrum Universiteit van Amsterdam, afdeling Sociale Geneeskunde; 2007.

198 | Appendix D

Appendix D: Characteristics of the included ICUs

Table D.1 Characteristics of the included ICUs.Characteristic No. of ICUs Mean (min-max)Hospital type

AcademicNon-academic

312

Number of beds 17 (6-35)FTE intensivists 7.3 (2.0-13.8)FTE nurses 61.1 (17.8-173.0)Abbreviations: ICU, intensive care unit; FTE, full-time equivalent.

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Appendix E: Intervention design compared against Brehaut et al.’s 15 A&F design suggestions

Table E.1 Summary of our intervention design by comparing it against Brehaut et al.’s [1] recent list of 15 A&F design suggestions. Note that the term ‘action’ in Brehaut et al.’s table refers to the clinical feedback topic (i.e. indicators) whereas in this study we use ‘action’ to indicate behaviour in response to receiving feedback.A&F design recommendation NICE dashboard interventionNature of the desired action1. Recommend actions that are

consistent with established goals and priorities

We used a modified RAND method [2] to develop a set of indicators that are perceived by ICU clinicians to be relevant, feasible and actionable.

2. Recommend actions that can improve and are under the recipient’s control

The indicators were selected based on relevance, feasibility, and actionability. Next, pilot data were collected from six ICUs to assess variation between ICUs and room for improvement.

3. Recommend specific actions For each indicator specific information is available including the nominator and denominator, goal (e.g. measure pain at least each shift), relation to quality, definitions, and inclusion and exclusion criteria. The action implementation toolbox further suggests concrete quality improvement actions.

Nature of the data available for feedback4. Provide multiple instances of

feedbackFeedback is provided through an online dashboard which is accessible 24/7 and by all team members. The team is asked to meet monthly to discuss new feedback.

5. Provide feedback as soon as possible and at a frequency informed by the number of new patient cases

Feedback is automatically updated after each data upload by an ICU; which typically occurs monthly. The indicator scores and benchmark comparisons are based on the most recent 3 months of patient data to create a robust score that is steady over time.

6. Provide individual rather than general data

Feedback is provided at the level of the ICU team rather than individual. ICU care is delivered by multidisciplinary teams and individual professional data are not collected. To increase feedback relevance we additionally provide patient-level feedback that can be used to look up additional information in ICUs’ local patient records.

7. Choose comparators that reinforce desired behaviour change

Three external, data-driven targets are provided. Two are based on peer performance (median and top 10% benchmark) that provide achievable targets for both high and low performers; the third is past performance which can be used to assess progress. Finally participants set their own, internal targets guided by the information presented to increase target commitment.

200 | Appendix E

Feedback display8. Closely link the visual display

and summary messageFor each indicator the performance assessment rep-resented by a “traffic light” coloured icon is displayed directly next to the measured performance score.

9. Provide feedback in more than 1 way

Feedback is provided numerically (performance scores), graphically (coloured icons and charts) and textually (e.g. “improvement recommended”).

10. Minimize extraneous cognitive load for feedback recipients

The intervention targets four indicators. The performance summary is always visible in the top half of the dashboard. The bottom half adopts a tab-based structure to separate information. Dashboard use is supported by both visual cues (icons; colours) and actionable messages.

Delivering the feedback intervention11. Address barriers to feedback

useMedical manager of the ICU signs a consent form to formalise commitment. ICUs therefore consent to: al-locating quality improvement teams with at least one intensivist and one nurse; the feedback is believed to be under control of these professionals. One team member who typically has QI in their portfolio is ap-pointed local champion. The team is asked to spend at least four hours per month on the intervention, and to meet monthly to discuss new feedback and update the action plans. We motivate participants to continue using the intervention during monthly telephone calls.

12. Provide short, actionable messages followed by optional detail

The dashboard first provides a general overview of current performance; after which details are available in a tab-structure (e.g. trend charts, thresholds of coloured icons, scores grouped by patient subgroups, patient lists).

13. Address credibility of the information

Indicator calculations are made transparent by provid-ing all definitions, nominators and denominators, and downloadable lists of individual patient numbers and whether or not the indicator was violated.

14. Prevent defensive reactions to feedback

Multiple targets (median and top 10% benchmark) are provided to allow low performers to perceive achievable targets. Assignment of coloured icons depends on score and variation (see Intervention) so that performing just below the top 10% benchmark is still considered “good performance”. During the outreach visit and in the dashboard’s help function it is explained that colours are based on peer performance and designed to help participants quickly identify room for improvement; not to judge.

15. Construct feedback through social interaction

During the outreach visit feedback is discussed within the ICU teams. Teams set their own performance targets in the dashboard guided by the performance information received. The team is asked to meet monthly to discuss new feedback and update the action plans. We hold monthly telephone calls with the ICU’s local champion to discuss progress and provide assistance if necessary.

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References

[1] Brehaut JC, Colquhoun HL, Eva KW, Carroll K, Sales A, Michie S, et al. Practice Feedback Interventions: 15 Suggestions for Optimizing Effectiveness. Ann Intern Med 2016;164(6):435-41.

[2] Fitch K, Bernstein SJ, Aguilar MD, Burnand B, LaCalle JR, Lázaro P, et al. The Rand/UCLA appropriateness method user’s manual. Santa Monica: RAND Corporation; 2001.

202 | Appendix F

Appendix F: List of actionable pain management quality indicators

Table F.1 List of actionable quality indicators to monitor adequate pain management in an ICU.Indicator Definition Indicator

typeNumerator Denominator Optimal

value

1. Performing pain measurements

Percentage of patient-shift observations during which pain was measured at least once.

Specified for subgroups: 1) type of admission, 2) type of shift

Process Number of patient-shift observations during which pain was measured at least once

Total number of patient-shift observations with or without a pain measurement

100%

2. Re-measuring unacceptable pain within 1 h#

Percentage of patient-shift observations during which an unacceptable pain score was measured*, and pain was re-measured within 1 h


Process Number of patient-shift observations during which an unacceptable pain score was measured*, and pain was re-measured within 1 h

Total number of patient-shift observations during which an unacceptable pain score was measured*

100%

3. Acceptable pain scores#

Percentage of patient-shift observations during which pain was measured* and no unacceptable pain scores were observed


Outcome Number of patient-shift observations during which pain was measured* and no unacceptable pain scores were observed

Total number of patient-shift observations during which pain was measured*

100%

List of actionable pain management quality indicators | 203

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4. Unacceptable pain scores normalized within 1 h#

Percentage of patient-shift observations during which an unacceptable pain score was measured*, and pain was re-measured within 1 h indicating that the pain score wasnormalized


Outcome Number of patient-shift observations during which an unacceptable pain score was measured*, and pain was re-measured within 1 h indicating that the pain score was normalized

Total number of patient-shift observations during which an unacceptable pain score was measured*

100%

*Only pain scores measured with a standardized pain assessment tool, such as the Visual

Analog Scale (VAS), Numerical Rating Scale (NRS), Behavioral Pain Scale (BPS), or Critical-

Care Pain Observation Tool (CPOT) are included.#Unacceptable pain scores were defined as measurements with a VAS or NRS score of ≥4, a

CPOT≥3 or a BPS≥6. Acceptable or normalized scores were defined as VAS/NRS<4, CPOT<3

and BPS<6.

204 | Appendix G

Appendix G: Screenshot of dashboard

Figure G.1 Screenshot of details page which presents performance scores over time.

Figure G.2 Screenshot of patients page which presents performance scores per subgroup.

Action implementation toolbox pain management | 205

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Appendix H: Action implementation toolbox pain management

Action implementation toolbox containing possible barriers and subsequent improvement actions on each quality indicator arranged by the determinants of practice from the checklist of Flottorp et al. [1] and Systems Engineering Initiative for Patient Safety (SEIPS) model [2]. The last row on each block e.g. ‘Actions 4+5’ refer to actions mentioned at another barrier which are also possible improvement strategies for the barrier in question.

A. Barriers relating to the protocol (Work system and structure – Technologies and tools)

Barrier 1. The pain protocol is inadequate or missing

Relevant to indicator: 1 – 2 – 3 – 4 Improvement action Description of improvement action Material1. Develop a pain

protocolThe pain protocol contains at least information about; the frequency of pain measurements (at least once per shift), the use of valid assess-ment tools (VAS/NRS for ‘communicative’ pa-tients, CPOT/BPS for sedated patients), repeat pain measurements in a timely manner (within 1 h), pain medication and dosage. An adequate pain protocol can result in higher guideline ad-herence and better quality of care [3-8].

Standard format protocol

2. Revise the pain protocol regarding what pain medi-cation should be given

If the protocol includes information about appropriate pain medication prescription, it is clear to health professionals how to treat pain effectively [9].

3. Revise the pain protocol regarding what dosage of pain medication should be given

If the protocol includes adequate information about the dosage of prescribed pain medica-tion, pain can be treated more effectively [9].

Actions 4+5

Barrier 2. ‘Measure pain every shift’ is not included in the protocol

Relevant to indicator: 1Improvement action Description of improvement action Material4. Add the criterion

‘Measure pain every shift’ to the protocol

Measuring pain every shift can help to detect and treat pain early. Systemic evaluation is associated with a decrease in pain incidence [5].

206 | Appendix H

Barrier 3. ‘Repeat pain measurement within 1 h in case of an unacceptable score’ is not included in the protocol

Relevant to indicator: 3 – 4Improvement action Description of improvement action Material5. Add the criterion

‘Repeat pain measurement within 1 h in case of an unacceptable score’ to the protocol

In case pain measurements with an unacceptable score are repeated within 1 h to evaluate treatment effect, health professionals can decide on time if therapy should be changed [5, 10].

Barrier 4. The pain protocol is (not easily) accessible

Relevant to indicator: 1 – 2 – 3 – 4Improvement action Description of improvement action Material6. Make the pain

protocol available electronically

The pain protocol can be easily accessed when it is available electronically. For example, on a network or online, preferably with a link to it from the electronic health record (EHR) or patient data management system (PDMS) [11].

7. Develop a flowchart or pocket card with the highlights of the pain protocol

Information of the pain protocol can be clarified by offering a flowchart or pocket card covering essential information from the protocol [11].

Standard format flowchart or pocket card

8. Spread a digital newsletter with details or updates on the pain protocol

Information spread by email is an effective way to introduce people to (updates of) the antibiotic protocol [12].

9. Provide promotional posters on specific topics relating to pain management

Promotional posters that indicate when and with what instruments pain should be measured, can stimulate familiarity with the protocol and serve as a reminder [13].

Standard format posters

Action 19.

B. Barriers relating to the individual health care professional (Work system or structure – Person)

Barrier 5. Health care professionals are not (sufficiently) familiar with the pain protocol

Relevant to indicator: 1 – 2 – 3 – 4Improvement action Description of improvement action Material


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10. Organize an educational meeting on the contents of the pain protocol

Educational sessions help to raise familiarity with the pain protocol, and encourage discussion on the importance of pain measurement [14, 15].It can be helpful to point out a pain coordinator, pain nurse or manager as being responsible for the educational sessions [12].

Actions 7+8+9+15+18+19+21

Barrier 6. Validated pain assessment tools are not always used

Relevant to indicator: 1Improvement action Description of improvement action Material11. Measure pain using

validated pain assessment tools (VAS, NRS, BPS, CPOT or CIA)

The pain indicators are based on the use of the VAS, NRS, BPS, CPOT, or CIA. It is recommend-ed that one of these assessment tools is being used; VAS or NRS in case of communicative pa-tients, CPOT or BPS in case of sedated patients, CIA in case of non-communicative patients. These assessment tools are validated and proven to measure pain effectively within ICU patients [3, 7, 8].

Actions 8+9+10+21

Barrier 7. Health care professionals do not know (for sure) how to use or interpret pain assessment tools

Relevant to indicator: 1 – 2 – 3 – 4 Improvement action Description of improvement action Material12. Organize training

sessions on the application of pain assessment tools

If training sessions are organized during which pain assessment tools will be explained and difficult situations discussed, this may persuade someone or lower the threshold to use the tools [14].

It can be helpful to point out a pain coordinator, pain nurse or manager as being responsible for the educational sessions [12].

Educational PowerPoint presentation

Barrier 8. Pain is not (always) measured in case health care professionals do not expect a patient to have pain

Relevant to indicator: 1 – 3 – 4 Improvement action Description of improvement action Material13. Measure pain at

built-in (routine) moments

When pain is measured in a routine manner the chance to forget pain measurements or miss them due to other reasons is reduced [5].

Actions 4+8+10+15+19+21

208 | Appendix H

Barrier 9. Pain is not measured during shift of admission or discharge

Relevant to indicator: 1 – 3 Improvement action Description of improvement action MaterialActions 4+8+10+15+19+21

Barrier 10. Despite pain is suspected pain is not measured or treated directly

Relevant to indicator: 2 – 3 – 4 Improvement action Description of improvement action Material14. Measure pain on

indication to pre-vent worse

When pain is measured on indication and not only at regular intervals, it can be treated sooner and worse can be prevented.

Actions 4+9+10+15+19+21

Barrier 11. Effectiveness of pain treatment is not checked sufficiently

Relevant to indicator: 2 – 3 – 4 Improvement action Description of improvement action Material15. Build in alerts

in the EHR that remind health care professionals that pain should be measured (again)

Build in decision support in the EHR, reminding of pain measurement every shift and in case of a high pain score after one hour (f.e. with a pop-up), might lead to more adequate decisions in case (high) pain is measured [16, 17]. If the patient is absent from the ICU at the moment the reminder appears (f.e. the patient has left the ICU to get a surgery or MRI), it should be possible to delay the reminder and measure pain later during the shift.

Actions 4+5+9+10+19

Barrier 12. Pain scores remain high despite pain treatment

Relevant to indicator: 2 – 4 Improvement action Description of improvement action Material16. Check at random

if prescribed pain medication and dosages are correct

Check on the basis of the data in the PDMS or ascertain from random samples whether the correct pain medication and dosage was administered according to the protocol [18].

17. Improve vigilance on and treatment of underlying factors (such as fear) to prevent pain

It is important to recognize and treat underlying factors, such as fear, because patients experience worse pain if they suffer from underlying factors like fear [10].

Actions 4+5+9+10+19


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C. Barriers relating to professional interactions (Work system or structure – Organization)

Barrier 13. There is no culture in which measuring pain is considered important

Relevant to indicator: 1 – 3 Improvement action Description of improvement action Material18. Appoint a pain

coordinator or team to ensure pain policy

Pain policy and quality improvement initiatives can be ensured by appointing a role model or specific team with pain management as special responsibility [19, 20].

19. Organize a special meeting on the importance of pain management (create social support)

By organizing an interactive (theme) meeting on the consequences of not measuring pain and prejudices against medication administration, can lead to a better social culture of pain measurement [15]. It can be helpful to point out a pain coordinator, pain nurse or manager as being responsible for the educational sessions [12].

Actions 8+9+10+21

Barrier 14. Pain status is not sufficiently communicated at shift change or medical transferRelevant to indicator: 2 – 3 – 4 Improvement action Description of improvement action Material20. Ensure pain status

is communicated during shift change or medical transfer

When the pain status is handed on sufficiently, by f.e. taking up pain as a fixed part of ‘neu-rologic status’ and paying specific attention to high pain scores (VAS/NRS≥4, BPS≥6, CPOT≥3), pain can be treated more appropriately [21]. Furthermore, health professionals know, cov-ering different shifts, when they are expected to measure pain (again).

Actions 9+10+15+19+21

210 | Appendix H

D. Barriers relating to incentives and resources (Work system or structure – Technologies and tools)

Barrier 15. There is not enough time to measure pain

Relevant to indicator: 1 – 3Improvement action Description of improvement action Material21. Provide feedback

individually when pain was not being measured

When personnel is fed back individually in case pain was not assessed in every patient during a shift or not repeated within one hour, they may become more conscious of the problem [12].

22. Increase effectiveness of work process in such way there is more time to measure pain

By facilitating that pain can be measured or registered in the EHR or PDMS more easily and that is less time consuming, pain will be mea-sured more frequently and on time [11, 22].

Actions 10+13+18+19

Barrier 16. Pain is measured but not registered

Relevant to indicator: 1 – 2 – 3 – 4 Improvement action Description of improvement action Material23. Guarantee

all measured pain scores are registered in the health record

When pain is measured, assure the score is always registered, even when the patient indicated to have no pain. This way of working guarantees all health professionals to gain a clear understanding of the patient’s pain status and to act appropriate to it [23]. It might be of help to oblige pain documentation [12].

Actions 9+10+11+18+19+21

Barrier 17. Pain medication is not prescribed (on time)

Relevant to indicator: 2 – 4 Improvement action Description of improvement action Material24. Take care of

standard available prescriptions of pain medication

When prescriptions of pain medication are standard available this can help to start treatment and lower pain earlier [17].

25. Check for contraindications to pain medications at admission

Existing contraindications can lead to inadequate standard pain medication. By taking up contraindications for pain medication on the checklist (time-out) used at a patient’s admission, alternative medication can be discussed early [6, 24].


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26. Increase autonomy or responsibility of nurses to give pain medication

When nurses have more autonomy or respon-sibility to administer pain medication when needed, treatment of pain can be started sooner, because they are f.e. not dependent of the doctor in attendance. The pain protocol may include the steps nurses can undertake to reduce pain, such as what pain medication nurses can administer when needed, without involvement of the doctor [25].

Actions 10+19

Barrier 18. Responsible doctor is not available on time to prescribe pain medication

Relevant to indicator: 2 – 4 Improvement action Description of improvement action MaterialActions 10+24+25+26

212 | Appendix H

References

[1] Flottorp SA, Oxman AD, Krause J, Musila NR, Wensing M, Godycki-Cwirko M, et al. A checklist for identifying determinants of practice: a systematic review and synthesis of frameworks and taxonomies of factors that prevent or enable improvements in healthcare professional practice. Implement Sci 2013;8:35.

[2] Carayon P, Schoofs Hundt A, Karsh BT, Gurses AP, Alvarado CJ, Smith M, et al. Work system design for patient safety: the SEIPS model. Qual Saf Health Care 2006;15 Suppl 1:i50-8.

[3] Gelinas C, Fillion L, Puntillo KA, Viens C, Fortier M. Validation of the critical-care pain observation tool in adult patients. Am J Crit Care 2006;15(4):420-7.

[4] Gelinas C, Harel F, Fillion L, Puntillo KA, Johnston CC. Sensitivity and specificity of the critical-care pain observation tool for the detection of pain in intubated adults after cardiac surgery. J Pain Symptom Manage 2009;37(1):58-67.

[5] Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault PF, et al. Impact of systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006;34(6):1691-9.

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214 | Appendix I

Appendix I: Performance scores on adequate pain management

Figure I.1 Performance scores on adequate pain management of feedback only group and feedback with toolbox group over time

Topic guide for the telephone interviews | 215

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Appendix J: Topic guide for the telephone interviews

1. Have you consulted the dashboard since previous telephone call?· Alone or with team members?· What components of the dashboard (e.g. performance trend) are you

interested in?2. Which quality indicators did you target for improvement? Why?3. What improvement activities have taken place?

· What barriers did you experience?· What facilitators did you experience?

4. Is the action plan up-to-date?

ICUs with access to the toolbox:5. Which toolbox actions did you find useful? Which ones did you not find

useful? Why?

uva-dare (digital academic repository) improving quality of … · [2] d’amico r, pifferi s,...

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