would i be comfortable in icu? is it really safe?

8/11/2019 Would I be comfortable in ICU? Is it really safe?

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Would I be comfortable in ICU?Is it really safe?

Professor Cliff Hughes

A/Prof Tony Burrell

23 August 2014

Plenary 3


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Australia?


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Australia?


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Australia?

Home to seven of the worlds most deadly snakes!


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The ICU is a dangerous place

High error ratesmost likely to occur in

intensive care units, operating rooms, and

emergency departments (Institute of

Medicine 1999)

Wide range of incidents, inappropriate

medical decisions, adverse drug events,

preventable slips & lapses (unrecognisedomissions in care) and variable

implementation of evidence-based care


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The ICU is a dangerous place

High error ratesmost likely to occur in

intensive care units, operating rooms, and

emergency departments

Wide range of incidents, inappropriatemedical decisions, adverse drug events,

preventable slips & lapses (unrecognised

omissions in care) and variable

implementation of evidence-based care ESPECIALLY FOR RUSSELL


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Lilford Lancet 2004

Structure, process, outcome and

culture


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Structure/Culture

Occupancy After hours discharges = poorer outcomes

Goldfrad et al Lancet 2000

Tobin & Santamaria Med J Aust 2006

Pilcher et al Anaesth Intens care 2007

After hours admissions = ?poorer outcomes Bhonagiri et al Med J Aust 2011

Medical staffing After hours incidents

Nursing staffing Increased nursing staff associated with less adverse

events

Kane et al Med Care 2008

Blegan et al Medical Care 2011


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Process: How we do our business

Incident monitoring Incident/problem recognised at the time

Medication errors

Incidents often not recognised & require different

approach Checklists etc

Communications

Often fragmented, daily goals sheet

Emphasis on appropriateness of care -housekeeping

Growing body of evidence linking improved

process of care with better outcomes


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Outcomes

Morbidity & mortality meetings Traditional

Often mandatory for training programs

Peer review - case by case discussion

The objectives of the surgical M&M conference are tolearn from complications, to modify surgical behaviour

and judgement based on previous experience, and to

prevent repetition of the problems leading to the

complication. (Murayama) i.e. emphasis on

teaching/learning derive knowledge and insight without blame or

derision (quoted by Murayama)

Forum for discussion of major incidents

But not aggregated data


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Risk-adjusted Outcomes

Crude hospital mortality rates are unsatisfactoryfor measuring performance because do not adjust

for case mix or severity of disease

APACHE III, SAPS scoring systems adjust for

variation in patient outcomes that stem fromdifferences in patients and organisations ie

variations in casemix

Risk adjusted scores used to calculate

Standardised Mortality Ratios (SMR) - observed vspredicted mortalityallows benchmarking of ICUs

?helpful indentifying why ICUs are outliers


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OutliersData review

Data qualityespecially GCS

SMR of ventilated patients

SMR of acute pneumonia

SMR of cardiothoracic patients SMR of deteriorating patients/medical

emergencies admitted from the wards

SMR end-of-life Not much help


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Outlier

NB SMR

NSW Tertiary unit funnel plot (2009):


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Syrec study

79 ICUs in 76 hospitals in Spain 591/1017 (58%) patients suffered incidents (n=1224)

943 = no harm events

481 = adverse eventstemporary damage (29%) and

permanent damage or death (4%)

Causes: Medication (74%)

Equipment (15%)

Nursing care (14%) Accidental removal of vasc devices & catheters (10%) or

Airways & mechanical ventilation (10%)

Avoidable in 79%

Merino et al Int J Qual Health Care 2012


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Other Work

Performance level failures most commonly preventableslips and lapses

Rothschild et al Crit Care Med 2005

SEE Study 25.5% unintended events were ADEsincluding wrong drug in 39/147Valentin Intensive Care Medicine 2008

187 errors (3.3%) - vasoactive drugs (32.6%),

sedatives/analgesics (25.7%) & wrong infusion rate 71(40.1%) Calabrese et al Intensive Care Med 2001


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Incidents by principal incident type - NSW ICUs 2010


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Primary problem as perceivedby the notifier

Administration - 79

Prescribing - 28

Narcotic controlled drug

discrepancy - 17

Dispensing - 12 Storage/Wastage/Security - 11

Delivery - 5

Supply/Ordering - 5

Undesired drug effect drug

therapeutic use - 2

Presentation - 0

Total - 159

Diazepam - 3 Frusemide - 3

Nimodipine - 3

Noradrenaline - 3

Pantoprazole sodium - 3

Amiodarone hydrochloride - 4

Cephazolin sodium - 4

Heparin - 4

Midazolam - 4

Oxycodone - 4

Vancomycin hydrochloride - 4

Heparin sodium - 5 Morphine sulfate - 5

Fentanyl - 9

Morphine - 11

Total69

NSW Medication errors q3 2011


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Many medication errors are not recognisedmanyare acts of omission

Only a fraction of ADEs are identified by incidentreports

One study examined 55 ADEs

15 preventable

26 serious or life threatening but only 2 had incident

reports Conclusionvoluntary reporting identified only a

small fraction of ADEsCullen et al Jt Comm J Qual Improv 1995

Most errors go unreported


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Competency

All staff are competent to provide care to the patientsat the level at which they have responsibility

procedures, decision making, supervision

Competency to assess technical and non-technical

skills

Airway managementNB after hours

CVL insertion

Intercostal tube


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Airway incidents62.5% between 1600-0700


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High stress environment, fatigue, task saturation,

interruptions and reliance on MEMORY

Lack of knowledge

Medication safety management is complexprocessprescribing, preparation - between 80

200 steps

Errors in order writing are the most common

medical error - illegibility, mistakes in

transcription

Patient identificationask Cliff

Why do medication errors occur?


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NSW CVL Incidents 2008-2011 n=572


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Air Embolism

Incident report of death after removal of a

central line while patient was sitting upa

never event

Review of all incidents 2008-2014:

Reported cases

Two survived

6 died

RCA Causal statements:

Too difficult to put patient in bedI knew about policy but I was too busy


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Air Embolism


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Air Embolism


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Every day patients are not getting basic care

Routine care ie FASTHUG could happen

automatically and consistently with the use

of a checklist

Increasing evidence to show that checklists

are very useful in the ICU

Checklists


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A checklist in the intensive care environment could have thefollowing advantages:

Immediate patient safetyi.e. ensuring that the patientgets what he/she needs immediatelysafety lesson fromaviation

Educational toolconstant repetition reinforces theprinciplee.g. BSL


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71% pts had pain assessed by medical team

on the study day

Of the 115 patients in pain, 42% did not have

pain score recorded


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A pressure area risk assessment tool had not

been used in previous 24 hrs for 31%

110 pts (17%) had one or more pressure

areas, of these: 35% no risk assessment tool used

23% no targeted interventions

implementedElliott, McKinley, Fox Am J Crit Care 2008

Pressure Areas


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Significant number of dangerous human errorsattributed to problems of communication

Donchin, Gopher, Olin et al Qual Saf Health Care 2003

Staff often unclear about management planasfew as 10% residents & nurses in one studydaily Goals Sheet

Pronovost et al J Crit Care 2003

75% ward round time spent on communicationsconversation-initiating interruptions occurredat 14 /hour37% communication time

Alvarez, Coiera Int J Med Inform 2005

Communication


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Good Communication:

Accurate information exchange.

Enables us to:

Learn essential information

Share information

Form bonds Foster understanding

Grow

Express our needs and feelings

Learn of others needs and feelings

Connect in meaningful ways


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Communication In Health

Occurs between practitioners, patients, managers, consumers, community

Writtenemails, correspondence, newsletter, prescriptions, policies, posters,

noticeboards

Oralbedside manner, performance feedback, coffee room chat, managerial

style

Filteredimplied vs intended

Often life-threatening consequences if get it wrong


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In Health, multi-disciplinary

often means multi-lingual

Acronyms

Medi-speak

Nurse-speak Allied-speak

Clinician-speak

Manager-speak

Patient-speak

Bureau-speak


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Non-Verbals: c93% of the message


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NSW Central Line AssociatedBacteraemia

ICU Project

AR Burrell, M-L McLaws, A Pantle, M Murgo, E Calabria

Financial costs of CLAB


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Financial costs of CLAB

US estimates

15 680 lives and $1.3 billion medical costs could be saved annually by

reducing the number of CLABS*

The US Agency for Healthcare Research and Quality recently committed $3

million over 3 years to help reduce the incidence of CLAB

United States House of Representatives Committee on Oversight and Government

Reform Staff Report September 2008, Survey of State Hospital Association:

Practices to prevent hospitalassociated bloodstream infections

Health Care Advisory Board, Daily Briefing, 10 February 2008


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NSW CLAB-ICU

Top down/bottom up project NSW Intensive Care Coordination & MonitoringUnit and Clinical Excellence Commission

Methodology modelled on the work of Pronovost et al.

The project promoted a standardised insertion technique including: Hand washing

Full barrier precautions during insertion

Cleaning skin with chlorhexidine Avoiding femoral site if possible

Removing unnecessary catheters

Also included a retrospective review of all incidents entered into the NSWIncident monitoring system


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Guideline and checklist

8thApril 2014 C F Hughes


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Checklist detail


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Minimum practical requirement

and assessment

Observe

minimum of

1 insertion

Perform minimum of

3 supervised

insertions at each site

Perform

minimumof 5independent

insertions

Final

signoff

Practical

assessment

Theory

assessment

Continuingl

earning


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Results

Data on 10,890 line insertions Concurrent incident review:

Retained/lost guidewires

Arterial puncture

Multiple passes

Inadequately secured lines

Inadequate position check prior to use

Lack of access to ultrasound equipment

Policy breaches

Training & supervision common themes

Safety Alert for guidewires issued

Training framework developed


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Checklist Compliance:all ICUsJuly 07Dec 08Data on 10,890 line insertions

Competency assessed 48.3% (22.9% no, 28.8% missing)

Hat, mask, eyewear 79.9%

Hands washed 2 mins 91.6%

Sterile gown/gloves 95.9%

Alcoholic chlorhexidine prep allowed to

dry

95.8%

Entire patient draped 93.4%

Sterile technique maintained 95.6%

No multiple passes 80.9%

Confirm position radiologically 74.3%


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Impact of compliance

Non compliance with the clinician bundle: relative risk of CLAB was RR 1.62 (95% CI 1.1-2.4,

p=0.0178)

For central lines RR 1.99 (95% CI 1.2-3.2 ,

p=0.0037) For PICC RR 5.08 (95% CI 1.03-25 , p=0.059)

Dialysis cathetersno difference

If compliant with both clinician bundle and patientbundle then risk of CLAB was RR 0.6 (95%CI 0.4-0.9,p=0.0103)


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ResultsProgress


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The single biggest problem in

communication is the illusion

that it has taken place.

George Bernard Shaw


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Thank you

For further information:

www.cec.health.nsw.gov.au

would i be comfortable in icu? is it really safe?

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