Copyright © 2016 Carla A. Chrusch et al. 0000037007 00000 n There were five candidate indicators that all participants agreed met all the selection criteria. TE�A�ض��EX��7V+-��G �{�!YZ��4kR��:y��A�܎1O�*=V�m ��#�Ma�|�'\� 157, no. Percent readmissions per month as p-charts in small multiples. 0000004413 00000 n We also identified challenges with the collection of indicators relating to patient satisfaction and staff work life that require establishing entirely new processes of data collection directly from patients/families and from hospital finance, respectively. ; Department of Medicine, McGill University, Montreal, QC: Denny Laporta, M.D. Krayem, R. Butler, and C.Martin, “Unplanned extubation in the ICU: impact on outcome and nursing workload,” Annals of Thoracic Medicine, vol. All critical care admissions were captured in local data sets that contain patient demographic information, admission diagnoses, a severity of illness measure, admission and discharge times, ventilation days, and mortality. The iMobile team wished to improve the quality of critical care discharge summaries. Number of patients identified as MRSA positive from surveillance or clinical samples obtained within 24 hours of ICU admission, calculated as cases per 1000 ICU discharges. 71–75, 2006. Using factor analysis, Doll and Torkzadech [13] identified and validated five components of end-user computing satisfaction: content, accuracy, format, ease of use, and timeliness. The results of the survey supported the decision to use control charts for data display but also pointed out that education would be needed for end-users to get maximum value from them. Abbreviated definitions are shown for all quality indicators in Appendix A and an example of a detailed operational definition is shown in Appendix B. Process Quality Improvement in Radiology ment—is an integral part of an improvement project; second, team members and stake-holders must keep an open mind regarding what organizational changes will best meet the project objectives; and third, uncertainty of the likelihood of success often is greater for improvement projects than for implemen - Transfers may be required for medical reasons (need for a medical service/intervention not available at the initial hospital) or as part of ICU bed management, calculated at percent of live ICU discharges. Canadian jurisdictions with established ICU clinical databases were invited to participate in an iterative series of face-to-face meetings, teleconferences, and web conferences. Acknowledgements P. M. Atkins, L. C. Mion, W. Mendelson, R. M. Palmer, J. Slomka, and T. Franko, “Characteristics and outcomes of patients who self-extubate from ventilatory support: a case-control study,” Chest, vol. 0 Two more indicators (patient/family satisfaction and nurse absenteeism) were added based on the defined domains, bringing the total to 20 quality indicators. B. Sexton, J. C. Pham, C. Goeschel, B. D. Winters, and M. R. Miller, “Measurement of quality and assurance of safety in the critically Ill,”, A. D. Slonim and M. M. Pollack, “Integrating the Institute of Medicine's six quality aims into pediatric critical care: relevance and applications,”, M. C. Scanlon, K. P. Mistry, and H. E. Jeffries, “Determining pediatric intensive care unit quality indicators for measuring pediatric intensive care unit safety,”, P. J. Pronovost, S. M. Berenholtz, K. Ngo et al., “Developing and pilot testing quality indicators in the intensive care unit,”, A. Rhodes, R. P. Moreno, E. Azoulay et al., “Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the task force of Safety and Quality of the European Society of Intensive Care Medicine (ESICM),”, C. R. Nicolay, S. Purkayastha, A. Greenhalgh et al., “Systematic review of the application of quality improvement methodologies from the manufacturing industry to surgical healthcare,”, J. Thor, J. Lundberg, J. For example, wasted bed days were derived by dividing the number of avoidable days by the number of days in the month. ICU Length of Stay Calculated from the date/time of ICU admission and discharge. Statistical process control (SPC) charts were used as the primary mode of data sharing and display. 0000004362 00000 n The types of control charts available for data display included p-charts for individual units over time and x-bar charts for comparisons between units. 0000000016 00000 n Adjusting for severity of illness requires additional resources for data collection and adds complexity to the derivation of the indicators. Our process resulted in the selection and development of 22 indicators representing 6 domains of ICU function. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Patient/Family Satisfaction Total score and decision-making and care subscales from the Family Satisfaction-24 survey. 1912–1916, 2000. We are a huge organisation and this project is a unique platform for everyone to build the skills and confidence to turn ideas into improvement. The European Society of Intensive Care Medicine recently agreed upon 9 quality indicators of which approximately half are related to ICU organization and structure [9]. 1317–1323, 1997. Occupancy is a frequently used indicator of unit activity. Unplanned extubation is the unscheduled removal of an artificial airway (endotracheal or tracheostomy tube) due to accidental dislodgement or patient self-extubation. Caring for critically ill patients is complex and resource intensive. Comparative data was circulated and participating sites were required to validate or correct their data. Unit characteristics and average performance. Number of patients that died while under the care of the ICU team or following discharge from ICU during the same hospitalization, calculated as percent of all ICU discharges. 6, pp. be chosen based on usefulness, feasibility, and reliability. Quality Management Plan. For example, rather than sites submitting the rate of unplanned extubations, they instead submitted the number of unplanned extubations and the sum of invasive mechanical ventilation and the rate was calculated centrally. 1, no. One mixed ICU also admitted postoperative cardiovascular surgery patients. 1131–1137, 1998. 0000039372 00000 n The first round identified any undisputed quality indicators. 1317–1323, 1997. A meeting in November 2008 was used to further review the operational definitions, data submission, and data display. Following the conference, the group maintained discussions on a regular basis through a combination of email, teleconference calls, webinars, and internet groups. Refers to transfers to another hospital that occur during an ICU admission. Quality Improvement in Critical Care: Selection and Development of Quality Indicators, The Quality Improvement in Critical Care Project, Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada, Department of Medicine, University of Western Ontario, London, ON, Canada, The Quality Improvement in Critical Care Project, Canada. The Quality Improvement in Critical Care Project has succeeded with 5 Canadian health care organizations to develop and implement a system for sharing and displaying a common set of performance data. Fleck, Mojica, Priestap, and Shahpori performed acquisition of data. Examples of Quality Improvement Projects in Managing and Increasing Efficiencies for Patient Service: Appointments, Discharges, Follow-Up Care, and Emergency Department Service Examples of Quality Improvement Projects in Operational Efficiencies in a Medical Facility Average occupancy is calculated as the sum of the average maximum census and average minimum census divided by twice the number of ICU beds. Patients: All consecutive patients admitted from December 1, 2013, to September 30, 2015. Discussions were facilitated by the quality improvement consultant. o��=�:�g��Q^"G�isaŬ f����T�~b~\�M�Z5����.�513�:�!�ɴSU\��=�j�q��j��m#��tx'I?�f3{�FOD��#u�lbף���?C��&�,��w�-R���̫ ��iˢ�����{x��"��V+ʩZ�'������ G����q�By��EU�w8]� The last major revision to the operational definitions was at a conference in June 2011. Results. Santiago Borasino MD, MPH. Impact of Positive Feedback on Antimicrobial Stewardship in a Paediatric Intensive Care Unit: A Quality Improvement Project. Local data management centres were responsible for ensuring that the submitted data was clean and consistent with the current definitions of the project. For purposes of this paper, all sites resubmitted data consistent with the latest operational definitions to a central office as either Excel spreadsheets (Microsoft Corporation, Redmond, WA) or SAS data files (SAS Institute, Cary, NC) which were merged into a primary dataset. management of analgesia, sedation, and delirium. To achieve this, Nationwide launched an initiative to prevent hospital-acquired harm—a serious issue impacting every hospital—and expanded its quality improvement infrastructure to accommodate more than 150 harm-related projects. The upper and lower control limits are set at 3. (ii)The perspective is for management and quality improvement. Intensive care units were divided into three groups based on their case mix. Potassium Replacement Protocol. Prevalence of Methicillin-Resistant S. aureus (MRSA) Number of patients identified as MRSA positive from surveillance or clinical samples obtained within 24 hours of ICU admission, calculated as cases per 1000 ICU discharges. Data Display XmR statistical process control run chart with 3 sigma limits. Eighteen adult intensive care units across 14 hospitals and 5 provinces participated in the process. Additionally, using a data-driven approach can help engage stakeholders and … Statistical process control charts and graphs of composite measures were used for data display and comparisons. In this paper we have reported the average performance of our indicators. Best reported rates in the literature are <5%. Ventilated patient flow was added to complement patient flow in October 2008 bringing the total to 22 quality indicators (Table 1). An example of a process improvement project is timing of administration of surfactant. In December 2008, participants made presentations of representative data from the project to their respective ICU medical directors, nursing leadership, and hospital administrators. However, a more global description and balanced assessment of critical care performance is needed in order to understand how to make it better. Institute of MedicineInstitute of Medicine Report, A. E. Barnato, J. M. Kahn, G. D. Rubenfeld et al., “Prioritizing the organization and management of intensive care services in the United States: the PrOMIS Conference,”, P. J. Pronovost, J. We are committed to sharing findings related to COVID-19 as quickly as possible. 0000002760 00000 n Sum of invasive mechanical ventilation days in the reporting period: Unplanned extubations may be captured from nursing or respiratory therapist flow sheets or from review of patient incident/hazard/safety reports. r3ps�$3�Y/j2Pk^@�媢C����k��D%��J�W��I�2� A Health Foundation Innovating for Improvement grant (Innovating for Improvement Round 5) supported all phases of this study. Analysis and interpretation of data were performed by all authors. The importance of detailed, iterative review to address this variation cannot be overstated or overemphasized when it comes to comparing data between different institutions and jurisdictions. 112, no. The length of stay encompasses avoidable days. Denominator Sum of invasive mechanical ventilation days in the reporting period: Data Collection Unplanned extubations may be captured from nursing or respiratory therapist flow sheets or from review of patient incident/hazard/safety reports. 5, pp. be based on available evidence, or in the absence of high-level evidence on benchmarks; when using a benchmark, the target will be set at a high level as opposed to an average or median target. Background. 72 33 However, as the uncorrected ventilator utilization ratio was already 0.98 for this unit, the uncorrected ratio was used. Thanks so much!! 0000002528 00000 n Thus, we relied on a manual process for this and the current report is based on the final data submission, rather than real-time data that would be useful for the purposes of performance or quality improvement. One of the initial articles published by ALCCM was “Critical Care Organizations: Business of Critical Care and Value/Performance Building,” which provided a road map and key features to be considered when planning a value-based care program. Project: Creating a quality improvement practicum. 0000002418 00000 n The average performance on the developed ICU quality indicators is shown in Table 2. Calculated from the date/time of ICU admission and discharge. 4, pp. Data for monthly variables was complete with the exception of 3 indicators. ; Reza Shahpori, M.S; Improvement Associates, Edmonton, AB: Bruce Harries, MBA; Department of Medicine, University of Western Ontario, London, ON: Claudio M. Martin, M.D., M.S. 1.5 All Intensive Care Units should appoint a Quality Improvement Coordinator, who will be responsible for the implementation and supervision of the Quality Improvement program. The device must have been in place within the 48-hour period before the onset of infection and for at least 2 consecutive days, reported as VAP per 1000 ventilator-days. (See also Appendix. Mixed ICUs admitted a mix of general medical, surgical, and cardiac patients. A second conference was held on June 6-7, 2007, to review and finalize the list of quality indicators. Each institution is responsible for maintaining a process for recognizing and documenting all unplanned extubations. Figure 2 is an example of an x-bar statistical process control chart with rational subgrouping based on the type of the unit showing marked variation between units in the rate of night discharges. Centres could view their quality indicators as well as those of other participating sites. endstream endobj 73 0 obj <� �l��ʄ�� )/V 2>> endobj 74 0 obj <> endobj 75 0 obj <> endobj 76 0 obj [77 0 R 79 0 R] endobj 77 0 obj <>>> endobj 78 0 obj <>/Type/XObject/BBox[231.21 758.118 363.774 785.955]/FormType 1>>stream Sign up here as a reviewer to help fast-track new submissions. Number of nurses sick hours, calculated as percent of total number of hours. Incidence of ventilator associated pneumonia, Incidence of central line-related bloodstream infections, Incidence of intensive care unit-acquired methicillin-resistant, Prevalence of intensive care unit-acquired methicillin-resistant, Intensive care unit discharges that occur at night, Quarterly indicators-one year 2009Q4-2010Q3, Unplanned extubation/1000 ventilator days, G. W. Ewart, L. Marcus, M. M. Gaba, R. H. Bradner, J. L. Medina, and E. B. Chandler, “The critical care medicine crisis: a call for federal action,”, M. M. Levy, R. P. Dellinger, S. R. Townsend et al., “The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis,”. Consent Rate for Solid Organ Donation The number of neurologic determination of death (NDD) patients for whom consent was obtained for solid organ donation. Another challenge to be addressed is the development of methodologies for dealing with uncommon or rare events [5]. Inclusion of equity as a domain was beyond the scope of this initial project. Quality Improvement (QI) initiatives in the ICU to decrease nosocomial infections and maintenance of normoglycemia have been shown to improve outcomes as well as decrease costs. Ultimately, five healthcare organizations representing 14 hospitals across 5 provinces participated in the development of the scorecard. 2016: Projects [PDF]. This allowed more flexibility in deriving other indicators and in checking for internal consistency. 0000028005 00000 n 270–276, 2007. Experts interviewed for this article cited two nursing-related quality improvement projects they were involved with that were simple, but very beneficial. ; London Health Sciences Centre, London, ON: Fran Priestap, M.S. Similar process control charts, using either x-bar or p-charts, were used to report all indicators on a regular basis. The mean is shown as a solid line and the upper control limit (3, Percent of patients discharged at night. Previous versions were in June 2011. What they did: The University of British Columbia IHI Open School Chapter worked with its university to develop a shadowing program and then a practicum program for medical, undergraduate, health administration, business, and nursing students. Projects have included improving operating room turnover times, reducing operating room case cart discrepancies, … This type of reporting system will demonstrate variation between units and jurisdictions to help identify and prioritize improvement efforts. 2018: Projects [PDF]. ! “Kangaroo Care in the Neonatal Intensive Care Unit: A Quality Improvement Project” [view Project] Julie Lewis BSN, RN, DNP Student “using an Evidence-Based Ventilator-Associated Pneumonia Prevention Bundle with a Compliance Checklist to Reduce VAP Rates” [view Project] Jessica Libla BSN, RN, … 7, pp. 8, no. Patient flow indicates patient throughput and is a reflection of case mix and efficiency. In September 2007, a central, custom web-based application written specifically for this project was implemented to demonstrate how central data upload and data display could work. As the participants in the project represent large urban centres with highly motivated individuals, it is unclear to what extent the results are representative of the rest of Canada. The ICU length of stay was expressed as median and interquartile range in addition to mean. ... any sample obtained hours or m ore a er ICU. On behalf of all authors, the corresponding author states that there are no competing interests. Beth Israel Medical Center 366–371, 2007. Participating hospitals are the following: Calgary, AB: Rockyview General Hospital, Peter Lougheed Centre, and Foothills Medical Centre (2 ICUs); London, ON: Victoria Hospital and University Hospital (2 ICUs); Montreal, QC: Jewish General Hospital; Vancouver, BC: Vancouver General Hospital and St. Paul’s Hospital; Winnipeg, MB: Concordia Hospital, Grace Hospital, Seven Oaks General Hospital, Victoria General Hospital, Health Sciences Centre (2 ICUs), and St. Boniface Hospital (2 ICUs). Clinical practice guidelines recommend ICU patients be assessed for delirium at least once per shift. Over the 3.5-year study period, there were 49,762 admissions with 275,173 patient days. Small multiples are a way to display different slices of a data set. 0000027941 00000 n Additional Resources Bouza, E. Garcia, M. Diaz, E. Segovia, and I. Rodriguez, “Unplanned extubation in orally intubated medical patients in the intensive care unit: a prospective cohort study,” Heart & Lung, vol. Canadian healthcare organizations with established critical care datasets were invited to participate. Interfacility Patient Transfers Refers to transfers to another hospital that occur during an ICU admission. Incidence of Central Line-Related Bloodstream Infections (CLBSI) The number of cases with a laboratory confirmed bloodstream infection associated with a central venous catheter expressed per 1000 line days. This was reiterated at the PrOMIS (Prioritizing the Organization and Management of Intensive care Services in the United States) Conference that identified the lack of a standardized, national performance measurement of critical care services as a major problem [4]. Unplanned extubation may result in patient harm and prolonged length of stay due to loss of the airway and the risks associated with recapture. Graphs were created using OriginPro 7 (OriginLab Corporation, Northampton, MA). Number of unplanned extubations per 1000 invasive mechanical ventilation days. , wasted bed days were missing from the third round, each participant assigned a weight each... The primary mode of data beds versus average monthly occupancy by unit in... Constitutes an ICU bed for more than 4 hours after a transfer order is written is considered.... Disease and providing care for sick patients as evidenced by a ventilator ratio! 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Re, Price KL, Plunkett AC Appendix B ore a er ICU of issues many... Trauma and neurosurgical patients in addition to mean indicator from each of Research... Re, Price KL, Plunkett AC run chart with 3 sigma limits workload and burnout performance project... Of ICU function of composite measures were used as the uncorrected ventilator utilization ratio also uses correction... And nursing leaders as well as case reports and case series related to COVID-19 definitions and nomenclature provide... That a patient occupies an ICU bed is defined as the number of patients a... Requirements of the indicators helpful in revealing patterns and making comparisons an satisfaction! None and organizational and text edits be based on an understanding of past performance, need. June 2007 team conference call based on previous discussions the entire study period ; therefore wasted bed year... Existing workforce and how current staffing influences both workload and burnout and refined using the principles developed at the time. Checking for internal consistency, and anticipated population needs the third round, participant. Amount of time that a patient occupies an ICU bed is defined as the number of leaving! A structured method for generating and narrowing down a list of quality indicators were selected cite Jones! Failure rate the number of beds regularly available for patient care, regardless staffing! 14 hospitals and 5 provinces participated in the literature are < 5 % very active with patient patient... ’ s hospital in Columbus, Ohio, zero harm was the only appropriate goal was favored over the of! That is largely preventable, data submission, and administration scope of this initial.... Projects have shown that one can decrease unplanned extubation number of nurses sick hours, calculated percent. 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Corresponding author states that there are no competing interests influences both workload and burnout each participating site could be in! For the entire study period, there were five candidate indicators from this round were selected was missing the. And prolonged length of stay was expressed as a percent of total number of nurses leaving,! Used is shown in Figures 1 and 2 solid organ donation phases of this study demonstrated with the of! Of Pediatrics, Section of Cardiac critical care: selection and development of quality indicators for comparing characteristics... Unplanned extubations complete with the current definitions of the rate of unplanned extubations examples of quality improvement projects in icu to. Excessive resource use the lower left quadrant, however, maintain a low level compliance... Adjustment were in use by the new reporting system was how to interpret the data under consideration was known for... Derived by dividing the number of nurses sick hours, calculated as a percent of requiring! As those of other participating sites were required to validate or correct their data rounds [ 10 ] collection. Administrators found the system to be representative of 12 continuous months feasibility was with! Committed to sharing findings related to COVID-19 as quickly as possible, the author. Would allow for comparisons with others where data was clean and consistent with current! And narrowing down a list of quality improvement in healthcare covering a wide range of issues facing health. Mixed ICUs admitted trauma and neurosurgical patients in addition, our participants came from with. Ratio was already 0.98 for this article cited two nursing-related quality improvement, epidemiology, administration... Systems can learn from successful clinical examples of quality indicators were selected quality of critical services... 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Hospital in Columbus, Ohio, zero harm was the lack of severity of illness adjustment variation inherent the... Obtained hours or m ore a er ICU, Northampton, MA ) average of rate... Slices of a rate an iterative series of face-to-face meetings, teleconferences, and web conferences to... Appendix B left quadrant, however, maintain a low level of wasted ICU beds design: improvement. All ICU discharges while under the care of the project ICU team, calculated as the primary mode of sharing.

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