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CHAPTER 5: Preventing Morbidity in the ICU 33

Basic Human Knowledge 2. Identify local barriers to practice compliance: Once key inter-
Biomedical Clinical Translation ventions are identified, the next step is to actively investigate and
Research Research Research remedy local barriers to effective implementation (walking through
Improved the process). This is achieved by attempting to implement the prac-
Health tice (documenting all necessary steps), observing others doing it,
Understanding Identifying Ensuring patients and asking them about difficulties. Such a process can reveal where
disease effective get the right defects are likely to occur or where specific systems do not support
biology therapies therapies
evidence-based practice—in short, identifying why it is sometimes
FIGURE 5-1. The trajectory from basic biomedical research to improved patient outcomes difficult for clinicians to comply with recommended practices.
is illustrated. Knowledge Translation research helps ensure that proven therapies from human For example, intensivists may be aware of and agree with LPV
clinical research are used safely and effectively to reach the goal of improved health for patients. use, but find it difficult to know if they are actually compliant. 19-25
Moreover, accurate measurement of the patient’s height is neces-
■ A TAXONOMY OF PATIENT SAFETY ISSUES sary in calculating predicted body weight, but height is frequently
missing from the patient chart, resulting in unintentional noncom-
Fundamental to improving patient safety in the intensive care unit is pliance with LPV. 19,24-26
the ability to design systems of care that reliably deliver evidence-based 3. Measure performance: Once an intervention has been chosen
interventions and reduce preventable harm. Achieving this objective at and specific practice behaviors have been developed, perfor-
the local level will require an institutional investment of resources and mance should be measured to evaluate how frequently patients
a reordering of priorities to create and support a true culture of safety. who should receive a specific therapy actually receive it (process
With these goals in mind, it is imperative to use a systematic and multi- measures), or evaluate whether patient outcomes have improved
disciplinary approach and involve all stakeholders. (outcomes measures). Both types of performance measures have
In strategizing such an approach, it will help if a conceptual frame- strengths and weaknesses. In the ALI case example, compliance
work of safety issues and solutions is created to guide team efforts and with LPV varies with changes in ventilator settings during a
ensure common points of dialogue. Dy and colleagues have described patient’s ICU stay. Therefore, researchers must define the timing
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a consensus classification for patient safety practices in an effort to and frequency of measuring LPV, and determine what ventilator
provide a common language for interpreting patient safety literature. settings should be included in the definition of compliance. In gen-
Another approach, categorizing patient safety efforts into general eral, more frequent measures will provide a better but burdensome
themes, can be useful in focusing efforts to improve the culture of understanding of performance over the patient’s entire ICU stay.
safety within a particular intensive care unit. For example, the following 4. Ensure all patients receive the therapy: To change practice, qual-
project framework can serve as a starting point for a unit-based safety ity improvement teams can undertake a four-step process that
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program: involves engaging, educating, executing, and evaluating. Engage
A. Translating evidence into practice: With the majority of research clinicians by using local estimates of patient harm so clinicians
funding and efforts to date focused on understanding disease mecha- recognize the impact of noncompliance with evidence-based prac-
nisms and identifying effective therapies, there is little evidence tices in their clinical area. For ALI, this could be estimating the
describing how to effectively, efficiently, and safely deliver these number of preventable deaths based on prevalence of LPV nonuse
therapies to patients. Thus, errors of omission (failure to provide in ALI patients in an ICU. Clinician education is important to
evidence-based therapies) that result in substantial preventable harm ensure they know the evidence, agree with it, and understand the
to patients represent a significant challenge for health care in general, actions needed to comply with the evidence. Executing the inter-
for the individual hospital or critical care unit. Multiple methods vention to improve compliance with the evidence often requires
seek to increase the reliable delivery of evidence-based therapies some fine-tuning of the process to overcome local barriers. Change
to patients. These methods include evidence-based medicine and can often be achieved by using a checklist or other interventions
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clinical practice guidelines, professional education and development, to standardize care, or by defining a “care bundle” to ensure that
assessment and accountability, patient-centered care, and total qual- all patients meeting certain criteria receive the intervention(s). For
ity management. Unfortunately, most of these efforts focus exclu- ALI, that could mean requiring that patient height be recorded
sively on changing the physician’s behavior. Yet physicians are part of in the electronic medical record, stocking tape measures in each
a health care team, and little research has assessed how an entire team patient room, modifying rounding templates to prompt clini-
can improve the reliability of care. cians to record and report plateau pressure and tidal volume
A four-step process has been developed and successfully used measured in mL/kg of predicted body weight, or using prescribed
20,22,25,26
to reliably translate research into practice within the intensive care order sets and decision-support tools when providing LPV.
unit. 15,16 This model engages an interdisciplinary team to assume Performance should be evaluated with timely and accurate mea-
ownership of the improvement project, is based on evidence and sures and reported back to clinicians.
performance measurement, and creates a collaborative culture that is B. Working as a team: Although measuring harm rates and using effec-
essential for sustaining results. The steps are described below with an tive therapies are important for safety, they are insufficient without
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example of best practices for ventilation of acute lung injury patients. teamwork and a culture that embraces safety. An organization’s abil-
1. Summarize the evidence: Medicine traditionally summarizes ity to change is driven by its culture, which in turn has a significant
research evidence into practice guidelines that are scholarly but impact on safety. 29-31 Indeed, failures in communication, a pertinent
often impractical for bedside use. Guidelines fail to prioritize element of culture, are a common cause of sentinel events in health
lengthy lists of recommendations, are often ambiguous, and may care in the United States. 32
not guide practical clinical decision making. To change practice, The Comprehensive Unit-Based Safety Program (CUSP) is a
the evidence must be concisely summarized into several key comprehensive and longitudinal program designed to improve local
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33
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interventions described in an unambiguous manner. For example, culture and safety. It evolved from an eight-step to a five-step
the evidence supports the use of lung protective ventilation (LPV) program (Table 5-1), and is supported by a Web-based project man-
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for patients with ALI, which can be concisely defined as provid- agement tool. The CUSP is designed to be adopted by individual
ing a tidal volume 6 mL/kg of predicted body weight (based work units or care areas. Everyone that provides care within the unit
exclusively on patient sex and height) and a plateau pressure of is involved in CUSP, from physicians to nurses, pharmacists, admin-
<30 cm H O. 17,18 istrative clerks, and other support staff. The program also leverages
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