Page 66 - ACCCN's Critical Care Nursing

Quality and Safety 43

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Quality in Australian Health Care Study (QAHCS) and during patient assessment is the ‘FASTHUG’ which stands
the Australian Council on Healthcare Standards (ACHS) for Feeding, Analgesia, Sedation, Thromboembolism pro-
33
indicators. Current ACHS indicators for intensive care phylaxis, Head-of-bed elevation, stress ulcer prevention
39
include: and Glucose management. Along with care bundles and
checklists (detailed below) these tools facilitate stan-
● inability to admit a patient to the ICU due to inade-
quate resources dardised care and improve communication between
38
● elective surgery deferred or cancelled due to lack of clinicians.
ICU/HDU bed
● patients transferred to another facility due to unavail- CARE BUNDLES
ability of an ICU bed An evolving QI approach to the optimal use of best prac-
● delays on discharging patients from the ICU of more tice guidelines at the bedside is the development of ‘care
than 12 hours bundles’. A care bundle is a set of evidence-based inter-
● patients discharged from the ICU after hours (i.e. ventions or processes of care, applied to selected patients.
between 6pm and 6am) A number of bundles have been developed for critical
● recognising and responding to clinical deterioration care by the Institute for Healthcare Improvement (IHI) in
within 72 hours of being discharged from ICU the USA (see Table 3.6).
● patients being treated appropriately for VTE prophy-
laxis within 24 hours of admission to the ICU Table 3.7 outlines studies examining the process of
● ICU central line-associated bacteraemia rates care delivery in critical care units, including those
● use of patient assessment systems (participation in where care bundles were implemented and evaluated.
national databases and surveys). 33 Increased bundle compliance was associated with
decreased ICU length of stay (LOS), reduced ventilator
Similar activities are evident internationally, where con- days and increased ICU patient throughput, and
40
cepts of ‘safety science’ (error reduction and recovery) are decreased rates of ventilator-associated pneumonia.
41
being applied to critical care practice. 29,34-36 Process indi- Other quality improvement studies targeted similar pro-
cators of quality care have been developed, including care cesses of care without taking the bundled approach. A
related to the prevention of ventilator-associated pneu- range of measures demonstrated improved outcomes:
monia (VAP) and central venous catheter management.
Table 3.5 outlines process indicators with good clinical ● decreased VAP, 42,43 catheter-related bloodstream infec-
evidence and/or strong recommendations for use by tion (CR-BSI) rates and LOS 43
professional bodies, such as the Agency for Healthcare ● increased days between CR-BSIs 44
Research and Quality (AHRQ) in the USA. ● decreased hospital mortality as the number of process
interventions increased 45
A range of clinical support tools have been developed and ● reduction in severity-adjusted total hospital costs
are used to measure compliance with these best practice related to improvements in process measures of care,
clinical standards. Daily goals forms, for example, have including glucose control, use of enteral feeding and
been used to aid communication between clinicians appropriate sedation. 46
during and after multidisciplinary ward rounds and
ensure that all staff are aware of what care the patient Although studies revealed improvements in both pro-
should be receiving and what the clinical plan is. 37,38 A cesses and outcomes, variation in levels of compliance
popular mnemonic developed for use by ICU clinicians with process measures were also reported (see Table 3.7
47
for detail). One study revealed the more unwell the
patient was, the less likely they were to have received
practices they were eligible for.
TABLE 3.5 Evidence based process indicators
CHECKLISTS
Process Process indicator
Checklists have the potential to prevent omissions in care
1. Central venous Maximum sterile barriers by serving as reminders to healthcare providers for the
catheter Real-time ultrasound guidance during delivery of appropriate quality care for every patient,
management insertion every time, in complex clinical environments. A checklist
Antibiotic-impregnated catheter
typically contains a list of action items or criteria arranged
2. Prevention of Elevated head of bed in a systematic way, allowing the person completing it to
ventilator- Continuous aspiration of subglottic record the presence or absence of individual items to
associated secretions 48
pneumonia Stress ulcer prophylaxis ascertain that all are considered or completed.
3. Reducing Low tidal volumes for acute respiratory In critical care settings, checklists have been used to facili-
mechanical distress syndrome tate staff training, detect errors, check compliance with
ventilation Weaning protocols safety standards and evidence-based processes of care
Sedation protocols
Appropriate use of analgesia and sedation (such as those outlined previously), increase knowledge
of patient-centred goals and prompt clinicians to review
4. Pressure ulcer Use of pressure-relieving materials certain practices on morning rounds in the ICU. Findings
prevention
from studies noted that checklists: