Page 72 - ACCCN's Critical Care Nursing

Quality and Safety 49

reporting specific benefits of PDA use such as having effective elements of this technology in critical care
access to readily available data, validation of thinking settings. 102,108
97
processes and facilitation of care plan re-evaluation. In In addition to remote patient assessment and manage-
critical care, PDAs have been used to document clinical ment, telecommunications have been used to deliver
activities, such as logging critical care procedures, which continuing education to rural healthcare professionals
was demonstrated as feasible and useful, although adop- for many years via audio, video and computer. More
109
98
tion and user acceptance was not uniform. They have recently, distance education has been delivered via web-
also been used to deliver point-of-care decision support based courses accessed over the internet. For example,
110
84
99
to improve antibiotic selection and prescribing, and a web-based educational tool was used to provide infor-
an interactive weaning protocol that assisted care provid- mation about the classification of pressure ulcers and the
ers wean patients from mechanical ventilation more effi- differentiation between pressure ulcers and moisture
ciently when compared with the use of a paper-based lesions to both student and qualified nurses. The poten-
111
weaning protocol. 100
tial use of web logs or ‘blogs’, online communities and
112
110
The benefits of this mobile computing also create con- virtual preceptorships in nursing education has also
cerns, particularly regarding confidentiality of patient been discussed. Continuing professional development
information. Health services therefore need policies for (CPD) opportunities are also provided on-line, for
managing handheld devices, including password protec- example AusmedOnline contains a range of resources
tion, data encryption, authenticated synchronisation and and learning activities that count towards CPD for regis-
physical security. In particular, wireless applications tration requirements. However, more work is required to
95
require appropriate standards for data security (e.g. determine how successful these technological advances
78
wireless-fidelity protected access 2 [WPA2] compliance). are on educational outcomes. 113
As these issues are addressed, these technologies will
form an integral component of routine clinical practice PATIENT SAFETY
in critical care.
114
The signing of the Declaration of Vienna in 2009
(Appendix A4) committed critical care organisations
Telehealth Initiatives around the world, including the World Federation of
114
Remote critical care management (eICU) using Critical Care Nurses, to patient safety. Patient safety is
telemedicine/telehealth technologies is expanding as the viewed as a crucial component of quality. Over the
115
necessary high bandwidths for transmitting large amounts years, numerous definitions of patient safety have emerged
of data and digital imagery become available between in the literature. The Institute Of Medicine described it
116
partner units or hospitals. Videoconferencing functions as the prevention of harm, however, more recently, the
enable direct visualisation and communication of patients European Agency, Safety Improvement for Patients in
117
and on-site staff with the ‘virtual’ critical care clinician Europe, asserted it was about identifying, analysing and
or team. Review of real-time physiological data, patient minimising patient risk. This latter description is appeal-
flowcharts and other documents (e.g. electrocardiograms, ing as it leads us to consider the degree of risk situations
laboratory results) or images (e.g. radiographs) provide a pose for patient harm and targeting those that are either
comprehensive data set for patient assessment and high risk or frequent in occurrence.
management. 101
Three techniques used to understand patient risk are ana-
This technology-enabled remote care initiative is of par- lysing reports of adverse events, root cause analyses and
ticular value for critical care units where no or limited failure mode and effect analysis. Recent research on
on-site intensivist resources are available. Despite various adverse events in critical care has helped to both better
102
methodological limitations, several studies using understand patient risks and target improvement activi-
‘before and after’ comparisons have indicated improved ties. For example, medications, indwelling lines and
outcomes such as decreases in severity-adjusted hospital equipment failure were the three most frequent types of
mortality, incidence of ICU complications, ICU length adverse events in a study of 205 Intensive Care Units
1
of stay, and ICU costs. 101,103,104 One study demonstrated world-wide. Focusing on analysing the narratives written
improved outcomes for neurological ICU patients about adverse events is viewed as an important way to
through the use of a robotic tele-ICU system that made learn from errors. Root cause analyses is a structured
104
rounds in response to nurse paging. More recent process generally used to analyse catastrophic or sentinel
studies, however, have not found improvement in patient events. 118,119 Learning from both incident reporting such
outcomes as a result of telemedicine technology, 105-107 as AIMS and root cause analyses is based on the premise
highlighting the complex nature of these initiatives that the information they contain is of sufficient quality
and the difficulties evaluating them. One local study to allow accurate analysis, interpretation and detection of
instead observed improvements in patient management the root causes of problems, and even more importantly,
(i.e. increased discharges and decreased transfers) for the formulation and implementation of corrective actions.
moderate trauma patients upon implementation of a Failure mode and effect analysis identifies potential
virtual critical care unit that linked a district hospital failures and their effects, calculating their risk and
120
ED with a metropolitan tertiary hospital ED. Further prioritising potential failure modes based on risk. In
studies that include detailed descriptions of system addition to examining patient risk, another strategy has
implementation are required in determining the most focused on understanding the safety culture of a unit or