Top 10 Recent ICU Quality Initiatives

Plenary session at CHEST 2013 focused on the impact of early warning scores, medical response teams, availability of critical care attending intensivists, and other quality measures in intensive care.

Quality improvement has been an important topic of conversation at many medical conferences since the release of To Err is Human and other landmark reports from the Institute of Medicine 14 years ago. A plenary session given Wednesday at CHEST 2013, the annual meeting of the American College of Chest Physicians, discussed the top 10 recent quality initiatives in intensive care medicine.

According to “Top 10 Quality Initiatives in Critical Care,” the most important quality initiative in terms of potential benefits was determined to be “Establishing a Culture of Quality,” which includes everything from adhering to the latest guidelines and recommendations to measuring progress according to the metrics and standards in the annual Hospital Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality. Number 2 on the most important quality initiative list was a focus on handoffs, important transition points that are a frequent source of medical errors, especially in the ICU, due to the unstable nature of patients’ conditions.

One of the most novel issues identified in the list was the concept of “situation awareness,” described in the January 2013 issue of Pediatrics, and ranked as number 8. “This is not intuition, but attempting to quantify the intuition of an experienced provider,” explained Christopher Carroll, MD, associate professor of pediatrics at Connecticut Children’s Medical Center in Hartford, who gave the presentation.

“It means taking into account the overall situation, and this strategy attempts to replicate what a really good, experienced provider might do, looking at that patient at that time with the resources available and the risks that the patient might have, and putting it all into context,” Carroll added.

Number 9, “Early Warning Scores,” is effective at preventing errors once the patient has been admitted, but is not as effective in helping to determine which patients ought to be admitted to the hospital in the first place, said Carroll.

“Traditionally, early warning scores are codes, such as a code blue event on the floor,” he explained. “You want to prevent acute deterioration, such as respiratory arrest, cardiac arrest, or a neurological arrest (basically a seizure),” he said.

Number 10 on Carroll’s list was “Medical Response Teams,” which may include a physician, a mid-level provider, a critical care nurse, and a respiratory therapist, and can be quickly deployed without a change in the early warning score by any provider or perhaps even a family member.

A number of articles have quantified the reduction in code events associated with medical response teams outside the ICU; for example, Brilli et al in “Implementation of a Medical Emergency Team in a Large Pediatric Teaching Hospital Prevents Respiratory and Cardiopulmonary Arrests Outside the Intensive Care Unit,” found that code events declined from 0.27 per 1,000 patient days to 0.11 events after the institution of medical response teams (p=0.03), while Sharek et al found that they declined from 0.52 to 0.15 (p=0.008), and that mortality declined from 1.01 deaths per 100 discharges to 0.83 (p=0.007), the slide said.

Initiative 7 was in-house coverage from a critical care attending intensivist; number 6 was resident work hour restriction; initiative 5 was patient-centered quality indicators, and number 4 was point of care ultrasound, while initiative number 3 was ‘Checklists/Care Bundles/Protocols,’ according to Carroll.