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Patient Safety and Quality Healthcare
September / October 2007

Critical Care Safety Essentials

The critical care setting is one of the most complex environments in a healthcare facility. Critical care units must manage the intersecting challenges of maintaining a high-tech environment and ensuring staff competency in operating the equipment, providing high-quality care to the facility's sickest patients, and tending to the needs of staff members working in a very stressful environment. While other hospital units may need to manage one or two challenges at a time, critical care settings must manage them all simultaneously while remaining focused on the delivery of safe patient care.

Several important factors play a role in fostering patient safety in the intensive care unit (ICU) environment and are discussed in this article. These strategies include the following:

  • Having a culture that supports and promotes safety activities.

  • Operating an ICU structure in which the care of ICU patients is directed and managed by intensivists — physicians with specialized training in critical care medicine.

  • Ensuring that the work environment can support the ability of caregivers to interact productively, make vital decisions, and perform medical interventions and operate medical equipment safely.

Complications in Critical Care
Before building initiatives to enhance safety, healthcare managers must understand the extent of patient injuries and events in ICUs. Critically ill patients are at high risk for complications due to the severity of their medical conditions, the complex and invasive nature of critical care treatments and procedures, and the use of drugs and technology that carry risks as well as benefits.

In addition to complications of care, adverse events and errors — many of which are serious — are major risks in ICUs. The 2005 Critical Care Safety Study, published in the August 2005 issue of Critical Care Medicine, found that adverse events in ICUs occur at a rate of 81 per 1,000 patient-days and that serious errors occur at a rate of 150 per 1,000 patient-days, supporting the findings of an earlier study indicating that nearly all ICU patients suffer potentially harmful events.

Nearly half (45%) of the adverse events in the Critical Care Safety Study were deemed preventable. Common ICU errors are treatment and procedure errors especially errors in ordering or carrying out medication orders; errors in reporting or communicating clinical information; and failures to take precautions or follow protocols.

Getting Started
Any ICU patient safety improvement process must start by engaging leadership. Although the data on ICU adverse events and complications is compelling, risk managers, patient safety officers, and critical care clinicians should work together to make a business case to executives for patient safety investments.

Once leadership support is obtained, implementing ICU safety becomes a team effort, supported at all levels. There must be a clearly articulated plan for improvement developed with input and involvement from frontline staff that is understood by all managers, clinicians, and staff members. Identifying a specific group of individuals responsible for initiating, coordinating, monitoring, and communicating ICU safety improvements is a primary step in the process. Whether the group is an existing patient safety committee, a newly formed ICU task force, or some other combination of individuals depends on the facility's structure, knowledge base, and resources. The group can expect to be involved in education and training, communication, and baseline data gathering, which should include a safety assessment of the critical care units in the hospital.

Critical-Care Safety Assessment
Patient safety experts note that improvement initiatives are more successful in environments in which a culture of safety exists. A culture of safety flourishes in an ICU environment in which clinicians and frontline staff feel they are part of a team and understand how to exchange patient information and other information in a meaningful and respectful way. Absent a culture of safety, individuals expected to implement ICU safety initiatives do not know how best to work together or how to communicate most effectively. Therefore, before other patient safety practices are introduced, the healthcare facility must cultivate a culture of safety in its critical care units.

A starting point for improving safety culture in the ICU is to conduct an assessment of the current culture (or climate) in the critical care unit or units to determine whether and how it affects patient care. A survey of the safety culture should measure aspects of the units that affect patient safety as well as attitudes of clinicians and staff members. Such aspects include perceptions of leadership's commitment to patient safety, the degree to which teamwork and open communication prevail, and attitudes about nonpunitive response to error.

Many safety surveys and assessment tools are available. The committee or task force with oversight for critical care safety improvement should evaluate various assessment tools in light of the goals for ICU patient safety improvement.

Examples of such tools include a sample safety attitudes questionnaire from the University of Texas's (Houston) Center of Excellence for Patient Safety Research and Practice (available online at http://www.uth.tmc.edu/
schools/ med/imed/patient_safety/survey&tools.htm
) and a Critical Care Patient Safety Self-Assessment Questionnaire, developed by ECRI Institute (Plymouth Meeting, PA). The Self-Assessment Questionnaire gathers information about the following areas: staffing, structure, and model of care; safety culture; patient safety and risk management; and environment and technology. Sample questions from ECRI Institute's questionnaire are listed in the sidebar, "Sample Questions for a Critical Care Patient Safety Assessment."

The real work — setting priorities for action, making changes to improve safety, and measuring the effectiveness of the interventions — begins after survey and assessment results are communicated to staff and managers.

ICU Structure and Staffing
A facility's approach to providing safe critical-care services will depend largely on the way the ICUs are organized, staffed, and designed. Work environment also affects the ability of ICU staff to deliver quality care.

Generally, there are three organizational models for ICUs: the open model allows many different members of the medical staff to manage patients in the ICU; the closed model is limited to ICU-certified physicians managing the care of all patients; and the hybrid model, which combines aspects of open and closed models by staffing the ICU with an attending physician and/or team to work in tandem with primary physicians.

An overwhelming majority of ICUs in the United States use the "open" model of care, although the disadvantage of this model is the variety of medical staff members who attend to patients. Recent studies (Chang et al., 2005; Pronovost, et al., 2003; Rainey & Combs, 2003) suggest that the ideal organizational structure for the ICU is a closed unit staffed by dedicated intensivist physicians. These studies have demonstrated that hospitals with intensivists in their ICUs have lower hospital and ICU mortality rates, lower ICU and hospital lengths of stay, and are more effective and efficient in providing care. Similarly, the hybrid model ensures the presence of a critical-care-trained physician in the ICU who can make rounds and provide consultation regarding the care of critically ill patients, lending a higher level of expertise to the provision of critical care services. As more evidence supports the importance of other models to improved patient outcomes, reliance on the open model is slowly waning.

As with all medical providers, appropriate credentialing mechanisms should be in place for clinicians who manage patients in the ICU. The granting of clinical privileges based on education and level of skill is an issue of paramount importance to patient safety in the critical care setting. The Society of Critical Care Medicine (SCCM), representing healthcare professionals in critical care medicine, sets forth guidelines for granting privileges for the performance of high-risk, high-volume procedures such as central-venous catheterization, pulmonary artery catheterization, airway intubation, mechanical ventilation, and cardioversion and defibrillation. Also, SCCM recommends that non-ICU-certified physicians who care for critically ill patients take continuing education courses in managing critically ill or injured patients and handling sudden deterioration in patient condition.

New physicians and residents should be directly supervised when first performing invasive or other high-risk procedures. Equally important, especially in teaching facilities, is ensuring that ICU nurses and staff have ready access to information on which providers can perform which procedures under what degree of supervision.

Work Environment
Staffing an adequate number of critical-care-educated nurses is essential for the delivery of high-quality ICU care. Researchers have begun to demonstrate the key role of critical care nurses in intercepting medical errors in the ICU before they reach the patient. Appropriate nurse staffing levels are important to a safe work environment, which in turn is important to patient care and safety.

Within the environment of the ICU, high workload and fatigue have been identified as major negative contributors to patient safety. Critical care units and medical teaching programs, as well as their respective institutions, should earnestly consider establishing for physicians, nurses, and other staff members work hours, work shifts, and on-call duties that are most conducive to a safe work environment.

Additional measures can be used by facilities striving to enhance the ICU work environment as a strategy to promote patient safety:

  • Develop a code of conduct that defines and allows zero tolerance for abusive behavior and outlines a process for managing disruptive behaviors.

  • Provide safety science education, including a focus on teamwork and effective communication for the ICU.

Technology Ground Rules
Critical care devices and technology — ranging from ventilators and physiologic monitor systems to respirators and infusion pumps — are vital for the care and treatment of patients in the ICU. However, when devices do not undergo a rigorous evaluation for appropriateness during selection and acquisition, or when they are used improperly, they can contribute to patient harm.

The standardization of equipment and technology is an important strategy in human-factors design and in the reduction of human errors. Standardization reduces reliance on memory and helps individuals use devices and technology safely and efficiently. Therefore, ICU systems and technology should be standardized whenever possible.

ICU equipment, technology, and systems should also be assessed from a patient safety perspective before acquisition and implementation. Such an assessment includes an evaluation of required user skills, engineering concerns (including problems or recall history), infection control issues, environmental considerations, and credentialing and privileging requirements. Furthermore, new technology and equipment should be pilot-tested before being put into use, and there should be systems in place to anticipate new types of errors and enact measures to prevent such errors.

Sample Questions for a Critical Care Patient Safety Assessment
  • Does the ICU use a closed model in which intensivists specifically trained in critical care medicine manage ICU care?

  • Are the roles and responsibilities of individual ICU team members clearly defined in writing?

  • Have the ICU physicians, managers, and staff received education in safety science?

  • Does the ICU have a written patient safety plan?

  • Does the facility have a policy on communicating outcomes of care to patients that addresses disclosure of errors?

  • Are equipment and technology standardized to the extent possible throughout the critical care areas?

  • Are new ICU systems and technology (e.g. information systems, electronic records, computerized provider order entry programs) assessed from a patient safety perspective prior to acquisition and implementation?

  • Is there a means of involving patients and families in their own safety while they are in the ICU?


Kathleen Shostek is senior risk management analyst at ECRI Institute. She may be contacted a [email protected]

References

Chang, S. Y., Multz, A. S., Hall, J. B. (2005). Critical care organization. Critical Care Clinics, 21(5), 43-53.

Pronovost, P. J., Angus, D. C., Dorman, T., et al. (2003, November 6). Physician staffing patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 288 (17), 2151-2162.

Rainey, G., & Combs, A. H. (2003, May 5). Making the business case for the intensivist-directed multidisciplinary team model. In: Proceedings from the Society of Critical Care Medicine Summit on ICU Quality and Cost, Chicago, IL.

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