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![SURVIVING SEPSIS CAMPAIGN BUNDLES
TO BE COMPLETED WITHIN 3 HOURS
1) Measure lactate level
2) Obtain blood cultures prior to administration of antibiotics
3) Administer broad spectrum antibiotics
4) Administer 30 mL/kg crystalloid for hypotension or lactate
4mmol/L
TO BE COMPLETED WITHIN 6 HOURS
5) Apply vasopressors (for hypotension that does not respond to
initial fluid resuscitation
to maintain a mean arterial pressure [MAP] 65 mm Hg)
6) In the event of persistent arterial hypotension despite volume
resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL):
-Measure central venous pressure (CVP)
-Measure central venous oxygen saturation (ScvO2)
7) Remeasure lactate if initial lactate was elevated](https://image.slidesharecdn.com/qualityinicu-150525045211-lva1-app6891/75/Quality-in-icu-47-2048.jpg)
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Quality in icu
- 1. QUALITY IN ICU MagedAbulmagd,MD,EDIC
- 4. What is Quality? “the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Institute of Medicine, 1990 ResultsQuality = Objectives Quality is defined byQuality is defined by goalsgoals
- 5. ICU and Aircraft Safetyis primary goal Technological innovation Multiple sources of threat Teamwork is essential
- 6. ICU versus aircraft •Patientsmore varied than aircraft •Patients more complex than aircraft •Many more staff to coordinate •Many more possible complications •An ICU stay is far longer than any flight
- 7. The science ofsafety Understand system performance Use strategies to improve system performance Standardize Create Independent checks for key process Learn from Mistakes Apply strategies to both technical work and team work. Recognize that teams make wise decisions
- 8. Adverse Events inAdverseEvents in Hospitalized PatientsHospitalized Patients 13.5% of Medicare patients experience a serious13.5% of Medicare patients experience a serious adverse event during hospitalizationadverse event during hospitalization (134,000 pts/month)(134,000 pts/month) Most common causes:Most common causes: Medications (31%)Medications (31%) Ongoing patient care (28%)Ongoing patient care (28%) Surgery (26%)Surgery (26%) Infection (15%)Infection (15%) Office of Inspector General. Adverse events in hospitals: National incidence among Medicare beneficiaries. November 2010.
- 9. Audit • from Latinauditus = act of hearing • Synonyms: examination, analysis, checkup, inspection, perlustration, review, scan, scrutiny, survey, view • Related: investigation, probe, check, control, corrective
- 10. Reasons for auditingyour ICU Audit is an essential tool for quality improvement you only manage what you measure Audit is in the interest of your patients to ensure safe and evidence-based care Audit is in the interest of your ICU team to enhance team culture, professionalism, job satisfaction Audit is in the interest of health systems to ensure efficient and fair use of resources Audit is an essential tool for quality improvement you only manage what you measure Audit is in the interest of your patients to ensure safe and evidence-based care Audit is in the interest of your ICU team to enhance team culture, professionalism, job satisfaction Audit is in the interest of health systems to ensure efficient and fair use of resources
- 11. A. Valentin 10/2004 Tidalvolume≤ 6ml PBW in ARDS/ALI: Lungprotective Ventilation in Reality Brunckhorst F, Crit Care Med 2008 Perceived adherence:Perceived adherence: 80%80% Real adherence:Real adherence: 3%3% Perceived adherence:Perceived adherence: 80%80% Real adherence:Real adherence: 3%3%
- 12. A thorough, systematicexamination of the processes and results of a health care service. External Audit External Audit Internal Audit Internal Audit Benchmarking Internal Benchmarking Internal Quality Indicators Quality Indicators Benchmarking External Benchmarking External
- 13.
- 14. A. Valentin 10/2004 Anotherreason for auditing your ICUAnother reason for auditing your ICU If you don‘t compare your ICU with others someone else will do it ! If you don‘t compare your ICU with others someone else will do it !
- 15. Purpose of anaudit • to blame • to improve • to enhance • to ensure • to change ASSESSMENT AND IMPROVEMENTASSESSMENT AND IMPROVEMENT OF QUALITYOF QUALITY
- 16. To audit means tocompare Objectives and Reality • Structure what you need vs what is provided • Process what you should do vs. what you do • Outcome what you expect vs. what you find
- 17. Time Indicator Single ICU InternalcomparisonInternal comparison
- 18.
- 19. • Audit – Whatis it? A search for opportunities to improveA search for opportunities to improve – Who should do it? Yourself with the help of experts & networksYourself with the help of experts & networks • Can we identify high quality ICUs? Probably, but not at a quick glanceProbably, but not at a quick glance • Combining measures May be helpful, but models need to be developedMay be helpful, but models need to be developed • • Audit – What is it? A search for opportunities to improveA search for opportunities to improve – Who should do it? Yourself with the help of experts & networksYourself with the help of experts & networks • Can we identify high quality ICUs? Probably, but not at a quick glanceProbably, but not at a quick glance • Combining measures May be helpful, but models need to be developedMay be helpful, but models need to be developed •
- 20. Quality Areas andManagement Tools
- 21. Quality Indicator (QI) Thisis a measure of a structure, process or outcome that could be used by local teams to improve care. A QI helps to understand a system, compare it and improve it but they all will have limitations. They can only serve as flags or pointers
- 22. List of indicators •Presence of an intensivist in the ICU 24h/365d • Critical incident reporting system in use • Early enteral nutrition • Mild therapeutic hypothermia after CPR • Reintubation • Ventilator associated pneumonia • Unplanned readmission • Mortality after severe brain trauma • Standardised mortality ratio StructureProcessOutcome Ö STER RE ICH ISC HES ZEN TRU M FÜR D OK UM EN TA TION U ND QU ALIT ÄTS- SIC HERU NG IN DE R INTE NSIVMED IZIN ASDI
- 23. Ffundamental Quality Indicators!!!!Ffundamental Quality Indicators !!!! • Early ASS in ACSEarly ASS in ACS • Early reperfusion in STEMIEarly reperfusion in STEMI • Semirecumbent position in MVSemirecumbent position in MV • Surgical intervention in TBISurgical intervention in TBI with SDH of EDHwith SDH of EDH • ICP in severeTBI withICP in severeTBI with pathologic CTpathologic CT • Early management of severeEarly management of severe sepsis/septic shocksepsis/septic shock • Early enteral nutritionEarly enteral nutrition • GI-bleeding prophylaxis in MVGI-bleeding prophylaxis in MV • Appropriate sedationAppropriate sedation • Early ASS in ACSEarly ASS in ACS • Early reperfusion in STEMIEarly reperfusion in STEMI • Semirecumbent position in MVSemirecumbent position in MV • Surgical intervention in TBISurgical intervention in TBI with SDH of EDHwith SDH of EDH • ICP in severeTBI withICP in severeTBI with pathologic CTpathologic CT • Early management of severeEarly management of severe sepsis/septic shocksepsis/septic shock • Early enteral nutritionEarly enteral nutrition • GI-bleeding prophylaxis in MVGI-bleeding prophylaxis in MV • Appropriate sedationAppropriate sedation • Pain management in unsedatedPain management in unsedated ptspts • Inappropriate transfusion of RBCInappropriate transfusion of RBC • Organ donorsOrgan donors • Compliance with hand-washingCompliance with hand-washing protocolsprotocols • Information to familiesInformation to families • Withholding/Withdrawing lifeWithholding/Withdrawing life supportsupport • Quality survey at ICU dischargeQuality survey at ICU discharge • Presence of intensivist 24h/dayPresence of intensivist 24h/day • Adverse event registerAdverse event register • Pain management in unsedatedPain management in unsedated ptspts • Inappropriate transfusion of RBCInappropriate transfusion of RBC • Organ donorsOrgan donors • Compliance with hand-washingCompliance with hand-washing protocolsprotocols • Information to familiesInformation to families • Withholding/Withdrawing lifeWithholding/Withdrawing life supportsupport • Quality survey at ICU dischargeQuality survey at ICU discharge • Presence of intensivist 24h/dayPresence of intensivist 24h/day • Adverse event registerAdverse event register
- 24. Unintended Event : Anoccurrence that harmed or could have harmed a patient SEE: multicenter, multinational, single day study in ICU Reporting by all ICU staff members : Voluntarily – Anonymously - Confidential
- 25. Selected Events • Medicationwrong drug, dose, or route • Airway unplanned extubation artificial airway obstruction cuff leakage • Lines, Drains dislodgement Catheters inappropriate opening/disconnection • Equipment power supply, oxygen supply, failure ventilator, infusion pump • Alarms inappropriate turn off SEE STUDYSEE STUDY
- 26. SEE Study –participating Countries 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 6 7 7 8 11 12 14 19 22 27 28 35 0 5 10 15 20 25 30 35 40 Australia USA Estonia Indonesia Macedonia Norway Poland Romania Singapore Latvia Slovakia Albania Finland Brasil Belgium Netherlands Slovenia Hongkong Greece Denmark India France Switzerland Germany Czech Republic Spain Portugal UK Austria Italy Number of ICUs 220 ICUs in 29 countries 2090 patients
- 27. Adverse events inICU Frequent and in relation with Severity of the patients Procedures Impact on : Morbidity and mortality Finance : − Iatrogenic pneumothorax : 17,312 US$ − DVP and post operative pulmonary emboli : 21,709 US$ Legal issues Psychology and competency of the team Preventability ?
- 28. You should concludethat this is a very dangerous ICU No documentation of events No evaluation No corrective action
- 29. If you hearthis “I am proud to say that I have no adverse event in my ICU” May be even no patient in that ICU……
- 30. Critical Care Bundles VentilatorBundle Central Line Bundle Severe Sepsis Bundles
- 31. Bundles A "bundle" isa group of evidence-based care components for a given disease that, when executed together, may result in better outcomes than if implemented individually.
- 32. Bundle Design Guidelines •The bundle has three to five interventions (elements), with strong clinician agreement. • Each bundle element is relatively independent. • The bundle is used with a defined patient population in one location. • The multidisciplinary care team develops the bundle. • Bundle elements should be descriptive. • Compliance with bundles is measured using all-or-none measurement, with a goal of 95 percent or greater.
- 33.
- 34. Ventilator-Associated Pneumonia (VAP)Bundle DVTprophylaxis GI prophylaxis Head of bed (HOB) elevated to 30-45° Daily Sedation Vacation Daily Spontaneous Breathing Trial
- 35. DVT prophylaxis Include deepvenous prophylaxis as part of your ICU order admission set and ventilator order set. Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds. Empower pharmacy to review orders for patients in the ICU. Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.
- 36. Head of Bedelevation Implement a mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds. Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation. Involve families in the process by educating them about the importance of head-of-the-bed elevation.
- 37. Daily sedation vacation/ SpontaneousBreathing Trials Assess that compliance is occurring each day on multidisciplinary rounds. Consider implementation of a sedation scale such as the Riker scale to avoid oversedation. Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.
- 38. Central line bundle HandHygiene Maximal Barrier Precautions Upon Insertion Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection, with Avoidance of the Femoral Vein Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
- 39. Hand Hygiene Include handhygiene as part of your checklist for central line placement. Keep soap/alcohol-based hand washing dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment.
- 40. Hand Hygiene Post signsat the entry and exits to the patient room as reminders. Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand washing. Create an environment where reminding each other about hand washing is encouraged. Signs often become "invisible" after just a few days. Try to alter them weekly or monthly (color, shape size).
- 41. Maximal Barrier Precautions UponInsertion Include maximal barrier precautions as part of your checklist for central line placement. Keep equipment ready stocked in a cart for central line placement to institute maximal barrier precautions.
- 42. Chlorhexidine skin antisepsis: IncludeChlorhexidine antisepsis as part of your checklist for central line placement. Include Chlorhexidine antisepsis kits in carts storing central line equipment. Many central line kits include povidone-iodine kits and these must be avoided. Ensure that solution dries completely before an attempted line insertion.
- 43. Daily review ofLines/ Prompt removal Include daily review of line necessity as part of your multidisciplinary rounds. Include assessment for removal of central lines as part of your daily goal sheets. Record time and date of line placement for record keeping purposes and evaluation by staff to aid in decision making.
- 44.
- 45. severe sepsis bundles Thesepsis resuscitation bundle The sepsis management bundle
- 46. Sepsis resuscitation bundle describesseven tasks that should begin immediately, but must be accomplished within the first 6 hours of presentation for patients with severe sepsis or septic shock. Some items may not be completed if the clinical conditions described in the bundle do not prevail in a particular case, but clinicians should assess for them. The goal is to perform all indicated tasks 100 percent of the time within the first 6 hours of identification of severe sepsis.
- 47. SURVIVING SEPSIS CAMPAIGNBUNDLES TO BE COMPLETED WITHIN 3 HOURS 1) Measure lactate level 2) Obtain blood cultures prior to administration of antibiotics 3) Administer broad spectrum antibiotics 4) Administer 30 mL/kg crystalloid for hypotension or lactate 4mmol/L TO BE COMPLETED WITHIN 6 HOURS 5) Apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure [MAP] 65 mm Hg) 6) In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate ≥4 mmol/L (36 mg/dL): -Measure central venous pressure (CVP) -Measure central venous oxygen saturation (ScvO2) 7) Remeasure lactate if initial lactate was elevated
- 48. Quality is notabout individual performanceQuality is not about individual performance Structures and processes in the ICU that ensure that every patient, every time, receives every applicable evidence-based best practice Structures and processes in the ICU that ensure that every patient, every time, receives every applicable evidence-based best practice
- 49. What a teamneeds to knowWhat a team needs to know •What are our goals ? •Do we reach our goals ? •What are our strengths ? •What are our weak points ? •Are we getting better ? •What are our goals ? •Do we reach our goals ? •What are our strengths ? •What are our weak points ? •Are we getting better ?
Editor's Notes
- #6 Tasks and achievements
- #14 Brunkhorst, F. M., C. Engel, et al. (2008). "Practice and perception--a nationwide survey of therapy habits in sepsis." Crit Care Med 36(10): 2719-25. OBJECTIVE: To simultaneously determine perceived vs. practiced adherence to recommended interventions for the treatment of severe sepsis or septic shock. DESIGN: One-day cross-sectional survey. SETTING: Representative sample of German intensive care units stratified by hospital size. PATIENTS: Adult patients with severe sepsis or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Practice recommendations were selected by German Sepsis Competence Network (SepNet) investigators. External intensivists visited intensive care units randomly chosen and asked the responsible intensive care unit director how often these recommendations were used. Responses "always" and "frequently" were combined to depict perceived adherence. Thereafter patient files were audited. Three hundred sixty-six patients on 214 intensive care units fulfilled the criteria and received full support. One hundred fifty-two patients had acute lung injury or acute respiratory distress syndrome. Low-tidal volume ventilation < or = 6 mL/kg/predicted body weight was documented in 2.6% of these patients. A total of 17.1% patients had tidal volume between 6 and 8 mL/kg predicted body weight and 80.3% > 8 mL/kg predicted body weight. Mean tidal volume was 10.0 +/- 2.4 mL/kg predicted body weight. Perceived adherence to low-tidal volume ventilation was 79.9%. Euglycemia (4.4-6.1 mmol/L) was documented in 6.2% of 355 patients. A total of 33.8% of patients had blood glucose levels < or = 8.3 mmol/L and 66.2% were hyperglycemic (blood glucose > 8.3 mmol/L). Among 207 patients receiving insulin therapy, 1.9% were euglycemic, 20.8% had blood glucose levels < or = 8.3 mmol/L, and 1.0% were hypoglycemic. Overall, mean maximal glucose level was 10.0 +/- 3.6 mmol/L. Perceived adherence to strict glycemic control was 65.9%. Although perceived adherence to recommendations was higher in academic and larger hospitals, actual practice was not significantly influenced by hospital size or university affiliation. CONCLUSIONS: This representative survey shows that current therapy of severe sepsis in German intensive care units complies poorly with practice recommendations. Intensive care unit directors perceive adherence to be higher than it actually is. Implementation strategies involving all intensive care unit staff are needed to overcome this gap between current evidence-based knowledge, practice, and perception.
- #17 Effectiveness: does it work ? Efficiency = the ratio of the output to the input of any system
- #18 Is it not worth to work on this ?
- #23 Classic view of quality indicators