Patient Safety in the ICU

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Patient Safety in the ICU

• Goals for 2005-2006

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What has been accomplished?2003-2004

• Critical Care Committee for system
• Multi-disciplinary rounds
• Sedation and Analgesia protocol
• Ventilator Bundle
• Central line Bundle
• Intensive insulin therapy
• Ventilator weaning and liberation protocol

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Goals2005 -2006

• Establishment of the Fundamental Critical Care
  Support (FCCS) course (MUH)
• Early Goal Directed Therapy for septic shock
  (Surviving Sepsis Campaign) (MG)
• Lower TV mechanical ventilation for patients with
  ARDS/ALI (Surviving Sepsis Campaign) (MS)
• Development of a patient safety program in the
  ICU (MN)

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Patient Safety Program

• Epidemiology
• 44,000 - 98,000 deaths each year in the US from
  medical errors
• every patient in the ICU has an adverse event
• System Factors have the largest impact on safety
• available equipment, staffing (nurses,
  physicians, pharmacist), policies and protocols,
  work environment
• COMMUNICATION is vital in identifying factors
  that might contribute to patient harm (change in
  culture)
• Establish a SAFETY PROGRAM
• www.patientsafetygroup.org (login jhopkins
  password jhopkins)

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Safety Programexample

• Meet once monthly specifically to discuss patient
  safety
• Learn about potential adverse outcomes by asking
  - How are we going to harm the next patient?
• Create an environment that encourages those who
  work in the ICU to communicate concerns about
  patient safety without consequences
• Implement improvement measures
• Document improvement
• Executive participation

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EGDTNEJM 20013451368-1377

• Protocol for adequate resuscitation during the
  first 6 hours of severe sepsis. In-hospital
  mortality was 16 less in the treatment group.
• Goals CVP 8 -12 mmHg, MAP gt 65 mmHg, UOP gt 0.5
  ml/kg/hr, and CV or MV oxygen sat gt 70
• keys
• early identification of patients with
  sepsis-induced hypoperfusion (hypotension and
  lactic acidosis)
• initiation of protocol in the EMD
• placement of CL or PAC to measure CV or MV O2 sat

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Low TV Strategy for ALI/ARDSARDS Network (NEJM
20003421301-1308)

• High tidal volumes associated with elevated
  plateau pressures should be avoided in ALI/ARDS.
  Patients ventilated with a tidal volume of 6
  ml/kg preferred body weight had an approximate
  reduction in mortality of 9 compared to patients
  receiving a tidal volume of 12 ml/kg
• Keys to success
• identifying patients at risk for ALI/ARDS
• best method to determine proper tidal volume
  (bedside calculation or chart) and maintaining
  IPP lt 30 cm H2O
• education especially about tolerance of higher RR
  /or PaCO2

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FCCSFundamental Critical Care Support

• Two day course in basic critical care for the
  nonintensivist sponsored by the Society of Crit
  Care Med
• Target audience
• physicians (hospitalists, emergency room
  physicians)
• nurses (CCRN, ACNP)
• PA
• physicians-in-training
• Lectures life-threatening infections, acute
  respiratory failure, mechanical ventilation,
  management of shock, etc.
• Skill stations airway management, mechanical
  ventilation, vascular access, etc.

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FCCSWhat will participants learn?

• Assess needs and initiate treatment for the
  critically ill patient
• Respond to changes in the unstable patient
• Identify appropriate diagnostic test
• Recognize need for patient transfer or expert
  consultation

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FCCSAdvantages

• Extended hour coverage
• 24/7 inhouse intensivist program for 1 ICU
  requires 5 full time intensivists and cost over 1
  million per year
• Leapfrog recognizes coverage by physician
  extenders completing the FCCS course as compliant
• Encourages compliance with evidence based
  protocols and guidelines
• Public Relations (new for the surrounding area)
• PATIENT SAFETY

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FCCSWhat do we need to do?

• Administrative support
• sponsor application
• financial
• course coordinator
• equipment for skill stations
• room for lectures and skill stations
• Choose date
• Arrange for course consultant (1st course only)
• Arrange for lecturers and skill station helpers

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SummaryWeb sites

• www.ihi.org
• www.survivingsepsis.org
• www.patientsafetygroup.org
• password jhopkins
• login jhopkins
• www.icusrs.org (ICU safety reporting system)