Plenary 3

Would I be comfortable in ICU?

Is it really safe?

Professor Cliff Hughes

A/Prof Tony Burrell
23 August 2014

Australia?

Australia?

Australia?

Home to seven of the worlds most deadly snakes!

The ICU is a dangerous place

High error ratesmost likely to occur in

intensive care units, operating rooms, and

emergency departments (Institute of
Medicine 1999)

Wide range of incidents, inappropriate

medical decisions, adverse drug events,
preventable slips & lapses (unrecognised
omissions in care) and variable
implementation of evidence-based care

The ICU is a dangerous place

High error ratesmost likely to occur in

intensive care units, operating rooms, and

emergency departments
Wide range of incidents, inappropriate
medical decisions, adverse drug events,
preventable slips & lapses (unrecognised
omissions in care) and variable
implementation of evidence-based care
ESPECIALLY FOR RUSSELL

Structure, process, outcome and

culture

Lilford Lancet 2004

Structure/Culture
Occupancy
After hours discharges = poorer outcomes

Goldfrad et al Lancet 2000

Tobin & Santamaria Med J Aust 2006
Pilcher et al Anaesth Intens care 2007

After hours admissions = ?poorer outcomes

Bhonagiri et al Med J Aust 2011

Medical staffing

After hours incidents

Nursing staffing

Increased nursing staff associated with less adverse

events

Kane et al Med Care 2008

Blegan et al Medical Care 2011

Process: How we do our business

Incident monitoring

Incident/problem recognised at the time

Medication errors

Incidents often not recognised & require different

approach

Checklists etc

Communications

Often fragmented, daily goals sheet

Emphasis on appropriateness of care -

housekeeping
Growing body of evidence linking improved
process of care with better outcomes

Outcomes
Morbidity & mortality meetings
Traditional
Often mandatory for training programs
Peer review - case by case discussion
The objectives of the surgical M&M conference are to
learn from complications, to modify surgical behaviour
and judgement based on previous experience, and to
prevent repetition of the problems leading to the
complication. (Murayama) i.e. emphasis on
teaching/learning
derive knowledge and insight without blame or
derision (quoted by Murayama)
Forum for discussion of major incidents
But not aggregated data

Risk-adjusted Outcomes
Crude hospital mortality rates are unsatisfactory

for measuring performance because do not adjust

for case mix or severity of disease
APACHE III, SAPS scoring systems adjust for

variation in patient outcomes that stem from

differences in patients and organisations ie
variations in casemix
Risk adjusted scores used to calculate

Standardised Mortality Ratios (SMR) - observed vs

predicted mortality allows benchmarking of ICUs
?helpful indentifying why ICUs are outliers

Outliers Data review

Data quality especially GCS

SMR of ventilated patients
SMR of acute pneumonia
SMR of cardiothoracic patients
SMR of deteriorating patients/medical
emergencies admitted from the wards
SMR end-of-life
Not much help

NSW Tertiary unit funnel plot (2009):

NB SMR

Outlier

Syrec study
79 ICUs in 76 hospitals in Spain
591/1017 (58%) patients suffered incidents (n=1224)
943 = no harm events

481 = adverse events temporary damage (29%) and

permanent damage or death (4%)

Causes:

Medication (74%)
Equipment (15%)
Nursing care (14%)
Accidental removal of vasc devices & catheters (10%) or
Airways & mechanical ventilation (10%)

Avoidable in 79%
Merino et al Int J Qual Health Care 2012

Other Work
Performance level failures most commonly preventable

slips and lapses

Rothschild et al Crit Care Med 2005

SEE Study 25.5% unintended events were ADEs

including wrong drug in 39/147

Valentin Intensive Care Medicine 2008

187 errors (3.3%) - vasoactive drugs (32.6%),

sedatives/analgesics (25.7%) & wrong infusion rate 71

(40.1%)
Calabrese et al Intensive Care Med 2001

Incidents by principal incident type - NSW ICUs 2010

NSW Medication errors q3 2011

Diazepam - 3
Frusemide - 3
Nimodipine - 3
Noradrenaline - 3
Pantoprazole sodium - 3
Amiodarone hydrochloride - 4
Cephazolin sodium - 4
Heparin - 4
Midazolam - 4
Oxycodone - 4
Vancomycin hydrochloride - 4
Heparin sodium - 5
Morphine sulfate - 5
Fentanyl - 9
Morphine - 11
Total 69

Primary problem as perceived

by the notifier
Administration - 79
Prescribing - 28
Narcotic controlled drug
discrepancy - 17
Dispensing - 12
Storage/Wastage/Security - 11
Delivery - 5
Supply/Ordering - 5
Undesired drug effect drug
therapeutic use - 2
Presentation - 0
Total - 159

Most errors go unreported

Many medication errors are not recognised many
are acts of omission
Only a fraction of ADEs are identified by incident
reports

One study examined 55 ADEs

15 preventable
26 serious or life threatening but only 2 had incident
reports
Conclusion voluntary reporting identified only a
small fraction of ADEs
Cullen et al Jt Comm J Qual Improv 1995

Competency
All staff are competent to provide care to the patients

at the level at which they have responsibility

procedures, decision making, supervision
Competency to assess technical and non-technical

skills
Airway management NB after hours
CVL insertion
Intercostal tube

Airway incidents 62.5% between 1600-0700

Why do medication errors occur?

High stress environment, fatigue, task saturation,
interruptions and reliance on MEMORY
Lack of knowledge
Medication safety management is complex
process prescribing, preparation - between 80
200 steps
Errors in order writing are the most common
medical error - illegibility, mistakes in
transcription
Patient identification ask Cliff

NSW CVL Incidents 2008-2011 n=572

Air Embolism
Incident report of death after removal of a
central line while patient was sitting up a
never event
Review of all incidents 2008-2014:
Reported cases
Two survived
6 died
RCA Causal statements:
Too difficult to put patient in bed
I knew about policy but I was too busy

Air Embolism

Air Embolism

Air Embolism

Checklists

Every day patients are not getting basic care

Routine care ie FASTHUG could happen

automatically and consistently with the use
of a checklist

Increasing evidence to show that checklists

are very useful in the ICU

Checklists: Daily goals

A checklist in the intensive care environment could have the
following advantages:

Immediate patient safety i.e. ensuring that the patient

gets what he/she needs immediately safety lesson from
aviation

Educational tool constant repetition reinforces the

principle e.g. BSL<8 a method of immediately
implementing evidence based practice

If the data collection process can be worked out e.g. PDA it

could be an effective method of collecting process
indicators. This approach requires the clinicians on the
round to address the issue and not a separate quality
process. It takes less than a minute to review the data.

Depending how developed improved communication

Pain
71% pts had pain assessed by medical team

on the study day

Of the 115 patients in pain, 42% did not have
pain score recorded <4 hrs
Pts who had surgery in past 4 days were more
likely than non-surgical pts to:
have pain assessed by medical team
(p=.001)
have a pain score documented in past 4
hours (p=.0001)

Pressure Areas
A pressure area risk assessment tool had not

been used in previous 24 hrs for 31%

110 pts (17%) had one or more pressure

areas, of these:

35% no risk assessment tool used

23% no targeted interventions

implemented
Elliott, McKinley, Fox Am J Crit Care 2008

Communication

Significant number of dangerous human errors

attributed to problems of communication
Donchin, Gopher, Olin et al Qual Saf Health Care 2003

Staff often unclear about management plan as

few as 10% residents & nurses in one study
daily Goals Sheet
Pronovost et al J Crit Care 2003

75% ward round time spent on communications

conversation-initiating interruptions occurred
at 14 /hour 37% communication time
Alvarez, Coiera Int J Med Inform 2005

Good Communication:

Accurate information exchange.

Enables us to:

Learn essential information

Share information

Form bonds

Foster understanding

Grow

Express our needs and feelings

Learn of others needs and feelings

Connect in meaningful ways

Communication In Health

Occurs between practitioners, patients, managers, consumers, community

Written emails, correspondence, newsletter, prescriptions, policies, posters,

noticeboards

Oral bedside manner, performance feedback, coffee room chat, managerial

style

Filtered implied vs intended

Often life-threatening consequences if get it wrong

In Health, multi-disciplinary
often means multi-lingual
Acronyms

Medi-speak
Nurse-speak
Allied-speak
Clinician-speak
Manager-speak

Patient-speak
Bureau-speak

Non-Verbals: c93% of the message

NSW Central Line Associated

Bacteraemia ICU Project
AR Burrell, M-L McLaws, A Pantle, M Murgo, E Calabria

Financial costs of CLAB

US estimates
15 680 lives and $1.3 billion medical costs could be saved annually by
reducing the number of CLABS*
United States House of Representatives Committee on Oversight and Government
Reform Staff Report September 2008, Survey of State Hospital Association:
Practices to prevent hospital associated bloodstream infections

The US Agency for Healthcare Research and Quality recently committed $3

million over 3 years to help reduce the incidence of CLAB
Health Care Advisory Board, Daily Briefing, 10 February 2008

NSW CLAB-ICU
Top down/bottom up project NSW Intensive Care Coordination & Monitoring
Unit and Clinical Excellence Commission
Methodology modelled on the work of Pronovost et al.
The project promoted a standardised insertion technique including:

Hand washing
Full barrier precautions during insertion
Cleaning skin with chlorhexidine
Avoiding femoral site if possible
Removing unnecessary catheters

Also included a retrospective review of all incidents entered into the NSW
Incident monitoring system

Guideline and checklist

8th April 2014

C F Hughes

Checklist detail

Minimum practical requirement

and assessment

Perform minimum of
3 supervised
insertions at each site

Perform
minimum of 5
independent
insertions

Observe
minimum of
1 insertion

Theory
assessment

Practical
assessment

Final
signoff

Continuingl
earning

Results
Data on 10,890 line insertions
Concurrent incident review:
Retained/lost guidewires
Arterial puncture
Multiple passes
Inadequately secured lines
Inadequate position check prior to use
Lack of access to ultrasound equipment
Policy breaches
Training & supervision common themes
Safety Alert for guidewires issued
Training framework developed

Checklist Compliance:
all ICUs July 07 Dec 08
Data on 10,890 line insertions
Competency assessed

48.3% (22.9% no, 28.8% missing)

Hat, mask, eyewear

79.9%

Hands washed 2 mins

91.6%

Sterile gown/gloves

95.9%

Alcoholic chlorhexidine prep allowed to

95.8%

dry
Entire patient draped

93.4%

Sterile technique maintained

95.6%

No multiple passes

80.9%

Confirm position radiologically

74.3%

Impact of compliance
Non compliance with the clinician bundle:
relative risk of CLAB was RR 1.62 (95% CI 1.1-2.4,
p=0.0178)
For central lines RR 1.99 (95% CI 1.2-3.2 ,
p=0.0037)
For PICC RR 5.08 (95% CI 1.03-25 , p=0.059)
Dialysis catheters no difference
If compliant with both clinician bundle and patient
bundle then risk of CLAB was RR 0.6 (95%CI 0.4-0.9,
p=0.0103)

Progress
Results

 The single biggest problem in

communication is the illusion
that it has taken place.
George Bernard Shaw

Thank you
For further information:
www.cec.health.nsw.gov.au