Category: Improving Patient Care

ICU Harm Related Topics

The critical care unit can be the location where a patient harm event occurs or it can be the unit where patients are transferred following an event elsewhere. With this in mind, we have grouped the following Patnership for Patients (PfP) option year (or Leading Edge Advanced Practive Topics – LEAPT) topics together under “ICU Harm Related Topics”: Failure to Rescue, Hospital Acquired Acute Renal Failure, Iatrogenic Delirium, and Sepsis. A brief description of each topic is provided below. More detail, along with strategies and tools for improvement are included in each of the topic change packages.

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Failure to Rescue

Failure to rescue refers to the lack of a caregiver’s ability to recognize early signs and symptoms of deterioration in a patient’s condition, or acting too late to prevent a cardiac arrest. It is a measure of the degree to which providers respond to adverse events that develop on their watch, and may reflect the quality of monitoring, the effectiveness of actions taken once complications are recognized, or both. Three fundamental problems lead to failure to rescue in hospitals:

• Failure to plan or be ready for unexpected deterioration in patient conditions
• Failure to recognize early warning signs and symptoms of impending deterioration in patients
• Failure to respond to patients in distress in a timely and systematic manner

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Hospital Acquired Acute Renal Failure

Acute Renal Failure (ARF) is predominately an acquired hospital disorder and the high mortality rate of patients with ARF cannot be explained entirely by the comorbid conditions of these patients. Hospital acquired ARF occurs in 22-67% of critically ill patients and is a significant indicator of mortality, morbidity and increased health care costs. Mortality from ARF ranges from 25-80% with the elderly having the highest mortality. The largest percentage of hospital acquired ARF is caused by ischemic or toxic exposure.
Prevention of hospital acquired ARF is critical to the early recognition of acute kidney injury (AKI) to minimize the progression of AKI to ARF.

References

Venkataraman, Ramesh, MD, and John Kellum, MD. “Prevention of Acute Renal Failure.” Chest 131.1 (2005): 300–08.

Kellum, John A., and Derek C. Angus. “Patients Are Dying of Acute Renal Failure *.” Critical Care Medicine 30.9 (2002): 2156-15

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Iatrogenic Delirium

Iatrogenic delirium (acute state of confusion) is a common and severe neuropsychiatric syndrome with core features of acute onset and fluctuating course, attentional deficits, and generalized severe disorganization of behavior acquired in the hospital. Iatrogenic delirium may be the single most common acute disorder affecting adults in general hospitals. It affects 10-20% of all hospitalized adults, 30-40% of elderly hospitalized patients, and up to 80% of ICU patients. Iatrogenic delirium increases the risk of longer stays in the hospital, higher cost of care, death, and more long-term cognitive impairment up to one year later.

Delirium detection in the hospital setting is critical in the ability to understand the incidence and then therefore the treatment. Iatrogenic delirium prevention strategies are relatively limited- sleep protocols and early ambulation. The ABCDE bundle is one way to align and coordinate care, which includes specific focus on delirium as a component of the overall care patients receive, including sedation and pain medications, breathing machines, and mobilization.

Read more…

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Resources

CDC Antimicrobial Stewardship Tools

AHRQ Toolkit for Reduction of Clostridium difficile Infections Through Antimicrobial Stewardship

APIC Guide to Reducing Clostridium difficile Infections

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Procedural Harm – Blood Management Top Ten Evidence Based Interventions

HRET’s Reducing Over-Utilization of Blood & Blood Products – 2014 Change Package

Airway Safety Top Ten Evidenced Based Interventions

Undue Radiation Exposure Top Ten Evidenced Based Interventions

HRET’s Preventing Undue Radiation Exposure – 2018 Change Package

Acute Renal Failure/Acute Kidney Injury Top Ten Evidenced Based Interventions 

HRET’s Prevention of Hospital Acquired Acute Renal Failure/Acute Kidney Injury – 2014 Change Package

Iatrogenic Delirium Top Ten Evidenced Based Interventions

HRET’s Preventing Iatrogenic Delirium – 2018 Change Package

Hospital-associated venous thromboembolism (HA-VTE) is a common source of morbidity and mortality. While VTE sometimes occurs despite the best available prophylaxis, there are many lost opportunities to optimize prophylaxis and reduce VTE risk factors in virtually every hospital. This guide targets these failure modes in the process of preventing VTE in the inpatient setting and provides improvement teams with field-tested strategies and tools to enhance their chances of success. Several essential elements are needed to achieve meaningful improvement in VTE prevention. These include an empowered, interdisciplinary team, supported by the institution, to standardize processes, monitor and measure VTE processes and outcomes, implement institutional policies, and educate providers and patients. Guidelines for VTE prevention are numerous and do not always agree, and the complexity of the inpatient setting and the variability of patients make implementation of evidence-based guidelines challenging. This implementation guide reviews several guidelines, with a particular focus on the implications for implementation; it then breaks down the steps to translate these guidelines into practice in the form of a VTE prevention protocol. Read more…

Continue reading “AHRQ’s Preventing Hospital Associated VTE Guide”

VAE Summary:

Mechanically ventilated patients are at high risk for complications. These risks include VAE, peptic ulcer disease (PUD), gastrointestinal bleeding, aspiration, venous thromboembolic events (VTE), and problems with secretion management. Evidence-based interventions can reduce the risk of these complications and reduce the occurrence of VAE. Implementing the ventilator bundle has shown to reduce VAE. The VAE prevention bundle includes: head of bed elevated 30 to 45 degrees, oral care with chlorhexidine 0.12%, peptic ulcer prophylaxis, deep vein thrombosis prophylaxis, and spontaneous waking trials and spontaneous breathing trials.

 VAE  2017 Top Ten, Evidenced Based Interventions

 HRET’s  2018 VAE Change Package 

 Eliminate Harm Across the Board HRET’s Days Since Last VAE

VTE Summary:

Venous thromboembolism (VTE) is a blood clot that starts in a vein. It is the third leading vascular diagnosis after heart attack and stroke, affecting about 300,000-600,000 Americans each year. There are two types: Deep vein thrombosis (DVT) is a clot in a deep vein, usually in the leg, but sometimes in the arm or other veins. Pulmonary embolism (PE) occurs when a DVT clot breaks free from a vein wall, travels to the lungs and blocks some or all of the blood supply. Blood clots in the thigh are more likely to break off and travel to the lungs than blood clots in the lower leg or other parts of the body.

What is the cause?

DVTs form in the legs when something slows or changes the flow of blood. The most common triggers for DVT and PE are surgery, cancer, immobilization and hospitalization. In women, pregnancy and use of hormones like oral contraceptive or estrogen for menopause symptoms are also important. Clotting is more likely to happen in people who are older, are obese or overweight or have conditions – such as cancer or autoimmune disorders such as lupus. It’s also more likely in people whose blood is thicker than normal because too many blood cells are made by bone marrow. Genetic causes of excessive blood clotting are also important. These occur when there are changes in the genetic code of some proteins needed for clotting or proteins that work to naturally dissolve blood clots in the body. VTE is most common in adults 60 and older, but they can occur at any age.

Symptoms:

If the clot moves into your lungs and you develop PE, you may have symptoms such as:

• chest pain, which may get worse when you breathe deeply or cough
• coughing
• coughing up blood
• dizziness or even fainting
• rapid breathing (called tachypnea)
• rapid heartbeat
• irregular heartbeat
• shortness of breath

Treatment

The primary objectives for the treatment of deep venous thrombosis (DVT) are to prevent pulmonary embolism (PE), reduce morbidity, and prevent or minimize the risk of developing the postthrombotic syndrome (PTS). The mainstay of medical therapy has been anticoagulation since the introduction of heparin in the 1930s.

VTE 2017 Top Ten, Evidenced Based Interventions 

HRET’s 2017 VTE Change Package

Eliminate Harm Across the Board HRET’s Days Since Last VTE

Airway Safety

Approximately 25,000 potentially life-threatening errors occur daily in hospital intensive care units (ICUs), and up to 10 percent of these adverse events involve unintended incidents in airway management; more than half of these errors have been deemed preventable (Needham, et al., 2004). Airway safety events refers to complications related to high-risk patients for airway compromise, airway placement and airway maintenance. Airway management processes must be in place for critically ill patients in the ICU who are at risk for difficult intubations (Leeuwenburg, 2015).

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Failure to Rescue (FTR)

Failure to rescue (FTR) is the failure to recognize and appropriately respond to early signs of patient deterioration. It is considered an indicator of the quality of care within a health care organization, irrespective of patient severity and other health factors (McKee, Coles & James, 1999). More specifically, FTR is the:

• failure to recognize clinical deterioration;
• failure to communicate and escalate concerns;
• failure to physically assess the patient; and
• failure to diagnose and treat appropriately (Moldenhauer et al., 2009).

Attentive bedside care is integral to being able to detect changes which could be a sign of an impending critical event; nurses, physicians and all caregivers are responsible for vigilance in patient assessment. Patients can display signs and symptoms of impending arrest for up to 72 hours before an event (Subbe & Welch, 2013). Reported FTR incidence is 8.0 to 16.9 percent and communication failures are a root cause of escation delays (Johnston et al., 2015).A common intervention is the implementation and use of a rapid response team (RRT) within the organization. RRTs are usually a multidisciplinary team of intensive care-trained staff, who are available at all times to respond to a deteriorating patient (Moldenhauer et al., 2009). The use of RRTs has been shown to reduce mortality in hospitals (Beitler et al., 2011). While RRTs are an important resource for clinicians and hospital staff, patients and families should also be educated on the hospital’s rapid response system and empowered to activate it should the need arise.

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Airway Safety  2017 Top Ten, Evidence Based Interventions

HRET’s 2018  Airway Safety Change Package