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PATIENT SAFETY: Handoffs between ICU and OR

There is a lot of literature describing problems with, and best practices for, the transfer of care of post-surgical patients moving into the intensive care unit setting.  However, after conducting a comprehensive literature search, the authors of this brief commentary found no comparable literature about the reverse type of handoff – for patients going from the special care unit into surgery.  They suggest that a checklist be adopted and give an example of one such checklist.  They also recommend that a verbal handoff be required.

What do I like about this article?  The authors are authoritative (Mount Sinai and Johns Hopkins medical schools) and I like the actual example of the handoff checklist.  Also, I like it that they appear to be filling a gap in the medical literature – at least at the time that they wrote this commentary.

Source: Evans, A.S., Yee, M.S., and Hogue, C.W. (2014, Mar.). Often overlooked problems with handoffs: From the intensive care unit to the operating room.  Anesthesia & Analgesia, 118(3), 687-689.  Click here for free full text: http://journals.lww.com/anesthesia-analgesia/Fulltext/2014/03000/Often_Overlooked_Problems_with_Handoffs___From_the.31.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICUs: How do high-performing hospitals reduce CLABSI rates?

This is a study out of Johns Hopkins of 17 intensive care units at 7 hospitals – comparing practices related to reducing the central line-associated bloodstream infection (CLABSI) rate.  High performers were defined as those with less than 1 infection per 1000 catheter-days over the period of at least one year.  Low performers were defined as having over 3 infections per 1000 catheter-days.

I particularly like the tables and the appendices to this article.  The tables identify characteristics of high-performers in bullet-point brevity for each of the following levels of hospital employees: senior leadership, ICU managers, infection prevention and quality improvement staff, and frontline staff.  The appendices contain specific questions that make up a CLABSI Conversation – again differentiated between senior management, infection control / quality improvement staff, and ICU staff.

Source: Pham, J.C., and others. (2016, Apr.-June). CLABSI Conversations: Lessons from peer-to-peer assessments to reduce central line-associated bloodstream infections. Quality Management in Health Care, 25(2), 67-78.  Click here for publisher’s website:  http://journals.lww.com/qmhcjournal/pages/articleviewer.aspx?year=2016&issue=04000&article=00001&type=abstract  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ICU: Wearing gowns and gloves for all ICU patients studied

Caregivers entering patient rooms in intensive care units typically use contact precautions – putting on gowns and gloves – when the patient is known to have antibiotic-resistant bacteria.  This study was a randomized trial of universal gown and glove use for adult patients in intensive care units in 2012.  Data on 1800 patients at different hospitals were studied.  The authors comment that:

  • “The observation that universal glove and gown use may result in fewer adverse events was unanticipated.  Universal glove and gown use could potentially have led to a decrease in HAIs [healthcare-associated infections] by serving as a barrier to acquiring new bacteria both through physical use of gloves and gowns as well as fewer HCW [health care worker] visits and better hand hygiene.”

Source: Croft, L.D., Harris, A.D., Pineles, L., and others. (2015, Aug. 15). The effect of universal glove and gown use on adverse events in intensive care unit patients. Clinical Infectious Diseases, 61(4), 545-553.  Click here for full text: cid.oxfordjournals.org/content/61/4/545.full.pdf  Posted by AHA Resource Center (312) 422-2003, rc@aha.org


ICUs: Where do patients come from? Data on source of admissions from large-scale Project IMPACT database

Cerner’s Project IMPACT (Improved Methods of Patient Information Access of Core Clinical Tasks) is – or perhaps was – a database to which many different hospitals submitted information about their intensive care unit (ICU) patients.  Although I have not yet been able to confirm this, it appears that the IMPACT database may no longer be in existence, or perhaps not being added to any more.  Researchers have studied this database and published a number of articles in the medical literature based on it.  Let’s take a look at some interesting data from one such article, based on over 250,000 adult (aged 18 or older) ICU patients who were hospitalized in 138 ICUs during the period 2001-2008.

Notes: All of the following statistics are given in the original source to one decimal place – I’ve rounded them off in this blog post.  The following statistics are based on patients who were admitted for the first time to the ICU during a hospitalization.

Where did they come from?  Source of adult ICU admissions:

  • 42 percent from the emergency department
  • 32 percent from the surgical suite
  • 16 percent from general care floor or step-down unit
  •  8 percent from another hospital
  •  3 percent from another location

What kind of adult patient is admitted to ICU?

  • 66 percent medical
  • 22 percent scheduled surgical
  • 12 percent unscheduled surgical

Is the ICU a closed model or an open model?

  • 75 percent open model with optional or no intensivist consult
  • 20 percent open model with mandatory intensivist consult
  •   4 percent closed model

Payer mix for adult ICU patients

  • 50 percent Medicare
  • 30 percent private insurance
  •  9 percent self pay
  •  9 percent Medicaid
  •  3 percent other

Source: Brown, S.E., Ratcliffe, S.J., and others. (2014, Aug.) An empirical comparison of key statistical attributes among potential ICU quality indicators. Critical Care Medicine, 42(8), 1821-1831. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4212919/pdf/nihms635834.pdf   Posted by AHA Resource Center (312) 422-2050, rc@aha.org  Note: The link takes you to a free full text “author manuscript,” which is what I used to provide the data noted above.  It was later published in the journal Critical Care Medicine, as noted in the citation.

HEALTH CARE ASSOCIATED INFECTIONS: Gowning and gloving needed for ALL ICU patients? Maybe not.

Whether the practice of gowning and gloving should be expanded beyond the current Centers for Disease Control recommendations to include staff caring for ALL patients in intensive care units was studied in this large-scale randomized trial.  The researchers collected data from 20 participating hospitals in 2012 to see if universal gowning and gloving would be found to reduce the acquisition of MRSA or VME (antibiotic-resistant infections).  There was no compelling statistical evidence that universal gowning and gloving should be used for all patients in ICUs to achieve this objective.

Source: Harris, A.D., Belton, B., and others.  Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial.  JAMA, Oct. 4, 2013 [published online before print].  Click here for access to article: http://jama.jamanetwork.com/article.aspx?articleID=1746112&utm_source=Silverchair%20Information%20Systems&utm_medium=email&utm_campaign=JAMA%3AOnlineFirst10%2F04%2F2013.  There is also an editorial and a video!  Posted by AHA Resource Center (312) 422-2050, rc@aha.org




ICUs: Are we making the best use of critical care?

Critical care costs the nation about $80 billion per year.  Observers predict a coming shortage of intensive care unit beds and of intensivists.  In this commentary, the authors draw upon the findings of their study of over 100,000 non-surgical patients admitted to 121 Veterans Affairs (VA) hospitals in FY2009.  They found, not surprisingly, that sicker patients tended to be admitted to ICUs.  But this held true for noncardiac patients; for cardiac patients, severity of illness was not strongly related to CCU admission decisions.   The authors conclude that there are factors other than severity of illness that also guide the use of critical care — such as peace of mind, staffing issues, bed availability.  The VA has developed an ICU severity score, which has proved to be a reliable predictor of a patient’s risk of death within 30 days of admission.  Routine incorporation of this tool at patient admission to the hospital is suggested as a way to help plan the overall care process and address the appropriate use of ICU resources.

Source: Chen, L.M., and others.  Use of health IT for higher-value critical care.  The New England Journal of Medicine;368(7):594-597, Feb. 14, 2013.  Click here for full text: http://www.nejm.org/doi/pdf/10.1056/NEJMp1213273  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

INTENSIVE CARE: About 14% of adult inpatients

How many patients receive intensive care?  In this study of 2006 data for 90 hospitals with critical care admissions in Maryland and the State of Washington, 14 percent of patients over age 18 received intensive care and 86 percent did not.  These findings were based on an analysis of just over 1 million admissions.  The use of intensive care was found to vary widely between hospitals.

Source: Seymour, C.W., and others.  Hospital-level variation in the use of intensive care.  HSR. Health Services Research;47(5):2060-2080, Oct. 2012.  Click here for the publisher’s website: http://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2012.01402.x/abstract Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

PATIENT ROOM DESIGN: Tips on acuity-adaptable units

Representatives from six hospitals that operate acuity-adaptable units were interviewed about how these units were implemented.  The hospitals included three academic medical centers, one heart hospital, and two community hospitals.  Cardiology was identified as the type of unit best suited to the acuity-adaptable unit concept because of the relatively predictable nature of the patient care needs.  Managers who are implementing new acuity-adaptable units must pay careful attention to organizational culture issues.  This is a lengthy scholarly article with lots of pragmatic tips.

Source: Zimring, C., and Seo, H-B.  Making acuity-adaptable units work: lessons from the field.  HERD. Health Environments Research & Design Journal;5(3):115-128, Spring 2012.  Click here to view the publisher’s website: http://www.herdjournal.com/ME2/Default.asp  Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Overflow policy: ok to put your MICU patients in CCU

Jacobi Medical Center (Bronx, NY) is a large teaching hospital that established a policy of admitting critically ill patients to the coronary care unit when no bed is available in the medical ICU.  In this study of about 1100 patients over a four-year period, no higher mortality or longer length of stay was found.  The authors conclude that it is a safe practice.

Source:  Sidlow, R., and, Aggarwal, V.  “The MICU is full”: one hospital’s experience with an overflow triage policy.  The Joint Commission Journal on Quality and Patient Safety;37(10):456-460, Oct. 2011.  Click here for more information: http://www.ingentaconnect.com/content/jcaho/jcjqs/latest Posted by AHA Resource Center, (312) 422-2050, rc@aha.org

Hospital-acquired infections: ICU CLABSI rates declining

 The US Department of Health and Human Services (DHHS) has set a goal of cutting central line-associated blood-stream infections (CLABSIs) in half by 2013.  Some substantial progress has already been made, as seen in the new CDC Vital Signs article cited below.  In intensive care units, the CLABSI rate has decreased from an estimated 43,000 infections in 2001 to an estimated 18,000 in 2009, or a reduction of 58 percent.  CDC also provides 2009 estimates for CLABSIs in other inpatient units (23,000), and in outpatient hemodialysis clinics (37,000).  The impact of the reduction in CLABSIs in ICUs in 2009 is estimated to from 3,000 to 6,000 lives saved and $414 million in averted extra health care costs.  Providers spotlighted as having best practice initiatives in place for reducing CLABSI include the Pittsburgh Regional Healthcare Initiative and the MHA Keystone Center for Patient Safety & QualityBest practices for reducing CLABSIs can be found in the CDC document: Guidelines for the Prevention of Intravascular Catheter-Related Infections, cited below.

Sources: Vital signs: central line-associated blood stream infections, United States 2001, 2008, and 2009.  MMWR. Morbidity and Mortality Weekly Report;60:1-6, Mar. 2011.  http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf; and, Guidelines for the prevention of intravascular catheter-related infections.  MMWR. Morbidity and Mortality Weekly Report;51(RR10):1-26, Aug. 9, 2002.  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm