Introduction
Intensive care is one of the most expensive forms of care delivered by a hospital system. In 1993, intensive care represented 25% to 30% of acute hospital costs and constituted 1% of the gross national product (GNP). It has become increasingly important in an era of public and private accountability to measure and benchmark quality of intensive care unit (ICU) care; however, this is a complicated task. Quality measures of health care are divided into three broad areas: (1) process (appropriate delivery of health care), (2) outcome (measured endpoints of care), and (3) structure (adequate resources to provide health care). Process measures include appropriate uses of stress ulcer and deep vein thrombosis (DVT) prophylaxis, appropriate transfusion thresholds, daily interruption of sedation, appropriate glycemic control, and use of aspirin and beta-blockers in acute myocardial infarctions among other benchmarks. Outcome measures include such parameters as mortality, incidence of catheter-related bloodstream infections, or rates of ventilator-associated pneumonia (VAP). Typical structural quality indicators include the presence of an ICU medical director, daily rounds by an intensivist, appropriate ICU nurse-to-patient ratio, and multidisciplinary rounds involving a pharmacist.
Use of each type of quality metric has its advantages and disadvantages. For example, although structural quality indicators are easy to define and measure, they may not translate to immediate improvement in care. Process quality indicators may require tailoring to specific disease processes and may become cumbersome. Although the public (and health care providers) are most interested in outcome metrics, data that pertain to outcome measures may take a long time to obtain and there is little definition of appropriate standards. In addition, outcome measures often require risk factor stratification for valid comparisons and although much work has been done in general critical care, there has been less research on benchmarking specific to neurocritical care.
History of and Impetus for Qualitative Initiatives
The Institute of Medicine (IOM) defines quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Patient safety is integral to quality because it is difficult to provide successful care when safety is compromised; that is, it is difficult to examine quality and safety in isolation. The IOM defines safety as “the absence of clinical error, either by commission [unintentionally doing the wrong thing] or omission [unintentionally not doing the right thing].” This is similar to the World Health Organization (WHO) definition.
The concept of quality in health care is central to clinical practice and is as old as medicine. Indeed the phrase primum non nocere (first do no harm) dates back to Hippocrates and is one of the principal tenets of medical ethics. In the early 20th century, Codman advocated public reporting of outcomes by both physicians and hospitals. Modern quality initiatives (QIs) started in other industries that realized that unexplained variation leads to poor quality, and processes that decrease variation coupled with continuous evaluation can improve quality and therefore profit. For example, in the 1950s Japanese car manufacturers applied Deming’s theory that improving quality will reduce expenses while increasing productivity and market share; this led to an international demand for Japanese automobiles. For example, Toyota became a model of operational excellence, in part through kaizen , a Japanese philosophy of continuous improvement. However, in 2009, there was a recall of more than 8 million vehicles and a decline in stock value thought by some to be a subtle abandonment of these principles. In the 1980s Donabedian introduced the structure, process, and outcome paradigm to assess quality in health care but also cautioned that before assessment can begin it must be determined how quality is to be defined, something that is still ongoing. During the past decade there has been increased focus on quality and safety of medical care with the recognition of the high cost of health care, potential for harm, and a perceived need for transparency about hospitals to the public. The report “To Err Is Human” by the IOM in the United States in 1999 led to an increased focus on safety and quality of care. In 2009 the European Society of Intensive Care Medicine (ESICM) initiated a task force to improve the safety and quality of care provided to ICU patients, leading to a publication of prospectively defined indicators to improve quality of critical care. QIs are increasingly a focus of hospitals because pay-for-performance (P4P) programs are under development by organizations that purchase health care such as the Leapfrog Group and the Centers for Medicare & Medicaid Services (CMS). To measure quality a combination of process and outcome indicators may be best, but measuring ICU performance can be a complex and time-consuming task because it depends on multiple domains such as patient- and family-centered outcomes, the work environment, personnel satisfaction, and economic performance among others.
Process and Outcome Quality Indicators
Donabedian proposed that structure, process, and outcome be reviewed to improve quality of health care. Processes of care usually are the easiest to target initially, modify them if necessary, and then measure outcomes associated with the process. Outcomes such as mortality are easy to measure. However, many variables and processes influence mortality, and so attributing variation in mortality to a single intervention or process change is not always feasible. There thus can be some overlap between outcome and process in QIs. For example, process can include use of available technology and staff education and training, whereas outcome may include resource use and appropriate use of diagnostic or therapeutic procedures. The following text reviews process and outcome indicators together.
Risk Adjustment
Quality and benchmarking initiatives require accurate stratified risk adjustment. The main prognostic models used to assess overall illness severity of adults admitted to the ICU are the Acute Physiology and Chronic Health Evaluation (APACHE), Simplified Acute Physiology Score (SAPS), and Mortality Probability Model (MPM). The SAPs and MPM have been updated to their third versions and APACHE to its fourth version (see also Chapter 10 ).
Mortality—Outcome
Short-term (e.g., 30 days) mortality often is used to measure success of management strategies in general ICU care. However, mortality as an outcome quality indicator has limitations. Crude mortality cannot be used to evaluate ICU care because it does not adjust for underlying patient mix or disease state. The standardized mortality ratio (SMR) compares the observed to the expected mortality rate. The expected mortality rate may be derived from a number of physiologic parameters including APACHE scoring, SAPS, and the MPM. These models, however, all have limitations in external validation series when applied to data sets outside their original population. For example, Sirio et al. observed consistent overestimation of the SMR (actual/predicted mortality) developed from a national sample that was applied to a community-based sample of hospital ICUs in a metropolitan area. The data further suggested that the methods used to describe standard outcome measures may require recalibration when applied to new samples and to reflect practice changes over time. Glance et al. compared the SMRs based on three different scoring systems (APACHE II, SAPS II, and MPM II) to see if each system could identify the same low-performance ICUs. There was fair to moderate agreement in identifying ICU quality outliers among the three scoring systems. However, the majority of ICUs in the study were classified as above average and so the authors questioned the utility of SMRs if high-performance ICUs cannot be reliably highlighted as role model institutions and questioned the ability of the various models to be used for benchmarking. More recent study from Europe using validation sets each of more than 50,000 patients and from multiple ICUs suggest that the original APACHE IV shows good discrimination and accuracy but poor calibration, whereas a risk profile management using the new SAPS II can be used to evaluate individual ICUs according to the specific risk for patients to die compared with a reference sample over the whole spectrum of hospital mortality.
There are other limitations to the hospitalized SMR because it was developed for all patients admitted to a hospital with a primary diagnosis that is associated with 80% of all in-hospital mortality based on national outcomes. SMR, therefore, may better reflect hospital rather than ICU mortality. Consistent with this Brinkman et al., in a cohort study that included 66,564 ICU patients from 55 Dutch ICUs, found that a model based on clinical data (SAPS II) outperformed SMR. Hence when comparing ICU performance it may be better to use a clinical (ICU) rather than an administrative or hospital model, because there is great variation across ICUs in disease severity and hospitals (or ICUs) that admit more severely ill patients are disadvantaged when compared with institutions that admit less severely ill patients. Instead the SMR could be used to indicate when performance may be poor rather than as a quality indicator. Furthermore, although short-term mortality may be sufficient to differentiate outcomes in general ICUs, it is not an adequate measure to reflect recovery after many neurologic conditions that require ICU admission or to assess quality in a neurocritical care unit (NCCU) because long-term functional recovery is more important in these patients.
Process Quality Indicators
Process indicators usually refer to how something is done (or not). These indicators describe the interactions among patients, their families, and health care providers and the complex tasks performed by the ICU staff to achieve a specified outcome. There often may be a gap between process quality indicator establishment and use in ICU care. For example, Pronovost et al. developed and tested ICU performance measures in a study that involved 13 ICUs, including 3 medical, 3 surgical, and 7 combined ICUs at nonteaching hospitals. Three types of performance monitors—infection control forms, daily rounding forms, and team leader forms—were used to gather data. There was significant variation in compliance with quality measures among ICUs and within individual ICUs. For example, elevated head-of-bed position to prevent VAP was observed in 67% (range 42%-99%) of the ICUs. Other quality measures—appropriate blood transfusion goals (9%-66%) appropriate peptic ulcer (71%-98%), or DVT prophylaxis (48%-98%)—also had a wide range. Based on compliance with the process quality indicators the authors suggest that 1604 excess ICU and 198 excess hospital days per year were incurred. Detailed data derived from patients contained in the eICU Research Institute (eRI) data repository who were discharged from the hospital during 2008 further describe adherence with critical care best practice including stress ulcer (90.8%) and venous thrombosis prophylaxis (86.8%), beta-blocker use (68%-79%), low tidal volume ventilation (28% for <6 mL/kg), and glycemic control (56% in 110-180 mg/dL) in current clinical practice in 271 ICUs in 188 institutions across diverse regions of the United States. The following text examines individual process QIs and suggests strategies toward their implementation.
End-of-Life Care
Quality end-of-life care, also sometimes referred to as palliative care, is an important aspect of ICU treatment because one in five U.S. deaths occurs in the ICU. Many of these deaths are in patients in whom treatment goals are changed to comfort measures. Interviews with family members after a patient dies using a 31-item Quality of Dying and Death (QODD) questionnaire demonstrate that higher scores (i.e., quality) are associated with death at home or in a location of the patient’s choice, lower symptom burden, satisfaction with symptom management, communication about treatment preferences, and satisfaction with communication from health care providers. Other investigators have found that among ICU patients high QODD scores are associated with documentation of a living will, withdrawal of tube feeding, a family conference to discuss the patient’s end-of-life care, family at the bedside at the time of death, and absence of cardiopulmonary resuscitation (CPR). In particular, symptom control, preparation for death, perceived preservation of dignity and respect, and enough time to visit family members are associated with high QODD scores.
Quality indicators for palliative care have been developed. However, most of these quality indicators cover one specific setting or target group, for example, cancer or patients who are at home. Ghafoor et al have recently described a set of indicators for palliative care and for support of relatives before or after the patient’s death that appears applicable to all settings where palliative care is provided to adult patients. In addition, there are policy, standard orders, and quality-assurance monitoring described for palliative sedation therapy, but there are few validated outcome measures to use in improving end-of-life care in the ICU. There are two main models to integrate ICU and palliative care: (1) “consultative,” which increases the involvement of palliative care consultants for ICU patients and their families, particularly those patients at greatest risk for poor outcome; and (2) “integrative,” which embeds palliative care into daily practice for all patients and families in the ICU. These models, however, are not mutually exclusive.
Ventilator-Associated Pneumonia
VAP is a common event in the ICU (8%-28% of mechanically ventilated patients) and can increase ICU length of stay and adversely affect outcome. For example, Yang et al. found that traumatic brain injury (TBI) and stroke patients who develop VAP have greater hospital expenses, longer length of stay in the hospital and in the ICU, and a greater number of readmissions than those without VAP. Consequently the incidence and efforts to prevent VAP often are used as a benchmark of quality of ICU care. However, the complexity and subjectivity of VAP surveillance can limit its value to assess and compare care for ICU patients, and so the use of VAP as a benchmark of ICU “quality” is debated for several reasons. First, VAP can be difficult to diagnose because of underlying cardiopulmonary disorders (e.g., pulmonary contusion, acute respiratory distress syndrome, atelectasis) and the nonspecific radiographic and clinical signs associated with VAP. One third of patients diagnosed with VAP have no evidence of VAP at autopsy and one fourth of mechanically ventilated patients who are not diagnosed with VAP actually have a VAP at autopsy. Second, clinical criteria described by the American Thoracic Society (ATS) lack specificity because other conditions may mimic VAP. For example, purulent secretions often are present in intubated patients because of poor mucociliary clearance. Furthermore colonization of oral secretions can confuse respiratory culture data, and surveillance for VAP requires dedicated and skilled staff. Third, reporting of VAP is variable. For example, Eggimann et al. examined different denominators (1000 patient-days, patient-days at risk, ventilator-days, and ventilator-days at risk) used to report VAP and found that the method of reporting VAP could underestimate its incidence, particularly if reported as ventilator-days or ventilator-days at risk. External reporting pressures also may encourage stricter interpretation of subjective signs and other surveillance initiatives that then may artificially lower VAP rates.
In 2005 the ATS and the Infectious Diseases Society of America (ATS/IDSA) published guidelines to manage hospital-acquired pneumonia (HAP), VAP, and health care–associated pneumonia (HCAP). There is consistent evidence that strategies that affect the primary pathophysiologic mechanisms of VAP reduce the incidence of the disease. Preventive measures are best implemented when grouped into “bundles” to improve overall efficacy and sustain compliance. Several different protocols (or bundles) to reduce VAP are described. For example, Lansford et al. described use of head-of-bed elevation, twice-daily chlorhexidine oral cleans, once-daily ventilator wean, and conversion from nasogastric to orogastric tube in a trauma ICU; the VAP incidence decreased from 6.9 episodes per 1000 patient-days to 2.8 episodes per 1000 patient-days. Cocanour et al. described a ventilator bundle (head-of-bed elevation, stress gastritis prophylaxis, DVT prophylaxis, and planned sedation weans). They found that the VAP incidence was not altered with use of the ventilator bundle alone. Instead a benefit was observed when compliance with the ventilator bundle was audited daily with weekly caregiver feedback. Other techniques that can be included into VAP bundles include proper hand hygiene, high nurse-to-patient ratio, avoidance of unnecessary transfer of ventilated patients and manipulation of ventilator circuits, incorporation of sedation control and weaning protocols into patient care, use of noninvasive mechanical ventilation, maintenance of adequate pressure of endotracheal cuffs, selective digestive tract decontamination, and use of oral rather than nasal intubation, among others. These techniques need to be supplemented with appropriately educated and trained staff and a daily checklist. Initiation of a VAP bundle generally is associated with a reduced VAP incidence (on average from 10 cases/1000 ventilator-days to 3 or 4 cases/1000 ventilator days) and with cost savings, but it remains unclear if this reduces overall ICU mortality.
A reduction in the number of days of mechanical ventilation is an important goal to reduce VAP. This may be accomplished through use of protocol-driven weaning parameters by a multidisciplinary team, including nursing staff and respiratory therapists. For example, Kollef et al. in a randomized trial of different weaning methods in medical and surgical ICUs observed that weaning protocols were associated with significant reduction in duration of mechanical ventilation. The least success with a weaning protocol occurred in the ICU without an ICU director and critical care fellows. Use of a multidisciplinary weaning protocol also can help reduce ventilation time in patients ventilated greater than 7 days. Inclusion of parameters such as assessment of sedation status using a standardized form and standard clinical criteria for weaning eligibility including hemodynamic status, oxygenation requirements, and minute ventilation can be used to help clear patients for T-piece or pressure support weans.
Today many hospitals report VAP rates at or close to zero, so health care–regulating bodies propose that HAP should not be reimbursed and potentially should be a “never event.” However, VAP rates reported by hospital administrative sources appear to be less accurate than physician-reported rates and underestimate VAP incidence, that is, a never event may not be possible. It also is difficult to unravel the relative contribution of care improvements rather than surveillance effects on the low VAP rates. Furthermore, whether a VAP rate of zero is obtainable in the ICU is unclear because many patients who are admitted already intubated have evidence of early pneumonia or bacterial growth within 48 hours of arrival. This suggests that early infection or colonization occurred before admission. In the future, surveillance definitions that use more objective criteria may better mirror and inform clinical practice. This includes objective alternatives such as average duration of mechanical ventilation, length of stay, mortality, and antibiotic prescribing to estimate disease burden and guide quality improvement.
Pressure Ulcer
The National Quality Forum has identified a pressure ulcer as a hospital-acquired condition (HAC) that is high cost and may be prevented by using evidence-based guidelines. The CMS intends to no longer reimburse acute care facilities for the cost associated with facility-acquired (FA) ulcers. ICU patients are at risk for pressure ulcer development because of comorbid diseases, immobility, and use of sedation and analgesia that reduce patient perception of high pressure points. In the International Pressure Ulcer Prevalence Survey (IPUPS), an observational, cross-sectional cohort study conducted in the United States during 2008 and 2009, FA pressure ulcer rates were highest in ICUs (~10%), although the incidence varied according to ICU type. In 2009, 3.3% of ICU patients developed severe pressure ulcers (stage III, stage IV). There are several risk assessment scales for pressure ulcers, although often they are not specific to ICU populations. The APACHE score also correlates with pressure ulcer risk. Development of hospital-wide protocols including early skin assessments and transfers to pressure-reducing mattresses can help reduce the incidence of pressure ulcers or increase the length of time it takes for an ulcer to develop.
Bloodstream Infections
Hospital acquired infections (HAIs) and in particular bloodstream infections (BSIs), are common and adversely affect patient outcome. The U.S. Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN; formerly the National Nosocomial Infections Surveillance [NNIS] group) collects national data on catheter-associated bloodstream infections (CA-BSIs). How the condition is defined may affect the incidence. For example, CA-BSIs and catheter-related bloodstream infections (CR-BSIs) differ in the degree of proof needed to show that the catheter “causes” the infection, so the CR-BSI rate is significantly lower than the CA-BSI rate. In October of 2008, Medicare enacted new regulations that reduced reimbursement for HAIs and CA-BSIs and in 2009 the IDSA published updated guidelines for the diagnosis and management of all intravascular catheter-related infections.
Several factors such as central venous catheters (CVCs), total parenteral nutrition (TPN) days, and hemodialysis catheters are associated with nosocomial BSIs. Consequently a variety of protocols and techniques now are in use to reduce the incidence of infections associated with central lines, that is, central line–associated bacteremia (CLAB) or central line–associated bloodstream infections (CLABSIs). First, is the use of chlorhexidine or silver sulfadiazine or antibiotic-impregnated CVCs that at the very least appear to reduce the risk of colonization and perhaps BSIs. These catheters can be expensive and there is a concern that use of antibiotic-impregnated catheters may be associated with an increased risk of antimicrobial resistance. In addition, adherence to standardization of the processes of care associated with CVC placement rather than use of coated CVCs (i.e., placement, dressing, and maintenance/removal protocols) appears to be a more important factor in reduction of CR-BSIs. Second is use of chlorhexidine-soaked dressings. For example, the Biopatch dressing surrounds the hub of the CVC and is saturated with chlorhexidine. Data from the manufacturer suggest that its use is associated with a 60% decrease in BSIs and 44% decrease in local site infections (see www.jnjgateway.com ). Third, a reduction in the duration of central venous access and peripherally inserted central catheter (PICC) rather than CVC use may help reduce the incidence of CR-BSI particularly in patients who are in the ICU a long time. Fourth, resident oversight and credentialing policy for CVC placement can help reduce CLABSIs. Finally and perhaps most important is a bundle approach with physician and patient specific steps and use of a checklist. Compliance with these protocols (bundles) has improved the safety of hospitalized patients, and better compliance appears to be associated with a reduction in infection and CLABSIs. Bundle adherence and CLABSI rates may depend on the institution; where compliance is low the sites often lack a functional team, forcing functions, and feedback systems.
Glycemic Control (See Also Chapter 14 )
Both hyperglycemia and hypoglycemia can adversely affect ICU outcome. Furthermore increased insulin administration and poor glycemic control in nondiabetic patients may aggravate outcome, hence insulin and glycemic control protocols have developed. The most successful protocols include bedside glucose monitoring, nursing-driven protocols, and computerized decision-making algorithms. Although there are many clinical and fiscal benefits to glucose control there are barriers to “tight” glucose control in the ICU that include lack of a defined target glucose range, health care provider fear of hypoglycemia, and changes to subcutaneous insulin, particularly when patients’ nutritional and clinical status is in flux.
Hyperglycemia is common among ICU patients, and 90% of critically ill patients develop blood glucose concentrations greater than 110 mg/dL (6.1 mmol/L). Van den Bergh’s landmark study published in 2001 supported the use of intensive insulin therapy (IIT) to target normoglycemia (a blood glucose concentration of 80-110 mg/dL [4.4-6.1 mmol/L]) in the critically ill and postoperative patient. However, other investigators have not been able to replicate these findings, and a meta-analysis that included 29 randomized trials with 8432 patients showed that tight glucose control is not associated with reduced hospital mortality but is associated with an increased risk of hypoglycemia in critically ill adult patients. A paradigm shift in glucose control in the ICU occurred after the publication in 2009 of the normoglycemia in intensive care evaluation survival using glucose algorithm regulation (NICE-SUGAR). This trial demonstrated increased mortality and incidence of hypoglycemia in patients managed with IIT. Current recommendations are more moderate and target a blood glucose (BG) concentration between 144 mg/dL and 180 mg/dL (8-10 mmol/L). These “moderate” insulin protocols are in use in many ICUs and appear to avoid hyperglycemia and low glucose variability while rarely inducing hypoglycemia. These various studies were conducted largely in non-NCCU patients, and laboratory studies that indicate the deleterious effects of severe hyperglycemia in the context of anaerobic conditions in the brain and clinical microdialysis studies in severe brain injury that show interstitial hypoglycopenia in NCCU patients with tight glucose control underscore the still unsettled question on optimal glucose management in NCCU patients.
Most hospitals have established glycemic control programs. Based on reports from the 2009 Remote Automated Laboratory System (RALS) that provides trends in glycemic control between 2006 and 2009 from 576 U.S. hospitals (including 175 million BG results, 25% from the ICU) for many institutions, glycemic control has improved: the mean range of BG results in ICU patients in 2009 was 121.1 to 217 mg/dL. Earlier RALS reports show that hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% in the ICU and 31.7% outside the ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was 10.1% in the ICU and 3.5% for non-ICU readings. What is unclear is whether quality indicators for diabetes care are associated with patient outcomes. For example, Sidorenkov et al. conducted a systematic literature review of 24 studies (but not limited to ICU patients) to test this relationship. There was insufficient evidence that quality indicators predicted better patient outcomes. Consequently insulin infusion protocols (IIPs) to achieve desired BG targets must be individualized and validated to the ICU and institution where they are used. The implementation of IIPs is not a simple process but requires a carefully planned, inclusive, and continual team effort. Continual assessment of protocol errors, adverse events, staff satisfaction, and outcomes is vital to success, the goal of which is effective glucose control while avoiding hyperglycemia, hypoglycemia, and glucose variability, all of which are detrimental. Accurate and efficient glucose monitoring devices, including automated point-of-care (POC) BG data management software therefore are essential. Each of these devices is subject to federal and state regulations, and accreditation standards developed by the College of American Pathologists and The Joint Commission. Future research will need to address whether computerized decision support systems and newer technologies that allow accurate and continuous or near-continuous BG measurements improves the quality of glycemic control.
Structural Quality Indicators
Structure in the ICU refers to the type and size of the ICU, ICU design, availability of technology, and staffing among others (see Chapter 3 for a review on ICU design). Interventions that influence structure usually take longer to implement and are more expensive than changes to processes of care. The following text discusses organization and management in critical care by reviewing ICU staffing, transport, handovers, and telemedicine.
Physician Staffing Models
Models of physician staffing in the ICU include low intensity, or open, and high intensity, or closed. In low-intensity systems there is either no or only partial intensivist direction. A patient’s primary attending physician controls the patient’s admission to and discharge from the ICU. Intensivists may serve as part of an acute resuscitation team or be consulted for a particular management question. In a closed unit, a patient’s attending physician yields control of patient care to a critical care team. The team model that characterizes the closed unit empowers medical and nursing administrators to effect standard protocols of care. In the United States, the model of ICU care historically has been a low-intensity system. For example, in 2000 Angus et al. published a survey of 393 ICUs; 23% were managed by a full-time intensivist; an intensivist consultant was available in 14%; and 29% had no access to an intensivist at all. High-intensity units usually are associated with teaching hospitals, hospitals with large patient volume, surgical ICUs, or trauma ICUs and are more prevalent.
Several studies describe a benefit to closed rather than open systems. For example, Pronovost et al. reviewed 27 randomized or observational trials that described the effect of physician staffing on mortality and length of stay in medical, surgical, mixed medical and surgical, or pediatric ICUs. In nearly every study, decreased mortality was associated with a closed ICU and in half decreased ICU length of stay was associated with a closed ICU system. The benefits of a high-intensity model may be greatest when patients are admitted at night or during the weekend, patients admitted more than 48 hours, or among elderly patients with more comorbid diseases. The benefits of closed systems on patient outcome, ventilator-days, length of stay, morbidity, cost, and discharge disposition among other measures also are seen in various subspecialty ICUs including trauma, surgical, and neurocritical care in patients with acute lung injury or who undergo specific high-risk procedures such as abdominal aortic surgery or esophageal resection. For example, Varelas et al. compared patient outcome and disposition using historical controls in a university hospital NCCU that changed from an open ICU to one with a dedicated neurointensivist. Hospital and ICU length of stay were reduced and fewer patients were discharged to nursing homes when the NCCU was led by a neurointensivist. Implementing a high-intensity staffing model including continuous (24 hour) onsite presence of a critical care specialist also is associated with improved processes of care and staff satisfaction.
Evidence-Based Protocols
The mechanisms that underlie improved outcomes in high-intensity ICUs are unclear but may be associated with increased use of evidence-based quality indicators and increased use of evidence-based guidelines or protocols. These protocols include DVT prophylaxis, stress ulcer prophylaxis, sedation interruption, spontaneous breathing trials, and glycemic control, among others. Even just having an available intensivist can contribute to evidence-based protocol enforcement. Other processes that may be associated with better outcomes and are improved in a closed system include weaning by respiratory therapist protocol, daily rounds with pharmacists, nurse-to-patient ratio of greater than 1 : 2, and ICU mortality and morbidity reviews. A mandatory bedside checklist can be a simple, cost-effective method to prevent errors of omission and improve implementation of ICU best practices.
Introduction of evidence-based protocols requires an audit of current practice, expert-led education sessions, and dissemination of algorithms (because adoption of protocols with low baseline adherence changes clinical practice little). Evidence-based guidelines create a base to allow change in health care practitioner behavior. However, they do not in and of themselves effect change or outcome unless their use is accompanied by conversion of a core of key goals in the guideline recommendations to quality indicators, and with regular feedback on performance, for example, weekly. In addition, the protocols must be updated to incorporate new guidelines and evidence if these new guidelines and evidence meet rigorous critical appraisal. Most appraisal systems consider randomized controlled trials (RCTs) the gold standard given their ability to limit bias. However, many RCTs in critical care have failed, or a number of trials have had results that are initially positive and then subsequent trials are less positive. This has led to uncertainty about the scientific approach to ICU research and that guideline development may need reevaluation. In part this may be explained by the heterogeneous nature of ICU patients, who all have differing physiologic requirements over time. Consequently, ICU clinicians routinely adjust treatment dose and care based on multiple factors that can be difficult to simulate in a clinical trial. Procedure or disease-specific registries, observational cohorts, or studies that aim to understand variation in performance and delivery of care and how to reduce individual and organizational underperformance may help answer some of the limitations observed with RCTs in critical care. The past decade also has seen the bringing together of positive studies and interventions into bundles of care (goal-directed therapy, protocolized care). While these bundles appear to be associated with improved outcomes, there needs to be a balance between individualized versus protocolized care.
There are several concerns with protocols in ICU care. First, the use of clinical protocols may negatively affect medical education by eliminating clinical decision making from trainees. However, a study by Prasad et al. suggests this is not so. Second, the ICU environment is complex and highly dynamic and often requires that clinicians adjust and deviate from standard protocol when confronted with nonstandard circumstances. These deviations may be errors or innovations. Observations in acute trauma care indicate that protocol deviations by more experienced physicians are a combination of errors and innovations, whereas the deviations by less experienced practitioners are mostly errors. Finally, bundles of care often are implemented under pressure from hospital administrators or regulatory bodies with little regard for the context in which the evidence was generated and without understanding the difference between efficacy and effectiveness; that is, the interventions could be implemented to a larger group of ICU patients that differ from those in whom the evidence was gathered. The risk then is that the bundle tools or protocols can be used for quality control, performance evaluation, and legal and regulatory purposes out of context and without robust validation. This will put patients and professionals at risk of being harmed by the protocols or bundles of care.
Intensive Care Unit Physician Staffing Plan
In the United States there still is a relative paucity of ICUs that are closed and have a board-certified intensivist available at all times. These staffing issues are changing in part because of the Leapfrog initiative or addressed through the development of the eICU and telemedicine (see Chapter 42 , Chapter 43 , Chapter 44 ). The Leapfrog organization recommends all ICUs have a board-certified intensivist available onsite during daytime hours and be immediately reachable through a pager during nighttime hours with a critical care physician or “physician extender” available within 5 minutes of the ICU at night. These rules formulate the Leapfrog’s 2002 ICU Physician (IPS) Standard ( www.leapfroggroup.org ). There are, however, several obstacles to the Leapfrog standard, including (1) primary physician resistance to yield control over patient care, (2) perceived loss of continuity of patient care, (3) shortage of critical care physicians to staff ICUs, (4) limited fiscal incentive for critical care–certified physicians, and (5) poor fiscal incentive for hospitals with small ICUs to hire full-time ICU physicians. These factors are greater in smaller nonacademic hospitals where there may not even be an ICU director. To overcome some of these obstacles, many ICU directors recommend financial incentive from either a hospital, the government, or a third party to ensure compliance with the Leapfrog initiative. Consistent with this a survey of ICU directors as well as chief medical officers suggest that adoption of the IPS standard was facilitated by intensivist salary support.
What is the cost of achieving the Leapfrog IPS standard? Hypothetical financial models have been applied to 6-, 12-, and 18-bed ICUs. The variables in the model include annual admissions, intensivist salary, revenue from intensivist billing, and salary of critical care physician extenders among others. Savings, because of improved patient outcomes and shorter ICU length of stays, range between $510,000 and $3.3 million. The greatest savings occur in larger ICUs and are associated with ICU beds, length of stay, and cost of ICU bed per day. However, under worst-case scenario conditions, costs may range from $890,000 to $1.3 million. Small ICUs may be disproportionately more vulnerable to worst-case conditions and experience net loss more frequently under the IPS standard.
The final obstacle is having enough staff. The Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS), commissioned by the American College of Chest Physicians, the ATS, and the Society of Critical Care Medicine, assessed the future supply and demand for intensivists until 2030. COMPACCS found that the supply of intensivists likely will be static until 2030, whereas the demand for critical care services, particularly by older patients, will increase as the baby boomer generation ages. Other critical care workforce analyses estimate a 35% shortage of intensivists by 2020, particularly in surgical critical care in the United States. The likely intensivist workforce shortage calls for creative staffing solutions. Among these are (1) use of “novel” critical care personnel including critical care–certified physician assistants and nurse practitioners and physicians from emergency medicine and anesthesiology who receive ICU training; (2) regionalization; and (3) telemedicine. In many countries around the world anesthesiologists provide critical care but in the United States in 2006, less than 4% of board-certified anesthesiologists were also certified in critical care. There are two major barriers to dual certification: a paucity of programs that offer such certification, and surgeons and anesthesiologists who practice critical care tend to take a pay cut. An alternative may be increased use of acute care nurse practitioners (ACNPs). In a “semiclosed” surgical intensive care unit (SICU) the presence of ACNPs increases compliance with clinical practice guidelines.
In 2004 the American Association of Critical-Care Nurses, the American College of Chest Physicians, the ATS, and the Society of Critical Care Medicine, convened the Critical Care Workforce Partnership and published a white paper titled “FOCCUS—Framing Options for Critical Care in the United States.” The conference highlighted that although trauma patients are classified by need into level of trauma service, there is no tiered critical care delivery system. Such a regionalized and standardized triage system may appropriately direct intensivist workforce demand to higher-level, higher-acuity centers.
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