Article Figures & Tables
Figures
- Figure 1
Number of quality indicators identified according to Institute of Medicine classification. (4)
Tables
National critical care societies Canadian Critical Care Society (www.canadiancriticalcare.org) Society of Critical Care Medicine (www.sccm.org) European Society of Intensive Care Medicine (www.esicm.org) Australian and New Zealand Intensive Care Society (www.anzics.com.au) Intensive Care Society (www.ics.ac.uk) Provincial critical care societies Alberta Critical Care Clinical Network (now Critical Care Strategy Clinical Network of Alberta) (email communication) BC Society of Critical Care Medicine (www.bcsccm.ca) Critical Care Secretariat (Ontario) (www.health.gov.on.ca/en/pro/programs/criticalcare) Provincial health quality councils BC Patient Safety & Quality Council (http://bcpsqc.ca/clinical-improvement) Health Quality Council of Alberta (www.hqca.ca) Saskatchewan Health Quality Council (http://hqc.sk.ca/improve-health-care-quality/measure) Manitoba Institute for Patient Safety (www.mbips.ca) Health Quality Ontario (www.hqontario.ca) New Brunswick Health Council (www.nbhc.ca) National health providers Health Canada (www.hc-sc.gc.ca/index-eng.php) National Health Service (www.nhs.uk) Quality improvement and patient safety Canadian Patient Safety Institute (www.patientsafetyinstitute.ca)
Safer Healthcare Now! Initiative
Critical Care Vital Signs Monitor projectCanadian Healthcare Association (now HealthCareCAN) (www.healthcarecan.ca) National Quality Forum (www.qualityforum.org) Institute for Healthcare Improvement (www.ihi.org) Agency for Healthcare Research and Quality (www.ahrq.gov)
Healthcare Cost and Utilization ProjectNational Quality Measures Clearinghouse (www.qualitymeasures.ahrq.gov) Institute of Medicine (now Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine) (www.nationalacademies.org/HMD) Canadian Institute for Health Information (www.cihi.ca) Intensive Care National Audit & Research Centre (www.icnarc.org) Accreditation Accreditation Canada (www.accreditation.ca) Other Health Talk Online (www.healthtalkonline.org/Intensive_care) U.S. Department of Veterans Affairs (www.va.gov) Institute of Medicine domain Donabedian domain; no. (%) of indicators Structure Process Outcome Total Safety 1 (0.5) 33 (17.0) 29 (14.9) 63 (32.5) Effectiveness 8 (4.1) 33 (17.0) 20 (10.3) 61 (31.4) Patient-centredness 0 (0) 8 (4.1) 2 (1.0) 10 (5.2) Timeliness 3 (1.5) 19 (9.8) 5 (2.6) 27 (13.9) Efficiency 2 (1.0) 13 (6.7) 2 (1.0) 17 (8.8) Equity 0 (0) 0 (0) 0 (0) 0 (0) Staff work-life 8 (4.1) 4 (2.1) 4 (2.1) 16 (8.2) Total 22 (11.3) 110 (56.7) 62 (32.0) 194 (100) *A total of 127 records were considered unique indicators, but indicators could be assigned to more than 1 domain.
Area of care; quality indicator Evidence grade* Implementation results reported Mechanical ventilation Ventilator-associated pneumonia bundle Moderate to high† Yes‡ Elevation of head of bed Level 1‡ Daily sedation vacation and assessment of readiness to extubate Level 1‡ Prevention of venous thromboembolism Level 1‡ Pressure ulcer disease prophylaxis Level 1‡ Daily oral care with chlorhexidine Level 1‡ Pneumonia Blood cultures performed within 24 hr or before arrival Evidence synthesis§ No Antibiotics consistent with guidelines Evidence synthesis§ No Invasive procedures Ultrasound guidance for central venous catheter insertion High† No Central line insertion bundle Moderate to high† Yes‡¶ Maximal barrier precautions 1B¶; evidence synthesis§ Chlorhexidine skin antisepsis 1A¶ Hand hygiene 1B¶ Optimal catheter type and site selection 1A-1B¶ Central line care bundle Yes‡¶ Daily review of line necessity 1A¶ Aseptic lumen access 1A¶ Catheter site and tubing care 1B¶ Patient-centred care Documentation of goals of care Moderate† No Sepsis management Sepsis management bundle Administer low-dose steroids by standard policy 2C‡** No Maintain adequate glycemic control 1B‡ No Prevent excessive inspiratory plateau pressures 1C‡** Yes** Sepsis resuscitation bundle Serum lactate levels measured 1B‡ No Timing of blood cultures 1C‡** No Treat hypotension and/or elevated lactate with fluids 1B‡ No Maintain adequate central venous oxygen saturation 1C-2C‡ No Antibiotics given by time goal 1B‡** No Apply vasopressors for ongoing hypotension 1C‡ No Maintain adequate central venous pressure 1C‡** Yes** Patients with sepsis: second litre of crystalloid administered by time goal 1C** No Blood for culture drawn before antibiotics administered 1C** No Glycemic control policies Moderate to high† No After initial stabilization for patients with severe sepsis 1B** No Validated protocol for insulin dosage adjustments 2C** No Prevention of adverse events Appropriate transfusion practices Not graded Yes‡ Pharmacist on rounds Moderate to high† No Medication reconciliation by a pharmacist Moderate† Yes‡ Venous thromboembolism prophylaxis Evidence synthesis§ Yes¶†† Preventing pressure ulcers Moderate†; evidence synthesis§ Yes‡ Simulation training Moderate to high† No Training on infusion pumps Low† No Infection control Isolation of patients with resistant infections Moderate† No Hand hygiene improvement Low† Yes‡‡ Staffing Establishment of rapid-response team Moderate† Yes‡¶ Staffing ratios: increasing nurse to patient ratio to prevent death Moderate† No *See Table 4.
†Agency for Healthcare Research and Quality.
‡Institute for Healthcare Improvement.
§National Quality Measures Clearinghouse.
¶Canadian Patient Safety Institute.
**Society of Critical Care Medicine, European Society of Intensive Care Medicine.
††Australian and New Zealand Intensive Care Society.
‡‡Health Quality Ontario.
- Table 4: Reporting organizations, evidence grading tools and interpretation of each evidence grade
Organization Evidence grading tool Grade Interpretation Agency for Healthcare Research and Quality Evidence-based Practice Centers program13 High High confidence that the evidence reflects the true effect. Further research is very unlikely to change our confidence in the estimate of the effect. Moderate Moderate confidence that the evidence reflects the true effect. Further research may change our confidence in the estimate of the effect and may change the estimate. Low Low confidence that the evidence reflects the true effect. Further research is likely to change our confidence in the estimate of the effect and is likely to change the estimate. Insufficient Evidence is either unavailable or does not permit a conclusion Institute for Healthcare Improvement14 Level 1 Evidence obtained from at least 1 properly designed randomized controlled trial National Quality Measures Clearinghouse15 Evidence synthesis - Clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence Category 1A Strongly recommended for implementation and strongly supported by well-designed experimental, clinical or epidemiologic studies Category 1B Strongly recommended for implementation and supported by some experimental, clinical or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence Society of Critical Care Medicine, European Society of Intensive Care Medicine16 Grading of Recommendations, Assessment, Development and Evaluation (GRADE)11 1A Strong recommendation, high quality of evidence 1B Strong recommendation, moderate quality of evidence 1C Strong recommendation, low quality of evidence 2C Weak recommendation, low quality of evidence Grading of Recommendations, Assessment, Development and Evaluation (GRADE)11
Canadian Patient Safety Institute
Centers for Disease Control and Prevention framework12
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