A. Valentin Vienna, Austria andreas.valentin@meduniwien.ac.at

1. Audit of quality indicators in intensive care medicine A. Valentin Vienna, Austria andreas.valentin@meduniwien.ac.at

2. Topics • Audit • What is it? • Who should do it? • Can we identify high quality ICUs? • Combining measures • The role of intensive care in the whole chain of care

3. Intensive Care is about medicine, care, compassion and organisation Are we doing a good job ?How could we do even better ?

4. Tidalvolume ≤ 6ml PBW in ARDS/ALI:Lungprotective Ventilation in Reality Brunckhorst F, Crit Care Med 2008

5. Tidalvolume ≤ 6ml PBW in ARDS/ALI:Lungprotective Ventilation in Reality Perceivedadherence: 80% Real adherence: 3% Brunckhorst F, Crit Care Med 2008

6. Audit • from Latin auditus = act of hearing • Synonyms: examination, analysis, checkup, inspection, perlustration, review, scan, scrutiny, survey, view • Related: investigation, probe, check, control, corrective

7. A thorough, systematic examination of the processes and results of a health care service. Internal Audit External Audit Quality Indicators Benchmarking External Benchmarking Internal

8. Deaths 764 Potentially preventable: 7.8% Preventable: 2.1% Human factors: 97% Patient safety in trauma: maximal impact management errors at a level I trauma center Ivatury RR, J Trauma 2008

9. Patient safety in trauma: maximal impact management errors at a level I trauma center Ivatury RR, J Trauma 2008 • Poor bleeding control and volume resuscitation 30 • Inability to secure a proper airway 13 • Missed injuries 9 • Inadequate deep vein thrombosis prophylaxis 6 • Delayed diagnosis of bowel gangrene 3 • Miscellaneous 15 Summary of management errors among the 76 deaths

10. Purpose of an audit • to blame • to improve • to enhance • to ensure • to change ASSESSMENT AND IMPROVEMENT OF QUALITY

11. What is Quality ? “the degree to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge” Institute of Medicine, 1990 Results Quality = Objectives Quality is defined by goals

13. Good-Better Q + - t Paradigm of Quality Good-Bad Q + good - bad t

14. 4 Reasons for auditing your ICU • Audit is an essential tool for quality improvement • you only manage what you measure • Audit is in the interest of your patients • to ensure safe and evidence-based care • Audit is in the interest of your ICU team • to enhance team culture, professionalism, job satisfaction • Audit is in the interest of health systems • to ensure efficient and fair use of resources

15. Another reason for auditing your ICU Ifyoudon‘tcompareyour ICU withothers someoneelse will do it !

16. BBC News Online: Health Wednesday, October 27, 1999 Published at 13:40 GMT 14:40 UK Intensive care: Why the differences? An Audit Commission report has highlighted that some hospital intensive care services have higher death rates than others. BBC News Online examines the reasons behind this.

17. To audit meansto compare Objectives and Reality • Structure what you need vs what is provided • Process what you should do vs. what you do • Outcome what you expect vs. what you find Perception ?

18. Quality Interactions Environment Structure Process Outcome

19. Quality interactions innosocomial infection • Process • Handwashing • Isolation/infection precaution • Infection reporting • Room cleaning, desinfection • Antibiotic use • Communication • Structure • Room design • Fixed installations • Medical equipment • Air conditioning • Staffing • Training level • Funding

20. Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit Alcohol solution easily available 42.4 (621) 60.9 (905) 4 months later: 51.3 % Maury E, AJRCCM 2000

22. Internal comparison Indicator Single ICU Time

23. External comparison Indicator ICUs

24. What do we need? • A network of ICUs who collect data • Temporally limited • Temporally unlimited (benchmarking project) • Standardization of data collection • Common data set • A set of tools to compare institutions • Defined indicator variables

25. Clinical Audit To determine • whether you have done what you set out to do • whether you have achieved your objectives Requirement • a standard or guidelines for intended care to audit against.

26. Quality Areas and Management Tools

27. 120 Quality Indicators

28. Early ASS in ACS Early reperfusion in STEMI Semirecumbentposition in MV Surgicalintervention in TBI with SDH of EDH ICP in severeTBIwithpathologic CT Early managementofseveresepsis/septicshock Early enteral nutrition GI-bleedingprophylaxis in MV Appropriatesedation Painmanagement in unsedatedpts Inappropriatetransfusionof RBC Organ donors Compliance with hand-washingprotocols Information tofamilies Withholding/Withdrawinglifesupport Quality surveyat ICU discharge Presence ofintensivist 24h/day Adverseeventregister SEMICYUC20 fundamental Quality Indicators

29. Austrian Center for Documentation and Quality Assurance in Intensive Care Medicine • Founded in 1994 • Support of several multinational studies in intensive care: • SAPS 3 • SEE 1 & 2 • 130 ICUs in Austria use the documentation standard with the software ICdoc • 70 ICUs take part in the ASDI benchmarking • Annual reports to participating ICUs

30. ASDI benchmarking ICUs Data cleaning Analysis Report

31. Quality Indicators Criteria for selection • Already integrated in the ICU documentation • Cover specific problems of intensive care • Easy to review

32. List of indicators • Presence of an intensivist in the ICU 24h/365d • Critical incident reporting system in use • Early enteral nutrition • Mild therapeutic hypothermia after CPR • Reintubation • Ventilator associated pneumonia • Unplanned readmission • Mortality after severe brain trauma • Standardised mortality ratio Structure Process Outcome

35. Enteral NutritionStart within < 48h

36. Reintubation:Proportion of all intubated pts

37. Unplanned Readmission

38. Observed/ExpectedMortality Ratio

39. O/E ratio± transferred patients

40. Can we identify high-quality ICUs ?

41. Enteral NutritionStart within < 48h

42. Reintubation:Proportion of all intubated pts

43. Unplanned Readmission

44. Observed/ExpectedMortality Ratio

45. O/E ratio± transferred patients

46. Quality report for ICUs

47. SMR by reasons for admission Valentin A, Crit Care Med 2003

48. Different relationships between the performance of the ICU and the severity of illness of the admitted patients Moreno R, Curr Opin Crit Care 2010

49. Performance of the ICU and the severityof illness of the admitted patients 70 ICUs Single ICU

50. Interpreting results Quality indicators should prompt a look into details