Quality Control	80
Subhash Todi and Ashit Bhagwati

Case 1

A 70-year-old male patient with dementia and Parkinson’s disease was admitted to the ICU with the confusional state. He fell from his bed on the night of admission and suffered scalp injuries. How would you ensure that similar accidents do not happen in the future?

Case 2

A 60-year-old male patient was admitted to hospital with hypertensive intracerebral bleed and required ventilatory support. On the fourth day of admission, he developed features of ventilator-associated pneumonia. What measures should have been in place to avoid this complication?

Case 3

A 30-year-old male patient was admitted to hospital with gastroenteritis and severe hypokalemia. He was inadvertently administered high concentration of potassium in intravenous infusion through the central line and suffered a cardiac arrest. How could you have prevented such errors?

In a landmark publication, To Err Is Human: Building a Safer Health System, a decade ago by the Institute of Medicine USA, it was described that human error was one of the common causes of morbidity, mortality, and increased health care cost in hospitalized patients worldwide. Experts estimate that as many as 98,000 people die

S. Todi, M.D., M.R.C.P. (*)

Critical Care & Emergency, A.M.R.I. Hospital, Kolkata, India e-mail: [e-mail]

A. Bhagwati, M.D.

Department of Internal Medicine and Critical Care, Bhatia Hospital, Mumbai, India

R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach,	649
DOI 10.1007/978-81-322-0535-7_80, © Springer India 2012

650	S. Todi and A. Bhagwati

every year due to medical errors in hospitals. This number is more than the number of deaths due to motor vehicle accidents, breast cancer, and AIDS—three causes that receive far more public attention. This error is more evident in the critically ill patients in the ICU. Increasing accountability and demand from public and accrediting agencies have led to a movement of quality care in ICUs.

Step 1: Understand the concept of quality and safety

•Quality and safety are two sides of the same coin. Quality reflects measures that should have been taken or errors of omission, and safety reflects actions that were taken inappropriately or errors of commission.

•Case 1 may be taken as quality issue as proper precautions were not taken, which led to compromise in patient safety.

•Case 2 reflects need for preventive protocols for ventilator-associated pneumonia to be in place, another quality control issue.

•Case 3 reflects not only an error of commission, clearly a safety issue, but also lack of protocol for intravenous potassium infusion, a quality issue.

Step 2: Understand Donabedian’s theory on quality control

•Three important ingredients are as follows:

1.Structure (what we have)

2.Process (what we do)

3.Outcome (what we get)

•Structural issues consist of organizational elements, personnel, and finance and are predominantly under administrative control.

•Process issues are the care given to the patient by health care providers. Daily checklists of such issues are always helpful.

•Outcome reflects what happens to the patient from morbidity and mortality point of view, given the structure in place and processes being implemented (Tables 80.1).

Step 3: Implement standardized data collecting and reporting system

•This should be done for all the three elements: structure, process, and outcome.

•It should follow SMART principle (specific, measurable, achievable, reliable, and time bound). A well-trained data collector is the backbone of any quality control program (Fig. 80.1).

Step 4: Understand principles of data collection

•Any data should have a numerator (affected persons) and a denominator (persons at risk) (Table 80.2).

Step 5: Prioritize

• Identify important elements for which data need to be collected (Table 80.3).

Step 6: Identify team members

•This should be done for data collection, data entry, data analysis, and data reporting.

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Table 80.1 Donabedian’s model of quality control
Structure	Process	Outcome
Closed model of ICU care	Compliance with hand	Crude ICU mortality
	hygiene
Critical care consultant	Family conference	Risk-adjusted ICU mortality
availability
24 × 7 intensivist coverage	End-of-life support policies	Standardized mortality
		ratio = crude mortality/
		predicted mortality
Ward design	Compliance with ventilator	Hospital mortality
	bundle
Nurse–patient ratio	Compliance with central line	ICU length of stay
	insertion bundle
Doctor–patient ratio	Antibiotic consumption	Hospital length of stay
Policies and protocols	Implementation of catheter-	Family satisfaction
	related blood stream infection
	prevention policies
Infectious disease consultant	Implementation of urinary	Cost of care
Infection control nurse	tract infection prevention	Resource utilization
Multidisciplinary ward round	policies
Infection control committee
Daily goal sheet
Antibiotic form
Adequate equipment

Step 7: Identify benchmarks

•This should be done for comparison of data.

•There are national and international benchmarks for various quality control processes and outcomes.

•In the absence of a comparative benchmark, one can follow one’s own trend and performance over time.

Step 8: Adopt the plan-do-study-act cycle for quality control

•After identifying specific elements for data collection, collect, analyze, and compare reliable data with benchmark, take corrective action, and revisit the same process periodically to maintain a standard of care.

Step 9: Understand terminology for reporting of safety issues

•Patient safety data should be reported in the format including error, incident, near miss, adverse event, and preventable adverse event (Table 80.4).

Step 10: Implement

•One of the measures for evaluating patient safety such as incident report, root cause analysis, and failure mode effect analysis should be implemented:

652	S. Todi and A. Bhagwati

Quality control and safety

Error, incident, near miss, adverse event, preventable adverse event

	Team—ICU director,	Incident report, root
		cause analysis,
	data collector,
		failure mode, effect
	statistician, residents,
		analysis
	nurses, administrator

Data collection, entry, analysis, reporting

Compare with benchmark, own performance

Plan-do-study-act

cycle

Fig. 80.1 Quality control approach in the ICU

Table 80.2 Formulae for urinary tract infections, central line-associated blood stream infections, and ventilator-associated pneumonia

Number of catheter - associated urinary tract infections ´1,000

Number of urinary catheter - days

Number of central line - associated blood stream infections ´1,000

Number of central line - days

Number of ventilator - associated pneumonias ´1,000

Number of ventilator - days

–Incident report: It evaluates how a single patient comes to a harm. An incident reporting system should be voluntary, anonymous, and not linked with any form of punitive measures.

–Root cause analysis: This is a more focused enquiry on certain incidents deemed to be important for patient safety. A sentinel event is identified, and

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Table 80.3 Fundamental quality indicators

(a)Early administration of acetylsalicylic acid in acute coronary syndrome

(b)Early reperfusion techniques in ST-elevation myocardial infarction

(c)Semirecumbent position in patients undergoing invasive mechanical ventilation

(d)Prevention of thromboembolism

(e)Surgical intervention in traumatic brain injury with subdural and/or epidural hematoma

(f)Monitorization of intracranial pressure in severe traumatic brain injury with pathologic CT findings

(g)Pneumonia associated to mechanical ventilation

(h)Early management of severe sepsis/septic shock

(i)Early enteral nutrition

(j)Prophylaxis against gastrointestinal hemorrhage in patients undergoing invasive mechanical ventilation

(k)Appropriate sedation

(l)Pain management in unsedated patients

(m)Inappropriate transfusion of packed red blood cells

(n)Organ donors

(o)Compliance with hand-washing protocols

(p)Information of patients’ families in the ICU

(q)Withholding and withdrawing life support

(r)Perceived quality survey at discharge from the ICU

(s)Presence of an intensivist in the ICU 24 h/day

(t)Adverse events register

Adapted from Spanish quality control guideline

Table 80.4 Terminology for reporting adverse events

Patient safety	Absence of the potential for, or occurrence of, health care-associated injury
	to patients
Error	It is defined as mistakes made in the process of care that result in, or have
	the potential to result in, harm to patients. Mistakes include the failure of a
	planned action to be completed as intended or the use of a wrong plan to
	achieve an aim. These can be the result of an action that is taken (error of
	commission) or an action that is not taken (error of omission)
Incident	Unexpected or unanticipated events or circumstances not consistent with
	the routine care of a particular patient, which could have, or did lead to, an
	unintended or unnecessary harm to a person, or a complaint, loss, or
	damage
Near miss	An occurrence of an error that did not result in harm
Adverse event	An injury resulting from a medical intervention
Preventable	Harm that could be avoided through reasonable planning or proper
adverse event	execution of an action

important preventive aspects of this event are discussed by the safety team, and safeguards are implemented.

–Failure mode and effects analysis: An error-prone process is identified, and a multidisciplinary team is formed to analyze prospectively the process from multiple perspectives before a sentinel event has occurred.