The only ones who care about improving quality - Marlice van Dyk

THE ONLY ONES WHO CARE
ABOUT IMPROVING
QUALITY CARE IN THE ICU
ARE THE PATIENTS
Marlice van Dyk
Unitas Hospital

HOW DOES THIS TRANSLATE TO QOC FOR
THE PATIENT
• Poly Trauma patient A
• Doctor too busy to see patient immediately
• EN looks after patient, doesn’t know that she must resus
patient
• Miss golden hour
• Rhabdomyolysis

PATIENT A
• Doctor prescribes but doesn’t check that orders are followed
• Fluid overload patient

PATIENT A
• Abdominal compartment syndrome
• Acute renal failure
• Does not adjust dose of drugs for the renal failure
• Convulsions
• Bone marrow depression from anticonvulsant therapy
• Sepsis
• ARDS
• Prolonged injurious ventilation, sedation
and muscle relaxation

PATIENT A
• Acalculous cholesistitis
• Surgery
• Breakdown of anastomosis
• Numerous courses of antibiotics
• C. Diff
• Malnutrition
• ICU acquired weakness
• Protracted, difficult ICU stay >3mnth
• 1 year later
• Physically weak
• Retrenched
• Major depression
• Financially ruined

PATIENT B
• ICU trained doctor awaits patient arrival in ICU
• Immediate resuscitation, lines, prescription
• Highly qualified, highly motivated ICU trained nurse following
the prescription and protocols of the unit
• ICU doctor see patient frequently during the resus period
• Communications with all other specialists involved
• Well-resussitated patient goes to theatre to have all his
fractures attended to
• Optimal fluid, pain and nutrition strategy post theatre
• Early extubation with optimal pain and fluid control
• Early ICU and hospital discharge
• 1 year later: no problem

WHAT IS QUALITY
• Defined as:
• Degree to which a set of inherent characteristics fulfil
requirements
• Quality care is an organisation-wide approach to understanding
precisely what customers need and consistently delivering
accurate solutions within budget, on time and with the
minimum loss to society.
• Quality is about meeting the needs and expectations of
customers - John Rilley

WIKIPEDIA
• Quality in business, engineering and manufacturing has a
pragmatic interpretation as the non-inferiority or superiority
of something; it is also defined as fitness for purpose.
• Quality is a perceptual, conditional and somewhat subjective
attribute and may be understood differently by different
people.
• Consumers may focus on the specification quality of a
product/service, or how it compares to competitors in the
marketplace. Product/service was produced d correctly. Support
personnel may measure quality in the degree that a product is
reliable, maintainable, or sustainable.

QUALITY
• There are 5 aspects of quality:
• Producing - providing something.
• Checking - confirming that something has been done correctly.
• Quality Control - controlling a process to ensure that the
outcomes are predictable.
• Quality Management – directing an organisation so that it
optimises its performance through analysis and improvement.
• Quality Assurance – obtaining confidence that a product or
service will be satisfactory.

WHO ARE THE ROLE PLAYERS IN ICU
• Patients
• Nurses
• ICU trained RN
• RN
• EN
• Nursing assistants
• Doctors
• Non-ICU trained vs. ICU trained
• Part-time vs. Full time
• Funders
• Private Hospital Groups
• Public sector
• Health Care System

PATIENTS
• Patient disempowered
• Nearest hospital
• Doctor on call
• Nurse on duty
• HRQL assessments, 1 yr, 60% of pre-ICU functionality are
regained
• ICU acquired weakness
• Long-term cognitive dysfunction
• Psychiatric i problems: major depression, PTSD, anxiety disorders
d
• Post-Intensive Care Family
• Long-term caregivers
• Financial burden
• Emotional burden

THE NURSES
• The highly trained, highly motivated ICU nurse
• Too few ICU trained
• Not worth their while to study more
• Must look after all the non-trained nurses in ICU – burn-out
• Find the standards of care unacceptable
• 2:1 or even 3:1 patient care and shift leading
• Overworked and Underpaid!
• The qualified, very experienced nurse

NURSES
• The not-interested-in-anything-but-pay-check (agency) nurse
• The Enrolled Nurse
• Knowledge and training inadequate
• The nursing assistant
• What is he/she doing in ICU!
• Outcome
• Drug administration errors
• Basic nursing care not done

NURSES
Time Knowledge Interest
ICU trained nurse X
RN
EN X
Nursing assistant X
Agency nurse
• Producing - providing something.
• Checking - confirming that something has been done correctly.
• Quality Control - controlling a process to ensure that the outcomes are
predictable.

DOCTORS
• Time constrains
• Too few doctors
• Too many patients to see
• Part-time ICU work
• Spends 3 minutes / patient
• No time to change the CVP even with new sepsis

• Perverse incentives
• TPN
• Ventilation
• Brain dead patients
• Terminal patients
• Inadequate training
• Injurious ventilation
• Fluid overloaded patients
• Nutrition!

DOCTORS
• Non-existing ICU teams
• No Team leader
• No communication between doctors, or nurses and doctors
• Money!

DOCTORS
Time Knowledge Interest
Non-ICU trained X X
ICU trained
Part time ICU X
Full-time ICU
• Producing - providing something.
• Checking - confirming that something has been done correctly.
• Quality Control - controlling a process to ensure that the outcomes are
predictable.

THE FUNDERS
• AMAF (Acute Medical Aid Failure)
• Generics
• Its cheap but does it work
• Motivation for newer antibiotics
• More expensive sedatives
• The use of Precedex leads to on average a 19.2 points higher
ACE (adapted cognitive exam) score than Propofol : ANIST trial
• MRI/CT scans
• Lab costs

THE PRIVATE HOSPITAL GROUPS
• Closed vs. Open Units
• Allows anyone to work in ICU (nurses and doctors)
• EN cheaper than RN
• Minimum staff
• High patient: staff ratio

THE PRIVATE HOSPITAL GROUPS
• ICU bed occupancy
• The longer the patient stays the higher the bill
• Inadequate equipment because they can’t bill for it
• Beds
• Exercise equipment
• Dedicated NIV ventilators
• CO monitors
• Bronchoscopes
• Capped fees
• Drives costs down regardless

THE PRIVATE HOSPITAL GROUPS
• Producing - providing something.
• Sub-optimal service and equipment
• Checking - confirming that something has been done correctly
• No objective confirmation available
• Quality Control - controlling a process to ensure that the
outcomes are predictable.
• Open vs. closed Units
• Protocols and Guidelines

• Quality Management – directing an organisation so that it
optimises its performance through analysis and improvement
• LOS, Vent days, Mortality, Long-term outcome
• Quality improvement programmes
• Quality Assurance – obtaining confidence that a product or
service will be satisfactory.
• Data

PUBLIC SECTOR HOSPITALS
• Closed Units
• Dedicated ICU doctors
• ICU trained nurses
• Sometimes even good equipment
• Poor Management!
• No/poor lab service
• No MRI/CT service
• No continuity of care
• Communication!

PUBLIC SECTOR
• Only generics
• No empathy
• No linen
• Regular disposable and drug shortages because of nonpayment
of providers
• Inadequate number of beds for population

HEALTH CARE SYSTEM
• Training of nurses – number and quality
• Training of doctors – number and quality
• Allowing anyone to work in ICU regardless of training, knowledge
and experience
• No data on disease profiles in general population that will need
access to ICU
• No data on number of ICU beds needed
• No national business plan to address ICU shortages
• No regional or national plan to address mismanagement of
allocated budgets and improve payment of providers

WHAT IS THEIR AGENDA
• Nurses
• Do they have the knowledge, Interest, and time to care
• Just a pay check
• Doctors
• Do they care
• All about money
• Funders
• Money!
• Hospital Groups
• ICU is the most lucrative part of the hospital
• Fill as many beds as possible at the lowest cost to the hospital
• National Health care
• Training
• Data analysis and system implementation

QUALITY CARE IN THE ICU
• The devil is in the detail!
• Every team member is vital
• Knowledge, Interest and Time spend with the patient is vital
to ensure Quality of Care
• Do we fulfil the need of our patients
Quality care is an organisation-wide approach to
Q y g pp
understanding precisely what customers need and
consistently delivering accurate solutions within budget,
on time and with the minimum loss to society.

QUESTIONS

WHY DO PATIENTS CARE ABOUT
QUALITY
• Acute Lung Injury/ARDS is an important health problem
• Around 75 000 deaths/year in USA
• Declining fatality rates around 1.1% 1% per year
• More survivors but at significant cost of surviving with significant
morbidity
• Reduced exercise capability
• Cognitive dysfunction
• Significant cognitive sequelae
• Depression
• Anxiety disorder
• PTSD
• Pulmonary dysfunction is ‘minor’ morbidity as symptoms less
likely from underlying lung pathology than from respiratory
muscle weakness and diaphragmatic atrophy

EARLY MOBILIZATION
• To prevent ICU acquired weakness
• Early rehab programmes
• Barriers: Patient
• Cardiorespiratory instability
• Raised intra cranial pressure
• Level of cooperation
• Pain
• Delirium
• Over sedation
• Presence of catheters t and devices
• Functional status (muscle strength, joint mobility, obesity,
recent surgery)

EARLY MOBILIZATION
• Barriers to early mobilization: health care providers
• Absence of leadership in the team
• Staffing levels
• Team spirit
• Equipment
• Knowledge
• Training
• Referral

WHY DO PATIENTS CARE
• Cognitive dysfunction after ICU may lead to the need for longterm
care or assisted living facility post-ICU
• There is decreased quality of living and increased
psychomotor symptoms in both the patient and the loved ones

• Post Intensive Care Family
• 70% of family members present with symptoms of anxiety
• 35% with depression
• PTSD also common
• 1 year post ICU loss: 40% present with criteria for psychiatric
illness such as generalized anxiety, major depressive, or
complicated grief
• Prevention of post-ICU burden: communication i strategies

TEAM
• Highly skilled team management
• Leadership
• Communication skills
• Excellent communication between physicians and teams
• Awareness of important clinical pitfalls
• Constant vigilance (multiple cross-checks)
• Centralized care planning

WHAT DOES THE PATIENT WANT
• Closed Unit
• ICU trained full time doctors
• ICU trained, highly motivated nurses
• Protocols or guidelines in place
• Adequate equipment
• Funders that look at cost-effectiveness and not just
at cost
• ICU teams with team leaders
• Long-term data for the specific unit to measure
performance
• Implementation of quality care programs

QUESTIONS