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Question 3 - 2000, Paper 1

On a busy Saturday morning in your fully occupied 14 bed lntensive Care Unit a fire 
suddenly develops in the electrical switching box beside a central bed. What are the 
principles of handling this emergency?

College Answer

This question  was aimed at testing fire drill awareness. a universal n:quirement.
A suggested response is:

(a) Rapidly remove all patients and staff from the immediate danget area. This means safely disconnecting Lines, monitors and ventilators. Move me patients towards the exits and bag
the ventilated patients.
(b) Notify switchboard. Activate fire alarm, state location and nature of fire.
(c) Shut aU doors and windows. Turn off oxygen outlets.
(d) Attempt to control and extinguish the fire with appropriate extinguishers and fire blankets, provided it is safe to do so.                                   .
(e) lffire is uncontrolled, commence evacuation of the patients via the fire exits.

Discussion

This question is almost identical to Question 8 from the second paper of 2011, though this later version does not specify that it is a busy Saturday morning.

In brief, the major objectives are:

  • Protect the patients in immediate danger (be evacuating them, as well as your staff)
  • Protect the rest of the hospital (basically, allow them to evacuate by telling them that your ICU is on fire)
  • Prevent the spread of fire (by decreasing its supply of substrate, be it oxygen or fuel)
  • Limit the damage to property. If it is not completely stupid to do so, make an effort to actually extinguish the fire.

Evacuate:

  • Follow orders from the fire warden
  • Evacuate to designated assembly points
    • On the same floor, away from the burning room; or:
    • Down the stairs, away from the burning floor; or:
    • Out of the building, away from the burning building
  • Check all ICU rooms and areas (unless it is unsafe)
  • Evacuation resembles inter-hospital transport:
    • Life-sustaining therapies are to be continued
    • Essential treatment is an ongoing part of ICU stay and continues while the patient is in transit or being evacuated. For instance, this means the bedside nurse can continue giving antibiotics to the septic patient while they are parked in the evacuation zone.
  • Transfer to safety
    • Usually designated evacuation areas are not suited to sustaining critically ill patients in the medium-to-long term
    • For this reason, the ICU team leader needs to liase with the emergency department, high dependency units, operating theatre and recovery rooms to accept some of the patients, eg. those who need to be ventilated

Reverse triage evacuation priorities:

  • Visitors first
  • Stable patients next
  • Unstable patients last

Fire containment

  • Turn off the wall oxygen supply
  • Close the doors and windows
  • Extinguish the fire:
    • Only if it doe snot place yourself at risk
    • Only if you are trained to do so
    • Only if the fire is of a manageable size (LITFL suggests a waste paper basket)
    • Using appropriate extinguishers (eg. CO2 instead of foam  or water for electrical fires)

Preventative measures

  • Response to damage:  life and property
    • Open disclosure to affected staff, patients and their families
    • Appropriate use of medicolegal representation, particularly if patients or staff were harmed
    • Contact with hospital executive unit to manage the media response and to control the public perception of the situation. At Chase Farm Hospital fire, TV crews gained access to the site and pestered rescuers with demands for individual statements.
  • Analysis of causes
    • Launch of root cause analysis 
    • Fire investigation may take a forensic or structural engineering pathway
    • Formation of a working party to create preventative policies and to steer the future fire safety approach
  • Preventative policies
    • Make basic fire safety training mandatory for staff
    • Ensure fire extinguishers are present and staff are trained in their use
    • Ensure fire department is rapidly contractible
    • Oxygen / medical air supply shut-off valves to be obvious and easily available in a central location of the ICU
    • Easy access to emergency assembly areas; rapidly obvious emergency egress paths (eg. flashing light directing the staff which way to evacuate)
  • Quality assurance program
    • Routine fire extinguisher checks
    • Fire safety committee (to ensure the policies are championed and audited)
    • Program of annual re-credentialing of fire safety for the staff
  • Assessment of adherence
    • Random audits to ensure passive fire safety standards are being followed (eg. no hospital beds parked in positions where they obstruct fire exits; no wardies smoking joints in the stairwells)
    • Log of staff members who have/haven't completed their mandatory fire training
    • Random fire drills and simulation exercises

References

Question 2a - 2001, Paper 1

You have taken over the directorship of a district hospital ICU.  Part of your mandate is to establish a Quality Assurance program.

(a) How will you achieve this?

College Answer

When moving into a new role it may take time to assess the individual needs of the unit and staff. Changes will need to be introduced sequentially and with the cooperation of the staff.  Quality assurance projects will need to be learning experiences and productive rather than punitive.

The candidate was expected to discuss the elements of an organised program and what he/she would do including:
-      ICU Morbidity and Mortality data collection and review
-     Incident Monitoring data collection and review
-     Hospital Outcome data collection and review
-     Staff working hours, retention, continuing education
-     Occupational safety record
-     Appointment of a Quality Assurance Coordinator

Discussion

CICM have (on their own website) an article by L.I. Worthley on this very topic. Given that an examiner wrote the article, one might expect it to contain some material relevant to this question.

In addition, one can find a NSW Health policy document which provides some information about what a quality assurance program should look like. However, the most relevant document turned out to be this review article from Crit Care Med (2006)

The following points have been compiled from this article, and several others.

Preparation of a quality assurance project:

  • Identify critical areas of interest and collect data about meaningful outcomes.
  • Prioritise potential projects
  • Prepare a plan for the identified projects, with a task list, budget considerations, a timeline, and clearly defined leadership with central reporting
  • Clearly define the measured variables
  • Assess the logistics of collecting this data
  • Create a data collection system, eg. a regularly maintained database of adverse events

Collection of quality data

  • Assess the current quality of care using the established data collection methods
  • Morbidity and mortality data collection
  • Incident monitoring
  • Patient and family satisfaction surveys
  • Staff satisfaction surveys
  • Feedback from external non-ICU services and prehospital staff

Assessment of quality data

  • Morbidity and mortality audit - regulargly
  • Incident review meetings - regularly
  • Encourage the attendance and contribution from all staff

Generation of recommendations

  • Evidence-centered literature search for solutions to identified problems
  • Consultation with relevant specialists and with local medical staff
  • Evaluation of evidence-based recommendations for improvement, and their cost-benefit analsysis
  • Assessment of the tolerability of their implementations, the logistics of this and changes to funding.
  • The presentation of recommendations at department meetings to encourage discussion

Monitoring and audit

  • Ongoing data collection
  • Regular review of outcome trends and assessment of effective and ineffective QA strategies

Structure of the QA program

  • Education of all staff to be involved in incident reporting
  • Specific staff groups responsible for data colelction
  • Specific staff allocated the task of ensuring high data quality
  • A leader for the project, who reports to the head of department
  • Data entry and database maintenance staff

References

Worthley, L. I. "Quality control, audit, adverse events and risk in the intensive care unit." (2000): 304. Critical Care and Resuscitation Volume 2 Issue 4 (2000 Dec)

 

Brook, Robert H., Elizabeth A. McGlynn, and Paul Cleary. "Measuring quality of care." (1996). New England Journal of Medicine, v. 335, no. 13, September 26, 1996, pp. 966-970

 

NSW Health Information package for quality assurance committees seeking qualified privilege

 

McMillan, Tracy R., and Robert C. Hyzy. "Bringing quality improvement into the intensive care unit." Critical care medicine 35.2 (2007): S59-S65.

 

Curtis, J. Randall, et al. "Intensive care unit quality improvement: A" how-to" guide for the interdisciplinary team*." Critical care medicine 34.1 (2006): 211-218.

Question 7 - 2001, Paper 1

What are the important elements of a Medical Emergency Team (MET) program?  

How may a MET improve in-hospital morbidity and mortality?

College Answer

A discussion or debate about the role of MET was not sought. It required a simple statement about theoretical structure and advantage.

(a) The important elements of the MET team include:

-     call criteria for alerting the team to a sick patient

-     education of ward staff to recognise deteriorating patient condition

-     effective training and composition of MET team with diagnostic and procedural skills

-     review of calls, aggregation of data and follow-up

(b)   How may this improve in-hospital morbidity and mortality: early signs of deteriorating function leading  to  cardiac  arrest  and  death  have  been  identified.  Early  intervention  will  prevent irreversible organ damage. In most studies 50-60% of patients were admitted to hospital with a respiratory  illness.  Early  intervention  in  a  deteriorating  patient  will  prevent  an hypoxic/hypercarbic arrest.

Education and increased awareness of all staff of the signs and symptoms of critical illness leads to improved management of these patients.

Discussion

This question closely resembles Question 12 from the first paper of 2005, which asks the candidates to critically evaluate the role of the MET team. However, in their answer, the college sternly warn us that "a discussion or debate about the role of MET was not sought".

So: here is a simple statement about theoretical structure and advantage of a MET program

Organisation of MET program:

  • Calling criteria to protocolise the recognition of the deteriorating patient
  • Education of ward staff to use the calling criteria protocol
  • Rostering of 24/7 staff to act as members of the MET team

Membership of the Medical Emergency Team:

This is merely a suggestion

  • Medical team leader
  • Medical staff skilled in airway management (eg. anaesthetics staff or ICU staff)
  • Medical staff skilled in vascular access (eg. anaesthetics staff or ICU staff)
  • Junior medical officer
  • Nursing Team Leader
  • Wardsperson
  • Administrative (bed management) staff to facilitate transfer

Quality assurance

  • Database of MET calls
  • Regular audit of MET calls
  • Regular multidisciplinary review of trends in MET call events
  • Follow-up of patients who were the subjects of a MET call

Theoretical advantages:

  • Call criteria are simple parameters to measure, already routinely collected
  • Potentially, lifesaving treatments can be administered at the appropriate moment
  • Early intervention to prevent cardiac arrest is likely to improve hospital mortality
  • MET services deploy an ICU-level skill set in the ward, which should improve the quality of care for critically ill patients
  • Prevention of ICU admission should be a cost-effective measure, working on the premise that ICU admission is more costly than MET team maintenance.
  • End-of-life care quality should improve with the involvement of ICU staff

References

Goldhill, D. R., et al. "The patient-at-risk team: identifying and managing seriously ill ward patients.ANAESTHESIA-LONDON- 54 (1999): 853-860.

 

Hillman, Ken, et al. "Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial." Lancet 365.9477 (2005): 2091-2097.

 

McGaughey, Jennifer, et al. "Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards." Cochrane Database Syst Rev 3 (2007).

 

Howell, Michael D., et al. "Sustained effectiveness of a primary-team–based rapid response system." Critical care medicine 40.9 (2012): 2562.

 

Buist, Michael D., et al. "Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study." Bmj 324.7334 (2002): 387-390.

 

Bellomo, Rinaldo, et al. "A prospective before-and-after trial of a medical emergency team." Medical Journal of Australia 179.6 (2003): 283-288.

 

Question 4 - 2002, Paper 2

Outline the factors you would consider in making a cost-benefit analysis of introducing a new component of care into your Intensive Care unit.

College Answer

Any component of care could be assessed (eg. staffing levels, equipment, new techniques or drugs).
•    Strength of evidence supporting the new component of care (eg. more than one adequately powered prospective randomised clinical trial). Internal validity of trials (adequacy of methodology).
•    External validity of trials or other supporting information (ie. ability to extrapolate to the patients that you are managing).
•    Ability to accurately identify those patients who would benefit from new component of care.
Accurate identification of patients prospectively decreases costs by decreasing the number of patients who will need to be treated but who will not benefit (or may even be harmed).
•    Magnitude of outcome benefit found (eg. number needed to treat to achieve specific outcome). Consider survival to hospital versus 30 day survival versus 12 month survival.
•    Additional costs that may be generated by achieving that outcome (eg. costs of hospitalisation or other care, incurred after survival). Comparison with costs generated (or saved) by alternative strategy.
•    Source of funding for costs should be considered. Special grant (above and beyond current budget) or would any additional costs be paid from existing budget (requiring cost cutting in other areas).

Discussion

Of the vague questions from the early papers of the CICM fellowship, this one is a peach. The poor candidate would have to guess what was meant by "new component of care". Do they mean the puchase of new equipment? The implementation of a new hand-washing protocol? The hiring of new cleaners? A modification of the departmental toast-buttering policy? These things are unclear.

Let us consider the question in generic terms.

Evidence in support of the new component

  • Is there robust evidence to support the use of this component
  • Is this evidence generaliseable to the relevant population
  • What is the expected benefit (eg. expressed as OR or RRR)
  • What is the magnitude of its impact (eg. expressed in NNT)

Cost-benefit analysis of new component

  • What is the cost of the new component
  • How does this cost compare to the cost of existing practice
  • Does the cost-benefit ratio favour this new component over the existing practice (eg. if the new component is more expensive but also more effective, how much extra QALY does each extra dollar buy?)
  • How does this specific new component compare to an alternative in terms of cost-benefit ratio? A comparison of several alternatives would be required.

Logistics of implementation

  • Where will the funding come from
  • Is the incremental cost of the component covered by the funding
  • What savings or costs will be generated by the abandonment of the existing practice
  • What costs are involved in the training and education of staff
  • What costs are involved in the processes of quality assurance audit and follow-up for this new component
  • What degree of acceptance is there for this new component among the staff
  • How will the satisfaction of staff with this new component be assessed?

References

Valentin, Andreas, and Patrick Ferdinande. "Recommendations on basic requirements for intensive care units: structural and organizational aspects."Intensive care medicine 37.10 (2011): 1575-1587.

 

Laupacis, A., et al. "How attractive does a new technology have to be to warrant adoption and utilization? tentative guidelines for using clinical and economic evaluations." CMAJ: Canadian Medical Association Journal 146.4 (1992): 473.

Question 13 - 2003, Paper 1

What  is a Standardised Mortality Ratio?   What  are the limitations  of using this ratio to compare the performance of Intensive Care Units?

College Answer

Standardised Mortality Ratio is defined as the observed mortality rate/expected mortality rate. Need to estimate expected mortality rate using a scoring system (eg. APACHE II or III, SAPS II or MPM). Better than comparison of non-adjusted mortality data.

The potential limitations of the system are multiple including: inconsistencies and inaccuracies associated with collection of data and scoring (eg. GCS, recording of parameters); problems of missing data limiting inclusion of all patients; problems of patient mix not adequately accounted for by the original population used for calculation of formulae (eg. transferred patients or delays before admission); small numbers of patients (increasing the error of the SMR estimate); accuracy of the prediction model; relying on mortality as a surrogate marker for quality of care; cost of use of proprietary system; etc.

Discussion

This question closely resembles Question 30 from the second paper of 2006.

Definition of the SMR

  • This is the ratio of the observed hospital mortality vs. predicted hospital mortality for a specified time period.
  • One can use this to compare hospitals and ICUs
  • One needs to first calculate the predicted hospital mortality using an illness severity scoring system.
  • An SMR of 1 means the mortality is as expected.
  • An SMR of < 1 is better than expected, and >1 is worse than expected.

Limitations of the SMR

  • Acceptable deviations from the SMR are not defined
  • Suffers from inaccuracies associated with data collection
  • SMR may be influenced by ICU admission and discharge practices (eg. discharging patients who are palliated, or admitting patients who are inevitably going to die).
  • Accuracy of the SMR as a quality assessment tool may be influenced by patients who have been predominantly cared for at another ICU, and who have been received as a transfer.
  • Mortality is not a surrogate for quality of care
  • The populations used to calculate the predicted hospital mortality are potentially non-representative (i.e. the population may also contains a number of dying critically ill patients, or it may contain an unusually large proportion of people in robust health).

Limitations of comparing ICUs with the SMR:

  • The SMR assumes all pre-ICU care is identical
  • Ignores differences in case mix
  • Sample sizes need to be large enough to obey the laws of logistic regression
  • Data is assumed to be flawless and complete

References

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.

Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.

Jones, Michael E., and Anthony J. Swerdlow. "Bias in the standardized mortality ratio when using general population rates to estimate expected number of deaths." American journal of epidemiology 148.10 (1998): 1012-1017.

van Gestel, Yvette RBM, et al. "The hospital standardized mortality ratio fallacy: a narrative review." Medical care 50.8 (2012): 662-667.

Combes, Alain, et al. "Adverse effect on a referral intensive care unit's performance of accepting patients transferred from another intensive care unit*."Critical care medicine 33.4 (2005): 705-710.

Question 12 - 2005, Paper 1

Critically evaluate the role of the Medical Emergency Team.

College Answer

Medical Emergency Teams in various formats have been used to manage in-hospital emergencies for over a decade.  Despite this, only limited data is available for an evidence- based review.   One very large prospective randomised (by hospital) study (MERIT) has been performed but its results have not been published.  Various lower levels of evidence are available (eg. before and after intervention studies Goldhill 1999, Buist 2002, Bellomo

2003) and some of these have shown improvements in a number of outcomes (including cardiac arrest rates and improved survival, and length of ICU stay following cardiac arrest). Other studies have also demonstrated trends to improvement in overall mortality and unplanned ICU admissions (Bristow 2000, Kenward 2004).  Potential problems associated with implementation include cost (staff, equipment), diversion of staff from other roles, and obvious requirement for appropriate educational strategies.

Discussion

The MET concept - even in 2005 - was not exactly fresh and new.

However, this question came at a time during which MET research consisted largely of small-scale single centre experiences, which were uniformly positive -largely because they were implemented by enthusiastic and highly motivated personnel. Thus, one can conclude that the early bedside intervention by enthusiastic and highly motivated critical care personnel improves in-hospital survival and prevents cardiac arrest. Subsequent meta-analysis literature was not so favourable. If one applies strict exclusion criteria to the available bank of studies, one is forced to exclude the vast majority on the grounds of poor methodology (just as the Cochrane reviewers did). The remaining high quality data is poxy wih heterogeneity and offers an unsteady foundation upon which to build conclusions.

The answer to this question, compiled from the LITFL review of this topic as well as the relevant evidence from the literature, would ideally look like this:

Rationale

  • Deterioration of patient is ususally heralded by steretypic changes in physiological parameters
  • If this deterioration is detected and averted, the patient is less likely to require ICU admission
  • MET systems aim to increase the rate of early detection, and focus critical care services to the aid of deteriorating patients
  • MET service are coordinated by a system of call criteria based on physiological parameters which - with even minor deviations from normal values - can be sensitive in detecting a patient at risk of ICU admission or death.

Advantages

  • Call criteria are simple parameters to measure, already routinely collected
  • Potentially, lifesaving treatments can be administered at the appropriate moment
  • Early intervention to prevent cardiac arrest is likely to improve hospital mortality
  • MET services deploy an ICU-level skill set in the ward, which should improve the quality of care for critically ill patients
  • Prevention of ICU admission should be a cost-effective measure, working on the premise that ICU admission is more costly than MET team maintenance.
  • End-of-life care quality should improve with the involvement of ICU staff

Disadvantages

  • Diverts ICU resources out of ICU
  • Creates a dependence on ICU for the managemet of deteriorating patients
  • Creates a dependence on ICU staff for end-of-life decisionmaking
  • Decreases the critical care skills of ward staff
  • Expensive in terms of MET maintenance, ward staff education programs, audit activities and ICU resource diversion

Evidence in support of the MET system

Evidence against the use of the MET system

  • No effect on hospital mortality or incidence of cardiac arrest, at the cost of increased resource use (greatly increased MET callouts) according to the MERIT trial from 2005, as well asanother more recent (2012) trial by Howell et al.
  • Poor study methodology had resulted in the exclusion of all but two studies from a 2007 Cochrane review. The two remaining studies disagreed as to whether there was any mortality improvement. The Cochrane authors were forced to conclude that no recommendations can be made on the basis of such poor quality evidence.
  • Thus far, no strong evidence exists to support the use of MET teams as a means of decreasing in-hospital mortality.

References

Goldhill, D. R., et al. "The patient-at-risk team: identifying and managing seriously ill ward patients.ANAESTHESIA-LONDON- 54 (1999): 853-860.

 

Hillman, Ken, et al. "Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial." Lancet 365.9477 (2005): 2091-2097.

 

McGaughey, Jennifer, et al. "Outreach and Early Warning Systems (EWS) for the prevention of intensive care admission and death of critically ill adult patients on general hospital wards." Cochrane Database Syst Rev 3 (2007).

 

Howell, Michael D., et al. "Sustained effectiveness of a primary-team–based rapid response system." Critical care medicine 40.9 (2012): 2562.

 

Buist, Michael D., et al. "Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: preliminary study." Bmj 324.7334 (2002): 387-390.

 

Bellomo, Rinaldo, et al. "A prospective before-and-after trial of a medical emergency team." Medical Journal of Australia 179.6 (2003): 283-288.

Question 4 - 2005, Paper 2

Outline  the  principles  of  illness  severity  scoring  systems  used  in  the  critically  ill patient,  and using examples outline their relationship to clinical outcome.

College Answer

Scoring systems stratify groups of critically ill patients by severity, compare groups of patients in research trials, compare ICUs, and predict mortality for individuals and groups. Most measure physiological variables, some measure interventions. Derived by logistic regression from large demographic data sets of critically ill patients. Commonly used systems include:
•    APACHE II. Commonly used in Australia to measure patient severity. Uses 12 physiological variables and previous health estimate. Requires measure of worst values in first 24 hours in ICU, so affected if ICU admission delayed. Not reliable for predicting outcome in individuals. Limited by derivation from an historical data set.
•    APACHE III. Better outcome predictions by using additional variables and a more recent data set for comparisons. Outcome predictions for Australian patients more accurate.
•    GCS. Used to quantify severity of coma. Scale from 3-15. Eye (1-4), Verbal (1-5), and Motor (1-6) components. Key score for outcome prediction after head injury. Affected by alcohol and sedation. Should be scored in non-sedated non-paralysed patients.  Important component of other scoring systems eg APACHE 11.
•    TISS. System to score patient severity by counting procedures done. Less widely used.
Physician dependent, so less useful to compare ICUs.
•    SOFA. Organ dysfunction scores. Often a secondary endpoint in research trials.

Discussion

Here is a link to the LITFL article on ICU scoring systems.

Here are some links to the seminal articles which describe these systems:

So.

How are these scoring systems useful?

  • They (try to) predict outcome and length of stay
  • They can be used to compare predicted and observed outcome
  • They stratify patients for clinical trials, according to disease severity
  • They assess ICU performance
  • They allow resources to be allocated to ICUs according to the illness severity of their patients
  • They allow a comparison of ICUs

Some examples:

APACHE

APACHE stands for Acute Physiology, Age and Chronic Health Evaluation (I-IV).

  • APACHE II is the most commonly used one
  • 12 variables are measured
  • Scores range from 0 to 71
  • The risk of hospital death is computed by combining APACHE II score with Knaus' weighted coefficient for different types of disease entities. A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.
  • Derived from histrical data set

SOFA

SOFA stands for Sequential Organ Failure Assessment .

  • 6 organ systems are scored according to their function
  • The degree of organ support is taken into account
  • Used to analyse secondary endpoints in clinical trials

There is a defined score of 1-4 for each organ system, which is collected daily. This not a predictive model- there are no mortality algorithms here. A higher SOFA score can be said to relate to increased mortality, but there is no mathematical model to help us figure out exactly how the total score relates to survival.

TISS: Therapeutic Interventions Scoring System

  • 76 variables (interventions and treatments)
  • Collected daily
  • Indicates nursing and medical workload
  • Does not indicate severity of illness
  • Most useful for accountants

SAPS: Simplified Acute Physiology Score

  • SAPS 1 only looked at physiology, and was used by French ICUs
  • SAPS 2 added chronic health conditions, and was used in Europe and North America
  • SAPS 3 had 20 variables and was used worldwide

MPM: Mortality Prediction Models

  • MPM measures variables at admission and in the first 24 hours
  • It calcuates the risk of in-hospital death on the basis of these variables, using a logistic regression model.
  • MPM II was based on the same historical data set as SAPS 2 and predicts mortality at 24, 48 and 7 hours.

POSSUM: = Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity

  • 12 physiological parameters for surgeons
  • Used by surgeons as a risk adjustment tool
  • Different subspecialties have their own: V-POSSUM is for vacular surgeons, Cr-POSSUM is for colorectal, etc

References

Gunning, Kevin, and Kathy Rowan. "Outcome data and scoring systems." Bmj319.7204 (1999): 241-244.

 

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

 

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.

 

Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.

 

 

Balci, C., et al. "[APACHE II, APACHE III, SOFA scoring systems, platelet counts and mortality in septic and nonseptic patients]." Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES 11.1 (2005): 29-34.

 

Halim, Dino Adrian, Tri Wahyu Murni, and Ike Sri Redjeki. "Comparison of Apache II, SOFA, and Modified SOFA scores in predicting mortality of surgical patients in intensive care unit at Dr. Hasan Sadikin General Hospital." Critical Care & Shock 12 (2009): 157-169.

 

Knaus, William A., et al. "APACHE II: a severity of disease classification system." Critical care medicine 13.10 (1985): 818-829.

 

Vincent, J-L., et al. "The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure." Intensive care medicine 22.7 (1996): 707-710.

 

Ferreira, Flavio Lopes, et al. "Serial evaluation of the SOFA score to predict outcome in critically ill patients." Jama 286.14 (2001): 1754-1758.

 

Vincent, Jean-Louis, and Rui Moreno. "Clinical review: scoring systems in the critically ill." Crit Care 14.2 (2010): 207.

 

Livingston, Brian M., et al. "Assessment of the performance of five intensive care scoring models within a large Scottish database." Critical care medicine28.6 (2000): 1820-1827.

 

Wong, David T., et al. "Evaluation of predictive ability of APACHE II system and hospital outcome in Canadian intensive care unit patients." Critical care medicine 23.7 (1995): 1177-1183.

 

Cullen, David J., et al. "Therapeutic intervention scoring system: a method for quantitative comparison of patient care." Critical care medicine 2.2 (1974): 57-60.

 

Le Gall, Jean-Roger, Stanley Lemeshow, and Fabienne Saulnier. "A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study." Jama 270.24 (1993): 2957-2963.

 

Lemeshow, Stanley, et al. "Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients." Jama 270.20 (1993): 2478-2486.

 

Neary, W. D., B. P. Heather, and J. J. Earnshaw. "The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM)." British journal of surgery 90.2 (2003): 157-165.

Question 30 - 2006, Paper 2

What  is Standardised  Mortality Ratio?    Outline  the  limitations  of using  this  ratio to compare the performance of Intensive Care Units.

College Answer

Standardised Mortality Ratio is defined as the observed mortality rate/expected mortality rate. Need to estimate expected mortality rate using a scoring system (eg. APACHE II or III, SAPS II or MPM). Better than comparison of non-adjusted mortality data.

The potential limitations of the system are multiple including: inconsistencies and inaccuracies associated with collection of data and scoring (eg. GCS, recording of parameters); problems of missing  data  limiting  inclusion  of  all  patients;  problems  of  patient  mix  not  adequately accounted for by the original population used for calculation of formulae (eg. transferred patients or delays before admission); small numbers of patients (increasing the error of the SMR estimate); accuracy of the prediction model; relying on mortality as a surrogate marker for quality of care; cost of use of proprietary system; etc.

Discussion

Definition of the SMR

  • This is the ratio of the observed hospital mortality vs. predicted hospital mortality for a specified time period.
  • One can use this to compare hospitals and ICUs
  • One needs to first calculate the predicted hospital mortality using an illness severity scoring system.
  • An SMR of 1 means the mortality is as expected.
  • An SMR of < 1 is better than expected, and >1 is worse than expected.

Limitations of the SMR

  • Acceptable deviations from the SMR are not defined
  • Suffers from inaccuracies associated with data collection
  • SMR may be influenced by ICU admission and discharge practices (eg. discharging patients who are palliated, or admitting patients who are inevitably going to die).
  • Accuracy of the SMR as a quality assessment tool may be influenced by patients who have been predominantly cared for at another ICU, and who have been received as a transfer.
  • Mortality is not a surrogate for quality of care
  • The populations used to calculate the predicted hospital mortality are potentially non-representative (i.e. the population may also contains a number of dying critically ill patients, or it may contain an unusually large proportion of people in robust health).

Limitations of comparing ICUs with the SMR:

  • The SMR assumes all pre-ICU care is identical
  • Ignores differences in case mix
  • Sample sizes need to be large enough to obey the laws of logistic regression
  • Data is assumed to be flawless and complete

References

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

 

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.

 

Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.

 

Jones, Michael E., and Anthony J. Swerdlow. "Bias in the standardized mortality ratio when using general population rates to estimate expected number of deaths." American journal of epidemiology 148.10 (1998): 1012-1017.

 

van Gestel, Yvette RBM, et al. "The hospital standardized mortality ratio fallacy: a narrative review." Medical care 50.8 (2012): 662-667.

 

Combes, Alain, et al. "Adverse effect on a referral intensive care unit's performance of accepting patients transferred from another intensive care unit*."Critical care medicine 33.4 (2005): 705-710.

 

Question 22 - 2007, Paper 1

Your intensive care unit collects APACHE III and mortality data and derives the  Standardized Mortality Ratio (SMR) every 3 months as a quality control measure. The SMR for your unit normally ranges between 0.65-0.7. In the latest 3 month figure, the SMR for your unit was noted to be 1.2. Outline, what are the possible reasons for the change in the SMR?

College Answer

SMR is the ratio of the observed hospital mortality and the actual hospital mortality. A ratio of > 1 implies a mortality higher than expected. Potential explanations:

a)  Ensure data entry is correct and accurate and consistent with prior practice (ie comparable)
b)  Issues like quantifying GCS accurately will have an impact on APACHE scores and consequently SMR. Quantification of GCS is a major source of inaccuracy. Also source of admission and diagnosis
c)  SMR reflects system wide performance rather than ICU performance alone, because based upon hospital mortality, not ICU mortality. Look at pre ICU and post ICU facilities in the hospital

d)  SMR affected by case-mix, so changes in case mix may account for increase in SMR and increased other hospital admissions

e)  One needs to examine if there has been a deviation from clinical protocols in the ICU
f)   Lead time bias (pre ICU care) has been shown to impact on SMR and this neds to be factored into.
g)  Are there new inexperienced staff in ICU who might need training?

Discussion

LITFL have a point-form summary. In this summary, there is an excellent final paragraph, which discusses the reasons as to why the SMR might be changing.

The SMR is the ratio of the observed hospital mortality vs. predicted hospital mortality for a specified time period. An SMR of 1 means the mortality is as expected, and an SMR of >1 is worse than expected. The massive jump in SMR as described in the college question is indeed a disturbing development, one which has prompted LITFL authors to blame influenza pandemics and terrorist attacks.

So. Why might the SMR be on the rise?

It would for two possible reasons.

Either the observed mortality rate is increasing, or the predicted mortality rate is decreasing.

Increase in the observed mortality rate

  • Change in protocols
  • Change in admission practices -i.e. more patients being admitted who have little chance for survival
  • Change in discharge practices - i.e. more patients remaining in hospital to be palliated instead of being discharged with community services (this is what happens when you cut funding to community palliative care nurses).
  • Change in staff (inundation by incompetent staff?)
  • Unstable transfer patients received from other hospitals
  • Hospital performance as a whole may be affected by system-wide policy or staff changes (i.e. did all the senior nursing staff suddenly go on annual leave?)

Decrease in the predicted mortality rate

  • Change in illness severity scale encoding - i.e. the encoding has been omitting factors which might otherwise have increased the APACHE and SOFA scores.
  • "Lead time bias" - treatment received prior to ICU admission may result in artifically normalised acute physiology scores
  • "Healthy worker effect" - a change towards selective ICU admission practices may be favouring patients who score low on illness severity scales, eg. young elective surgical patients.

References

Fletcher, John. "Standardised mortality ratios." BMJ 338 (2009).

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.

Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.

McMichael, Anthony J. "Standardized mortality ratios and the'healthy worker effect': scratching beneath the surface." Journal of Occupational and Environmental Medicine 18.3 (1976): 165-168.

Tunnell, R. D., B. W. Millar, and G. B. Smith. "The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratio in intensive care—a pilot study." Anaesthesia 53.11 (1998): 1045-1053.

Rosenberg, Andrew L., et al. "Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures." Annals of internal medicine 138.11 (2003): 882-890.

Question 11 - 2007, Paper 2

You are asked to put in place initiatives to improve hand washing in your intensive care unit. List what initiatives you would institute.

College Answer

Hand hygiene considered to be most effective measure to prevent health care related infections. However very poor compliance with hand washing in ICUs

Initiatives:

a) Education

Lectures to medical and nursing staff

Recognition that compliance amongst medical staff is worse

Education of relatives/visitors

Education needs to be ongoing

b) Signage

Entrance and exit to unit

Posters

Labels on ventilators

Voice prompts by nurses at bedside

c) Introduce best handwashing products

New emollient soap

Alcohol hand rub at each bed

Non-allergenic handwash liquid

d) Sinks

Automated sinks

Adequate number of sinks in the unit.

e) Audit

Data collection before and after instituting initiatives: Hand washing surveys

Microbiological surveillance

f) Feedback to staff

Discussion

LITFL have an excellent resource on this. Indeed, one can add little to the college answer, except some references. The definitive guide worldwide would probably be this WHO Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. The entire 45 page document is a thrilling read. A summary of the major recommendations in point form is available at the end, and I will summarise it in the form of an answer to this question.

System change

  • Regular workplace survey to assess unmet goals
  • Ensure that products for hand hygiene are available at the point of care.
  • Improve tolerability of hand hygiene products
  • Improve ward infrastructure to improve access to handwashing facilities

Training and education

  • Health-care workers should check each others' compliance
  • Regular education meetings
  • Engage external educators
  • Engage internal educations who can act as role models
  • Focus on the doctors, who are generally the worst offenders

Reminders in the workplace

  • Posters
  • Promotions and rewards
  • Schedule presentations
  • Frequent educational sessions

Evalation and feedback

  • Regular monitoring of compliance
  • System of observers with centralised reporting
  • Rewards and demerits for compliance (or its lack)
  • Audit of changes in incidence of health care associated infections
  • Establish a system for continuous recording and reporting hand hygiene product consumption

There is a massive amount of literature out there.

Here is a synopsis of a few papers:

According to Kaplan et al:

  • Complicance with handwashing seems to be proportional to the number of sinks per patient.Ideally, the ratio should be 1:1.

According to Dubbert et al:

  • Handwashing classes are helpful
  • Feedback to staff about observed handwashing errors (it improves compliance to 97%!)

According to Panhotra et al:

  • Education campaign must be continuous
  • Posters are helpful

According to Mayer et al:

  • A good emollient handwash is all-important

According to Naikoba and Hayward:

  • Once-off education sessions have little effect
  • Automated sinks improve the quality of handwashing
  • Continued feedback of performance seems to be the strongest strategy.

Ultimately, all authors note that the best way to improve handwashing is "regular feedback" - that is to say, somebody constantly watching everyone, and telling them off for not washing their hands.

References

Dubbert, Patricia M., et al. "Increasing ICU staff handwashing: effects of education and group feedback." Infection Control and Hospital Epidemiology(1990): 191-193.

 

Panhotra, B. R., A. K. Saxena, and Al-Ghamdi AM Al-Arabi. "The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit." British Journal of Infection Control 5.3 (2004): 15-18.

 

Mayer, Joni A., et al. "Increasing handwashing in an intensive care unit."Infection Control (1986): 259-262.

 

Naikoba, Sarah, and Andrew Hayward. "The effectiveness of interventions aimed at increasing handwashing in healthcare workers-a systematic review." Journal of Hospital Infection 47.3 (2001): 173-180.

 

Kaplan, Lois M., and Maryanne McGuckin. "Increasing handwashing compliance with more accessible sinks." Infection Control (1986): 408-410.

 

WHO have this statement: A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (2009)

Question 15 - 2007, Paper 2

Critically evaluate the role of a Clinical Information System (CIS) in intensive care

College Answer

CIS refers to a computerized system for managing the clinical record often within geographically designated areas within the hospital such as ICU, ED or OR.

Potential benefits of CIS include:

a)  Recording of bedside observations – automated, minimal transcription errors

b)  Legible record

c)  Electronic record of drug prescription

d)  Access to additional clinical information at the bedside – pathology, XRays

e)  Access to decision support systems – online databases, clinical pathways,algorithms

f)   Medicolegal – archiving, good audit trail

g)  Ease of collection of data for research.

Limitations of CIS

a)  Financial cost

b)  Rapidly changing nature of technology

c)  Lack of computer literacy amongst clinicians and the need for training prior to commencing work in the ICU

d)  No evidence that CIS decreases workloads or save expenditure on salaries e)  Data archiving and storage is a problem.

f)   No evidence that implementation of CIS results in improved patient outcomes.

g)  Interface with other computer systems

h)  Legality of drug prescription

i)  Other clinician entry

Discussion

These are computerised databases which store and retrieve the ICU medical records. They may integrate diagnostic test review, test ordering, prescription/administration of drugs, and storage/retrieval of imaging studies. LITFL has an excellent summary.

Whatever the public opinion of these things, at the time of writing (mid 2014) the inevitable invasion of ICCIS is coming to NSW and there is nowhere to hide.

The answer below is essentially a direct copy and paste effort from the summary of administrative topics.

Rationale

  • The amount of data recorded for ICU patients increases every year (some say, by ~ 6% per year)
  • Effective use of this information relies on the clinician;s ability to easily retrieve and search it, so as to make informed decisions
  • The increasing amount of information takes a toll by diverting time from patient-oriented workload towards non-patient-oriented documentation and administrative tasks
  • The rationale behind the use of CIS is to render easier the process of documentation by automating some routine tasks, and by improving access to the growing patient record

Advantages

  • Increased legibility and improved searchability of records
  • Automation and increased accuracy of repetitive tasks eg. recording of observations and ventilator settiings
  • May integrate with pathology results database
  • Electronic record of prescriptions offers improved and security with electronic signatures and passoword-protected ordering
  • Searchable database for audit and research

Disadvantages

  • Expensive to install and maintain
  • Difficult to integrate with other existing electronic systems
  • Steep learning curve
  • Computer literacy among staff influences the degree to which the CIS changes workload patterns(many things previously easy may suddenly become more difficult)
  • May degrade the quality of handover and ICU ward rounds (consultants focus their attention on surfing the CIS rather than on what the staff are telling them)
  • There are concerns that electronically signed prescriptions are legally invalid
  • There are concerns regarding the security of passwords, and the potential of untraceable "doctoring" of the records

Evidence in support of CIS use

Evidence against the use of CIS

  • No improvement in mortality in early studies of clinical decision support features of CIS
  • Many nurses are strongly opposed to this technology, largely due to a perceivedlack of training and support
  • Meta-analysis of studies did not confirm an improvement in time spent on direct patient care.
  • Computer keyboards act as a reservoir of nosocomial pathogens

References

Hammond, Jeffrey, et al. "A qualitative comparison of paper flowsheets vs a computer-based clinical information system." CHEST Journal 99.1 (1991): 155-157.

 

Wong, David H., et al. "Changes in intensive care unit nurse task activity after installation of a third-generation intensive care unit information system." Critical care medicine 31.10 (2003): 2488-2494.

 

Marasovic, Caroline, et al. "Attitudes of Australian nurses toward the implementation of a clinical information system." Computers in Nursing 15.2 (1996): 91-98.

 

Mador, Rebecca L., and Nicola T. Shaw. "The impact of a Critical Care Information System (CCIS) on time spent charting and in direct patient care by staff in the ICU: a review of the literature." International journal of medical informatics 78.7 (2009): 435-445.

 

Levesque, Eric, et al. "The implementation of an Intensive Care Information System allows shortening the ICU length of stay." Journal of clinical monitoring and computing (2014): 1-7.

 

Levesque, Eric, et al. "The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit." International journal of medical informatics 82.3 (2013): 177-184.

 

Lapinsky, Stephen E. "Computers in Intensive Care." The Organization of Critical Care. Springer New York, 2014. 53-69.

 

Ehteshami, Asghar, et al. "Intensive care information system impacts." Acta Informatica Medica 21.3 (2013): 185.

 

Amarasingham, Ruben, et al. "Clinical information technologies and inpatient outcomes: a multiple hospital study." Archives of Internal Medicine 169.2 (2009): 108-114.

 

Hunt, Dereck L., et al. "Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review." Jama 280.15 (1998): 1339-1346.

 

Bures, Sergio, et al. "Computer keyboards and faucet handles as reservoirs of nosocomial pathogens in the intensive care unit." American journal of infection control 28.6 (2000): 465-471.

Question 22 - 2007, Paper 2

 

Your intensive care unit collects APACHE III and mortality data and derives the  Standardized Mortality Ratio (SMR) every 3 months as a quality control measure. The SMR for your unit normally ranges between 0.65-0.7. In the latest 3 month figure, the SMR for your unit was noted to be 1.2. Outline, what are the possible reasons for the change in the SMR?

College Answer

SMR is the ratio of the observed hospital mortality and the actual hospital mortality. A ratio of > 1 implies a mortality higher than expected. Potential explanations:

a)  Ensure data entry is correct and accurate and consistent with prior practice (ie comparable)
b)  Issues like quantifying GCS accurately will have an impact on APACHE scores and consequently SMR. Quantification of GCS is a major source of inaccuracy. Also source of admission and diagnosis
c)  SMR reflects system wide performance rather than ICU performance alone, because based upon hospital mortality, not ICU mortality. Look at pre ICU and post ICU facilities in the hospital

d)  SMR affected by case-mix, so changes in case mix may account for increase in SMR and increased other hospital admissions

e)  One needs to examine if there has been a deviation from clinical protocols in the ICU
f)   Lead time bias (pre ICU care) has been shown to impact on SMR and this neds to be factored into.
g)  Are there new inexperienced staff in ICU who might need training?

Discussion

LITFL have a point-form summary. In this summary, there is an excellent final paragraph, which discusses the reasons as to why the SMR might be changing.

The SMR is the ratio of the observed hospital mortality vs. predicted hospital mortality for a specified time period. An SMR of 1 means the mortality is as expected, and an SMR of >1 is worse than expected. The massive jump in SMR as described in the college question is indeed a disturbing development, one which has prompted LITFL authors to blame influenza pandemics and terrorist attacks.

So. Why might the SMR be on the rise?

It would for two possible reasons.

Either the observed mortality rate is increasing, or the predicted mortality rate is decreasing.

Increase in the observed mortality rate

  • Change in protocols
  • Change in admission practices -i.e. more patients being admitted who have little chance for survival
  • Change in discharge practices - i.e. more patients remaining in hospital to be palliated instead of being discharged with community services (this is what happens when you cut funding to community palliative care nurses).
  • Change in staff (inundation by incompetent staff?)
  • Unstable transfer patients received from other hospitals
  • Hospital performance as a whole may be affected by system-wide policy or staff changes (i.e. did all the senior nursing staff suddenly go on annual leave?)

Decrease in the predicted mortality rate

  • Change in illness severity scale encoding - i.e. the encoding has been omitting factors which might otherwise have increased the APACHE and SOFA scores.
  • "Lead time bias" - treatment received prior to ICU admission may result in artifically normalised acute physiology scores
  • "Healthy worker effect" - a change towards selective ICU admission practices may be favouring patients who score low on illness severity scales, eg. young elective surgical patients.

References

Fletcher, John. "Standardised mortality ratios." BMJ 338 (2009).

 

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio."Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

 

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations.American Journal of Kidney Diseases 24.2 (1994): 290-297.

 

Gaffey, William R. "A critique of the standardized mortality ratio." Journal of Occupational and Environmental Medicine 18.3 (1976): 157-160.

 

McMichael, Anthony J. "Standardized mortality ratios and the'healthy worker effect': scratching beneath the surface." Journal of Occupational and Environmental Medicine 18.3 (1976): 165-168.

 

Tunnell, R. D., B. W. Millar, and G. B. Smith. "The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratio in intensive care—a pilot study." Anaesthesia 53.11 (1998): 1045-1053.

 

Rosenberg, Andrew L., et al. "Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures." Annals of internal medicine 138.11 (2003): 882-890.

Question 26 - 2007, Paper 2

What do you understand by ‘open’ and ‘closed’ Intensive Care Units. Outline the advantages  and limitations of each.

College Answer

‘Closed’ ICUs are those managed by dedicated staff intensivists. Potential benefits include: 

a) Being physically present allows for early identification and intervention when problems occur in order to help prevent disaster.
b) An intensivist's knowledge of relevant protocols and evidence-based practice will likely benefit patients.
c) Third, intensivists coordinate communication and collaboration with the patient, family members, other ICU clinicians and medical specialists to provide optimum and informed care.
d) Finally, the intensivists in the ICU manager to standardize processes of care, triage patients, effect timely discharges, and evaluate performance.

Published evidence

Intensivists staffing is associated with reduced length of ICU and hospital stay. Daily rounds by an ICU physician were associated with a 3-fold reduction in hospital mortality among abdominal aortic surgery patients, and reduced hospital length of stay and postoperative complications after esophageal resection. In addition, a recent review of ICU team models found that when intensivists actively managed all ICU patients, a further improvement in survival occurred. An estimated 162 000 lives could be saved annually if intensivists staffed all nonrural adult ICUs (data from USA).

However the term closed ICU implies a non collaborative, non inclusive approach, whilst in reality it is a team effort.

Open ICUs

Several specialists involved consult, Physicians feel less excluded.
No single point of responsibility, patient coordination and communication, responsibility for bed management not clearly spelt out.

Discussion

There is a good discussion of this in LITFL.

In summary:

  • An "Open" ICU is one where specialty teams have full admitting rights and where an intensivist is merely "consulting".
  • A "Closed" ICU is one where the intensivist is the admitting medical officer and the specialty teams collaborate with ICU staff.
  • A "High intensity" staffing model is one which involves either a closed ICU, or a "mandatory consult" situation where the specialty teams might still have admitting privileges to the ICU but every patient must be seen by an intensivist (hence "mandatory").
  • Most ICUs worldwide are closed.
  • The open vs closed debate is an American thing
  • In America, half of ICUs dont have any intensivist coverage
    • In context, this means that even large units would not meet with the CICM accreditation criteria, and would be ineligible to accept trainees for the ICU training program.

Advantages of a "closed" ICU

References

Pronovost, Peter J., et al. "Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review." Jama 288.17 (2002): 2151-2162.

 

Levy, Mitchell M., et al. "Association between critical care physician management and patient mortality in the intensive care unit." Annals of internal medicine 148.11 (2008): 801-809.

 

Wilcox, M. Elizabeth, et al. "Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses*." Critical care medicine 41.10 (2013): 2253-2274.

 

Wallace, David J., et al. "Nighttime intensivist staffing and mortality among critically ill patients." New England Journal of Medicine 366.22 (2012): 2093-2101.

 

Checkley, William, et al. "Structure, process, and annual ICU mortality across 69 centers: United States critical illness and injury trials group critical illness outcomes study*." Critical care medicine 42.2 (2014): 344-356.

 

Capanni, Francesca, and William Checkley. "Differences in Hospital Mortality by ICU Staffing Models: You Cannot Always Get What You Want, but Sometimes You Get What You Need*." Critical care medicine 41.10 (2013): 2433-2434.

Question 11 - 2009, paper 1

List the desirable features of an Illness  Severity Scoring System for Intensive Care patients.? Compare and contrast the Acute Physiology and Chronic Health Evaluation (APACHE) and Sequential  Organ Failure Assessment (SOFA) scoring systems.

College Answer

The ideal scoring system would have the following characteristics:

1.   Scores calculated on the basis of easily/routinely recordable variables
2.   Well calibrated
3.   A high level of discrimination
4.   Applicable to all patient populations in ICU
5.   Can be used in different countries
6.   The ability to predict mortality,functional status or quality of life after ICU discharge

Compare

APACHE

SOFA

Basis

Three factors that influence
outcome in critical illness- pre-existing disease, patient reserve and severity of
acute illness

Degree of organ
dysfunction related to acute illness (initially based of sepsis related organ dysfunction but later validated for organ dysfunction not related to sepsis

Score

Physiological variables,
chronic health conditions and emergency /elective admissions and post- operative/non- operative admissions

Defined score ( 1-4) for
each of six organ systems- respiratory, CVS, CNS, Renal, coagulation and liver

Scoring duration

Based on the most abnormal
measurements in the first 24 hours of ICU stay

Daily scoring of individual
and composite scores possible during course of ICU stay

Population Outcome
comparison

Standardized mortality
ratios (SMR) (observed/predicted) can be used for large patient populations.

No predicted mortality
algorithm. In general higher SOFA score is associated with worse outcome.

Treatment effects on SOFA

Individual patient outcomes

Not possible to predict
individual patient outcome or response to therapy

Response of organ
dysfunction to therapy can be followed over time

Discussion

The various illness severity scoring systems are summarised elsewhere.

LITFL gives the a list of qualities for the "ideal" ICU scoring system. In his 2010 review of scoring systems, Jean-Louis Vincent also gives this list of "ideal" features.

I have incorporated these opinions into one master list of ideal features.

  • Simple and inexpensive
  • Routinely available in all ICUs
  • Scores calculated on the basis of easily / routinely recordable variables
  • Reliable (intra and inter-observer)
  • Objective (that is, observer independent)
  • Specific to the function of the organ in question
  • Well calibrated and validated
  • A high level of discrimination
  • Therapy independent
  • Sequential (available at ICU admission or shortly thereafter and then at fixed periods of time)
  • Not affected by transient, reversible abnormalities associated with therapeutic or practical interventions 
  • Reflect acute dysfunction of the organ in question but not chronic dysfunction
  • Applicable to all patient populations in ICU
  • Reproducible in large, heterogeneous groups of ICU patients
  • Allows the comparison of groups in clinical trials
  • Reproducible in several types of ICUs from different regions of the globe
  • Abnormal in one direction only
  • Using continuous rather than dichotomous variables
  • Able to predict mortality, functional status or quality of life after ICU discharge

A comparison of SOFA and APACHE as a table is discussed in detail elsewhere; I will merely reproduce the comparsion table in the space below.

A Comparison of the SOFA and APACHE Scoring Systems
 

APACHE

SOFA

Basic premise

ICU mortality depends on three domains:

  • Premorbid health
  • Severity of illness
  • Patient's physiological reserve

Thus, if one can quantify these domains, one may be able to predict mortality on the basis of such measurements.

Degree of organ dysfunction is related to acute illness. Originally designed with sepsis in mind, but subsequently validated in other disease states.

Measured parameters

Heuristic groupings of 12 physiologic variables, Glasgow Coma Score (GCS), age, and chronic health evaluation status.

6 domains of organ system function

Measurement collection

Worst score within the first 24 hours

Daily measurement of

Unique features

Incorporates chronic illness, emergency admission, age, surgical vs non-surgical admission, and cardiorespiratory arrest

Incorporates the use of organ system support sug as vasopressors and dialysis

Scoring

0 to 71

0 to 24

Mortality prediction

The risk of hospital death is computed by combining APACHE II score with Knaus' 
weighted coefficient for different types of disease entities. A score of 25 represents a predicted mortality of 50% and a score of over 35 represents a predicted mortality of 80%.

SOFA does not predict mortality, and the original authors intended it to be used as a means of reproduceably describing a sequence of complications in the critically ill.

That said, higher SOFA scores are in factassociated with increased mortality.

Prognostic value

APACHE is a poor predictor of individual patient outcome.

One can monitor response to therapy by the change of daily SOFA scores

References

Balci, C., et al. "[APACHE II, APACHE III, SOFA scoring systems, platelet counts and mortality in septic and nonseptic patients]." Ulusal travma ve acil cerrahi dergisi= Turkish journal of trauma & emergency surgery: TJTES 11.1 (2005): 29-34.

Halim, Dino Adrian, Tri Wahyu Murni, and Ike Sri Redjeki. "Comparison of Apache II, SOFA, and Modified SOFA scores in predicting mortality of surgical patients in intensive care unit at Dr. Hasan Sadikin General Hospital." Critical Care & Shock 12 (2009): 157-169.

Knaus, William A., et al. "APACHE II: a severity of disease classification system." Critical care medicine 13.10 (1985): 818-829.

Vincent, J-L., et al. "The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure." Intensive care medicine 22.7 (1996): 707-710.

Ferreira, Flavio Lopes, et al. "Serial evaluation of the SOFA score to predict outcome in critically ill patients." Jama 286.14 (2001): 1754-1758.

Vincent, Jean-Louis, and Rui Moreno. "Clinical review: scoring systems in the critically ill." Crit Care 14.2 (2010): 207.

Livingston, Brian M., et al. "Assessment of the performance of five intensive care scoring models within a large Scottish database." Critical care medicine28.6 (2000): 1820-1827.

Wong, David T., et al. "Evaluation of predictive ability of APACHE II system and hospital outcome in Canadian intensive care unit patients." Critical care medicine 23.7 (1995): 1177-1183.

Question 21 - 2010, Paper 1

List  the  factors  predisposing  to  medication  error  in  ICU.  How  can  these  be minimised?

College Answer

Note to examiners: This is a very broad question. The following is an example of a good answer to this question. It is expected that there will be a range of different answers by candidates. No breakdown has been provided for the marks. Examiners are urged to use their discretion and should award marks to all reasonable answers.

Factors predisposing

Patient factors 
•    Severity of illness
•    Extremes of age
•    Prolonged hospitalisation
•    Sedation, patient unable to tell nurse medication wrong.

Medication errors 
Types of medications are infusions or weight based or programmed if an infusion pump is required.
Number of medications, more than on the ward
Number of interventions therefore increased risk of complications.

ICU environment 
Complex environment – high stress, high turnover, high nursing turnover. Emergency admission
Multiple care providers

Minimisation of medication errors 
•    Optimise medication process
•    Medication standardisation
•    Computerised physician order entry
•    Barcode technology
•    Computerised infusion device
•    Medication reconciliation

Eliminate situational factors 
•    Avoid excessive consecutive and cumulative working hours
•    Minimise interrupts and distractions
•    Trainee supervision and graduated responsibility

Oversight and error interception 
•    Primary doctor in charge of all drugs ( intensivist)
•    Adequate staffing
•    Pharmacist participation
•    Quality assurance  as part of education  program.  ( Evidence  of adverse drug events dropping by 66% with pharmacist involvement, results in reducing length of stay, decreasing mortality and medication expenditure)

Nursing/Patient ratio 
•    If increased patient/ nurse ratio, increasing error.
•    Mention AIMS ICU (Australian incident monitoring study in Intensive Care) has been  developed  with  goal  of  balancing  strengths  with  limitations  of  error reporting.

Discussion

LITFL have an excellent condensed synopsis of this topic. It draws upon large-scale review articles such as this one and this one.

The author of the college answer felt that the question was broad and general. However, one should note that the question asks for risk factors and the strategies for minimising them.

First, I will focus on answering the question:

Risk Factors for Medication Error
And the Various Means of Managing Them

Risk factor

Management strategy

Illness severity

  • Increase awareness of this as a risk factor through education
  • Increase the involvement of pharmacy staff with the most severely ill patients

Extremes of age

  • Increase awareness of this as a risk factor through education
  • Rationalise geriatric polypharmacy
  • Increase the involvement of geriatric medicine in the management of these patients

Unexpected admission

  • Procolise routine medication administration guidelines to make it available out of hours
  • Ensure the availability of pharmacy staff out of hours
  • Ensure protection from interruptions for staff who are responsible for preparing and administering medications

Prolonged hospital stay

  • Increase awareness of this as a risk factor through education
  • Ensure regular reviews of the medication list by qualified pharmacists

Doses of drugs which require dosage calculations

  • Computerise dose calculations (and integrate them into CIS prescription systems)
  • Ensure protocols for medication are widely circulated and easy to follow
  • Mandatory doublechecking of all dose calculations by a second nurse
  • Introduce electronic infusion pumps with built-in dose calculation firmware
  • Weigh the patients regularly, to have accurate anthropometric measurements for dose calculations.

Multiple medications

  • Structure medication delivery in a systematic manner
  • Ensure protection from interruptions for staff who are responsible for preparing and administering medications

Sedation and decreased participation of the patient

  • Engage the family to provide pharmacy staff with existing medication lists, allowing for improved medication reconciliation
  • Contact primary healthcare providers to get an up-to-date medication history and list of known or suspected allergies

High staff stress, poor nurse-to-patient ratios

  • Ensure the protection of 1:1 staffing for patients who are at risk of medication error
  • Maintain the availability of "floating" nursing staff to assist with preparation of medications, checking of calclations and administration of the drugs

Multiple simultaneous care providers

  • Provide a clear and well-structured schedule of medication administration
  • Maintain a plan of

"Broadly" speaking, a candidate with unlimited time resources would produce an answer resembling the one below

Significance of medication error

  • ICU patients have ~ 1.7 medical errors per day
  • Of these, ~ 78% are medication errors
  • Of these, ~ 54% are errors of medication administration
  • Of medication errors in ICU, ~ 20% are lifethreatening, and ~50% lead to the escalation of the level of support.

Risk factors for medication error:

Table 2 from this article has a more detailed breakdown.

  • Illness severity
  • Extremes of age
  • Unexpected admission
  • Sedation
  • Prolonged hospital stay
  • Doses of drugs which require dosage calculations
  • High staff stress, poor nurse-to-patient ratios
  • Multiple simultaneous care providers

Prevention of medication error

  • Standardise the medications
  • Medication reconciliation (reconciling the list of ICU medications with the normal list of medications which the patient takes at home)
  • Computerise dose calculation and infusion devices
  • Adequate staffing
  • Checklist for drug administration
  • Avoid excessive working hours
  • Pharmacist participation in ICU care

Management of a medication error

  • Full disclosure to the patient and their family
  • Documentation the medical record
  • Staff councelling and/or education
  • Audit of medication error events
  • Implementation of evidence-based preventative strategies

References

Moyen, Eric, Eric Camiré, and Henry Thomas Stelfox. "Clinical review: medication errors in critical care." Crit Care 12.2 (2008): 208.

 

Camiré, Eric, Eric Moyen, and Henry Thomas Stelfox. "Medication errors in critical care: risk factors, prevention and disclosure."  Canadian Medical Association Journal 180.9 (2009): 936-943.

 

Pronovost, Peter, et al. "Medication reconciliation: a practical tool to reduce the risk of medication errors." Journal of critical care 18.4 (2003): 201-205.

Question 8 - 2011, Paper 2

An electrical fire breaks out in the equipment room of your fully occupied 15-bed ICU. Outline the principles of management of this emergency.

College Answer

  • Remove all patients and staff from immediate danger area with safe disconnection of lines, monitoring and equipment and manual ventilation of patients.
  • Raise the alarm – notify switchboard, stating exact location and nature of fire and activate fire alarm. Activate unit fire drill and take instructions from the designated area fire warden.
  • Contain the fire closing all doors and windows. Turn off oxygen outlets.
  • If fire is smaller than a waste basket attempt to extinguish with appropriate extinguishers (CO2 and dry powder) and fire blankets if safe to do so
  • If fire cannot be controlled commence evacuation of patients with most stable first and most unstable last and continuing essential organ support, monitoring and essential medications.
  • Depending on the extent of the fire this may be:
    • Horizontal evacuation through at least one set of fire doors to another part of the ICU or an acute care area on the same floor
    • Vertical evacuation via stairs to the floor below
    • Out of building evacuation
  • Liaison with ED, OT, HDU, CCU and other high care areas in the hospital and/or neighbouring hospitals for ongoing care of the evacuated patients
  • Review of incident and response to identify cause of fire and any issues with management with subsequent review of fire policy and implementation of staff education and simulation exercises

Discussion

This weird question addresses the candidate's knowledge of fire safety in the ICU.

NSW health has a policy directive which describe this in some detail. However, it is not specific to the ICU. It revolves around the RACE acronym. The main difference is the concept of reverse triage (i.e. the sickest patients evacuate last) and the idea that you may need to get other departments to look after these ventilated patients while the ICU burns. An additional feature is the need to turn off all the oxygen (and nitrous oxide).

Remove the staff and patients from immediate danger.
Alert the switch board and fire department
Contain the fire by closing doors and windows 
Extinguish the fire if it is practical and safe to do so.

And after that, you evacuate the remaining patients.Reverse triage is applied at this stage.

Guidelines were also written for the British NHS in 1998 and these are available online. Again, these reiterate the above approach. There a few case reports of fires in the ICU which may be informative. This one is from a 24-bed NICU. The patients were easily evacuated, as only five were ventilated (but one needed three people to transfer, being paralysed with pancuronium and with two chest tubes in).

Major objectives are:

  • Protect the patients in immediate danger (be evacuating them, as well as your staff)
  • Protect the rest of the hospital (basically, allow them to evacuate by telling them that your ICU is on fire)
  • Prevent the spread of fire (by decreasing its supply of substrate, be it oxygen or fuel)
  • Limit the damage to property. If it is not completely stupid to do so, make an effort to actually extinguish the fire.

Evacuate:

  • Follow orders from the fire warden
  • Evacuate to designated assembly points
    • On the same floor, away from the burning room; or:
    • Down the stairs, away from the burning floor; or:
    • Out of the building, away from the burning building
  • Check all ICU rooms and areas (unless it is unsafe)
  • Evacuation resembles inter-hospital transport:
    • Life-sustaining therapies are to be continued
    • Essential treatment is an ongoing part of ICU stay and continues while the patient is in transit or being evacuated. For instance, this means the bedside nurse can continue giving antibiotics to the septic patient while they are parked in the evacuation zone.
  • Transfer to safety
    • Usually designated evacuation areas are not suited to sustaining critically ill patients in the medium-to-long term
    • For this reason, the ICU team leader needs to liase with the emergency department, high dependency units, operating theatre and recovery rooms to accept some of the patients, eg. those who need to be ventilated

Reverse triage evacuation priorities:

  • Visitors first
  • Stable patients next
  • Unstable patients last

Fire containment

  • Turn off the wall oxygen supply
  • Close the doors and windows
  • Extinguish the fire:
    • Only if it doe snot place yourself at risk
    • Only if you are trained to do so
    • Only if the fire is of a manageable size (LITFL suggests a waste paper basket)
    • Using appropriate extinguishers (eg. CO2 instead of foam  or water for electrical fires)

Preventative measures

  • Response to damage:  life and property
    • Open disclosure to affected staff, patients and their families
    • Appropriate use of medicolegal representation, particularly if patients or staff were harmed
    • Contact with hospital executive unit to manage the media response and to control the public perception of the situation. At Chase Farm Hospital fire, TV crews gained access to the site and pestered rescuers with demands for individual statements.
  • Analysis of causes
    • Launch of root cause analysis 
    • Fire investigation may take a forensic or structural engineering pathway
    • Formation of a working party to create preventative policies and to steer the future fire safety approach
  • Preventative policies
    • Make basic fire safety training mandatory for staff
    • Ensure fire extinguishers are present and staff are trained in their use
    • Ensure fire department is rapidly contractible
    • Oxygen / medical air supply shut-off valves to be obvious and easily available in a central location of the ICU
    • Easy access to emergency assembly areas; rapidly obvious emergency egress paths (eg. flashing light directing the staff which way to evacuate)
  • Quality assurance program
    • Routine fire extinguisher checks
    • Fire safety committee (to ensure the policies are championed and audited)
    • Program of annual re-credentialing of fire safety for the staff
  • Assessment of adherence
    • Random audits to ensure passive fire safety standards are being followed (eg. no hospital beds parked in positions where they obstruct fire exits; no wardies smoking joints in the stairwells)
    • Log of staff members who have/haven't completed their mandatory fire training
    • Random fire drills and simulation exercises

References

Guidelines for Fire Safety in the Intensive Care Unit; 1998, Ridley and Parry for the NHS. .

K Sankaran, A Roles, and G Kasian  Fire in an intensive care unit: causes and strategies for prevention CMAJ. 1991 August 15; 145(4): 313–315

Schaefer, H. G., R. L. Helmreich, and D. Scheidegger. "Safety in the operating theatre—part 1: interpersonal relationships and team performance." Current Anaesthesia & Critical Care 6.1 (1995): 48-53.

Reason, James. "Safety in the operating theatre–Part 2: Human error and organisational failure." Quality and safety in health care 14.1 (2005): 56-60.

Valentin, Andreas, Patrick Ferdinande, and ESICM Working Group on Quality Improvement. "Recommendations on basic requirements for intensive care units: structural and organizational aspects.Intensive care medicine 37.10 (2011): 1575-1587.

Kelly, Fiona E., et al. "Managing the aftermath of a fire on intensive care caused by an oxygen cylinder." Journal of the Intensive Care Society 15.4 (2014): 283-287.

Pollaris, Gwen, and Marc Sabbe. "Reverse triage: more than just another method." European journal of emergency medicine: official journal of the European Society for Emergency Medicine (2015).

Newdick, Christopher, and Christopher Danbury. "Reverse triage? Managing scarce resources in intensive care." Law and Ethics in Intensive Care(2010): 191.

Wigmore, T. "Evacuation of the ICU due to fire" (2014). JICS Volume 15, Number 4, October 2014

Wapling, Andy, et al. "Review of five London hospital fires and their management: January 2008-February 2009." RNational Health Service (NHS London), 2009.

Question 7 - 2012, Paper 1

You have been asked by your director to assist in the planning and development of a new level Ⅱ intensive care unit.

a) Define what is meant by level Ⅰ, level Ⅱ and level Ⅲ ICUs

b) Briefly outline the principal considerations you should cover during the planning phase with specific attention to physical design of the unit and staffing

College Answer

This information is covered in the college document IC-1 and candidates should be familiar with at least the broad areas that are covered when a new unit is planned.

a) Definitions

A Level I ICU should be capable of providing immediate resuscitation and short-term cardio-respiratory support for critically ill patients. It will also have a major role in monitoring and prevention of complications in “at risk” medical and surgical patients. It must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring for a period of at least several hours.

A Level II ICU should be capable of providing a high standard of general intensive care, including complex multi-system life support, which supports the hospital’s delineated responsibilities.

A Level III ICU is a tertiary referral unit for intensive care patients and should be capable of providing comprehensive critical care including complex multi-system life support for an indefinite period. Level III units should have a demonstrated commitment to academic education and research. All patients admitted to the unit must be referred for management to the attending intensive care specialist.

b) Design and staffing

Design

A Level II ICU should have at least 6 beds. The unit needs to provide a suitable environment with adequate space for patient care delivery, storage, staff accommodation (including office space), education and research. (CICM IC-1 2011)

Bed space

There should be adequate space around each bed to allow easy access to the patient from all sides

– with at least one hand basin for every 2 beds. Adequate lighting and service outlets need to be provided for each bed space and there should be provision for adequate privacy.

At least one isolation room should be available.

Environment

The unit should have appropriate air conditioning which allows control of temperature, humidity and air change.

Storage

Pharmacy/drug preparation

Equipment storage area.

Dirty utility – area for cleaning appliances, urine testing, emptying and cleaning bed pans and urine bottles.

Staff accommodation

Including offices, tea room and education areas.

Relatives Area

Including a waiting room with basic facilities and separate room for interviewing or seeing distressed relatives.

Staffing

Medical Staff

A dedicated director (should be a Fellow of the College) and team of specialists with junior medical cover. One specialist exclusively rostered to the unit at all times, structured bedside ward round.

Nursing Staff

A minimum of 1:1 for ventilated and other critically ill patients, and 1:2 nursing staff for lower acuity

Consideration should also be given to ancillary staff: Clerical, Wardsmen, Physiotherapists, social workers and cleaning staff

Discussion

This question distinguishes which candidates have been ferreting around in the morass of college policy documents.

What is this document IC-1, from 2011? Why, its Appendix 15: "Minimum Standards for Intensive Care Units" , of course. It outlines the minimum standards for ICUs in Australia. American guidelines are also available, and they are equally verbose, laying out rules about each minute detail of the ICU.

Staffing recommendations

  • A medical director
  • At least one specialist rostered
  • At least one other doctor rostered
  • Patient reviews at least daily, and ideally twice daily
  • 1:1 nursing for ventilated patients and 1:2 for HDU-level patients (any fewer nurses, andmortality seems to increase)
  • There should be a nursing team leader, and nurse in charge of the unit
  • There should be at least one nurse educator per 50 nurses
  • There should be a documented educational program

Structure

  • All patients should be easily visible.
  • At least 20m2 per patient, or 25m2 per single room
  • At least one isolation room per every 6 patient beds
  • At least one wash basin for every 2 patient cubicles
  • At least 16 powerpoints per bed space
  • Windows are "desirable".
  • There should be several dedicated areas:
    • A staff working area and adequate storage space
    • A pharmacy preparation room
    • An equipment storage room
    • A dirty utility
    • A staff room
    • A seminar room
    • Senior nurse offices
    • Senior medical offices
    • Secretary offices
    • A family room for relatives
    • A cleaner's room
    • A blood gas machine
    • Library facilities

Equipment

The following basic equipment should be available:

  • ventilators for invasive and/or non-invasive ventilation
  • hand ventilating assemblies
  • suction apparatus
  • airway access equipment, including a bronchoscope and equipment to assist with the management of the difficult airway
  • vascular access equipment
  • monitoring equipment, both non-invasive and invasive
  • defibrillation and pacing facilities
  • equipment to control patient temperature
  • chest drainage equipment
  • infusion and specialised pumps
  • portable transport equipment
  • specialised beds
  • lifting/weighing equipment
  • access to ultrasound for placement of intravascular catheters 

Monitoring

Patient monitoring equipment should be

  • modular
  • with trending capability
  • visible and audible alarms
  • unobstructed, comfortable viewing
  • capacity for alarm recording
  • capacity to print hard copy

Levels of intensive care units

Level 1

  • Mechanical ventilation
  • Simple invasive cardiovascular monitoring
  • 24-hour timeframe is the limit unless staffed by a FCICM

Level 2

  • Complex multi-system life support for an indefinite period
  • Minimum of 6 beds
  • At least 4 full time specialists on the roster

Level 3

  • Complex multi-system life support for an indefinite period
  • Commitment to academic education and research
  • At least 4 full time specialists per 12-bed "pod"

PICU

  • as for a Level 3 unit, but dedicated to the under-16s

References

CICM Policy Document IC-01: Minimum Standards for Intensive Care Units.

Leaf, David E., Peter Homel, and Phillip H. Factor. "Relationship between ICU design and mortality." CHEST Journal 137.5 (2010): 1022-1027.

Frankel, Stephen K., and Marc Moss. "The Effect of Organizational Structure and Processes of Care on ICU Mortality as Revealed by the United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study*." Critical care medicine 42.2 (2014): 463-464.

Stoddart, J. C. "Design, staffing, and equipment requirements for an intensive care unit." International anesthesiology clinics 19.2 (1981): 77-96.

Question 25 - 2013, Paper 1

With reference to intensive care outcomes, discuss the advantages and limitations of each of the following endpoints as a measure of quality of care:

  • ICU mortality
  • Hospital mortality
  • 90 day mortality
  • 1 year functional outcome

College Answer

a)

ICU mortality

Advantages:

  • simple, single metric
  • concrete endpoint which is already available in hospital databases
  • death is an important endpoint
  • aggregation of a large number of diagnoses with a small number in each increases power to detect variation
  • variation over time may reflect institutional and organisational events or characteristics- budget cuts, bed pressure etc. and be able to detect true quality deficiencies 
    · May be useful when combined as part of an overall quality program

Disadvantages:

  • Definition of ICU is very hospital specific which can influence mortality (e.g. non-ICU stepdown areas in some hospitals)
  • As a consequence can be ‘gamed’ e.g. transfers out to die in the ward or other units
  • Poor correlation between mortality and quality of care in some diagnoses - alternatives available e.g. diagnosis specific risk models e.g. EuroSCORE for CABG, APACHE SMR, trauma scores. Can mask problems in low volume diagnostic groups
  • Difficult to draw hospital comparisons and or allow league table construction
  • False conclusions can be drawn unless robust statistical methods used

Hospital Mortality

Compared to ICU mortality, avoids many problems of censoring at ICU discharge. Hospital mortality can often be 50% higher than ICU mortality, and is a reasonable surrogate (90%) for 90 days mortality.

Advantages – gets over differences in definition of ICU and ICU discharge thresholds. Still a simple and robust endpoint which is easy to obtain from exisiting hospital databases.

Disadvantages – can confound intensive care outcomes with deficiencies in ward or other post ICU care. Does not address in any way functional outcomes [so discharge from hospital to a nursing home in a vegetative state is counted as a positive outcome]

90 day mortality 
Simple robust endpoint which addresses the issue of ongoing mortality after hospital discharge (though this difference is about 10% relative in recent large trials).

Advantages – simple robust endpoint; data may be available by linkage with external registries (e.g. Births, Deaths and Marriages)

Disadvantages – still an arbitrary time point [while 28 days is clearly inadequate, 90 days may still be insufficient to accurately measure the attributable mortality from an episode of critical illness]. Problems with loss to follow up after ICU discharge. Ethical implications of contacting patients after discharge (especially for research studies).

1 year functional outcome

Advantages – a ‘POEM’ – (patient oriented endpoint that matters). Takes into account disability and true long-term consequences of critical illness.

Disadvantages – no ideal soring tool available – existing tools all have problems; some measure particular functional domains well; problems with face validity. All functional outcome measures are time consuming to apply. Problems with loss to follow up. Time consuming, labour intensive, costly face to face vs. phone vs. mail follow up. Depending on disease may reflect more the natural history of the disease rather than the ICU care per se.

Discussion

The above answer is used as a backbone of the LITFL article on this topic. A good discussion of "at what point do we measure mortality" can be found at the AIHW statement on Measuring and reporting mortality in hospital patients (page 6, ch. 2.4.2).

As a good guideline for other ICU outcome measures which should be used to assess the outcomes of Phase II trials, ANZICS has published this statement in 2012 (the 2013 update is for some reason not available for free).

A good discussion of ICU outcome measures and some of their limitations can also be found in the1999 workshop publication of the American Thoracic Society.

A question like this probably lends itself better to a tabulated answer.

A Comparison of Outcome Measures in Intensive Care Research
Outcome measure Advantages Disadvantages
ICU mortality
  • Mortality is simple and cheap to measure
  • It is an important outcome measure
  • It is already being recorded in hospital databases
  • It can be used to track the performance of an ICU, as it may detect true deficiencies in quality of care
  • The definition of "ICU" is different across different hospitals
  • ICU mortality neglects the influence of pre-hospital and emergency medical care on mortality
  • Perimortem patients can be discharged from the ICU before they die, thus "shifting" the statistics out into the hospital wards. Selection of low-risk patients in order to improve the statistics for mortality is known among cardiac surgeons.
  • Conversely, critically ill peri-mortem patients can be transferred to the ICU, increasing ICU mortality, thus shifting the mortality statistic into the ICU. This is called "transfer bias".
  • Mortality does not necessarily equate with quality of care - some patients receive good-quality appropriate palliation in ICU
Hospital mortality
  • Avoids the statistic-skewing practice of discharging palliated patients out of ICU
  • Avoids the problem posed by different definitions of what an "ICU" is.
  • Reflects the performance of the whole hospital, rather than just the ICU
  • Reasonable surrogate for 90day mortality
  • Many effects of hospital care on mortality do not become evident until after discharge from hospital
  • Like ICUs, hospitals may discharge poor prognosis patients home, thus reducing in-hospital mortality artificially
  • Hospital mortality as a measure of ICU care quality brings in confounders- ward care might negatively influence outcomes after ICU discharge
  • Mortality is not a surrogate for functional outcome - hospitals may discharge patients who are alive, but who are in a state of severe functional impairment (eg. persistent vegetative state).
90-day mortality
  • Avoids the statistic-skewing practice of discharging palliated patients out of ICU and out of hospital
  • Easy to measure through the record of births and deaths
  • The 90 day timeline is completely arbitrary
  • 90 days may not be an adequate duration during which the full effects of ICU and hospital care manifest themselves
  • Some patients may be lost to follow-up
  • Confounders such as quality of home care and community follow-up are introduced, which affect mortality
1-year functional outcome
  • Patient-centered outcome measure (i.e. it matters to the patients)
  • A more accurate estimate of the long-term health cost of critical illness
  • Scoring systems of functional outcome are not without their flaws
  • Functional outcome scores may score some functional domains better than others, and broadly speaking they all have poor validity. Much of the time focus is on respiratory and cardiovascular function surrogate measures (such as exercise tolerance and FEV1)
  • Some patients may be lost to follow-up
  • This sort of data collection is neither cheap not easy
  • This is an invasive data collection technique - patients need to be contacted 1 year after their diascharge, which may be an unethical invasion of their privacy for the purposes of research
  • The natural history of the disease acts as a confounder, as it may influence functional outcome. The influence of ICU care and hospital care may become obscured by the progression of the disease.

References

Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.

Young, Paul, et al. "End points for phase II trials in intensive care: Recommendations from the Australian and New Zealand clinical trials group consensus panel meeting." Critical Care and Resuscitation 15.3 (2013): 211. - this one is not available for free, but the 2012 version still is:

Young, Paul, et al. "End points for phase II trials in intensive care: recommendations from the Australian and New Zealand Clinical Trials Group consensus panel meeting." Critical Care and Resuscitation 14.3 (2012): 211.

Suter, P., et al. "Predicting outcome in ICU patients." Intensive Care Medicine20.5 (1994): 390-397.

Martinez, Elizabeth A., et al. "Identifying Meaningful Outcome Measures for the Intensive Care Unit." American Journal of Medical Quality (2013): 1062860613491823.

Tipping, Claire J., et al. "A systematic review of measurements of physical function in critically ill adults." Critical Care and Resuscitation 14.4 (2012): 302.

Gunning, Kevin, and Kathy Rowan. "Outcome data and scoring systems." Bmj319.7204 (1999): 241-244.

Woodman, Richard, et al. Measuring and reporting mortality in hospital patientsAustralian Institute of Health and Welfare, 2009.

Vincent, J-L. "Is Mortality the Only Outcome Measure in ICU Patients?."Anaesthesia, Pain, Intensive Care and Emergency Medicine—APICE. Springer Milan, 1999. 113-117.

Rosenberg, Andrew L., et al. "Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures." Annals of internal medicine 138.11 (2003): 882-890.

Burack, Joshua H., et al. "Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons." The Annals of thoracic surgery 68.4 (1999): 1195-1200.

Hayes, J. A., et al. "Outcome measures for adult critical care: a systematic review." Health technology assessment (Winchester, England) 4.24 (1999): 1-111.

RUBENFELD, GORDON D., et al. "Outcomes research in critical care: results of the American Thoracic Society critical care assembly workshop on outcomes research." American journal of respiratory and critical care medicine 160.1 (1999): 358-367.

Question 19 - 2013, paper 2

Outline how you would plan the ICU response to an influenza epidemic, including in your answer how you would increase resources.

College Answer

Activate ICU/Hospital pandemic plan, if available.

Liaison / pandemic planning with other departments within the hospital, ambulance services, ICUs of other hospitals and state department of health.

Surveillance & early detection of influenza patients.

Increase ICU bed capacity. 
Increase ICU healthcare staffing levels.

Anticipated need for ICU equipment – identify where additional equipment can be resourced (ED, OR etc.)

Infection control measures to reduce the spread to other patients and ICU staff. Provision of antiviral prophylaxis / virus vaccine (if becomes available) for the staff. Establish real-time communication link with laboratory and healthcare administration.

Increased ICU bed capacity:

  • Opening additional beds in existing non-commissioned physical critical care bed spaces.
  • Defer elective surgery requiring post-operative ICU/HDU care.
  • Progressively convert HDU beds to Intensive Care
  • Identify potential additional capacity for ICU ventilated beds in alternative clinical areas such as recovery, CCU, peri-operative units and respiratory units.
  • Discharge of suitable patients to other ward areas (with appropriate upgrade in medical/nursing support)
  • Maximise the use of non-ventilatory strategies in care of ICU patients freeing up devices and equipment for patients for whom mechanical ventilation is essential
  • Facilitate end-of-life discussions and decisions in those appropriate ICU patients assessed as not reaching a meaningful recovery
  • Increase threshold for referral of patients for ICU from other hospitals
  • Consider using available private hospital ICU capacity.

Increased staffing:

  • Increase nursing staff shift length (e.g. 8 to 12 hour shifts)
  • Expansion of nursing capacity by increasing casual, agency or bank staff support
  • Cancellation of leave for medical and nursing staff
  • Provision of anti-viral prophylaxis and virus vaccine (if becomes available) to staff to reduce staff absenteeism due to sickness
  • Train staff from other non-ICU monitored areas to provide intensive care
  • Secondment of additional medical staff from elective duties (e.g. anaesthesia)
  • Change in nurse:patient ratio to provide intensive care
  • Allocation of pregnant / immuno-compromised staff to” non-flu” patients
  • Train staff in the use of PPE

Discussion

The question could be easily answered by a person who is intimately familiar with the summary statement of the Task Force for Mass Critical Care of the American College of Chest Physicians, as well as the recommendations of the European Society of Intensive Care Medicine Task Force for Intensive Care Unit Triage during an Influenza Epidemic or Mass Disaster.

The answer suggested below incorporates their recommendations, as well as the suggestions from the college answer, and the LITFL article on this topic which is heavily exam-oriented. The LITFL article in turn takes its inspiration from this 2006 MJA article, as well as published experiences from the recent H1N1 pandemic.

Preparation of disaster protocols

  • Have a prepared protocol, a graded response plan
  • Prepare to provide care at triple bed capacity
  • Prepare to provide this care for at least 10 days

Management of ICU resources during the pandemic

How to create beds:

  • Cancel elective surgery
  • Transfer non-influenza patients to private ICUs
  • Transfer stable patients to high dependency beds
  • Urgently open extra ICU beds which are not funded:
    • Annex the recovery wards and CCU
    • Convert HDU beds to ICU
  • Ration the use of mechanical ventilation for patients genuinely dependent on it, freeing up equipment

How to acquire more staff:

The major resource problem during the H1N1 pandemic in Australia was actually the availability of ICU-trained nurses.

  • Cancel medical and nursing staff scheduled leave
  • Increase working hours for medical and nursing staff
  • Bring seconded staff back from secondment
  • Increase proportion of casual nursing staff
  • Appeal to locum agencies
  • Train non-ICU staff to care for ICU-level patients
  • Administer antiviral prophylaxis to decrease absenteeism

References

Question 15 - 2014, Paper 1

You are asked to review the guidelines for transfusion of packed red blood cells in critically ill patients in your hospital.
 
Outline the steps that you will take to achieve this.

College Answer

1. Form a multidisciplinary team including medical, nursing and haematology/blood bank staff to help you prepare the guideline.
2. Review current guidelines of your unit if available. Review the date of publication of those guidelines and times of updates.
3. Audit the indications and volume of transfusions in your ICU.
4. Review the current literature for packed cell transfusion. In particular review any statements or guidelines form national blood bank authority or professional bodies. In the absence of strong evidence, expert opinion is available in these statements.
5. Determine the relevance of the current literature to you case mix – e.g. transfusion threshold for stable post cardiac surgical patients are important.
6. Prepare a draft guideline and circulate widely including to ED/ theatres / haematology.
7. Review comments and issues raised after circulating draft guidelines.
8. Prepare final guideline and circulate and publish for use in your ICU.
9. Plan to monitor compliance with these guidelines.
10. Date for future review.

Discussion

In brief, guideline development should consist of the following key stages:

  • Define the process which requires a practice guideline
  • Compose a panel of experts and stakeholders, and nominate its leader
  • Develop the questions answered by the guideline
  • Develop selection criteria for the published evidence
  • Perform a literature search according to these criteria
  • Appraise the evidence, extract data from it, and synthesise recommendations
  • Draft guidelines, and expose the draft to external review
  • Publish the final draft
  • Monitor adherence and uptake
  • Audit the practice to monitor outcome changes associated with the new guidelines
  • Prepare scheduled updates

Identify the practice

  • A need for review is identified, and the department manager approves of this.
  • The specific area is defined as a practice policy or work process which requires a protocol to standardise practice,  improve outcomes or prevent adverse events.
  • An existing guideline or policy may be in need of revision

Compose the guidelines panel

  • Key stakeholders form a multidisciplinary working party .
  • multidisciplinary approach is called for which involves consumers
  • The working part appoints a Team Leader (or, one if appointed from the top down)
  • Timeframes are identified, as to how long it should take to create the policy, and the mandatory review period (for the next time this policy needs to be updated)
  • A schedule of meetings is drawn up, with key dates for completion of policy drafts and other important time intervals in the process

Identify the question

  • The purpose and scope of the guidelines is clearly defined
  • Specific questions are determined, eg. "Should any specific haemoglobin concentration trigger a mandatory transfusion?"
  • The target audience for the guidelines is defined
  • Specific health outcomes are defined, which the guideline should address

Develop research strategies

  • Evidence selection criteria are developed
  • A literature search is performed with the abovementioned criteria. If possible, a systematic literature review should be undertaken.
  • The evidence is reviewed and critically appraised
  • Data relevant to the guideline is extracted and presented for the working party to assess
  • The working part develops a series of recommendations according the the presented data
  • Other similar policies and guidelines from other institutions are explored and useful material is borrowed or adapted
  • A cost analysis is performed and the cost of the new policy is compared to that of existing practice
  • Possible barriers to implementation  are considered
  • A draft of the guideline is generated

Specific features and properties of the guidelines document

  • A good guidelines statement should:
    • Identify the organisation responsible
    • Define the purpose of the guideline
    • List individuals and groups responsible for its development
    • Document clearly the process of evaluation of the evidence
    • Provide a bibliography
    • Detail the assumptions
    • Record public policy and economic questions which were considered
    • Identify the need for special training required for implementation
    • Record how consumer concerns were taken into account
    • Detail methods for dissemination
    • Detail the timeframe for evaluation

Recursive improvement

  • The draft is widely circulated
  • Key personnel outside the working panel are nominated to critique the draft
  • Consideration is given to suggestions and commends on the draft, and by recursive improvement a final draft is created which is approved by all key stakeholders.
  • The final draft is then framed in a pre-defined publication format for thematic consistency with other existing guidelines
  • The final product is submitted for approval by the department manager.

Implementation

  • Roll-out occurs on a previously specified date, of which all key audiences are made aware well in advance.
  • The final policy is then widely circulated. Alternatively, the guidelines may be piloted in pre-specified locations or scenarios before wirder circulation.
  • Internal and external education sessions are held to update staff on the new practice
  • Guideline documents are made accessible
  • Contact is made with educators, to act as ‘champions’  to promote the guideline
  • Experts are made available for contact and questions

Audit and quality assurance

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

Moulding, Nicole Therese, C. A. Silagy, and D. P. Weller. "A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines." Quality in Health Care 8.3 (1999): 177-183.

Schünemann, Holger J., Atle Fretheim, and Andrew D. Oxman. "Improving the use of research evidence in guideline development: 1. Guidelines for guidelines." Health Research Policy and Systems 4.1 (2006): 1.

Silagy, C., et al. "A guide to the development, implementation and evaluation of clinical practice guidelines." National Health and Medical Research Council, Canberra, Commonwealth of Australia (1998): 1-79.

Question 24 - 2015, Paper 2

As part of a nationwide quality improvement program, the standardised mortality ratio (SMR) of your Intensive Care Unit was compared to other similar Intensive Care Units using a funnel plot.

You are ICU “A”

a)    What does the graph show about your ICU “A”?    (20% marks)

b)    Explain how the SMR is calculated.    (20% marks)

c)    Give the causes of an increased SMR.    (60% marks)

College Answer

a)

The SMR of ICU A is above the upper 99% CI indicating the SMR is significantly higher than similar hospitals. Your ICU has significantly more deaths than expected compared to similar hospitals.

The overall SMR for the group is less than 1 and the SMR for ICU A is less than 1

b)

SMR = O/E    O= observed number of deaths, E = expected number of deaths

E is derived from the average of the sample/ population.

Usually a risk adjustment model is used to calculate and account for severity of illness.

c)

Can be “apparent” or “real”.

Data quality

Incomplete or errors in data submission causing underestimated expected risk Widely different casemix of this ICU compared to others.

Statistical model (risk adjustment) may no longer well calibrated True increase in mortality which can be due to

i.    Factors internal to ICU: very high occupancy, poor processes,, inadequate staffing,

ii.    Factors external to ICU; problems in services that are high users of ICU e.g. surgery, system issues

Additional Examiners’ Comments:

Many candidates showed a significant knowledge gap relating to this commonly used quality indicator with insufficient details and structure in their answers.

Discussion

Again, the college did not include their images here. The SMR funnel plot above has been ripped off from the ANZICS own database for 2013-2014, via the propaganda materials from The Alfred. The red dot in the bottom right of the funnel plot is that abovementioned centre of excellence, soaring ever higher into "good outlier" territory.

Generally, the college loves SMRs. Specifically, they like to discuss which it might be abnormally high, and what are its limitations as a measure of the quality of care.

  • Question 24 from the second paper of 2015 asked to explain causes of a raised SMR, as well as to interpret a funnel plot of SMR data and to explain how it is calculated.
  • Question 22 from the first paper of 2007 asked why an SMR might be raised suddenly
  • Question 22 from the second paper of 2007 was identical to Question 22 from the first paper of 2007, i.e. the same question used twice within the same year.
  • Question 13 from the first paper of 2003 wanted you to discuss the limitations of the SMR
  • Question 30 from the second paper of 2006 was identical to Question 13 from the first paper of 2003

a)  ICU "A" is clearly having some sort of crisis. However, the overall SMR is still less than 1, which means that mortality has not exceeded the average mortality predicted by APACHE data. Which is good, because some might say APACHE data is crap for predicting mortality: these day mortality is probably lower for any given APACHE score than the outdated system might predict.

b)

  • SMR is the ratio of the observed  mortality vs. predicted mortality for a specified time period.
  • One can use this to compare hospitals and ICUs
  • One needs to first calculate the predicted hospital mortality using an illness severity scoring system.
  • An SMR of 1 means the mortality is as expected.
  • An SMR of < 1 is better than expected, and >1 is worse than expected.

The above definition is probably enough to satisfy the minimum requirements for the college. 
In short,

SMR = observed number of deaths / expected number of deaths

In order to calculate this, one requires three main variables:

  • A time interval (you decide - three months, one year, etc.)
  • A measurement of the observed number of deaths (ICU mortality numbers should be available widely)
  • An estimate of the predicted mortality (this can be achieved using a scoring system).

c)

Reasons for a spuriously elevated SMR

  • Unfair mortality measurements should not be a problem, as there is no serious situation in which mortality might get over-reported (i.e. some patients walking around after ICU discharge who are formally dead according to the official record). An under-reporting of mortality is much more likely, and might occur in resource-poor environments where public record-keeping is rudimentary. Such dodgy records might still list the person as alive, whereas they died shortly after ICU discharge and nobody bothered to file the paperwork.
  • Unfair comparison group mortality / APACHE mortality estimate is usually the culprit.
    • Poor data entry, eg. constant overestimation of GCS or failure to tick the chronic illness boxes, which makes the patients appear healthier than they actually are.
    • Missing data is (in the author's experience) usually rich in APACHE points, eg. the missed urine output entry obscuring anuria, or the failure to document biochemistry results which conceals the potassium level of 8.0mmol/L.
    • "Lead time bias" - treatment received prior to ICU admission may result in artifically normalised acute physiology scores
    • "Healthy worker effect" - a change towards selective ICU admission practices may be favouring patients who score low on illness severity scales, eg. young elective surgical patients

Reasons for a truly elevated SMR

  • Issues external to the ICU
    • A population with greater pre-ICU morbidity is suddenly available (eg. to borrow an example from LITFL, you have suddenly decided to become a destination for the state's ECMO retrieval service).
    • Pre-ICU care has changed its practice (for the worse)
    • Parameters which govern ICU admission have changed (eg. administrative pressure is being placed on the ICU to rapidly admit ED patients who have had little management or workup)
    • Discharge arrangements have changed (eg. a local palliative care ward had shut down, and you keep dying patients in the ICU because it would be insensitive to transfer them to the next nearby palliative care unit)
  • Issues internal to the ICU (i.e. genuine under-performance)
    • This could be a long list...
    • A new staffing model is in place (inexperienced staff)
    • Understaffing has impaired patient care
    • Junior people are not following unfamiliar protocols, or the new protocols are crap
    • New equipment you bought is useless

References

Young, Paul, et al. "End points for phase II trials in intensive care: Recommendations from the Australian and New Zealand clinical trials group consensus panel meeting." Critical Care and Resuscitation 14.3 (2012): 2111.

Suter, P., et al. "Predicting outcome in ICU patients." Intensive Care Medicine20.5 (1994): 390-397.

Martinez, Elizabeth A., et al. "Identifying Meaningful Outcome Measures for the Intensive Care Unit." American Journal of Medical Quality (2013): 1062860613491823.

Tipping, Claire J., et al. "A systematic review of measurements of physical function in critically ill adults." Critical Care and Resuscitation 14.4 (2012): 302.

Gunning, Kevin, and Kathy Rowan. "Outcome data and scoring systems." Bmj319.7204 (1999): 241-244.

Woodman, Richard, et al. Measuring and reporting mortality in hospital patientsAustralian Institute of Health and Welfare, 2009.

Vincent, J-L. "Is Mortality the Only Outcome Measure in ICU Patients?."Anaesthesia, Pain, Intensive Care and Emergency Medicine—APICE. Springer Milan, 1999. 113-117.

Rosenberg, Andrew L., et al. "Accepting critically ill transfer patients: adverse effect on a referral center's outcome and benchmark measures." Annals of internal medicine 138.11 (2003): 882-890.

Burack, Joshua H., et al. "Public reporting of surgical mortality: a survey of New York State cardiothoracic surgeons." The Annals of thoracic surgery 68.4 (1999): 1195-1200.

Hayes, J. A., et al. "Outcome measures for adult critical care: a systematic review." Health technology assessment (Winchester, England) 4.24 (1999): 1-111.

RUBENFELD, GORDON D., et al. "Outcomes research in critical care: results of the American Thoracic Society critical care assembly workshop on outcomes research." American journal of respiratory and critical care medicine 160.1 (1999): 358-367.

Turnbull, Alison E., et al. "Outcome Measurement in ICU Survivorship Research From 1970 to 2013: A Scoping Review of 425 Publications.Critical care medicine (2016).

Solomon, Patricia J., Jessica Kasza, and John L. Moran. "Identifying unusual performance in Australian and New Zealand intensive care units from 2000 to 2010." BMC medical research methodology 14.1 (2014): 1.

Liddell, F. D. "Simple exact analysis of the standardised mortality ratio." Journal of Epidemiology and Community Health 38.1 (1984): 85-88.

Ben-Tovim, David, et al. "Measuring and reporting mortality in hospital patients." Canberra: Australian Institute of Health and Welfare (2009).

McMichael, Anthony J. "Standardized Mortality Ratios and the'Healthy Worker Effect': Scratching Beneath the Surface." Journal of Occupational and Environmental Medicine 18.3 (1976): 165-168.

Wolfe, Robert A. "The standardized mortality ratio revisited: improvements, innovations, and limitations." American Journal of Kidney Diseases 24.2 (1994): 290-297.

Kramer, Andrew A., Thomas L. Higgins, and Jack E. Zimmerman. "Comparing observed and predicted mortality among ICUs using different prognostic systems: why do performance assessments differ?.Critical care medicine 43.2 (2015): 261-269.

Spiegelhalter, David J. "Funnel plots for comparing institutional performance." Statistics in medicine 24.8 (2005): 1185-1202.

Teres, Daniel. "The value and limits of severity adjusted mortality for ICU patients." Journal of critical care 19.4 (2004): 257-263.

Question 4 - 2016, Paper 2

You are asked to head a working party to establish a Rapid Response System (RRS) in your hospital. Outline the steps you will take to do this.

College answer

A hospital-wide system to recognise and respond to the deteriorating patient is a requirement as set out in Standard 9 of the National Safety and Quality Healthcare Standards.

Implementation of RRS

  • Engage all hospital staff and involve representation from all groups: hospital executive, senior nursing and medical, junior nursing and medical, allied health and ancillary staff and community representative
  • Appoint “champions” from these groups to promote the system and to form the working party
  • Review the literature and RRS models in other institutions and seek help from experts in the field
  • Collect baseline data pre-implementation
  • Determine appropriate RRS model for the hospital based on o Hospital case-mix o Hospital culture o Resources and funding
    • Pre-existing system e.g.: cardiac arrest team
  • Issues to consider
    • Criteria for activation o Team composition o Home team involvement o ICU involvement o Projected number of calls
    • Consequent effects on existing services as staff take up these additional responsibilities & service provision
  • Education of users of system hospital-wide
  • Team training for MET personnel including clinical skills, communication, teamwork and endof-life decision-making
  • Source appropriate equipment / drugs for RRS calls and storage when not in use, with systems for checking & maintenance
  • Establish system for data collection and audit
  • Consider phased introduction of RRS or pilot project initially
  • Data collection and audit from first day of implementation
  • Review of data and benchmarking with other hospitals
  • Feedback from RRS users and RRS team
  • Modification of RRS as needed
  • On-going education of staff and RRS team training
  • Contribute to national database

Appropriate information not in the template was given credit.

An acceptable answer addressed the following points: 

  • The elements of the audit cycle
  • The need to engage staff hospital-wide in the process
  • Design of the system to suit hospital culture, case-mix, resources
  • Team training and education
  • Data collection and audit

Additional Examiners‟ Comments:

Many candidates lost marks for an answer that included relevant points but was clearly not at the level of a junior consultant.

Discussion

Clearly this issue has importance, as it has been dedicated the very second chapter of Oh's Manual ("Outreach"). On page 13 of the 7th edition, Welch and Subbe discuss the issue of "setting up an outreach service", a heading which seems relevant to this question. The "key steps in planning an RRS" seems like an important point-form table to reproduce here, with appropriate copyright-defensive paraphrasing (see below). Other major sources for this answer come from the helpful references made in Chapter 2, specifically to the (mainly British) series of RRS guidelines. 

The "Standard 9" referred to in the college answer can be found in this horrific committee-spawned standards document. it is actually quite unhelpful if you are trying to build an RRS from scratch, and only outlines the hospital executives' expectations of such a service.

With luck a junior consultant would be able to express this sort of answer in writing within the space of 10 minutes.

  • Planning the administration of RRS service
    • Appointment of  senior staff to develop the service
    • Managerial and clincal staff
    • Imperatve to include ward staff
    • This forms the "working party"
  • Planning and research by appointed committee members
    • Epidemiology of critical illness in the hospital
      • i.e. where is the service going to be required most: ED, recovery suite, in the wards
    • Epidemiology of unexpected deaths in the hospital
    • Source and timing of unplanned ICU admissions
    • "what is the pattern of adverse events where harm can be attributed to the process of care?"
    • Consider in this process the content of patient and family complaints, the results of root cause analysis and morbidity/mortality data
    • Use these to design a system of criteria for triggering an RRS response, and a system of clearly defined referral/escalation protocols.
  • Needs analysis of
    • Patient mix
    • Ward staff skill levels
    • Proposed hours of service operation
    • Expected demand based on hospital size and specialty services
    • Availability of training facilities
    • Equipment needs
    • Funding
  • Audit process planning
    • Identify data for prospective collection
    • "It is essential that robust data are collected", they said.
    • Assess key practices against "specific, measurable standards"
    • Have discrete goals for audit and evaluation:
      • to identify areas where training is required
      • to identify sources of systematic error
      • to identify the changes in critical care workload
    • Specific prospectively collected data may include:
      • numbers of referrals
      • Referral details (date, time, reason for referral)
      • Patient details
      • Significant problems identified
      • Interventions performed
      • Patient outcome
  • Rapid Response Service design
    • "At a minimum, the team should be capable of assessment, diagnosis, initiation of resuscitation, and rapid triage of the critically ill patient"
    • The key word is "multiprofessional". You want a multiprofessional team.
    • Composition of the team and skills of the members should represent the niche need identified by the planning committe.
    • Some basic  airway and vascular access skills are probably the expected minimum skill level
  • A "pragmatic, staged implementation":
    • Education of ward staff regarding the use of the trigger criteria
    • Education of RRS members to compete their skill set
    • System for update and recredentialling of RRS-relevant skills (eg. annual ALS course)
    • Incremental spread of RRS, increasing the number of clinical areas covered, the number of team members, and the responsibilities of the team
  • Regular scheduled audit and evaluation
    • Nominate independent auditors
    • Organise multidisciplinary audit meetings
    • At a smaller level, organised regular RRS debrief sessions
    • "Successful systems are based upon multiprofessional working, and effective communication education, data collection/audit, learning from errors, and planned improvement of whole systems of care."

References

Chapter 2. (pp.10)   Critical  care  outreach  and  rapid  response  systems   by John  R  Welch  and  Christian  P  Subbe

Department of Health and NHS Modernisation Agency. The National Outreach Report 2003/Critical
Care Outreach 2003 – progress in developing services.
London: Department of Health; 2003.

Australian Commission on Safety and Quality in Health Care guidelines:

Question 10 - 2017, Paper 1

As a newly appointed Intensive Care Specialist, you are put in charge of Safety and Quality in your ICU. The infection control department informs you that your ICU has a higher than acceptable rate of central line associated blood stream infections (CLABSI).

Define CLABSI rate.    (10% marks)

Outline your approach to this problem in terms of initial investigation and ongoing management and monitoring.     (90% marks)

College answer

a) CLABSI rate = confirmed blood stream infections / central line days x 1000

i.e. Number of confirmed blood stream infections per 1000 central line days
CLABSI count and central line days defined by Australian Commission on Safety and Quality in Health Care

b) The ANZICS CORE CLABSI Registry provides a national reporting and benchmarking system

Investigation 

  • Review data/audit to ensure counts are correct and that data quality issues are not responsible for a false estimation
  • Review the cases of confirmed blood stream infection and ensure no false positives or negatives
  • Review method of counting line days as missed days will result in artificially high rate
  • Involve relevant stakeholders – nurses, infection control, ICU medical staff – and form working party
  • Compare with historical CLABSI data for the unit – is this a spike or has it always been a problem
  • Benchmark rate against published targets or benchmarked targets referenced against peer hospitals. Generally reported as number of infections per 1000 line days with expectation of rate <1/1000
  • Ideally benchmark based on contemporary registry based data (ANZICS CORE CLABSI Registry) with risk adjustment although no risk adjustment exists within current reporting

Management

If increased rate confirmed investigate potential causes of high rate.

Implementation of specific strategies based on best available evidence and ideally as part of an established wider program.

Specifically:

  • Staff training and use of correct aseptic technique (ANZICS Central Line Insertion and Maintenance Guideline)
  • Insertion site selection
  • Use of insertion bundle or checklist
  • Consideration of limiting insertion to fewer more experienced operators (insertion team) with accreditation process
  • Documentation of daily review of line
  • Removal of all lines at earliest feasible time
  • Specific evidence for
    • Use of antimicrobial impregnated lines and biopatches
    • Use of Chlorhexidine plus alcohol as disinfectant
  • Consider alternatives to conventional CVC when possible e.g. PICC lines and tunneled lines

Ongoing monitoring

Audits of process such as observation of aseptic technique. Ongoing monitoring of rates over time with review based on appropriate statistical process control to distinguish special cause from common cause variation. That is essentially to ensure that any change is statistically significant. For example:

  • Funnel plots
  • EWMA charts – exponentially moving weighted average
  • CUSUM charts – cumulative sum control

Implementation and monitoring may require additional resources to be provided by administration (equipment, staff etc.)

Submission of data to ANZICS CORE CLABSI Registry

Regular reporting back to staff and hospital S&Q / infection control committee

Additional Examiners’ Comments:

This was poorly answered overall; only a minority of candidates could correctly define CLABSI rate. Most candidates produced standard proforma answers that ignored specifics and could have been referring to any QI issue.

Discussion

This question could just as easily have fit into the "infectious diseases" section, but the focus is on departmental policymaking rather than anything directly clinical. It was therefore shoved into the administrative group of SAQs. Judging by the pass rate of 52.5%, a standard proforma answer could still score highly enough to scrape under the barrier. 

Oh's Manual has a section on "line sepsis" (page 730 of the 7th edition) nested within Rishi and Dhillon's "Nosocomial Infections" chapter. Though brief, the section contains several important definitions worth knowing. Among these is this definition of CLABSI as "Isolation of the same organism from the catheter segment as from a peripheral blood culture in a patient with signs of infection and in the absence of another source." Unfortunately, no CLABSI rate definition is given.  This is another example of the Manual not being enough even for a 10% answer.

The CLABSI rate definition quoted by the college (which "only a minority of candidates could correctly define") comes from the ACSQHC, specifically from this 2015 document

The rest of the answer would have to take the shape of a routine "implement a policy" SAQ. Much of the actual policy can be extracted from the ANZICS statement on prevention of central line associated infections. The rest is a pile of corporatese garbage.

Initial investigation:

  • Create a multidisciplinary committee, involving the Infection Control department. The savvy candidate will use such key words as "relevant stakeholders" and "working party" to tickle the examiners in just the right places.
  • Define the problem and track it retrospectively, so it might be associated with specific events (eg. annual recruitment of new staff, etc)
  • Review the data collection methods for errors
  • Explore existing CLABSI control measures and barriers to their implementation
  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document

Management of CLABSI risk

  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document, detailing practices associated with a decreased risk of CVC infection:
    • Use of subclavian lines.
    • Minimum number of lumens.
    • Use of dedicated lumens for lipid infusions.
    • Immunosuppressed patients or those with burns should have antibiotic-coated lines.
    • For insertion, use aseptic technique and maximal barrier precautions.
    • 0.5% chlorhexidine in 70% alcohol is the preferred cleaning agent.
    • Handle ends of administration sets with gauze soaked in chlorhexidine.
    • Review the line daily.
    • Remove the line as soon as possible.
    • Change lines early - ideally, every 7 days.
    • Sterile, transparent semipermeable dressings
    • Change dressings regularly (every 7 days for standard dressings)
    • Avoid/minimise CVCs if possible
    • Accredit staff in the use of safe technique (if word gets around that your ICU limits CVC insertion experience to some sort of elite "insertion team", your recruitment of junior staff will suffer)
  • Implement these practices: circulate the document widely, and hold meetings to discuss it with key staff
  • Appoint champions who ensure adherence to these practices
  • Assign specific timeframes over which the practice is to be audited

Monitoring

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

Marschall, Jonas, et al. "Strategies to prevent central line–associated bloodstream infections in acute care hospitals: 2014 update." Strategies 35.7 (2014): 753-771.

ANZICS statement on prevention of central line associated infections

ANZICS statement on insertion and maintenance of CVCs

LIFL have made as short a summary as one can manage without omitting vital facets of the overall strategy.

Maki, Dennis G., Daniel M. Kluger, and Christopher J. Crnich. "The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies." Mayo Clinic Proceedings. Vol. 81. No. 9. Elsevier, 2006.

Australian Commission on Safety and Quality in Health Care; Wilkinson, et al "Implementation Guide for Surveillance of Central Line Associated Bloodstream Infection", 2015

Moulding, Nicole Therese, C. A. Silagy, and D. P. Weller. "A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines." Quality in Health Care 8.3 (1999): 177-183.

Schünemann, Holger J., Atle Fretheim, and Andrew D. Oxman. "Improving the use of research evidence in guideline development: 1. Guidelines for guidelines." Health Research Policy and Systems 4.1 (2006): 1.

Silagy, C., et al. "A guide to the development, implementation and evaluation of clinical practice guidelines." National Health and Medical Research Council, Canberra, Commonwealth of Australia (1998): 1-79.

Question 26 - 2019, Paper 1

The findings of your departmental mortality and morbidity meeting suggest that delirium is an increasing problem in the patient population in your ICU.

Describe how you would design a quality improvement (QI) project to minimise delirium in your unit, including in your answer a list of potential strategies and interventions.
 

College answer

  1. Elements of QI project are:

    1. Identify local motivation, support and change champions and establish a multi-disciplinary team

    Review evidence for strategies and interventions to minimise delirium

    Environment:

    • Excessive noise and insufficient light associated with delirium

    • Ideal design allows patient exposure to daylight, space to facilitate early mobilisation, space for family and visitors to be involved in care. Access to outdoor spaces for long stay patients.

    • Monitoring equipment quiet, audible alarms adjusted to accepted physiologic parameters.

    Unit practices:

    • Use of valid screening tool for delirium e.g. Confusion Assessment Method for the ICU (CAM-ICU)

    • Sedation – minimise sedation, titrated to sedation target e.g. Richmond Agitation and Sedation Score. Avoidance of benzodiazepines.

    • Early mobilisation – physical environment, equipment, allied health staff

    • Cues for orientation – easy to read clocks, whiteboards or similar with day plan

    • Day/ night maintenance - low lights and quiet overnight, promotion of sleep, minimising interventions at night, grouping cares

    • Staff awareness and education – identification of high-risk patients, routine monitoring for delirium, seek staff input to quality initiative

    • Family involvement in care

    1. Prioritise interventions and implement with staff education and training as needed

    2. Evaluate outcomes

      • Ongoing monitoring and data collection

    • Benchmarking with previous results and other comparable units

An acceptable answer addressed a breadth of initiatives including departmental design, processes and individual patient care. Details of treatment and management of delirium not relevant to the question.

Discussion

Your ICU is in the grip of an epidemic of delirium. Confused patients are smearing faeces on the all the walls. How will you manage this bedlam?  Obviously, by identifying change champions and establishing a multi-disciplinary team. It is clear that the objectives of this SAQ were to determine whether the exam candidate is familiar with the appropriate administrative buzzwords. Actual management of delirium is discussed elsewhere. 

In summary, "departmental design" of this intitiative should follow the following process outline, where the appropriate mark-scoring corporatespeak  is italicised. 

Compose the guidelines panel

  • Key stakeholders form a multidisciplinary working party .
  • A multidisciplinary approach is called for which involves consumers
  • The working part appoints a Team Leader (or, one if appointed from the top down)
  • Timeframes are identified, as to how long it should take to create the policy, and the mandatory review period (for the next time this policy needs to be updated)
  • A schedule of meetings is drawn up, with key dates for completion of policy drafts and other important time intervals in the process.

Perform research to answer the question, "how to decrease the incidence of delirium in our unit"

  • Evidence selection criteria are developed
  • A literature search is performed with the abovementioned criteria. If possible, a systematic literature review should be undertaken.
  • The evidence is reviewed and critically appraised
  • Data relevant to the guideline is extracted and presented for the working party to assess
  • The working part develops a series of recommendations according the the presented data
  • Other similar policies and guidelines from other institutions are explored and useful material is borrowed or adapted
  • A cost analysis is performed and the cost of the new policy is compared to that of existing practice
  • Possible barriers to implementation  are considered
  • A draft of the guideline is generated

Interventions which could form a part of this review would include:

  • Anaesthesia guidelines for booked post-op ICU admissions
  • Routine nursing interventions:
    • Early mobilisation
    • Screening for bowel and bladder dysfunction
    • Sleep enhancement strategies (eg. "lights out" time)
    • Therapeutic cognitive activities and orientation
    • Vision and hearing protocols
  • Routine medical interventions
    • Geriatric consultation
    • Medication revoew
    • Analgesia protocols
  • Environmental changes
  • Visitor policy
  • Mobility policy
  • Education for staff
  • Education for families
  • Delirium screening

    (this is all from Reston & Schoells (2013), who summarised the elements of successful delirium prevention programs)

Recursive improvement

  • The draft is widely circulated
  • Key personnel outside the working panel are nominated to critique the draft
  • Consideration is given to suggestions and commends on the draft, and by recursive improvement a final draft is created which is approved by all key stakeholders.
  • The final draft is then framed in a pre-defined publication format for thematic consistency with other existing guidelines
  • The final product is submitted for approval by the department manager.

Implementation

  • Roll-out occurs on a previously specified date, of which all key audiences are made aware well in advance.
  • The final policy is then widely circulated. Alternatively, the guidelines may be piloted in pre-specified locations or scenarios before wirder circulation.
  • Internal and external education sessions are held to update staff on the new practice
  • Guideline documents are made accessible
  • Contact is made with educators, to act as ‘champions’  to promote the guideline
  • Experts are made available for contact and questions

Audit and quality assurance

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

Moulding, Nicole Therese, C. A. Silagy, and D. P. Weller. "A framework for effective management of change in clinical practice: dissemination and implementation of clinical practice guidelines." Quality in Health Care 8.3 (1999): 177-183.

Schünemann, Holger J., Atle Fretheim, and Andrew D. Oxman. "Improving the use of research evidence in guideline development: 1. Guidelines for guidelines." Health Research Policy and Systems 4.1 (2006): 1.

Silagy, C., et al. "A guide to the development, implementation and evaluation of clinical practice guidelines." National Health and Medical Research Council, Canberra, Commonwealth of Australia (1998): 1-79.

Reston, James T., and Karen M. Schoelles. "In-facility delirium prevention programs as a patient safety strategy: a systematic review." Annals of internal medicine 158.5_Part_2 (2013): 375-380.

Question 6 - 2019, Paper 2

As a newly appointed intensive care specialist, you are put in charge of safety and quality in your ICU. The infection control department informs you that your ICU has a higher than acceptable rate of central line associated blood stream infections (CLABSI).

a)    Define CLABSI rate.    (10% marks)

b)    Outline your approach to this problem in terms of initial investigation and ongoing management and monitoring.    (90% marks)
 

College answer

CLABSI = confirmed blood stream infections / central line days x 1000
i.e. Number of confirmed blood stream infections per 1000 central line days
CLABSI count and central line days defined by Australian Commission on Safety and Quality in Health Care

Investigation

Review data/audit to ensure counts are correct and that data quality issues are not responsible for a false estimation.
Review the cases of confirmed blood stream infection and ensure no false positives or negatives. Review method of counting line days as missed days will result in artificially high rate.

Involve relevant stakeholders – nurses, infection control, ICU medical staff – and form working party Compare with historical CLABSI data for the unit – is this a spike or has it always been a problem
Benchmark rate against published targets or benchmarked targets referenced against peer hospitals. Generally reported as number of infections per 1000 line days with expectation of rate <1/1000. Review practices of centres with favourable CLABSI rates and compare with local practice.

Ideally benchmark based on contemporary registry based data (ANZICS CORE CLABSI Registry) with risk adjustment although no risk adjustment exists within current reporting

Management

If increased rate confirmed investigate potential causes of high rate
Implementation of specific strategies based on best available evidence and ideally as part of an established wider program.

Specifically:
Staff training and use of correct aseptic technique (ANZICS Central Line/Local Health jurisdiction Insertion and Maintenance Guideline)
Insertion site selection
Use of insertion bundle or checklist
Consideration of limiting insertion to fewer more experienced operators (insertion team) with accreditation process
Documentation of daily review of line
 
Removal of all lines at earliest feasible time

Specific evidence for
Use of antimicrobial impregnated lines and biopatches Use of Chlorhexidine plus alcohol as disinfectant
Consider alternatives to conventional CVC when possible e.g. PICC lines and tunnelled lines.

Ongoing monitoring
Audits of process such as observation of aseptic technique
Ongoing monitoring of rates over time
Implementation and monitoring may require additional resources to be provided by administration (equipment, staff etc.)
Submission of data to ANZICS CORE CLABSI Registry
Regular reporting back to staff and hospital S&Q / infection control committee

Important Points:
Lists at least one reason for possible inaccuracy of data
Management and monitoring include elements of audit cycle (identification of issue, working party, implementation of change, audit and follow-up data collection, feedback, re-training, ongoing audit etc) Includes importance of technique in CVC insertion and maintenance and use of insertion bundle

Discussion

This question is identical to Question 10 from the first paper of 2017, except this time the pass rate was about 10% higher. Also, the college answer to this question is not entirely identical: some elements were chopped, and others rearranged, by unknown forces and to unknown purpose. These Lovecraftian mysteries aside, the answer below is essentially unchanged from what was used in 2017:

Definitions:

  • Cental line colonisation:
    • The growth of >15 colony-forming units (semiquantitative) or 100 (quantitative) from a proximal or distal catheter segment, in the absence of accompanying clinical symptoms and signs.
  • Central line associated blood stream infection (CLABSI):
    • A laboratory-confirmed bloodstream infection in a patient where the central line was in place for over 48 hours on the date of the event, where the organism cultured from blood is not related to an infection at another site.
  • CLABSI rate
    • CLABSI rate = (Number of CLABSI / number of central line days ) ×1000
    • i.e. CLABSI rate is number of CLABSIs per 1000 central line days

Management approach:

Initial investigation:

  • Create a multidisciplinary committee, involving the Infection Control department. The savvy candidate will use such key words as "relevant stakeholders" and "working party" to stimulate the examiners' central ganglia.
  • Define the problem and track it retrospectively, so it might be associated with specific events (eg. annual recruitment of new staff, etc)
  • Review the data collection methods for errors
  • Explore existing CLABSI control measures and barriers to their implementation
  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document

Management of CLABSI risk

  • Explore the evidence for CLABSI control measures
  • Combine the best evidence into an updated policy document, detailing practices associated with a decreased risk of CVC infection:
    • Use of subclavian lines.
    • Minimum number of lumens.
    • Use of dedicated lumens for lipid infusions.
    • Immunosuppressed patients or those with burns should have antibiotic-coated lines.
    • For insertion, use aseptic technique and maximal barrier precautions.
    • 0.5% chlorhexidine in 70% alcohol is the preferred cleaning agent.
    • Handle ends of administration sets with gauze soaked in chlorhexidine.
    • Review the line daily.
    • Remove the line as soon as possible.
    • Change lines early - ideally, every 7 days.
    • Sterile, transparent semipermeable dressings
    • Change dressings regularly (every 7 days for standard dressings)
    • Avoid/minimise CVCs if possible
    • Accredit staff in the use of safe technique (if word gets around that your ICU limits CVC insertion experience to some sort of elite "insertion team", your recruitment of junior staff will suffer)
  • Implement these practices: circulate the document widely, and hold meetings to discuss it with key staff
  • Appoint champions who ensure adherence to these practices
  • Assign specific timeframes over which the practice is to be audited

Monitoring

  • Repeated data analysis and collection should be carried out after the guidelines are disseminated and implemented.
  • Guideline dissemination efficacy, uptake and adherence by practitioners, consumer satisfaction and health outcomes are possible data to be collected for audit.
  • Auditors are nominated from departments to implement this policy monitoring processes
  • The auditing team creates short-term and long-term frameworks for evaluation and identifies who will conduct the studies.
  • Regular meetings are scheduled by the auditors to monitor compliance and to feed back on the implementation process

Revision

  • A multidisciplinary group not unlike the one which developed the guidelines should meet regularly to determine whether new evidence needs to be incorporated.
  • The group should review research strategies of the original group, and improve on the process where possible
  • Outcomes and recommendations arising from audit activity should be incorporated into the revision process

References

Question 12 - 2020, Paper 1

A junior  trainee  in  distress  has asked to speak to you regarding a medical error they have made that has resulted in a life-threatening adverse outcome for the patient.

Outline the key points of the initial discussion with the trainee.
 

College answer

The key points that the candidate needed to cover were:

  1. Facilitating the initial critical incident debrief of the Registrar and allowing him/her to vent and tell his/her version of events
  1. Ensuring there is ongoing psychological and emotional support for the Registrar
    1. Give him/her the option of standing down for the rest of the  shift  or  providing support if he/she chooses to stay
    2. Arranging a mentor within the department (e.g. SOT)
    3. Ensuring there is back-up from friends/family at home
    4. Offering professional counselling
  1. Providing
    1. Open disclosure with family advice on the medico-legal process that will ensue
    2. Need for comprehensive and accurate documentation in records and factual account for registrar’s own records
    3. Early contact with medical defence organisation and hospital medico-legal advisors
    4. Reporting to coroner if/when the patient dies
    5. The event will be the subject of a Root Cause Analysis by the hospital
  1. Counselling with regards to future career and training
  1. Arrange follow-up meeting with mentor and departmental head for next day
 

Examiners Comments:

A common omission from candidates’ answers was failing to discuss medico legal issues and root cause analysis.

Discussion

  • Ensure the critical incident is being managed appropriately from a medical standpoint
    • Commit staff to ensure the patient is safe 
    • Ensure appropriate steps are being taken to ameliorate the risk from the critical incident (for example,  where a line has been accidentally inserted into a carotid artery causing a stoke - ensure that the vascular surgical team, neurology team and neurosurgical team have been consulted and have offered their opinions).
    • Delegate clinical duties so as to focus yourself on the debriefing session
  • Critical incident debrief (management of the traumatised trainee)
    • Debrief session
    • Organise time off work for the trainee, if appropriate
    • Involve an impartial mentor
    • Ensure that there are support people available from the extraclinical environment (friends, family)
    • Make an offer of professional counselling
    • Give advice regarding open disclosure process and medicolegal risk
  • Management of the affected patient and family
  • Management of the organisation
    • Factual and detailed documentation
    • Inform the clinical governance administrators
    • Inform the hospital medicolegal team
    • Inform the director of the department
    • Inform own medicolegal indemnity and defence organisation - as you were supposed to be supervising that trainee, and may even be responsible for the training program locally (if you happen to be the SOT).

References

CICM: GUIDELINES FOR ASSISTING TRAINEES WITH DIFFICULTIES (T-13), 2010

Mitchell, Jeffrey T. "Stress. The history, status and future of critical incident stress debriefings." JEMS: a journal of emergency medical services 13.11 (1988): 46-7.

Mitchell, Jeffrey T., and George S. Everly Jr. "Critical Incident Stress Debriefing (CISD) and the Prevention of Work-Related Traumatic Stress among High Risk occupational Groups.Psychotraumatology: Key papers and core concepts in post-traumatic stress (1994): 267.

Bledsoe, Bryan E. "C RITICAL I NCIDENT S TRESS M ANAGEMENT (CISM): B ENEFIT OR R ISK FOR E MERGENCY S ERVICES?."Prehospital Emergency Care 7.2 (2003): 272-279.

Harris, Morag B., Mustafa Baloğlu, and James R. Stacks. "Mental health of trauma-exposed firefighters and critical incident stress debriefing.Journal of Loss &Trauma 7.3 (2002): 223-238.

Laurent, Alexandra, et al. "Error in intensive care: psychological repercussions and defense mechanisms among health professionals." Critical care medicine 42.11 (2014): 2370-2378.

Question 20 - 2020, Paper 1

An audit has revealed your ICU has an MRSA infection rate which exceeds national benchmarks. Outline the steps you would take to improve this situation


 

College answer

Investigation/planning-

  • Review the audit.
  • Breakdown of hand hygiene audit data by groups of staff.
  • Observe the daily habits of the unit staff and availability of hand washing stations
  • Liaise with ID department

Acknowledgement/ownership

  • Open disclosure within the unit of the problem. Where do the staff feel the problem lies?

Education

  • Local champions, train staff to preform hand hygiene audits, cleaning product education, hand hygiene education. Signage for staff. 5 moments of hand hygiene, visiting teams to the ICU. Ensure regulations re clothing, jewellery etc are being followed
  • Encourage all staff patients and visitors to challenge staff that do not follow unit policy

Physical cleaning

  • Is the cleaning in the unit adequate, consider closure and re-opening after cleaning?

Unit design and procedures

  • Frequency of washing or disposal of linens, curtains
  • Isolation of high-risk patient, or cohorting
  • Availability and type of hand rub
  • Review nursing ratios and nursing procedures

Antibiotic Stewardship

  • Review antibiotic usage.
  • Assess community rate of MRSA

KPIs and Re assessment

  • Audit and review that changes are improving habits

Higher marks were allocated to answers which gave a structured approach consisting of

  • Identifying the problem
  • Instituting change measures, which must include hand washing
  • Measuring the effect of the change.

Examiners Comments:

Generally answered well; generic answers without reference to the specific issue were marked poorly.

Discussion

Normally this sort of "organisational approach to MRO spread" question has stereotypical elements. Even though the examiners remark that "generic answers without reference to the specific issue were marked poorly", what they gave was in fact a fairly generic looking answer, in terms of its structure. 

Thus:

Commence active surveillance cultures to determine the extent and source of the problem:

  • Identifies the "reservoir" for spread
  • Allows precautions to be cost-effectively focused on the reservoir.
  • The health care workers themselves may become colonised reservoirs.
  • Performed on all patients, on admission, and then periodically (eg. weekly).
  • In facilities found to have a high prevalence on initial sampling, a facility-wide culture survey is indicated.

Control the outbreak:

  • Contact precautions to prevent new cases
    • Hand hygiene
      • Soap and water for visibly contaminated hands
      • Alcohol-based rub for routine pre-and-post-contact hygiene
      • Monitoring of compliance should be performed
    • Disposable gloves
    • Disposable gowns
    • Patients colonised by the same MRO may be cohorted together.
    • Contaminated areas should be identified by obvious cautionary signs
  • Decontamination of existing sources
    • Decontamination ("decolonisation") of MRSA/VRE patients
    • Decontamination of colonised health care workers
    • Environmental disinfection
    • Routine disinfection of equipment between patient contacts
    • Wherever possible, individualised equipment for every patient

Coordinate a response and empower a team to execute the response:

  • Infection control specialty team, composed of ICU specialists, infectious diseases specialists, senior nursing staff, laboratory staff and administration staff.
  • Allocated resources to MRO surveillance, compliance monitoring and education
  • "Champions" - staff allocated to promote the existing policies and monitor adherence

Promote adherence to the new policies

  • "Widespread campaign"
  • Awareness-rasing posters
  • Lunchtime meetings
  • Promulgated reading material
  • Education bundle as a part of mandatory employee training

Collect data regarding MRSA colonisation and the effect of your new strategies

  • Data collection and MRO colonisation record
    • Records of MRO results allow colonised patients to be identified early
  • Regular review of collected information, resistance and transmission patterns
  • Regular audit of the efficacy of implemented strategies
  • Regular comparison of policies to those of peer hospitals
  • Regular reevaluation and amendment of infection control policies

References

Chapter 70  (pp. 724)  Nosocomial  infections by James  Hatcher  and  Rishi  H-P  Dhillon

Widmer, A. F. "Infection control and prevention strategies in the ICU." Intensive care medicine 20.4 (1994): S7-S11.

Eggimann, Philippe, and Didier Pittet. "Infection control in the ICU." Chest Journal 120.6 (2001): 2059-2093.

Lucet, Jean-Christophe, et al. "Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units." Intensive care medicine 31.8 (2005): 1051-1057.

Dhillon, Shah, Rimawi: "Chapter 12: ICU Infection Control and Preventive Measures", page 54 in: "Bedside Critical Care Guide." by Rimawi, Ramzy H.(2013). OMICS Group eBooks

Muto, Carlene A., et al. "SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus." Infection Control 24.05 (2003): 362-386.

Gniadkowski, M. "Evolution and epidemiology of extended‐spectrum β-lactamases (ESBLs) and ESBL‐producing microorganisms." Clinical microbiology and infection 7.11 (2001): 597-608.

Huskins, W. Charles, et al. "Intervention to reduce transmission of resistant bacteria in intensive care." New England Journal of Medicine 364.15 (2011): 1407-1418.

Kollef, Marin H., and Victoria J. Fraser. "Antibiotic resistance in the intensive care unit." Annals of internal medicine 134.4 (2001): 298-314.

Kaki, Reham, et al. "Impact of antimicrobial stewardship in critical care: a systematic review." Journal of antimicrobial chemotherapy 66.6 (2011): 1223-1230.