Printable list of all administration and data management SAQs

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

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

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.

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?

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.

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.

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)

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

• A "high intensity" model is associated with decreased mortality and ICU length of stay.
• However, at least in the United States a "closed" model does not seem to be associated with any mortality benefit independently of a "high intensity" model (According to a 2008 study by Levy et al as well as a subsequent meta-analysis by the same author). Essentially, it does not matter who the admitting specialist is, so long as the patients have mandatory daily intensivist involvement.
• An intensivist does not need to be on site for the whole 24 hours provided they are seeing every patient daily (a "high intensity" model).
• Focused critical care skills into a critical care environment
• Better coordination of critical care services
• A more cohesive treatment strategy, with better leadership
• More efficient use of resources (some patients do not need admission to ICU, and intensivists are better at triaging these cases)

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.

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:

"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

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.

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

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.

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

Daugherty, Elizabeth L., and Lewis Rubinson. "Preparing your intensive care unit to respond in crisis: Considerations for critical care clinicians." Critical care medicine 39.11 (2011): 2534-2539.

Devereaux, Asha, et al. "Summary of suggestions from the task force for mass critical care summit, January 26–27, 2007." CHEST Journal 133.5_suppl (2008): 1S-7S.

Horvath, John S., Moira McKinnon, and Leslee Roberts. "The Australian response: pandemic influenza preparedness." Medical journal of Australia185.10 (2006): S35.

Sprung, Charles L., et al. "Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster."Intensive care medicine 36.3 (2010): 428-443.

Harrigan, P. W., et al. "The practical experience of managing the H1N1 2009 influenza pandemic in Australian and New Zealand intensive care units." Crit Care Resusc 12.2 (2010): 121-130.

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 .
• 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

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

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.

College answer

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

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.

College answer

College answer

Not available.

Discussion

This question is identical to Question 25 from the first paper of 2013.

Sigh:

College answer

Candidates commonly discussed how to have a family meeting where the family have some difficult questions or issues they would like answered. Few candidates spoke about the nature of the complaint, and therefore would it be informally dealt with, require a formal process, or even referral. No candidate spoke about either hospital, LHD, or state guidelines for dealing with complaints. Virtually all trainees discussed the need for empathy and an apology.

Discussion

Reading the question stem, one would have to agree with the comments made by the examiners, insofar as a family meeting is only one aspect of the "stepwise processes" involved in managing a complaint. To be fair, the candidates are likely end-stage ICU trainees who have been largely insulated from this sort of thing by senior staff, and would probably have no direct experience of managing complaints in any formal sense, except where they are confronted with the complaint directly and need to meet with the family (hence this tendency to focus on the face-to-face Q&A with a bunch of angry people). 

• Receive the complain - this is usually the part that requires a face-to-face or telephone meeting with the complainant, where empathy is essential
• Identify and log the complaint. This is an essential part of the process, and usually consists of a written notification made to the person who handles such complaints, or a submission into a centralised system that compiles and archives these events for audit (which most large health services will have).
  • Determine whether a response is required: A complaint is often something that requires addressing and following up with a response, whereas feedback from patients and families does not necessarily require follow-up.
• Acknowledge the complaint. This usually requires the complaints manager to
  • contact the complainant (ideally, soon)
  • Make an apology
  • assure them the complaint has been considered
  • indicate a contact person for them to have access to if they have further questions, and 
  • establish a timeframe over which the response should be expected
• Assess the complaint. 
  • This likely requires somebody senior to look at the complaint and determine the level of seriousness, which will then determine the priority and the need for escalation
  • This requires some risk assessment, to determine whether the complaint raises "significant operational, legal, financial or reputational risks" to the organisation.
  • Information needs to be gathered to identify the personnel involved and the issues raised, to help determine the level of risk (but this is not the investigation phase)
• Address the complaint
  • Depending on the type of complaint, possible outcomes include something informal, like an apology and acknowledgement without investigation, or an internal investigation, or even an escalation of the referral 
  • This will depend on what was complained about, and this process should be collaborative,i.e. the complainant's expectations of what needs to happen should be taken into account.
  • The solutions may include some (or all) of the following:
    • Making an apology in some formal sense
    • Providing the complainant with information
    • Meeting with the complainant to have ongoing discussion
    • Escalating the complaint to a regulatory body
    • Investigating the allegations made in the complaint
  • Not all complaints will require an investigation, but where they do, the investigation must be impartial, confidential, and fair.
• Communicate the outcome
  • This may be in the form of a written statement or another meeting
  • Any decisions, as well as the reasons behind them, including remedial actions or preventative measures, would be important here
  • System issues should be fed back to any staff or agencies involved in the complaint or otherwise.
• Finalise the complaint
  • ​​​​​​Determine whether the complainant is satisfied with the outcome
  • Invite them to access review and escalation options
  • Update the record of the complaint to reflect the end of these events

College answer

Aim: To explore the theory and process of complaint resolution, a key skill in ICU leadership. Specifically in relation to written complaints and cultural safety.
Key sources include: IC 20- CICM document, Paper 2022.2 Q22. CanMEDS Communicator.
Discussion: Complaint resolution is a repeat topic from last paper 2022.2. and comprised most of the marks. A high level of detail in the complaint resolution process was expected given its importance and its recency in the previous paper. Candidates gained more marks if they addressed concerns AND provided appropriate sensitive follow up in a quality and safety structural format. These candidates did better than candidates who diffused the situation only, without closing the review process in minimal or absent detail.
A list of statements without structure or prioritisation did not address the question as well as a prioritised step wise outline of appropriate investigations and resolution. Some answers escalated the complaint inappropriately suggesting lawyers, police, and hospital administration involvement. The better answers included appropriate referrals through formal or informal channels of resolution and identified the key drivers of change for improvement within the department. The expert answers concluded with methods to monitor and maintain sustainable change for future best practice in this area.
Cultural safety 30% marks – The importance of health equity has been an important topic in health education for many years. No candidate failed this question on cultural safety content. Some candidates went into great depth about specific care and sensitivity to patients with diverse cultural backgrounds they bring to their practice. They were allocated expert pass marks accordingly and are to be commended.
 

Discussion

The CICM document IC-20 (Prevention of Bullying, Discrimination and Harassment in the Workplace) is fifteen pages of dense bleak horror that was published many years ago and that has remained unaltered since 2016. It is therefore unsurprising that such a large number of trainees were able to score so highly on this SAQ. Moreover, as the answer is right there on the college website, there was no excuse for getting it wrong.

As the college answer has pointed out, Question 22 from the second paper of 2022 has already warned people that something like this might be coming, and considering the pass rate has improved (from 40.4% to 66.3%) they clearly paid attention, suggesting there is still some value in doing the past papers.

So: a standard conflict resolution process is produced below, as it would have satisfied the 70% component: 

• Receive the complain - this is usually the part that requires a face-to-face or telephone meeting with the complainant, where empathy is essential
• Identify and log the complaint. This is an essential part of the process, and usually consists of a written notification made to the person who handles such complaints, or a submission into a centralised system that compiles and archives these events for audit (which most large health services will have).
  • Determine whether a response is required: A complaint is often something that requires addressing and following up with a response, whereas feedback from patients and families does not necessarily require follow-up.
• Acknowledge the complaint. This usually requires the complaints manager to
  • contact the complainant (ideally, soon)
  • Make an apology
  • assure them the complaint has been considered
  • indicate a contact person for them to have access to if they have further questions, and 
  • establish a timeframe over which the response should be expected
• Assess the complaint. 
  • This likely requires somebody senior to look at the complaint and determine the level of seriousness, which will then determine the priority and the need for escalation
  • This requires some risk assessment, to determine whether the complaint raises "significant operational, legal, financial or reputational risks" to the organisation.
  • Information needs to be gathered to identify the personnel involved and the issues raised, to help determine the level of risk (but this is not the investigation phase)
• Address the complaint
  • Depending on the type of complaint, possible outcomes include something informal, like an apology and acknowledgement without investigation, or an internal investigation, or even an escalation of the referral 
  • This will depend on what was complained about, and this process should be collaborative,i.e. the complainant's expectations of what needs to happen should be taken into account.
  • The solutions may include some (or all) of the following:
    • Making an apology in some formal sense
    • Providing the complainant with information
    • Meeting with the complainant to have ongoing discussion
    • Escalating the complaint to a regulatory body
    • Investigating the allegations made in the complaint
  • Not all complaints will require an investigation, but where they do, the investigation must be impartial, confidential, and fair.
• Communicate the outcome
  • This may be in the form of a written statement or another meeting
  • Any decisions, as well as the reasons behind them, including remedial actions or preventative measures, would be important here
  • System issues should be fed back to any staff or agencies involved in the complaint or otherwise.
• Finalise the complaint
  • ​​​​​​Determine whether the complainant is satisfied with the outcome
  • Invite them to access review and escalation options
  • Update the record of the complaint to reflect the end of these events

Cultural awareness content for 30% of the marks would likely have been passed by the candidate mentioning that they would make a referral to the Aboriginal Liaison Officer (in Australia) or a corresponding healthcare service position in Aoteroa NZ. However this is really the same thing as reflexively calling for the social worker the moment a family starts crying in your waiting room, and "great depth about specific care and sensitivity to patients with diverse cultural backgrounds" is probably a better standard to aspire to. But how would you demonstrate that standard in three minutes?

The specific main principles of cultural safety (not listed in IC-20) are self-determination, social and restorative justice,  equity, partnership, reciprocity, accountability, sustainability and cultural context. It would have been useful for the candidate to demonstrate that they are aware of these principles; and at the same time it would have been difficult to do so without peppering the answer with stock-sounding phrases like "increased advocacy for, and partnering with, Indigenous communities and health organisations". Some kind of bare minimum answer would probably have consisted of something like this, mainly derived from the excellent 2019 MJA paper by Paul Secombe et al. 

Recognition of the importance of health equity:

• Aboriginal and Torres Strait Islander Australians have:
  • a higher rate of of acute critical care admission, especially sepsis and trauma
  • a higher burden of chronic disease
  • poorer access to healthcare (more come from remote communities)

Practical interventions to improve the healthcare experience of Indigenous Australians requiring ICU:

• Increase the representation of Indigenous people among staff, including CICM fellows and trainees
• Increase access to cultural safety training for frontline staff
• Focus outreach and retrieval services to increase access for rural and remote communities 

Specific interventions in response to the family's complaint

• Establish cultural context by seeking advice from an Indigenous liaison officer or local elder prior to the family meeting
• Encourage self-determination by offering the family a culturally appropriate mechanism for escalating their concerns
• Address social and restorative justice by offering an apology and demonstrating to the family the specific steps being implemented to improve cultural safety in the department
• Partner with the family to decide the best most mutually acceptable resolution to the complaint to help them feel respected and safe

College Answer

Syllabus topic/section:

2.3.1 Intensive Care Administration.

Aim:

Hand hygiene is internationally standardized, and part of routine standard of care.

Discussion:
A question on a core topic of daily relevance to intensive care practice. Generally, well answered. Many candidates answered by reproducing a generic "audit cycle" template, with limited marks able to be awarded. Answers containing information on specific strategies to improve hand hygiene compliance attracted higher marks. Candidates are reminded to read the question carefully, and answer the specific question being asked – a generic listing of the 5 moments of hand hygiene was not adequate to pass the first part of the question, rather an understanding of the rationale for moment 5 was expected.

Discussion

The definition of Moment 5, as per the Australian Commission on Safety and Quality in Healthcare, is "After touching a patient's surroundings", and the plain language rationale explanation for its importance is "To protect the healthcare worker and the healthcare environment from becoming contaminated with the patient’s microorganisms." 

Moment 5: "After touching the patient's immediate surroundings": it is necessary to wash hands at this stage because the patient's immediate environment may be a reservoir of pathogens. Handwashing may interrupt the spread of resistant organisms from the donor surfaces around one patient to another patient.

Strategies to improve compliance:

• 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
    • Complicance with handwashing seems to be proportional to the number of sinks per patient.Ideally, the ratio should be 1:1.
• 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
    • Handwashing classes are helpful
    • Feedback to staff about observed handwashing errors (it improves compliance to 97%!)
• Evalation and feedback (That "generic audit cycle template" again):
  • 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

College answer

Syllabus topic/section:

2.3.1 Leader and Manager / Intensive care administration: L1

Discussion:  

The CICM international fellowship covers many diverse regions and geography. An awareness of the different environments and challenges in which we practice intensive care is required.
To display the standard of competence required of a transitional fellow, candidates are reminded to provide an organised answer, use headings and subheadings, group common themes together and provide sufficient detail. The better answers understood that ICU is not a standalone service and is part of the hospital therefore local and state hospital policies apply. Many candidates forgot to consider the implications of communications breakdown, and the effects of this on the ICU, the hospital and families. The superior answers detailed staffing, energy supplies, equipment, drugs and oxygen requirements.

Discussion

From what appears to be a constant battery of tropical storms beating down on the grim rocks of Far North Queensland, one might expect that CICM or QLD Health might have some kind of "shelter in place" protocol for their ICUs, but if they do, they are keeping them safe and secret. The trainees would have had to create this answer from nothing other than their own imagination.

Staffing

• Allocate roles for specific aspects of the preparation, eg. "roster person", "family liaison", "SITREP monitor", "pathology/blood bank runner", "electronic medical record downtime record keeper"
• Assess the disaster staffing. Ask staff members about their plans. " Most staff found the decision difficult, balancing the needs of their own families with that of the community", Sexton et al remark about their doctor's and nurses response to Cyclone Yasi, preparing to work double shifts as the Queensland government were telling them to grab their loved ones and run.
• Allow for storage space and personal space for staff who are likely to be cut off from their homes by weather/water
• Source additional meals for trapped staff

Internal communication

• Develop an internal mechanism of distributing information to the staff- ideally not reliant on landline phone services 

Equipment

• Charge removable power sources and stock reserves of bottled water for staff and patients
• Create paper copies of electronic medical records and reference texts (eg. pharmacy manuals) for the eventuality of power failure
• Create a reserve of torches and batteries

Consumables

• Ensure pharmacy is well stocked and estimate several weeks of stock for common drugs, expecting prolonged disruption to supply chains and increased demand
• Share a pool with the other remaining services (ED, ward) to centralise ordering
• Liaise with gas suppliers and acquire excess stock of oxygen and compressed air cylinders

Infrastructure

• If possible, relocate vital systems (pathology department analysers, ICU, backup generators ) out of easily flooded basements and to higher floors
• Move patient beds away from windows

Patient care

• Establish a patient manifest: decide who needs to stay and who can be evacuated
• Send out anyone who can be retrieved safely, to decrease the workload of the remaining staff

Families and visitors

• Establish the identities of all next of kin and secure contact details
• Discorage visiting
• Determine which family plan to evacuate and which plan to remain local

External communication

• Disaster-proof devices (emergency landlines, satellite phones, radio) need to be located checked and distributed to key staff
• Maintain open lines (avoid unnecessary phone calls on critical protected phones)

Facility level support

• Recommend for the closure of non-emergency theatres and cancellation of elective surgery
• Recommend for the retrieval of any patient for whom it would be safe and appropriate
• Listen for communication from central disaster control 

Media and public engagement

• Observe for updates from media sources regarding the progress of the disaster and the prospects of improvement or new challenges (eg. access limitations due to rising water)

Debrief

• Engage with the post-disaster debrief with staff and hospital leadership 
• Ensure counselling services and leave/rest are available for staff who were imposed upon during the period of upheaval.

Preparedness

• Simulated tabletop exercises involving other departments
• Internal position of disaster preparation officer, to maintain documents and revise plans as infrastructure changes

College answer

Syllabus topic/section:

2.3.1 Intensive care administration: Safety and quality: Clinical Audit

Discussion: 

This question sought a discussion which requires some depth to the answers, including addressing the key principles and where appropriate, the advantages and disadvantages. Attention to structure is rewarded in a question such as this. Starting with a list of the steps involved provides the headings from which a discussion can flow but is not in itself enough to achieve high marks. Candidates that scored higher marks provided detail about the individual steps to explain the key principles.

Candidates who scored less well on this question wrote about how to implement a change management or quality improvement intervention rather than how to conduct a clinical audit. Whilst there is some overlap between them it meant candidates missed some of the key steps involved if they didn’t address the question.

The marking rubric is included to aid the candidate’s future study.
 

Discussion

Whereas each other time the examiners had "audit, but it's a rapid response service" or "audit, but its blood products", this time the SAQ was not dressed up in any scenario, and asked for an abstract administrative approach.

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

Engage stakeholders

• Involve key interdisciplinary decisionmakers early in the process
• Eg. patients, families, quality experts, and management/executive
• Create a leadership group and appoint champions from among locally respected clinical leaders and experts

Identify standards

• Select benchmarks from guidelines or policies
• Establish clear criteria targeting a specific area of interest to narrow the audit

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 - regularly
• Incident review meetings - regularly
• Encourage the attendance and contribution from all staff
• Sample must be sufficient for the population, e.g for small populations (n <30) 100% of the population may need to be sampled - can be calculated using models such as Donabedian’s

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

College comments

Syllabus topic/section: 2.3.1 Intensive Care Administration: Safety and quality

Discussion: 

Candidates generally did well in part (a) by thinking broadly about the consequences for hospital, staff and patients, as the question asked. Credit was given for ICU-associated complications (eg delirium, delays in allied health intervention), however candidates are encouraged to separate markers of poor-quality care in the ICU (MRO acquisition, poor clinician engagement) from patient flow issues related to exit block; and to use objective language appropriate to an academic exam. Candidates are reminded that if the question lists eight potential causes only the first eight will be included for marking.

Those who scored highly in part (b) demonstrated an ability to interpret the graph by referencing in-hours vs out-of-hours discharges, rather than simply describing the discharge times displayed. Candidates who scored lower tended to approach the question from the viewpoint of a junior trainee, being mostly concerned with ICU workflow patterns and the impact on handover to ward teams. Above-standard answers demonstrated a broader, more conceptual understanding of out-of-hours discharge, considering causes other than ICU workflow (eg discharge of patients with more complex or specialised needs vs the requirement to create capacity for unplanned admissions), and included the specific consequences of out-of-hours discharge such as increased mortality and readmission rates. The understanding of how unit workflow interacts with broader concerns within the hospital and the effect on patient care was a marker of the superior answer.
 

Interpretation

The statement "candidates are encouraged to ... use objective language appropriate to an academic exam" suggests all kinds of hilarious possibilities. The imagination is inflamed by scandal, when one considers what kind of coarse vulgarity would have debased the responses of those frustrated candidates. Without giving in to the strong urge to mould these thoughts as words, the following answer sticks to some basic propriety, so as not to bring our institutions into disrepute.

Anyway: here are eight consequences of ICU exit block:

• Access block for the ED and wards
• Cancellation of elective surgery
• Inefficient use of ICU resources
• ICU staff burnout
• Numerous ward-ready patients = reduced ICU training opportunities
• Delayed rehabilitation
• Ineffective handover during rushed discharge
• Prolonged exposure to the ICU environment (noise, sleep deprivation, nosocomial resistant infectious agents)
• Discharges delayed until after hours 

Now; about that graph. Clearly just listing the findings would not be enough here, as the examines had pointed out. One would probably need to put a spin on this that demonstrates "understanding of how unit workflow interacts with broader concerns", etc. 

Thus:

• Of the ICU discharges, the majority occur during the in-hours period
• A large minority of patients are discharged after hours
• The after hours discharges are associated with:
  • Increased mortality
  • Increased rates of ICU readmission
  • Increased length of hospital stay
• The cause of this is unknown, but the following factors are considered to be important:
  • Potentially some are premature discharges 
  • Higher proportion of patients with treatment limitations
  • Inadequate or absent handover 
  • Reduced vigilance by understaffed night services
  • Delayed specialist attention
  • A representation of increased strain in the system