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PATIENTS SAFETY in INTENSIVE CARE UNIT

PATIENTS SAFETY in INTENSIVE CARE UNIT. Assoc. Prof. Sait Karakurt Marmara University Medical School Pulmonary and Critical Care Medicine. Patients safety practice - definition.

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PATIENTS SAFETY in INTENSIVE CARE UNIT

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  1. PATIENTS SAFETY in INTENSIVE CARE UNIT Assoc. Prof. Sait Karakurt Marmara University Medical School Pulmonary and Critical Care Medicine

  2. Patients safety practice - definition • A type of process or structure whose application reduces probability of adverse events resulting from exposure to health care system across a range of diseases and procedures.

  3. PATIENTS SAFETY-magnitude of problem • Medical-errors-releated deaths • 44.000 to 98.000/year • 100 patients/day die from their care in USA Adverse drug events • rates 2 to 7 per 100 admissions • 2 errors per patients per day in ICU Corrigan J et al. eds, For the Committee on Quality of Health Care of America Institute of Medicine To Err is Human: building a safer health system 2000

  4. Prevalance of medical errors • 1152 events during 6 years (JCAHO) • 62% in general hospitals • 2/3 self reported by the institutions • 1/3 patients complaints or media stories • 76% of events reported resulted in patients death

  5. ICU -treatment -monitorisation -continuous and same standart -24 hours PATIENT SAFETY- ICU definition

  6. PATIENTS SAFETY-closed vs open ICU • Low-intensity (no intensivist or elective intensivist consultation) or high-intensity (mandatory intensivist consultation or closed ICU [all care directed by intensivist]) groups. • High-intensity staffing was associated with lower hospital mortality of 0.71 • High-intensity staffing was associated with a lower ICU mortality of 0.61 Peter J. Pronovost et al. Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients A Systematic Review JAMA. 2002;288:2151-2162.

  7. ICU team Intensivist Doctors Respiratory therapists Clinicall pharmacy Nurses Other

  8. PATIENT SAFETY- Pharmacist in ICU team • The rate of preventable ordering ADEs decreased by 66% from 10.4 per 1000 patient-days before the intervention to 3.5after the intervention. • The presence of a pharmacist on rounds as a full member of the patient care team in a medical ICU was associated with a substantially lower rate of ADEs caused by prescribing errors. Lucian L. Leape et al Pharmacist Participation on Physician Rounds and Adverse Drug Events in the Intensive Care Unit. JAMA. 1999;282:267-270.

  9. PATIENT SAFETY- Pharmacist in ICU team • The mean of the weighted incidence rate detected by pharmacists was 0.33 ADE per admission the mean was 0.16 ADE per admission with detection by nonpharmacists (p = 0.003) Shobha Phansalkar at al.Pharmacists versus nonpharmacists in adverse drug event detection: A meta-analysis and systematic review American Journal of Health-System Pharmacy 2007, Vol. 64, Issue 8, 842-849

  10. ICU-level of care and staff number ’Recommendations on minimal requirements for intensive care departments’’ TASK FORCE of the ESICM. Intensive Care Med 1997;23:226-32.

  11. PATIENTS SAFETY-Intensivist workload • 2,492 patients • Four time periods based on intensivist-to-ICU bed ratios of 1:7.5, 1:9.5, 1:12, and 1:15. • No differences in ICU or hospital mortality. However, a ratio of 1:15 was associated with increased ICU LOS. (9.7 days vs 12.3 days p<0.001) Saqib I. Dara, Bekele Afessa, Intensivist-to-Bed Ratio Association With Outcomes in the Medical ICU Chest 2005;128:567-572.

  12. PATIENTS SAFETY-Staff workload • 1050 patients, 337 deaths, 49 more than predicted by the APACHE II • 1·3 nurses per patient (requirement 1·6 per patient) • Adjusted mortality was more than 2 times higher in patients exposed to high than in those exposed to low ICU workload. WO Tarnow-Mordi et al Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit The Lancet 2000; 355:1864-1868

  13. PATIENTS SAFETY-team work • Strategy for change: 1-physician led multidisciplinary rounds 2- daily "flow" meeting to assess bed availability 3- "bundles" (sets of evidence based best practices) 4- culture changes with a focus on the team decision making process Jain M,   Links Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006 Aug;15(4):235-9.

  14. PATIENTS SAFETY-team work • Ventilator associated pneumonia (from 7.5 to 3.2 per 1000 ventilator days, p = 0.04) • Bloodstream infections (from 5.9 to 3.1 per 1000 line days, p = 0.03), • A downward trend in the rate of urinary tract infections (from 3.8 to 2.4 per 1000 catheter days, p = 0.17). • There was a strong downward trend in the rates of adverse events in the ICU as well as the average length of stay per episode Jain M,   Links Decline in ICU adverse events, nosocomial infections and cost through a quality improvement initiative focusing on teamwork and culture change. Qual Saf Health Care. 2006 Aug;15(4):235-9.

  15. PATIENTS SAFETY-continuous standart care • 29.080 patients, Mayo Clinic, USA weekday weekend mortality mortality p Medical ICU 16.3% 15.2% NS Multispeciality ICU 10.1% 17.2% NS Surgical ICU 3.5% 6.4% p<0.01 S Allen Ensminger et al. The hospital mortality of patients admitted to the ICU on weekends. Chest 2004;126:1292-1298.

  16. Medication errors • Ordering • Transcribing • Dispensing • Administrating • missing dose • dose • route • frequency • Monitoring

  17. Preventable adverse drug events Ordering 56% Administration 34% Transcribing 6% Dispending 4% Drug Class 1. Analgesics 2. Sedatives 3. Antibiotics Adverse drug events

  18. Adverse drug reactions in ICU • 29.7 per 100 admission WHO Colloborating Center for International Drug Monitoring 2000

  19. Medication errors-prevention • Computerized physician order entery • Clinical decision support system

  20. Computerized physician order entery • Standardized, legible, complete orders by only accepting typed orders in astandart and complete format

  21. Clinical decision support system • Basic clinical decision support may include suggestion or default values for drug doses, routes and frequencies. • More sophisticated system can perform drug allergy checks, drud-laboratory value checks, drug-drug interactions checks and in addition to providind reminders about corollary orders or drug guidelines. • Incorporate patient-spesific or pathogen-spesific information

  22. ICU-patients safety • Nosocomial infections occur in about 7-10% hospitalized patients and account for 80.000 deaths per year in the US. • The evidence in favor of 79 patients safety practises of which 22 (28%) involved infection control Making health care safer: a criticall analysis of patients safety practices Evid Rep Tecnol Assess SUmm 2001;43:1-668

  23. PATIENTS SAFETY-prevention of nosocomial infections John P. Burke, M.D. NextInfection Control — A Problem for Patient Safety NEJM 2003 348:651-656

  24. PATIENTS SAFETY-prevention of nosocomial infections John P. Burke, M.D. NextInfection Control — A Problem for Patient Safety NEJM 2003 348:651-656

  25. PATIENTS SAFETY-Evidence-based approach • Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care or surgery.

  26. Practices with the strongest supporting evidence • Appropriate use of prophylaxis to prevent thromboembolism in patients at risk • Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality • Use of steril barriers while placing central intravenous catheters to prevent infections • Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections

  27. Practices with the strongest supporting evidence • Asking that patients recall and restate what they have been told during informed consent process • Continuous aspiration of subglottic secretions to prevent ventilator-associated pneumonia • Use of pressure relieving materials to prevent pressure ulcers • Use of real time ultrasound guidance during cental line insertion to prevent complications

  28. Practices with the strongest supporting evidence • Patient self management warfarin to achieve appropriate outpatient anticoagulation and prevent complications • Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients • Use of antibiotic-impregnated central venous catheters to prevent catheter-releated infections.

  29. ICU-patients safety • Standartization of ICU • Evidence-based approach can help identify practices that are likely to improve patient safety. • To reduce medication-releated errors by using computerized physician order entery with clinical decision support system • Prevention of nosocomial infections.

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