Department of Critical Care

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Quality & Patient Safety

Continuous improvement of patient care

The Department of Critical Care's mission is to provide exemplary, compassionate, and supportive care to critically ill patients and to support families through a continuously evolving multidisciplinary and evidence-based approach. We strive to promote accountability and excellence in clinical care, research and education, and aim to foster a safe, transparent and collegial working environment.

To that end, the Department of Critical Care is leading projects to improve patients outcomes. A dedicated quality leader and quality team generates, coordinates, and manages the department's efforts to continually improve the care of critically ill patients.

The Advocate Newsletter

Our quality newsletter The Advocate was established in 2014 and has become our pride & joy. Not only is it a great way for us to communicate relevant and informative material to our critical care team but it is also a way to share our quality efforts and progress to the province. We encourage you to check out some past issues of The Advocate below!

Quality Highlights

The Department of Critical Care's Quality & Patient Safety Committee has several priorities that align with those of Nova Scotia Health Authority (NSHA): (1) Clinical Best Practice (CBP), (2) Team Processes and Decision-Making (TPDM), (3) Infection Prevention & Control (IPAC), and (4) Medication Safety (MS). Examples of primary goals within these priorities: delirium awareness and prevention; pressure injury awareness and prevention; the mobility project; ventilator associated pneumonia (VAP) and central line infection prevention; and medication event reporting and event prevention.

With the amalgamation of our health authorities into one provincial authority, our focus has shifted somewhat toward growing and fostering our initiatives throughout the province, which is facilitated through the inception of the Provincial Critical Care Quality Council that reports up to the Provincial Critical Care Council.

We are very proud of our recent successful Accreditation (Fall 2018) which noted several leading practice initiatives in Critical Care, most notably our Mobility Project and our Safety Pause (upon admission of patients to the ICU).

Participation in ongoing Quality Reviews and Morbidity & Mortality rounds continue to foster improved practice. In adopting the Ottawa Model of M&M rounds we are achieving more actionable items from each rounds, and encouraging multidisciplinary participation.

Clinical Best Practice

For three years now, we have been using a Daily Rounds Tool (DaRT) in clinical daily practice.  The DaRT is a short survey available on both Computers On Wheels (present in each unit) that facilitates quality & patient safety data monitoring and auditing; the surveys are anonymized, and items collected are based on Accreditation ROPs, high priority tasks and “DHW reportables”. This data has dramatically helped us identify areas requiring further attention (e.g., completing consent forms, discussing target sedation levels) and those at which we excel (e.g., gut, VAP and VTE prophylaxis, delirium discussion). This year, we have modified our DaRT to align with the Society of Critical Care Medicine (SCCM)’s ABCDEF Bundle for Delirium prevention and management, which also aligns with Choosing Wisely Canada’s recommendations for minimizing unnecessary interventions in ICU.

We are particularly proud of our work with Delirium and the Mobility projects, which go hand in hand. The literature demonstrates that getting patients –especially the sickest patients- moving as soon as possible, mitigates delirium. This is of paramount importance because delirium increases patient mortality, ICU and hospital lengths of stay, cognitive impairment and functional decline. We have established dedicated physiotherapists in the units 7 days a week, who work closely with our Mobility Champions and the critical care nursing staff to get patients moving as safely as possible, as early as possible.

We have grown our Pressure Injury Prevention (PIP) program through the enthusiasm of PIP Champions in each unit; we have established protocols for identification and treatment and liaise routinely with the Wound Injury Team. We have generated an audit tool and incorporated PIP and care into the daily nursing lexicon and handover.  We have developed a policy for wound documentation using digital photography which has dramatically improved our objective assessment and documentation of pressure injuries. Work continues around physician education and engagement, and facilitated in part by Dr. Jack Rasmussen, a Plastic Surgeon & Intensivist with a special interest in wound prevention and care.

We have recently updated Routine ICU Admission Orders PPOs to reflect an analgesia-first/RASS-targeted, minimal sedation practice, which aligns with the latest PADIS (Pain Agitation Delirium Sedation) Guidelines (SCCM).  Ongoing updates to important pre-printed order sets continue, with protocolized reassessment every 3 years or sooner, as the need arises. With the provincial reorganization, all PPOs are updated with a provincial lens in order to facilitate and nurture evidence-based practices across our province.

Other exciting projects that are based in Quality Improvement but that are lead through separate initiatives include the THINK Research Provincial Order Set Project, and the Infusion Pump Implementation Project.

In addition to Mobility, Delirium and IPAC initiatives, we are working on improving sleep hygiene, inspiratory muscle training for prolonged wean patients, practitioner wellness, and reducing bleeding complications for our ECMO patients.

Infection Prevention and Control

We continue to monitor VAP and CLABSI rates and have very low transmission rates, as well as for C.Diff, MRSA and VRE. We believe the consistently low transmission rates of these significant DHW-reportable diseases rates in our units are a reasonable reflection of excellent ongoing infection prevention and control practices. That said, hand hygiene audit rates remain problematic in both units and we are seeking IPAC Champions in each unit, for whom one main goal will be working with frontline and physician members to achieve consistently improved Hand Hygiene rates, and toward mitigation of nosocomial outbreaks.

Despite low VAP transmission rates we continue to strive for ongoing improvement; toward that end, and in conjunction with mitigating Delirium in our units, we have updated and improved our Spontaneous Awakening Trial (SAT) and Spontaneous Breathing Trial (SBT) policy and are completing the roll-out for this improved endeavor currently.

Medication Event Reporting and Event Prevention

We conduct weekly medication “Safety Huddles” routinely, lead by our ICU Pharmacists, where medication safety questions and issues are discussed with the multidisciplinary team members; discussions are documented and circulated within the units and often lead to practice changes.

Additionally our Medication Reconciliation (Med Rec) Working Group (a Quality Subgroup) remains very active post Accreditation, working to provide province-wide solutions to gaps in the critical care Medication Reconciliation process which remains an electronic process caught in a paper world.

Two particularly significant achievements are our Mass Casualty Event/Surge Response Protocol and our Quality Newsletter:

Following the disastrous flood of Fall 2015 where all of 3A ICU and much of the centennial building were required to urgently evacuate, we took the opportunity to develop a Departmental Mass Casualty Event/ Surge Response Protocol. This was a massive undertaking lead by our quality leader Karen Webb-Anderson. It is based on Mass Casualty Protocols of larger city centres (Boston, New York) and incorporates invaluable lessons learned during the flood.  It was tested during the MayDay Mass Casualty Exercise (May 2016) and modified based feedback during that exercise. It has been widely vetted by a broad group of stakeholders and presented to the Emergency Operations Committee for use in the organizational disaster plan. Further work continues, as we are working with building safety specialists on creating evacuation plans for both units, for when the need arises.

We have also established a quarterly Quality Newsletter, The Advocate, where we keep Department members, frontline staff and senior leadership up-to-date with our ever-changing workplace quality initiatives.  We include updates on our major ongoing projects such as the Mobility Project, Delirium Prevention and Medication Safety. We also usually include articles on ongoing research, family satisfaction survey results, citizen engagement, and topics of interest in the wider world of quality and patient safety (sleep hygiene, self care, etc) and articles of “interest” highlighting recently encountered interesting cases in patient safety with significant learning points (e.g., propofol infusion syndrome, high-dose insulin infusion therapy). Recently, we have recently introduced a “Big Cheese” corner where members of Senior Leadership foster communication with frontline staff.

As always, we align our work with Accreditation Canada Standards; our practice of embracing and embedding Accreditation standards into our daily life has been a key strategy in serial successful Accreditations.

Team Processes and Decision-Making

The accomplishments of the Quality Team would not be possible without the dedication and contributions of team members and a vast network of health care professionals, administrators, patients and families.

We have enjoyed the membership on our committee of a dedicated community member, whose term has come to an end. We are seeking community members who wish to participate as a valued member of our team!

We have worked to improve the relevance of our Family Satisfaction Surveys, which are based on the FS-24 and FS-ICU research tools, and on such projects as improving family waiting areas, improving communication between staff and families, etc