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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 province. We encourage you to check out the many issues of The Advocate below!

Quality Highlights

 

In October 2014 the Quality & Patient Safety Team established a 3 year plan that included several goals nested within an overarching model of sustainability, born from our Critical Care Scorecard which had been built on a template that aligned with (then) Capital Health’s Our Promise In Action.  In the fall of 2014 we reviewed this scorecard and realigned priorities, recognizing that in order to be successful we needed to focus our efforts in key areas: (1) Clinical Best Practice (CBP), (2) Team Processes and Decision-Making (TPDM), (3) Infection Prevention & Control (IPAC) and (4) Medication Safety (MS).   The primary goals within each areas are: 1-CBP: Delirium (awareness, assessment, prevention and management), pressure injury prevention, mobility project; 2- TPDM; health care team function and patient-and-family centered care (team processes/decision-making); 3- IPAC: ventilator-associated pneumonia (VAP), central line –associated blood stream infections (CLABSI), hand hygiene; and 4- MS: medication event reporting and event prevention. The past year has seen many successes related to these areas, and extending far beyond.

Clinical Best Practice

We have implemented a Daily Rounds Tool (DaRT) into 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).

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 (Elinor Kelly and Marlene Ash) 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 kardex; work continues around physician education.

We have recently updated the Targeted Temperature Management (TTM), Palliative Care in ICU, ECMO in ICU and Routine ICU Admission Orders PPOs, in addition authoring an Amiodarone in ICU PPO (to mitigate inter-unit medication error and patient risk), updated our End-of-Life Checklist and participated in generation of the organizational ECMO Policy. We continue to update and monitor Department of Critical Care PPOs every 3 years or sooner, when the need arises (due to new evidence, etc).

Team Processes and Decision-Making

We have enjoyed the membership on our committee of a dedicated community member, whose husband had been a patient in one of our units; she is dedicated and engaged in the quality mandate and a vocal advocate for family centered decision-making.

We have worked closely with our community Quality team Family member 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.

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 largely due to overemphasizes of rates despite desperately low sample sizes. We have sought 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.

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, 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) is very active in the run-up to Accreditation, working to provide province-wide solutions to gaps in the critical care Med Rec process.

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 (Bsoton, 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. Currently we are reviewing the upcoming Accreditation Canada changes in the Crosswalk for Critical Care and sharing it with the larger group.

2016-2017 Priorities

Prepare for accreditation: The activities of hospitals and health centres in Canada are accredited by Accreditation Canada, which works through Canada's Qmentum Program to meet best practice standards and raise the quality of services. The ongoing accreditation process includes a number of milestones that allow health centres and their programs to assess whether they are meeting best practices in health care and, if not, to take action. Accreditation surveyors will be visiting our organization in the fall of 2017. Over the next year, the Critical Care Quality Committee will focus on further strengthening projects that improve patient safety and patient outcomes as part of the accreditation process.

Integrate the Daily Rounds Tool (DaRT) into more consistent practice: As consistency improves with data collection, the Team’s power for improvement will also grow.

Continue to work as a united group: Reflecting membership from both 3A and 5.2, the Quality Team constantly seeks to make improvements in both units, capitalizing on strengths.

Improve completion rate of Family Surveys: The aim is to strengthen the voice of families in change.

Improve and implement an updated approach to spontaneous daily awakening and spontaneous daily breathing trials in intubated and sedated patients: The Quality Team will work toward reducing the incidence of delirium in patients.

Seek opportunities to make process changes that support best practice: The Team strives to find “smart” improvements in a system with great front-line demands.

Leadership and teamwork

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. A few team members deserve special recognition and thanks:

The Quality Team's medical chair is Dr. Sarah McMullen. Dr. McMullen is dedicated to quality assurance and, in collaboration with her quality team, has implemented significant quality improvements in our ICUs to ensure we provide the best care possible to our patients.

The support of the interdisciplinary team, facilitated by quality leader Karen Webb-Anderson, is key to our success. Ms. Webb-Anderson brings boundless energy, a commitment to quality and attention to detail to her role.

Family representative Jean Collier provides an invaluable voice to discussions, bringing to the table her experience both as a former nurse and as a relative of a family member cared for in one of our units.

Unit managers Patricia Daley and Cynthia Isenor are amazing leaders who are fiercely committed to quality issues and care.

Pharmacy clinical coordinator Dr. Meghan Mackenzie is responsive to the needs of patients and the Quality Team, and always available to lead with her expertise and grounded approach to change.

 

Want to know more?
Check out some of the resources below!

ICU Liberation
Safer Healthcare Now!
Accreditation Canada