如何确保ICU安全性杜斌

如何确保ICU安全性杜斌HowHazardousIsHealthCare?LucianLeape,2/2001DefinitionofQualityandSafety

InstituteofMedicineHealthcareQualityThedegreetowhichhealthservicesincreasethelikelihoodofdesiredoutcomesPatientSafetyFreedomfromaccidentalinjurybecauseofmedicalcareormedicalerrorQualityandSafety:explicitlylinkedIf99.9%weregoodenough:1majorplanecrashevery3days12babiesgiventothewrongparentseveryday84unsafelandingseveryday500incorrectsurgicaloperationsweekly16,000mailslosteveryhour37,000ATMerrorseveryhour2,000,000documentslostattheIRSeveryyearAdverseDrugEvents:Facts4%hospitalizedpatientssufferadverseeventExtrapolatesto1,000,000injuries/yr180,000deaths/yr(45,000deathsfromautoaccidents)69%duetoanerrorinmanagementmedications=19.4%ofalladverseeventsmedicationsleadto35,000deaths/yr(96/day)TABrennan,LLLeape,etal.Incidenceofadverseeventsandnegligenceinhospitalizedpatients.ResultsoftheHarvardMedicalPracticeStudyI.NEJM1991;324:370-376WhereDoAdverseEventsOccur?PatientCareSite%dueto“negligence”EmergencyRoom70.4PatientRoom41.1ICU30.2Labor&Delivery27.7OperatingRoom13.7Modifiedfrom:Table5:SitesofCareThatResultedinAdverseEvents.LLLeape,etal.NEJM1991;324:377-384EstimatedDeathCausedbyPreventableMedicalErrorsinChina(HospitaladmissionsinChinain

2007=64,870,000pt)Colorado&Utah-based:64,870,000(adm.)x2.9%(AErate)x53%(AEpreventablerate)x8.8%(AEdeath)=87,741personsperyearNewYorkState-based:64,870,000

x3.7%x58%x13.6%=189,327

Australia-based:64,870,000

x16.6%x51%x4.9%=269,103Suicide=287,000(5thleadingdeath)FactorsAssociatedwithErrorsCommunicationFailuresFrequentdistractionsandinterruptionsInexperiencedstaff/traineesInadequatesupervisionShiftchangeDrugorderingissuesLimitedaccesstopatientinformationNoisyworkenvironmentEquipmentfailuresLackof24hour(pediatric)pharmacyBedavailabilityconstraintsSystemofpatientcross-coverageEmergencysituationsMagnettiS,Boston2005LeapfrogStandardsforAdultICUsAhigh-intensityICUstaffingpattern,ANDStaffintensivistsarepresentanddedicatedexclusivelytotheICUduringdaytimehoursand,Atothertimes,returnICUpagesin5mins95%ofthetimeandarrangeforanFCCS-certifiedassistant(e.g.,nursepractitioner)toreachICUpatientsin5minsDedicatedattendingcoverageduringdaytime,ANDDedicatedcoveragebyanyphysicianduringnighttimeAngusDC,ShorrAF,WhiteA,etal.CriticalcaredeliveryintheUnitedStates:DistributionofservicesandcompliancewithLeapfrogrecommendations.CritCareMed2006;34:1016-1024CompliancewithLeapfrogStandardsAngusDC,ShorrAF,WhiteA,etal.CriticalcaredeliveryintheUnitedStates:DistributionofservicesandcompliancewithLeapfrogrecommendations.CritCareMed2006;34:1016-1024255/5980AdverseEventsinICUNo.(/1000patientdays)IncidentMICUCCUAllPvalueAdverseeventPreventable34(41.4)20(29.9)54(36.2).19Nonpreventable37(45.1)29(43.3)66(44.3).55Either71(86.5)49(73.2)120(80.5).13NoninjuriousseriouserrorIntercepted65(79.2)68(101.6)133(89.3).23Nonintercepted53(64.6)37(55.3)90(60.4).57Either118(143.7)105(157.0)223(149.7).60RothschildJM,LandriganCP,CroninJW,etal.Thecriticalcaresafetystudy:theincidenceandnatureofadverseeventsandseriousmedicalerrorsinintensivecare.CritCareMed2005;33:1694-1700AdverseEventsinICURothschildJM,LandriganCP,CroninJW,etal.Thecriticalcaresafetystudy:theincidenceandnatureofadverseeventsandseriousmedicalerrorsinintensivecare.CritCareMed2005;33:1694-1700RankOrderofErrorReductionStrategies:ISMPRecommendationsForcingfunctionsandconstraintsAutomationandcomputerizationStandardizationandprotocolsChecklistsanddouble-checksystemsRulesandpoliciesEducation/informationMostEffectiveLeastEffectiveEducation/InformationFirst4weeksSecond4weeks1stweek4thweek1stweek4thweekNumberofencounters537?HandwashingPre-encounter(%)7829Post-encounter(%)9278Overall(%)65Gloves(%)43KhatibM,JamaleddineG,AbdallahA,etal.HandwashinganduseofgloveswhilemanagingpatientsreceivingmechanicalventilationintheICU.Chest1999;116:172-175Education/InformationKhatibM,JamaleddineG,AbdallahA,etal.HandwashinganduseofgloveswhilemanagingpatientsreceivingmechanicalventilationintheICU.Chest1999;116:172-175Education/InformationFirst4weeksSecond4weeks1stweek4thweek1stweek4thweekNumberofencounters537543HandwashingPre-encounter(%)78299492Post-encounter(%)92789492Overall(%)6592Gloves(%)4392KhatibM,JamaleddineG,AbdallahA,etal.HandwashinganduseofgloveswhilemanagingpatientsreceivingmechanicalventilationintheICU.Chest1999;116:172-175Education/InformationImportantandhelpfulIncreasesawarenessHowever,lecturesarequicklyforgottenSignsareoftenignoredLeasteffectivemeanstopreventoccurrenceoferrorRulesandPoliciesRequiredbyseveralagenciestohavewrittenrulesandpoliciesIncreasinglyavailableinelectroniconlineform Agoodresource,butnotaneffectivemeansofpreventingaspecificeventDailyQualityRoundingChecklistDuBoseJJ,InabaK,ShiflettA,etal.Measurableoutcomesofqualityimprovementinthetraumaintensivecareunit:theimpactofadailyqualityroundingchecklist.JTrauma2008;64:22-29ComplianceWithVAPBundleDuBoseJJ,InabaK,ShiflettA,etal.Measurableoutcomesofqualityimprovementinthetraumaintensivecareunit:theimpactofadailyqualityroundingchecklist.JTrauma2008;64:22-29DurationofCVC&MVDuBoseJJ,InabaK,ShiflettA,etal.Measurableoutcomesofqualityimprovementinthetraumaintensivecareunit:theimpactofadailyqualityroundingchecklist.JTrauma2008;64:22-29OutcomeComparisonDuBoseJJ,InabaK,ShiflettA,etal.Measurableoutcomesofqualityimprovementinthetraumaintensivecareunit:theimpactofadailyqualityroundingchecklist.JTrauma2008;64:22-29MeanMonthlyVAPRate(/1,000ventilator-days)MeanMonthlyCentralLineAssociatedBSI(/1,000CVC-days)SelfExtubationRate(/1,000ventilator-days)3mobeforeQItooluse16.311.37.83moofactiveQItooluse8.95.82.2DailyGoalsCheckoffFormHartfordhospital:800-bed,LevelItraumacenterUrbanteaching/tertiarycarefacility12-bedSurgicalICUAgoalsformforroundsOriginatedfromJohnsHopkinsHospitalinBaltimoreChecklistnotato-dolist,butenumerationofclinical,safety,andpsychosocialgoalsUsedtwicedailyduringroundsaccessonJuly8,2008DailyGoalsCheckoffFormWhyisthePatienthere?Appropriatelevelofsedation?Appropriatelevelofpaincontrol?HOBelevated30degrees?Weaning/extubationassessmentperformed?CurrentventsupportneededRWPcandidate?Tissueperfusionadequate?Arrythmiastreated/controlled?OptimalBPcontrol?Volumestatusappropriate?IVfluidsappropriate?Adequatenutritionalsupport?Bowelsregular?PUDprophylaxis?ElectrolytesWNL?Glucosecontrolled?H/Happropriate?Coagsappropriate?DVTprophylaxis?Cultureschecked?Woundschecked?Skinintact?Antibioticappropriate?Lines/tubesnecessary?Tests/proceduresordered?Testsread/reviewed?[DELTA]medsPO,adjustdosing?Consultsordered/contacted?Patientmobilized,OT/PT/ST?Primaryservice/consultscontacted,plandiscussed?Teamawareofendoflifeplan?Familyfeelsinformed?accessonJuly8,2008DailyGoalsCheckoffFormResultsMarkedimprovementinunderstandingofgoalsoftherapyNurses:about50%98–100%ReductioninLOSbyav.1.5daysReductioninventilatordaysbyav.1dayDecreaseofinunitmortalityfrom11.5%to8.3%accessonJuly8,2008ChecklistsandDouble-CheckSystemsMuchmoreeffectivemeansofpreventingerrorespeciallywhenentrenchedinpracticeNotfool-proofBestexample:surgicalspongeandinstrumentcounts AnincreasinglyeffectivemeansoferrorpreventionGlycemicControlForConsistencyKrinsleyJS.Effectofanintensiveglucosemanagementprotocolonthemortalityofcriticallyilladultpatients.MayoClinProc2004;79:992-1000152.393.4mg/dL130.7[107–172]mg/dL130.755.1mg/dL119[99–147]mg/dLGlycemicControlForConsistencyReedCC,StewartRM,ShermanM,etal.Intensiveinsulinprotocolimprovesglucosecontrolandisassociatedwithareductioninintensivecareunitmortality.JAmCollSurg2007;204:1048-1055141mg/dL134mg/dL129mg/dL125mg/dLStandardizationandProtocolsStandardizationminimizesriskoferrorProtocolsbringastandardapproachtoaclinicalissue WeakpointsmayexistandstillcanbepronetoerrorComputer-AssistedManagementProgramforAntibioticsEvansRS,PestotnikSL,ClassenDC.AComputer-assistedManagementprogramforantibioticsandotherantiinfectiveagenst.NEnglJMed1998;338:232-8Computer-AssistedManagementProgramforAntibioticsVariablePreinterventionPeriod(n=766)InterventionPeriodComputerRegimenFollowed(n=203)†ComputerRegimenOverridden(n=195)‡No.ofdifferentantiinfectiveagentsordered2.21.61.60.82.91.6Durationofantiinfectivetherapy–hr263441128169386434No.ofantiinfectiveagentdoses28.742.414.014.627.526.7Daysofexcessantinfectivedosage5.712.51.32.84.15.2Costofantiinfectiveagents

–$412844134236515644No.ofmicrobiologycultures8.213.23.74.912.213.6ICULOS

–d6.49.73.33.79.810.3DaysfromICUadmissiontohospitaldischarge

–d14.114.59.77.817.916.0TotalLOS–d15.916.911.510.719.718.4Totalcostofhospitalization–$40,29042,92829,51524,96550,51550,956Mortality–n(%)172(22)36(18)52(27)EvansRS,PestotnikSL,ClassenDC.AComputer-assistedManagementprogramforantibioticsandotherantiinfectiveagenst.NEnglJMed1998;338:232-8AutomationandComputerizationOneofthebestmeanstopreventmedicalerrorsfromoccurringDependentonextensiveFMAandFMEAtestingbeforeimplementationOnlyassafe/goodasthepersonenteringthedataForcingfunctionsandconstraintsThebestwaytopreventerrorthroughbuiltinsafeguardsSystems/productsengineeredtobesaferfromthegroundup“Forced”tousetherollinfrontbeforethenewonePokeYoke:errorproofing,forcingfunctionEverydayexperiencesApplyingbreaksbeforecarwillallowreversegearShuttingtheMicrowaveDoorAnesthesiagaslinecouplingsOpportunityforI.V.connections?SmokingCessationCounseling:forcingfunctioninNurseassessmentCentralLineBundleToReduceCRBSIHandwashingUsingfull-barrierprecautionsduringtheinsertionofcentralvenouscathetersCleaningtheskinwithchlorhexidineAvoidingthefemoralsiteifpossibleRemovingunnecessarycathetersPronovostP,NeedhamD,BerenholtzS,SinopoliD,ChuH,CosgroveS,SextonB,HyzyR,WelshR,RothG,BanderJ,KeprosJ,GoeschelC.Aninterventiontodecreasecatheter-relatedbloodstreaminfectionsintheICU.NEnglJMed2006;355:2725-2732CentralLineBundleToReduceCRBSIEducationAcentral-linecartwithnecessarysuppliesAchecklisttoensureadherencetoinfection-controlpracticesProviderswerestopped(innonemergencysituations)ifthesepracticeswerenotbeingfollowedTheremovalofcatheterswasdiscussedatdailyroundsFeedbackregardingthenumberandratesofCRBSIatmonthlyandquarterlymeetingsAlettertothehospitalCEOstorecommendtheuseofchlorhexidinePronovostP,NeedhamD,BerenholtzS,SinopoliD,ChuH,CosgroveS,SextonB,HyzyR,WelshR,RothG,BanderJ,KeprosJ,GoeschelC.Aninterventiontodecreasecatheter-relatedbloodstreaminfectionsintheICU.NEnglJMed2006;355:2725-2732CentralLineBundleToReduceCRBSIPronovostP,NeedhamD,BerenholtzS,SinopoliD,ChuH,CosgroveS,SextonB,HyzyR,WelshR,RothG,BanderJ,KeprosJ,GoeschelC.Aninterventiontodecreasecatheter-relatedbloodstreaminfectionsintheICU.NEnglJMed2006;355:2725-2732FAST-HUGforVAPPreventionDailyevaluationincriticallyillpatientsFeedingAnalgesiaSedationThromboembolicpreventionHeadofbedelevationUlcerprophylaxisGlucosecontrolVincentJL.Giveyourpatientafasthug(atleast)onceaday.CritCareMed2005,33:1225-1229FAST-HUGforVAPPreventionPapadimosTJ,HensleySJ,DugganJM,etal.Implementationofthe“FASTHUG”conceptdecreasestheincidenceofventilator-associatedpneumoniainasurgicalintensivecareunit.PatientSafetyinSurgery2008;2:319.3/1000ventilator-days7.3/1000ventilator-daysPhysicianAttitudesSurveyofEuropeanICUphysicians(n=504)from16countriesassessingwhattheywouldtellpatients/familiesintheeventofanerror32%wouldtellexactlywhathappened63%wouldminimizetheevent4%wouldgivenoinformation70%felttheyshouldgivefulldetailsVincent,IntensiveCareMedicine:1998SAFEReportCardHarrisCB,KraussMJ,CoopersmithCM,etal.Patientsafetyeventreportingincriticalcare:astudyofthreeintensivecareunits.CritCareMed2007;35:1068-1076MonthlyReportingRatesofAEsPre-intervention20.4/1,000patient-daysPost-intervention41.7/1,000patient-daysRateratio,2.05;95%CI,1.79–2.34HarrisCB,KraussMJ,CoopersmithCM,etal.Patientsafetyeventreportingincriticalcare:astudyofthreeintensivecareunits.CritCareMed2007;35:1068-1076LevelofHarmofReportedEventsHarrisCB,KraussMJ,CoopersmithCM,etal.Patientsafetyeventreportingincriticalcare:astudyofthreeintensivecareunits.CritCareMed2007;35:1068-1076LevelofHarmofReportedEventsHarrisCB,KraussMJ,CoopersmithCM,etal.Patientsafetyeventreportingincriticalcare:astudyofthreeintensivecareunits.CritCareMed2007;35:1068-1076DataPublication&QualityofCarePurpose:Tosynthesizetheevidenceforusingpubliclyreportedperformancedatatoimprovequality.DataSources:WebofScience,MEDLINE,EconLit,andWilsonBusinessPeriodicals(1999–2006)andindependentreviewofarticles(1986–1999)identifiedinaprevioussystematicreviewOnlysourcespublishedinEnglishwereincludedFungCH,LimYW,MattkeS,etal.Systematicreview:theevidencethatpublishingpatientcareperformancedataimprovesqualityofcare.AnnInternMed2008;148:111-123.DataPublication&QualityofCarePublicreportingstimulatesqualityimprovementactivityinhospitallevel7/11FungCH,LimYW,MattkeS,etal.Systematicreview:theevidencethatpublishingpatientcareperformancedataimprovesqualityofcare.AnnInternMed2008;148:111-123.