Angela K. M. Lipshutz

Effectiveness and Efficiency of Root Cause Analysis in Medicine

PREVENTABLE MISTAKES ARE COMMON IN MEDICINE. FOR example, at 1 hospital, a patient received patientcontrolled analgesia (PCA), a combination of local anesthetic and narcotic. The medication was intended to be infused into the epidural space. Instead, a nurse inadvertently connected the tubing to an intravenous catheter, delivering potentially lethal anesthetic into the patient’s bloodstream. What followed were the nurse’s anguish and guilt and, almost as inevitably, the hospital’s root cause analysis (RCA). In the last decade, this process has become the main way medicine investigates mistakes and tries to prevent future mistakes. But like many innovations in medicine, RCA has never been evaluated for effectiveness. In the case mentioned above, the team identified flaws in the design of the epidural catheter, but thought that fixing those flaws was beyond their scope. Therefore, they made a recommendation they could implement: reeducating staff about the equipment’s use. In the end, despite a significant investment of resources, this solution did not remove the underlying hazard and had little effect outside the institution. No one had confidence that things were safer. Indeed, since 1999, the US Pharmacopeia has received 1600 reports of epidural-to-intravenous misconnection (MEDMARX data in file, USP 2007). Many of these incidents undoubtedly received their own RCAs, but the mistake continues to occur. Root cause analysis was originally developed in psychology and systems engineering to identify “the basic and causal factor(s) that underlie variation in performance.” It provides structure to the retrospective analysis of errors and has been used successfully for decades to uncover latent errors in high reliability organizations, such as aviation and nuclear power. Root cause analysis is now a familiar tool for hospitals and health care organizations and has helped to identify many problems and solutions. The RCA process is designed to answer 3 basic questions: what happened, why did it happen, and what can be done to prevent it from happening again? What is missing in medicine is a fourth question: has the risk of recurrence actually been reduced? The fact that it generally is not known whether risk has been reduced is causing concern that some of the considerable resources and efforts expended on RCA are being wasted.

Perioperative glycemic control: an evidence-based review.

Hyperglycemia in perioperative patients has been identified as a risk factor for morbidity and mortality. Intensive insulin therapy (IIT) has been shown to reduce morbidity and mortality among the critically ill, decrease infection rates and improve survival after cardiac surgery, and improve outcomes in acute neurologic injury and acute myocardial infarction. However, recent evidence of severe hypoglycemia and adverse events associated with IIT brings its safety and efficacy into question. In this article, we summarize the mechanisms and rationale of hyperglycemia and IIT, review the evidence behind the use of IIT in the perioperative period, and discuss the implications of including glycemic control in national quality benchmarks. We conclude that while avoidance of hyperglycemia is clearly beneficial, the appropriate glucose target and specific subpopulations who might benefit from IIT have yet to be identified. Given the potential for harm, inclusion of glucose targets in national quality benchmarks is premature.

Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit

Survival from critical illness has improved in recent years, leading to increased attention to the sequelae of such illness. Neuromuscular weakness in the intensive care unit (ICU) is common, persistent, and has significant public health implications. The differential diagnosis of weakness in the ICU is extensive and includes critical illness neuromyopathy. Prolonged immobility and bedrest lead to catabolism and muscle atrophy, and are associated with critical illness neuromyopathy and ICU-acquired weakness. Early mobilization therapy has been advocated as a mechanism to prevent ICU-acquired weakness. Early mobilization is safe and feasible in most ICU patients, and improves outcomes. Implementation of early mobilization therapy requires changes in ICU culture, including decreased sedation and bedrest. Various technologies exist to increase compliance with early mobilization programs. Drugs targeting muscle pathways to decrease atrophy and muscle-wasting are in development. Additional research on early mobilization in the ICU is needed.

Strategies for success: A PDSA analysis of three QI initiatives in critical care.

BACKGROUND Implementation of evidence-based quality improvement (QI) initiatives is not without its challenges. Recent experience in the design, implementation, and evaluation of three QI initiatives at the University of California, San Francisco Medical Center (UCSF) suggests lessons learned that may be generalizable to other QI initiatives. INITIATIVES: Between December 2002 and May 2006, a ventilator bundle of care and a tight glycemic control (TGC) protocol were implemented in the intensive care units (ICUs), and early goal-directed therapy (EGDT) for patients with severe sepsis or septic shock was implemented in the ICUs and emergency department. The initiatives were selected on the basis of the magnitude of the problem, strength of the evidence regarding associated reductions in morbidity and mortality in the critically ill, and cost-effectiveness. LESSONS LEARNED A number of challenges in QI processes and strategies for success were identified via retrospective analysis within the construct of the Plan-Do-Study-Act model, representing a novel use of the model. Pitfalls most commonly occurred in the planning stage. Suggested strategies for success include using an interdisciplinary team, selecting a champion, securing additional resources, identifying specific goals and providing feedback on progress, using work-flow analyses and stepwise implementation and/or pilot testing, creating standard work, eliciting feedback from staff, and celebrating successes. The knowledge gained from these initiatives has been disseminated at UCSF, and the initiatives have helped to raise general awareness regarding the importance of quality. CONCLUSIONS The ventilator bundle of care, TGC, and EGDT are still in use at UCSF, with modification of the initiatives occurring as new evidence becomes available.

Early Mobilization in the Intensive Care Unit Evidence and Implementation

As mortality from critical illness continues to decrease, focus has shifted to long-term outcomes of ICU survivors. Neuromuscular weakness is a common sequela of critical illness. This weakness prolongs duration of mechanical ventilation, increases ICU and hospital length of stay, increases mortality, and can persist for years after hospital discharge. The differential diagnosis of weakness in the ICU is long, and includes critical illness polyneuropathy (CIP) and critical illness myopathy (CIM). Immobilization and bed rest likely contribute to the development of CIP/CIM. Thus, early mobilization therapy has been suggested as an intervention to prevent or ameliorate ICU-acquired weakness. Early mobilization is safe, feasible, and associated with improved ICU outcomes. Emerging evidence suggests patients receiving early mobilization are more likely to be discharged home, making early mobilization therapy a potential mechanism to contain health care costs. Successful implementation of an early mobilization ...

Preventing Harm in the Icu—building a Culture of Safety and Engaging Patients and Families

Objective: Preventing harm remains a persistent challenge in the ICU despite evidence-based practices known to reduce the prevalence of adverse events. This review seeks to describe the critical role of safety culture and patient and family engagement in successful quality improvement initiatives in the ICU. We review the evidence supporting the impact of safety culture and provide practical guidance for those wishing to implement initiatives aimed at improving safety culture and more effectively integrate patients and families in such efforts. Data Sources: Literature review using PubMed including evaluation of key studies assessing large-scale quality improvement efforts in the ICU, impact of safety culture on patient outcomes, methodologies for quality improvement commonly used in healthcare, and patient and family engagement. Print and web-based resources from leading patient safety organizations were also searched. Study Selection: Our group completed a review of original studies, review articles, book chapters, and recommendations from leading patient safety organizations. Data Extraction: Our group determined by consensus which resources would best inform this review. Data Synthesis: A strong safety culture is associated with reduced adverse events, lower mortality rates, and lower costs. Quality improvement efforts have been shown to be more effective and sustainable when paired with a strong safety culture. Different methodologies exist for quality improvement in the ICU; a thoughtful approach to implementation that engages frontline providers and administrative leadership is essential for success. Efforts to substantively include patients and families in the processes of quality improvement work in the ICU should be expanded. Conclusions: Efforts to establish a culture of safety and meaningfully engage patients and families should form the foundation for all safety interventions in the ICU. This review describes an approach that integrates components of several proven quality improvement methodologies to enhance safety culture in the ICU and highlights opportunities to include patients and families.

Central venous catheters: follow the evidence, not the guidelines.

Crit Care Med 2012 Vol. 40, No. 8 Catheter-related bloodstream infections (CRBSIs) are common, costly, and associated with significant morbidity and mortality. Central venous catheters (CVCs) are the culprit in most CRBSIs (1). In the United States, 15 million CVC days occur in the intensive care unit every year (2), resulting in an estimated 250,000 CRBSIs. With a mortality rate of 12%–25% and a cost of over

Intensive Care Unit-acquired Muscle Weakness: An Ounce of Prevention Is Worth a Pound of Cure.

50,000 per infection, CRBSIs have important public health implications (3). Furthermore, under the new Medicare and Medicaid payment scheme, hospitals are no longer being compensated for the cost associated with CRBSIs (4). Thus, there has been a recent emphasis on identifying methods of preventing CRBSIs. Of course, the most effective method of preventing CRBSIs is avoiding catheter insertion altogether. However, many critically ill patients require CVCs for drug administration, alimentation, access, and/or hemodynamic monitoring. Steps taken during catheter insertion, including hand hygiene (5), maximal barrier precautions (6), skin antisepsis with chlorhexidine (7), and the use of a checklist (8) can significantly decrease the incidence of CRBSI. Additionally, use of antimicrobial catheters (9), proper dressing materials and techniques (10), and optimization of nursing ratios are beneficial in reducing infection rates (11). Finally, the use of ultrasound guidance decreases the number of insertion attempts (12), which may result in fewer infectious complications. When choosing a site for catheter insertion, a number of factors must be taken into account. For example, the internal jugular (IJ) site readily lends itself to ultrasound guidance, whereas the femoral site avoids placing the patient in Trendelenburg, a position that could compromise respiratory function in the nonintubated patient. Whether the choice of site (i.e., subclavian vein, IJ vein, or femoral vein) affects the incidence of CRBSIs is controversial. The traditional teaching is that the subclavian site has the lowest incidence of CRBSIs, followed by the IJ, and finally, the femoral. Questioning this conventional wisdom (and the guidelines it has spawned), Marik and colleagues (13) performed a systematic review and metaanalysis comparing the risk of CRBSI for catheters placed in the femoral vein vs. the subclavian and IJ veins, the findings of which are reported in this issue of Critical Care Medicine. The authors identified studies published from 1966 to October 2011 that reported the rate of CRBSI at the femoral and subclavian and/or IJ site using MEDLINE, Embase, the Cochrane Database, and Google. They recorded the incidence and density of CRBSIs at each site, as well as the incidence of venous thrombosis of the cannulated vein. In their meta-analysis, they subgrouped according to study design, and went on to assess heterogeneity and bias. Most interestingly, though, they performed a metaregression to look for a change in the risk of infection by site over time. Marik and colleagues identified ten studies for inclusion: two randomized controlled trials and eight cohort trials. They found no randomized controlled trial level evidence to support choosing one CVC site over another to decrease the incidence of CRBSI or thrombosis. This finding was validated in a recent Cochrane review that included only randomized controlled trials and found no difference in CRBSI rates among the three sites (14). In the meta-analysis of all ten studies, Marik et al found:

1198: TARGET RASS: AN EXAMPLE OF LEVERAGING THE EHR TO STANDARDIZE GOAL-BASED INTERVENTIONS.

<zdoi;10.1097/ALN.0000000000000875> Anesthesiology, V 124 • No 1 7 January 2016 I ntensive care unit– acquired weakness (iCUAW) is defined as bilateral symmetrical limb weakness in critically ill patients. iCUAW is the clinical manifestation of critical illness neuromyopathy and is unrelated to any other etiology. it typically presents as flaccid quadiparesis with hyporeflexia or areflexia; the cranial nerves are usually spared. iCUAW presents a grave public health problem: it is a common complication of critical illness and has a profound impact on outcomes, increasing the duration of mechanical ventilation, prolonging intensive care unit (iCU) and hospital length of stay, worsening long-term functional status, and increasing mortality.1–5 The majority of literature on iCUAW focuses on the medical iCU population. However, patients in the surgical iCU differ from those in the medical iCU—they experience surgical trauma, pain, inflammation, and lingering effects of anesthetic medications—making iCUAW more common in the surgical population. in this issue of AnestHesiology, Farhan et al.6 provide the most thorough discussion of muscle weakness in the surgical iCU to date. They review the etiology and consequences of iCUAW in the surgical iCU, and, most importantly, they provide a lengthy discussion of preventative measures to assist the practicing clinician in averting muscle weakness in critical illness. The goal of this editorial is to highlight the key messages from their review, focusing on the impact of iCUAW in terms of incidence and long-term implications, as well as methods that can be used to prevent weakness in critical illness. iCUAW occurs because of the physiologic and immunologic effects of critical illness, immobilization and mechanical unloading of muscles, prolonged mechanical ventilation, medications, and inadequate nutrition. This weakness affects half to three quarters of patients admitted to the surgical iCU.7,8 iCUAW impairs the long-term functional status of iCU survivors.9 A study of survivors of acute respiratory distress syndrome found that, despite improvement in lung function, all patients complained of decreased physical function 1 yr after iCU discharge.3 Patients blamed this decrease on fatigue, weakness, and diminished muscle mass. less than half of survivors had returned to work in this time period. And, these complaints persisted over time—at 5 yr after iCU discharge, all patients complained of weakness and decreased ability to exercise compared with before their iCU stay, and only 77% had returned to work.4 Those who had returned to work often required a modified work schedule or other accommodation. Patients’ mental health was also affected by their illness, with more than 50% of survivors suffering from depression or anxiety. And, survivors incurred healthcare costs that were higher than those incurred by their healthy peers. similarly, a study of long-term outcomes in survivors of severe sepsis showed that severe sepsis was associated with functional disability and cognitive impairment that persisted for at least 8 yr.5 Fortunately, there are steps the practicing clinician can take to help prevent iCUAW, which Farhan et al. describe in detail. in our opinion, the most important of these preventative measures is early mobilization. early mobilization of critically ill patients is feasible, safe, and effective, and results in improvements in functional and neuropsychiatric outcomes.9 early literature on mobilization focused on the medical iCU population,10–14 perhaps because of fewer perceived barriers to exercise in medical patients. However, recent studies have shown its safety and effectiveness in surgical,15 trauma,16 and neurosurgical iCU patients.17 At our institution, we routinely mobilize our surgical patients, including those requiring mechanical ventilation, vasopressor therapy, renal replacement therapy, and extracorporeal Intensive Care Unit–acquired Muscle Weakness

561: ENGAGING AN ICU PATIENT AND FAMILY ADVISORY COUNCIL TO REDESIGN A PATIENT-ORIENTED WEBSITE

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) variability in rates prompted us to evaluate the sustainability of CLABSI reduction efforts and maintenance of evidence-based practices in Michigan ICUs. Methods: We conducted a gap analysis using a web-based survey of our participating ICUs. A survey link was sent to 100 Infection Preventionists whose hospital provides ICU care. Survey questions queried if evidence-based practices that were introduced in 2003 (e.g. insertion bundle checklist, hand hygiene, dedicated central line team and stop-the-line culture) are still utilized during central line placement. Results: Eighty hospitals submitted a completed gap analysis between January and mid-March 2016, an 80% response rate. Nearly all hospitals indicated continued use of an insertion bundle (96.5%) with 90% utilizing an insertion checklist. Further, 98.75% of respondents indicated applying full maximum barrier precautions during insertion. Hand hygiene protocols are in place at 98.75% of ICUs and enforced 88.9% of the time. Eighty percent report stop-the-line culture for an observed aseptic violation and 90% avoid a femoral insertion site. Central lines are discussed during rounds in 90% of the sample. Only 26%t report dedicated central line teams. Maintenance of central lines was identified as the primary concern of preventing CLABSI at 75% vs. insertion or removal. Conclusions: Michigan ICUs have maintained evidence-based central-line insertion practices and continued efforts to prevent CLABSI. Dedicated central-line teams and maintenance of central-lines represent the greatest opportunity for continued quality improvement efforts. Michigan ICUs continue to exhibit a high rate of compliance with CLABSI reduction interventions more than 10 years after conclusion of the initial grant funding.