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What makes a successful ICU? - Knighton
1. What makes a successful ICU?
John Knighton
Clinical Director
Academic Department of Critical Care
Portsmouth Hospitals NHS Trust
John.knighton@porthosp.nhs.uk
2. Successful?
• Outcome data – ICNARC validated data
• CVC-BSI rates - Matching Michigan; other HCAIs
• Avoidance of harm
• Patient & Relative’s experience
• Staff perceptions
• Research, Innovation
• CQC inspections; Network Peer Review
3. Why me, why Portsmouth?
• CQC Inspection Feb 2015 – rated “Outstanding”
• Reputation for training
• Research
• IT early adopter: CIS 2001+
• CQC Specialist Advisors
- 2 consultants
4. Portsmouth
• 1000 beds, PFI build 2009
• 670,000 population (1% pop’n)
• High social deprivation
• High alcohol-related
admissions
• Trust Financial deficit
• ED waiting times bottom
quartile
5. Portsmouth Critical Care
• DGH
• No Cardiothoracics, Neuro or PICU
• Regional Renal unit
• 24/7 Interventional Cardiology
• 1500 Critical Care admissions per year, inc children
• 24 beds, in 2 x 12 bedded units, used flexibly Levels 23
• 6/24 Isolation rooms
6. Portsmouth Critical Care
• Case-mix
• 75% emergency; 25% elective
• 60% Medical; 40% Surgical
• APACHE 2 physiology – 18.5
• ICNARC (2013) physiology - 16
• LOS mean – 4 days
• Occupancy > 90%
• Estimated Critical Care bed requirement ~ 30+
7. CQC highlighted
• Outcomes
• Designed layout and use of space
• Education & training
• Culture: safety, learning inc. “Safety Brief”
• Incidents & near misses
• Innovative use of IT (& social media)
• Strong ethos of team work
• Staff-led change initiatives: “Listening into Action”
12. Safety Culture - “Watch Out” notices”
CriticalCareWatchOutNotice
Watch Out for...
NIV mask related pressure sores
What Happened?
The Facts:
Protect Your Patients:
Watch Out Notice: 08 Date: 30 July 2014 Produced By: Critical Care Governance Group Authors: S Birkholzer, K Adeniji
• NIV masks can cause pressure sores,
especially on the bridge of the nose
• Sores can be prevented by:
- Applying nasal skin protection
- Using total face masks when tolerated
- Ensuring masks are not too tight
• Use a strip of Aderma Dermal Pad to protect bridge of nose for all patients on NIV
• Assess the risk of pressure sores and use a total face mask where appropriate.
• Monitor mask leak to ensure optimal fitting:
Academic Department of Critical Care | Queen Alexandra Hospital Portsmouth
A patient developed a grade 3 pressure
sore on the bridge of their nose after
intermittent use of a full face non-
invasive ventilation (NIV) mask.
This was changed to a total face mask
and the sore began to heal.
Mask Leak Fitting
0-10 l/min Beware- may be too tight
11-30 l/min Just right
31-60 l/min Check fit and monitor leak
>60 l/min Poor fit and/or too loose
Full Face Mask Total Face Mask
CriticalCareWatchOutNotice
Watch Out for...
Gentamicin Toxicity Causing
Acute Kidney Injury
What Happened?
The Facts:
Protect Your Patients:
Watch Out Notice: 07 Date: 5 Jan 2014 Produced By: Critical Care Governance Group
Authors: M Beadle, S Mathieu
• Aminoglycoside antibiotics used to treat both gram negative and positive bacteria
• Aminoglycosides are nephrotoxic and must be monitored to prevent the development of
• oto/vestibular toxicity
• nephrotoxicity
If BMI is > 30, use ideal body weight (IBW)
• IBW tables can be found in the ‘antibiotic serum level monitoring’ section in the
adult microguide (trust intranet home page & on CIS links)
Always monitor gentamicin levels after first dose
• Use the Urban & Craig nomogram
Monitor levels at least twice weekly even if patients renal function is stable
• Volume depletion and other drugs can affect gentamicin concentration, even with
normal renal function
Use the CIS prompts on Ward round entries, consider …
• Has renal function changed?
• When was the last gentamicin level measured?
Dosing for infective endocarditis is different
• refer to the microguide
Academic Department of Critical Care | Queen Alexandra Hospital Portsmouth
• Levels were checked twice in the first week and a
24hr dosing was appropriate
• The patient developed an AKI but gentamicin levels
were not re-checked until 4 days later
• 24 hr dose intervals led to toxicity, exacerbating AKI
• Retrospective levels indicated we should have
changed to 36 hr dose interval
13. Safety screens on unit
• Openly scrolling safety information
• Watch-Out notices
• Infection rates: C. diff, MRSA, CVC-BSI
• Recent hazards
• Recurrent risks
14. Safety Culture
• Awareness and anticipation of risks
• Incident reporting
• Open discussions: learn v blame…
• Awareness of Human Factors
• Empowering junior staff
• Virtuous cycle…
15. Teamwork - Consultants
• 13 WTE Consultants
• Generic annualised job plans: 6 DCC ICM; 2 DCC other; 2 SPA
• 2 Consultants each day; 1 at night.
• ICU cover 7 days Mon-Sun
• Weekends = weekdays
• Nights on call – 8.5 hrs in and working
• 48% hours worked @ evenings and weekends
• Acting down to cover trainee staff
• Continuity & Consistency
16. Teamwork - Trainee medical staff
• Registrar tier
• SHO tier – mostly no ICU/airway experience
• 2 day induction program, every 4/12
• Continuity block 5 days acting-up for senior trainees
• Increasing rota gaps…
• Post-CCT Fellow ECHO
• Out of program SPARC-ICM Fellow
• Advanced Critical Care Practitioners
17. Teamwork - Nursing, Physio & AHP
• No use of agency staff
• High proportion ICU qualification ~ 80%
• Ward round participation
• Band 5 lead roles
• Band 5 newly qualified ~ 10%
• Supernumerary 4 - 8/52, 2 mentors
• Competency based program
• HCSWs
• Dedicated Band 7 Physiotherapy
18. Education & Training
• ½ day per week protected-time teaching, running 20 yrs+
• Weekly MDT sessions
• Monthly Governance ½ day
• Induction program include Simulation Centre day
• Regional ½ day ICM SpR program with SUHT
• Deanery A* rating
• Associate Academic Dept: University of Portsmouth
• Introduced Standard Operating Procedures
24. Improving success in ICU?
• Outcomes and indicators – measurement & monitoring
• Patient experience
• Focus on education, training and development of staff
• Staff perceptions
• Open, aware, learning – Safety Briefs
• Culturally safe > rule-bound organisations*
Continuous improvement of patient safety: the case for change. Nov 2015
The Health Foundation
26. Links
1. Portsmouth ICU website - http://www.portsmouthicu.com/
2. WICS website - http://www.wessexics.com/
3. The Bottom Line - http://www.wessexics.com/The_Bottom_Line/
4. SPARC-ICM - http://wessex-sparc.com/sparc-icm/
5. Continuous improvement of patient safety: the case for change. Nov 2015 The Health
Foundation
6. Listening into Action – http://www.listeningintoaction.co.uk
Editor's Notes
I’d like to thank the organising committee for the invitation to speak (though perhaps not on this topic)
A few years ago I sat in the audience whilst one of my recently retired colleagues gave a talk in which he compared the practice and outcomes of Critical Care in the UK with that in North America. It made for pretty uncomfortable listening, and we (the UK) did not come out of it well
However, I think he was wrong so actually I am delighted to have the opportunity to discuss success in the UK Critical Care setting
So, what does success mean
Well, it probably depends partly on who you are
But of course any discussion of quality has to start with good outcome data, but also needs to include, but not necessarily be limited to, some of these other elements
And for the last couple of years, the Care Quality Commission, has been the vehicle for assessing element of all of these as it Inspects us as one of its Core Services
So: why am I giving this talk and is it going to be of any relevance to you?
Well we had our CQC Inspection in early Feb 2015, when the program for the SOA was being put together
We have long history of involvement with the ICS, as well as a reputation for….
We’ve embraced new technologies such as Clinical Information systems
We also have 2 consultants who have seen the CQC process from both sides, having worked as CQC Specialist Advisors
I hope it is going to be of some use, in that as a full time clinical intensivist myself, I know when I’m in the audience for this sort of session, what I want to hear is some ideas I can take back to have an impact in my own unit.
So it’s with that intention that I’m going to address the question, and in the hope that in so doing I don’t patronise or otherwise alienate you by describing things you are already doing better than we are!
Unfortunately it’s not all sunny in the South of England…
We’re not a teaching hospital
We have no…
In terms of our case mix, we are rather more emergency than average, and rather more medical than surgical compared to the normal around the UK
Our average physiology scores and lengths of stay on the other hand are pretty typical
We are however, despite being large, under capacity by any of the measures or benchmarks that one might use to determine Critical Care bed requirement.
WE should probably have somewhere in the order of 30+ beds, which is why our occupancy is well over 90% and we struggle on a daily basis to admit the patients booked for elective surgery
Our Inspection report was released in June this year and it highlighted a number of things that the CQC saw as markers of success in assigning their rating
I’m going to very briefly outline our approach to some of of these, in the hope that it may be of some interest to you
In terms of Outcomes:
I don’t know if I’m the only person who sometimes sits in the audience and Googles this data about the speaker’s centre of excellence as a credibility check, but anyway
To have the ICNARC CMP providing validated national benchmarking across the system is enormously powerful
Making it available on the web to the public also leads the way
Prof Sir Mike Richards, the Chief Inspector of Hospitals, is on record (at ICNARC meeting this year) saying that Critical Care is the easiest of the Core Services to inspect, starting as it does with a foundation of high-quality and transparently shared data
But superb though the CMP program is, those measures may not be the only important objective markers of quality
There are other useful indicators:
Some time ago we felt that CVC-BSI were an important marker of quality and avoidable harm for us, so we started collecting data prospectively, before the UK’s MM project
We now have data more than 6 years worth of data, on nearly 20,000 CVC DAYS, and as well as reassuring us that our infection rate remains low, what this has done is convinced me at least, that it is the continual surveillance itself that has driven quality, more than some of the specific interventions implemented with MM
(We do NOT and have never used BIOPATCH dressings for example…)
I’m going to mention this only in passing, given that it will have little relevance unless you are about to be involved in designing a new build
The CQC commented specifically on the quality of the designed space on our unit, and we are certainly very fortunate that having clinicians (both senior nurse and consultant) lead the design process over a 9 year period, we were able to get a lot of things at least close to the way we wanted them
But there are also things we would do differently now, and if anyone is about to embark on a design process and wants to talk about the lessons we learned I’ll be only too happy to do so over coffee.
What I would like to spend some time on and something that we have invested some time and effort on, is to begin trying to embed a deeper culture of safety across the unit
A couple of years ago we formalized a daily Safety Brief (with obvious reference to WHO Surgical Checklist)
We now do this at the same time EVERY day; with all medical staff, physios, pharmacists and nurses in charge attending
We try and keep it to literally 5 minutes…
Describe it in its stages…
Flattens hierarchy; Shares awareness of specific risks
Encourages/empowers junior staff to speak up
Reassures staff that its OK to talk about mistakes and near-misses, as an opportunity for the whole team to learn
Encouragingly, this small, no-cost change seems to have had real impact on awareness and anticipation of risks, especially in junior staff
The feedback from rotating medical SHO and REG staff has been very positive indeed, with many of them wanting to implement similar interventions when they move on
It’s also now being adopted, in locally adapted format, across our Trust, especially in other high risk areas (such as ED)
One of the things that has come out of daily safety discussions is a greater awareness of “NEAR MISSES”
And in response to one of these (a misplaced gastric tube) we’ve also introduced a series of visually high-impact Watch Out Notices
They’re designed to be punchy, quick lessons on every day risks
Now, when these sort of things happen they are shortly followed by the appearance on notice boards & toilet doors of these sort of notices highlighting the specific risk and how to avoid it
Because there’s only so much space on the toilet doors (and we’re not allowed to stick things on most walls)
To publiscise them even more effectively (and also transparently) we’ve also put in these SAFETY SCREENS, in publically visible areas of the units, which continually scroll through safety information such as these Notices, but also National Safety Alerts, up to date HCAI rates and other recurrent hazards or risks
Spirit of openness about risks, also helps mould culture
These things have, I think, all been contributions to promoting a more safety and quality-conscious culture and one in which we more rapidly and openly talk about and learn lessons from incidents.
It has also made our formal incident reporting much more effective
It has spread awareness of the potential impact of Human Factors and most has definitely helped empower more junior staff to speak up about the things they see
So it feels like there is something of a virtuous cycle of ongoing improvement under way at the moment…
But of course the key element that leads quality and success in our service is the way the teams work together…
The consultants all have an annualized job plan, with Critical Care as the principle and priority part
We have non-anaesthetics trained ICM consultants (renal, resp and ED background) and we all work exactly the same Critical Care work pattern
We work on the unit for 7 days running, and the weekend is no different to weekdays
I think our staff would say we are we’re very hands-on and physically present on the unit, including at night
Our focus is very much on trying to ensure continuity and consistency in the way we support the unit
Our trainees work in one of two tiers
The SHO tier is predominantly staffed by people without ICM experience or airway skills and so we are very dependent on the REG and CONSULTANTS
With the frequency of rotations, we now run a 2 day induction every 4/12
We try very hard to protect the trainees training experience, and their rota banding limitations, despite the increasing gaps in REG numbers that we are all experiencing
And in the hope of sustaining our service in the face of dwindling numbers and increasing demand we have started funding new posts, such as:
-ECHO Fellow post CCT
-South Coast Perioperative Audit & Research Collaborative – ICM, partly research post, funded jointly with SUHT. A superb Wessex trainee run Research and Audit collaboration. Sadly I don’t have time to talk about it now, but ask me later.
- ACCPs, which we are soon to start training
Our senior nursing staff made the conscious decision not to use Agency staff, and we are very fortunate to have an incredibly flexible workforce, who often change their shifts around at short notice, to cover the unit
We actively encourage nurses to take additional on responsibilities and many of them will routinely lead discussions on the ward round
With an increasing number of newly qualified and new starter (inc foreign) nurses, we have Education Team deliver a rigorous competency-based program of support and training, allowing them to settle in before “going live”
Across staff groups, the CQC identified the emphasis and delivery of Education and Training in the Department, and I’m sure most people would agree that training our future colleagues well is a valid marker of quality and success
Something we introduced a while ago, partly in response to the numbers of junior staff, and increasing frequency of rotations, and partly because our Trust’s guidelines system is so bad, are Standard Operating Procedures..
The idea being to make single page readily-accesable bedside guidance, for use by all staff
They have been hugely well-received, and new ones appear on a regular basis
We’ve also started sharing them openly, and they are available for anyone to see and download on our website (link at the end)
One of the other main ways of looking at success, of course, is in terms of PATIENT or RELATIVE experience
Long-established (strongly nurse-led) Follow-up clinic
Asks all appointments “what could we have done better and provision of ICU-stay diaries on request
Relatives are asked to complete generic F&F survey, but it’s a very blunt tool so we use our own dedicated questionnaire, and these are a coupler of snapshots from that
Q1: what do you think ofthe organisation of the Critical Care
Q2: Was the privacy and dignity of your relative maintained
And this provides useful information, that hopefully will continue to inform improvement
Where we certainly need to improve and a quality focus (that is of course capacity-limited) and I think will become more I mportant again nationally is related to CANCELLATIONS and NIGHTIME discharges
AND FINALLY, more recently..
Following increased engagement with the National Staff Survey, we’ve been trying to get a better idea of what our staff think about the quality of our service
Recently we distributed a very simple questionnaire asking:
“What works well”
These things seem to be everywhere at the moment, so here we go…
As I’m sure you know…
This is a word cloud that summarizes the key themes – the larger the word appears the more it appeared in responses
I suspect others may be more advanced than we are in this respect, but we have also started asking the corollary question:
“What areas need improvement…”
They really speak for themselves but one hopes this sort of information may provide some additional leverage in discussions with the Trust about spending priorities, as well as some insights into internal process problems that we can improve on
(Note that I’m already addressing the bottom one…)
SO IN SUMMARY…
I think, despite the pressures on the system, Critical Care in the UK is already in a great position and will continue building on its success
We have well-established benchmarking with Nationally validated outcome data, which few other countries (or UK specialties) can aspire to
Outcome data alone is probably not enough, locally determined indicators of quality also need to be measured and monitored, and in so doing drive quality improvement
Over the next few years, I think we will be making much more use of patient & relative experience in driving new aspects of quality, and getting far more effective at harnessing our own staff’s ideas and perceptions about the service they deliver
I have become convinced of the benefit that some low cost, big impact changes (such as introducing Daily Safety Briefs) has had on increasing the awareness, anticipation and discussion of risks across all staff groups and the cultural change that follows
As this culture develops and matures I would hope to see a real shift from a predominantly constraint and rule-based approach to safety and quality, to one that is far more intelligent and responsive, grounded on increased awareness and behaviours that anticipate and respond to risk and will further drive improvements in quality and safety.
I’d like to thank all the staff past and present in our Dept of Critical Care, but particularly to recognise the contributions of Dr Bruce Taylor, ex-president of the ICS, and retired Critical Care Consultant in Portsmouth. Without any doubt the best and most committed clinician I’ve ever worked with, and someone who ceaselessly led the drive for better and safer services in Critical Care in Portsmouth, and the wider NHS.
Sadly forced into early retirement by disabling early onset dementia, and no longer able to do the job that he devoted his life to.
For all that you did to make Critical Care successful thank you Bruce.
I’m just going to leave you with a few sources of reference relating to some of the things I’ve described
Our Guidelines, SOPs and Watch Out notices are available on our Website
Follow us on Twitter
Check out the Bottom Line
And please link up with our trainees in the South Coast Perioperative Audit & Research Collaborative–ICM
