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Biomedical subjects

Peter Pronovost

Publications and source records attributed to Peter Pronovost.

At least 19 recordsLinked to original sources
PubMed2006

An intervention to decrease catheter-related bloodstream infections in the ICU.

BACKGROUND: Catheter-related bloodstream infections occurring in the intensive care unit (ICU) are common, costly, and potentially lethal. METHODS: We conducted a collaborative cohort study predominantly in ICUs in Michigan. An evidence-based intervention was used to reduce the incidence of catheter-related bloodstream infections. Multilevel Poisson regression modeling was used to compare infection rates before, during, and up to 18 months after implementation of the study intervention. Rates of infection per 1000 catheter-days were measured at 3-month intervals, according to the guidelines of the National Nosocomial Infections Surveillance System. RESULTS: A total of 108 ICUs agreed to participate in the study, and 103 reported data. The analysis included 1981 ICU-months of data and 375,757 catheter-days. The median rate of catheter-related bloodstream infection per 1000 catheter-days decreased from 2.7 infections at baseline to 0 at 3 months after implementation of the study intervention (P< or =0.002), and the mean rate per 1000 catheter-days decreased from 7.7 at baseline to 1.4 at 16 to 18 months of follow-up (P<0.002). The regression model showed a significant decrease in infection rates from baseline, with incidence-rate ratios continuously decreasing from 0.62 (95% confidence interval [CI], 0.47 to 0.81) at 0 to 3 months after implementation of the intervention to 0.34 (95% CI, 0.23 to 0.50) at 16 to 18 months. CONCLUSIONS: An evidence-based intervention resulted in a large and sustained reduction (up to 66%) in rates of catheter-related bloodstream infection that was maintained throughout the 18-month study period.

Adult↗
PubMed2006

Intensive care unit quality improvement: a "how-to" guide for the interdisciplinary team.

OBJECTIVE: Quality improvement is an important activity for all members of the interdisciplinary critical care team. Although an increasing number of resources are available to guide clinicians, quality improvement activities can be overwhelming. Therefore, the Society of Critical Care Medicine charged this Outcomes Task Force with creating a "how-to" guide that focuses on critical care, summarizes key concepts, and outlines a practical approach to the development, implementation, evaluation, and maintenance of an interdisciplinary quality improvement program in the intensive care unit. DATA SOURCES AND METHODS: The task force met in person twice and by conference call twice to write this document. We also conducted a literature search on "quality improvement" and "critical care or intensive care" and searched online for additional resources. DATA SYNTHESIS AND OVERVIEW: We present an overview of quality improvement in the intensive care unit setting and then describe the following steps for initiating or improving an interdisciplinary critical care quality improvement program: a) identify local motivation, support teamwork, and develop strong leadership; b) prioritize potential projects and choose the first target; c) operationalize the measures, build support for the project, and develop a business plan; d) perform an environmental scan to better understand the problem, potential barriers, opportunities, and resources for the project; e) create a data collection system that accurately measures baseline performance and future improvements; f) create a data reporting system that allows clinicians and others to understand the problem; g) introduce effective strategies to change clinician behavior. In addition, we identify four steps for evaluating and maintaining this program: a) determine whether the target is changing with periodic data collection; b) modify behavior change strategies to improve or sustain improvements; c) focus on interdisciplinary collaboration; and d) develop and sustain support from the hospital leadership. We also identify a number of online resources to complement this overview. CONCLUSIONS: This Society of Critical Care Medicine Task Force report provides an overview for clinicians interested in developing or improving a quality improvement program using a step-wise approach. Success depends not only on committed interdisciplinary work that is incremental and continuous but also on strong leadership. Further research is needed to refine the methods and identify the most cost-effective means of improving the quality of health care received by critically ill patients and their families.

Advisory Committees↗
PubMed2006

Shepherding change: how the market, healthcare providers, and public policy can deliver quality care for the 21st century.

BACKGROUND: Data are scarce that inform the ways consumers of health care and caregivers help improve the care that is delivered. The healthcare system is quite broad. To improve it, we first must understand it, understand its various subsystems, and understand how they shape individual behavior. DISCUSSION: Both consumers and providers can effectively improve health care. An example of an influential consumer is provided, focusing a successful effort to improve care in the intensive care unit. The overall model for improving outcomes assumes providers can be classified into high-quality and low-quality providers. The model then aims to increase the number of people exposed to high-quality caregivers. There are three primary levers for driving this change: using market forces, provider improvements, and policy change. This article touches briefly on the first and focuses on the second and third. CONCLUSION: A number of grassroots programs highlight ways providers can improve care by approaching patient safety and quality as a science. In addition, the Josie King Act and its legislative progeny provide some hope that a new policy environment can reward and reinforce providers' efforts to drive up safety and quality.

Delivery of Health Care, Integrated↗
PubMed2006

How will we know patients are safer? An organization-wide approach to measuring and improving safety.

OBJECTIVE: Our institution, like many, is struggling to develop measures that answer the question, How do we know we are safer? Our objectives are to present a framework to evaluate performance in patient safety and describe how we applied this model in intensive care units. DESIGN: We focus on measures of safety rather than broader measures of quality. The measures will allow health care organizations to evaluate whether they are safer now than in the past by answering the following questions: How often do we harm patients? How often do patients receive the appropriate interventions? How do we know we learned from defects? How well have we created a culture of safety? The first two measures are rate based, whereas the latter two are qualitative. To improve care within institutions, caregivers must be engaged, must participate in the selection and development of measures, and must receive feedback regarding their performance. The following attributes should be considered when evaluating potential safety measures: Measures must be important to the organization, must be valid (represent what they intend to measure), must be reliable (produce similar results when used repeatedly), must be feasible (affordable to collect data), must be usable for the people expected to employ the data to improve safety, and must have universal applicability within the entire institution. SETTING: Health care institutions. RESULTS: Health care currently lacks a robust safety score card. We developed four aggregate measures of patient safety and present how we applied them to intensive care units in an academic medical center. The same measures are being applied to nearly 200 intensive care units as part of ongoing collaborative projects. The measures include how often do we harm patients, how often do we do what we should (i.e., use evidence-based medicine), how do we know we learned from mistakes, and how well do we improve culture. Measures collected by different departments can then be aggregated to provide a hospital level safety score card. CONCLUSION: The science of measuring patient safety is immature. This article is a starting point for developing feasible and scientifically sound approaches to measure safety within an institution. Institutions will need to find a balance between measures that are scientifically sound, affordable, usable, and easily applied across the institution.

Forecasting↗
PubMed2005

Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.

BACKGROUND: A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January 2004, teams of critical care clinicians from 61 health care organizations participated in a collaborative on improving care in the ICU. METHODS: ICU team members posted data monthly on a Web-based extranet and submitted narrative descriptions describing the changes tested and the strategies implemented. RESULTS: For the 35 units that consistently collected data on ventilator bundle element adherence and VAP rates, an average 44.5% reduction of VAP was observed. DISCUSSION: The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability. The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs.

Canada↗
PubMed2005

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

BACKGROUND: Voluntary incident reporting systems that identify risks can be integrated into existing hospital reporting systems and can improve patient safety. FINDINGS: A voluntary and anonymous Web-based intensive care unit safety reporting system (ICUSRS) was implemented in a cohort of intensive care units (ICUs). The reporting system was integrated into hospitals' reporting systems after the adverse event reporting structures were investigated. Reporting systems were classified as mandatory or voluntary and internal or external; the extent of formal training was identified and the trajectory of completed adverse events in the exisiting systems were tracked. Information from reported incidents was sent back monthly to the hospital ICUs through case discussions and a quarterly newsletter. RESULTS: All seven hospitals had internal reporting systems and two also used external reporting systems. In general, the majority of incident reports were completed by registered nurses and were reported to the nursing chain of command. Many of the sites had little knowledge or understanding of their existing reporting systems. CONCLUSION: Voluntary external reporting systems such as the ICUSRS hold promise for improving patient safety.

Hospital Information Systems↗
PubMed2004

Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care.

OBJECTIVE: Transportation of critically ill patients within the hospital poses important risks. We sought to identify causes, outcomes and contributing factors associated with intra-hospital transport. DESIGN: Cross-sectional case review. SETTING: Incident reports submitted to the Australian Incident Monitoring Study in Intensive Care (AIMS-ICU). MEASUREMENT AND MAIN RESULTS: Between 1993 and 1999, 176 reports were submitted describing 191 incidents. Seventy-five reports (39%) identified equipment problems, relating prominently to battery/power supply, transport ventilator and monitor function, access to patient elevators and intubation equipment. Hundred sixteen reports (61%) identified patient/staff management issues including poor communication, inadequate monitoring, incorrect set-up of equipment, artificial airway malpositioning and incorrect positioning of patients. Serious adverse outcomes occurred in 55 reports (31%) including major physiological derangement (15%), patient/relative dissatisfaction (7%), prolonged hospital stay (4%), physical/psychological injury (3%) and death (2%). Of 900 contributing factors identified, 46% were system-based and 54% human-based. Communication problems, inadequate protocols, in-servicing/training and equipment were prominent equipment-related incidents. Errors of problem recognition and judgement, failure to follow protocols, inadequate patient preparation, haste and inattention were common management-related incidents. Rechecking the patient and equipment, skilled assistance and prior experience were important factors limiting harm. CONCLUSIONS: Intra-hospital transport poses an important risk to ICU patients. The adequate provision of highly qualified staff, specially designed and well maintained equipment, as well as continuous monitoring are essential to avoid/mitigate these incidents. Professional societies and local units should adopt guidelines/protocols for intra-hospital transportation. Monitoring of incidents should aid in the continuous improvement in patient safety.

Australia↗
PubMed2003

Medication reconciliation: a practical tool to reduce the risk of medication errors.

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient's discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Continuity of Patient Care↗
PubMed2003

Improving communication in the ICU using daily goals.

BACKGROUND: Clear communication is imperative if teams in any industry expect to make improvements. An estimated 85% of errors across industries result from communication failures. PURPOSE: The purpose of this study was to evaluate and improve the effectiveness of communication during patient care rounds in the intensive care unit (ICU) using a daily goals form. DESIGN: We conducted a prospective cohort study in collaboration with the Volunteer Hospital Association (VHA), Institute for Healthcare Improvement (IHI), and Johns Hopkins Hospital's (JHH) 16-bed surgical oncology ICU. All patients admitted to the ICU were eligible. Main outcome variables were ICU length of stay (LOS) and percent of ICU residents and nurses who understood the goals of care for patients in the ICU. Baseline measurements were compared with measurements of understanding after implementation of a daily goals form. RESULTS: At baseline, less than 10% of residents and nurses understood the goals of care for the day. After implementing the daily goals form, greater than 95% of nurses and residents understood the goals of care for the day. After implementation of the daily goals form, ICU LOS decreased from a mean of 2.2 days to 1.1 days. CONCLUSION: Implementing the daily goals form resulted in a significant improvement in the percent of residents and nurses who understood the goals of care for the day and a reduction in ICU LOS. The use of the daily goals form has broad applicability in acute care medicine.

Cohort Studies↗
PubMed2003

Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review.

OBJECTIVE: Quality assurance techniques applied within the healthcare industry have been widely used and are intended to improve patient outcomes. Two methods that have been utilized are incident reporting and medical chart review (MCR). The objectives for this study were to evaluate facilitated incident monitoring (FIM) and MCR in the intensive care setting. DESIGN: Cross-sectional comparison of prospective FIM and retrospective MCR. SETTING: Tertiary, 12-bed, closed intensive care unit (ICU) in Australia providing adult and pediatric intensive care to surgical, medical, trauma, and retrieval patients. PATIENTS: Patients present or admitted to the ICU during the 2-month study period. MEASUREMENT AND MAIN RESULTS: During the study period, there were 176 admissions involving 164 patients. A total of 100 FIM reports, of which 70 related to care provided by the ICU team, identified 221 incidents. There were 30 FIM reports that described adverse events, of which only one related to ICU team care. Potential of harm was estimated to be minimal in 49% and significant in 51%; 84% of incidents were considered preventable. Important contextual information was provided, including evidence for the importance of system factors. MCR identified 132 adverse events involving 48% of charts, and 47 related to ICU team care. Common adverse events included nosocomial infections, aspiration, neurologic compromise, respiratory arrest, delayed diagnosis, and treatment. Twenty percent of adverse events were considered preventable, and in 41%, there was evidence of system causation. CONCLUSION: FIM provided more contextual information about incidents and identified a larger number and higher proportion of preventable problems than MCR, but FIM identified few iatrogenic infections, problems with pain management, or problems leading to ICU admission. FIM is easily incorporated into the clinical routine. This study suggests that incident monitoring may be more useful for identifying quality problems, and it could be supplemented by selective audits and focused MCR to detect problems not reported well by FIM.

Adult↗
PubMed2002

Reorganizing the delivery of intensive care could improve efficiency and save lives.

Critically ill patients are at high risk for death and permanent disability. Their care is also very expensive. The method of delivering critical care services to these patients can have an impact on their clinical and economic outcomes. Researchers face significant challenges when attempting to identify an association between an intensive care unit (ICU) organizational characteristic and patient outcomes. In this paper we review the challenges faced when evaluating the impact of ICU organizational characteristics on patient outcomes and highlight ICU characteristics that are consistently associated with improved patient outcomes. These characteristics include: (i) the presence of specialist physicians devoted to the ICU; (ii) increased nurse : patient ratios; (iii) decreased use of tests and evaluations that will not change clinical management; (iv) development and implementation of evidence-based protocols and guidelines; (v) use of computer-based alerting and reminding systems; and (vi) having a pharmacist participate in daily rounds in the ICU. When implementing these in ICUs, it is important to evaluate the impact of these characteristics on patient outcomes. We provide a format for such an evaluation. Given the growing evidence supporting the association between specific ICU characteristics and improved patient outcomes, we hope the future realizes broad implementation of these beneficial characteristics.

Efficiency, Organizational↗
PubMed2002

Perioperative beta-blockers in high-risk patients.

One major risk to patients in the preoperative period is that of myocardial ischemia or infarction and cardiovascular death in high-risk patients. Historically, attempts to decrease the incidence of perioperative cardiac complications have focused on preoperative evaluation and identification of patients at risk for complications with referral for additional testing and/or revascularization. Evidence suggests that the use of perioperative beta-blockers in high-risk individuals can reduce the incidence of perioperative cardiac events. The Agency for Healthcare Research and Quality has identified that the use of perioperative beta-blockers can reduce perioperative morbidity and mortality. The focus of this article is to describe the evidence supporting perioperative beta-blocker use, to discuss potential barriers to their use, and to propose a strategy to improve their use.

Adrenergic beta-Antagonists↗
PubMed2002

Building safety into ICU care.

The Institute of Medicine's (IOMs) report, "To Err is Human," recently addressed patient safety in the United States, alerting the nation to the need for improved systems of health care. Seven main findings were addressed in this report, we focus on 3: (1) patient safety is a nationwide problem, (2) health care workers are not to blame, and (3) safety and harm are products of care systems. This article discusses systems in intensive care units (ICUs) and how these systems affect patient safety. We use a case example to outline the complex chain of medical and administrative system failures that can result in an adverse event. Then we discuss evidence linking ICU organizational characteristics with patient safety, focusing on how safer systems in ICUs can directly improve patient care.

Aged↗
PubMed2002

ICU incident reporting systems.

Intensive care is one of the largest and most expensive components of American health care. Studies suggest that errors and resulting adverse events are common in intensive care units (ICUs). The incidence may be as high as 2 errors per patient per day; 1 in 5 ICU patients may sustain a serious adverse event, and virtually all are exposed to serious risk for harm. Theories of error developed in aviation and other high-risk industries suggest that errors are likely to occur in all complex systems. Reporting of incidents, including both adverse events and near misses, is an essential component for improving safety. Voluntary, confidential reporting is likely to be more important than mandatory reporting. There have been a few efforts to apply such systems in medicine. In intensive care, the Australian Incident Monitoring System (AIMS)-ICU has been the most prominent. We have designed a Web-based ICU Safety Reporting System (ICUSRS). The goal is to identify high-risk situations and working conditions, to help change systems, and reduce the risk for error. The analysis and feedback of reports will inform the design of interventions to improve patient safety. The effort is aided substantially by collaboration with the 30 participating ICUs and important stakeholders including the Society of Critical Care Medicine, the American Society for Health-care Risk Management, the Food and Drug Administration Center for Devices and Radiological Health, the Foundation for Accountability, and the Leapfrog Group. A demonstration and evaluation of the system is underway, funded by the Agency for Healthcare Re-search and Quality.

Disclosure↗
PubMed2002

Intensive care unit errors: detection and reporting to improve outcomes.

Most efforts to identify and investigate errors in medicine have focused on active failures and general provider behaviors. We believe that the greatest improvements in error identification and management in the intensive care unit will be achieved by focusing on the intensive care unit's organizational characteristics. The results of three recent studies suggest that differences in intensive care unit organizational characteristics are significantly related to variation in the risk-adjusted morbidity and mortality. Physicians must assume greater leadership in creation of these safe systems for intensive care patients. We encourage the creation of multi-institutional communities to work collaboratively to advance patient safety in high-risk environments like the intensive care unit.

Journal Article↗
PubMedDate not supplied

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P=.02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

Accreditation↗