The ICU Corner: Safety Practices Target ICU Patients

by Richard C. Prielipp, MD, FCCM

Note: Welcome to the "ICU Corner." This recurring section of the APSF Newsletter will strive to keep anesthesiologists abreast of current issues, insights, concerns, technology, and controversies relevant to the safe perioperative care of critically ill patients. In that regard, physicians should be aware of recent AHRQ recommendations designed to improve patient safety, many which directly apply to the ICU and operating room environment.

AHRQ

The Agency for Healthcare Research and Quality (AHRQ) recently published an important evidence-based report entitled, "Making Health Care Safer: A Critical Analysis of Patient Safety Practices." This report is AHRQ publication 01-E058, prepared by the Evidence-based Practice Center at the University of California at San Francisco (UCSF)-Stanford University, and is available online at: http://www.ahrq.gov/clinic/ptsafety/. Note that this PDF file is 2.1 megabytes, and represents a document of about 650 pages!

Publication of the Institute of Medicine (IOM) report citing widespread patient injury and even death while receiving medical care [Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System, Washington, DC: National Academy Press; 1999] sounded the alarm for both the public and health care professionals. Statistics suggest that medical errors may contribute to 40,000 or more patients deaths per year in U.S. hospitals. AHRQ quickly responded to the IOM alarm by collecting existing evidence which could provide immediate guidance to institutions and clinicians on select practices to improve patient safety. These recommended practices most often promote systems changes to reduce medical error, rather than the identification and punishment ("retraining") of individual practitioners.

The Report: 11 Safety Practices You can Start Now

AHRQ identified 11 specific practices (out of a total of 79 such recommendations) which were rated most highly because of corroborating clinical evidence sufficient to justify their immediate widespread implementation:

• Routine venous thromboembolism prophylaxis for patients at risk
• Use of perioperative beta-blockers whenever feasible to prevent mortality
• Routine use of maximal sterile barriers while placing central venous catheters
• Real-time ultrasound guidance during insertion of central venous catheters
• Appropriate use of antibiotic prophylaxis in surgical patients
• Greater attention to the informed consent process, such as asking patients to recall and restate their understanding of the consent discussion
• Continuous aspiration of subglottic secretions (CASS) to decrease the incidence of ventilator-associated pneumonia (VAP)
• Optimal use of pressure-relieving bedding materials to reduce pressure ulcers
• Patient self-management for warfarin to prevent complications
• Appropriate provision of early enteral nutrition for critically ill and surgical patients
• Use of antibiotic-impregnated central venous catheters

Summary

This evidence-based approach is a timely effort to assist clinicians "in the trenches" with a mechanism to expedite change within their institutions to promote patient safety. As always, thoughtful consideration should be given to how these practices would fit into the clinical paradigm at a specific institution, and I would urge clinicians to read the corroborating evidence in detail before full-scale implementation. This is especially true regarding issues like costs, and other potential implementation hurdles. Nonetheless, this is a great resource which summarizes one agency's view of "best practices" to improve safety for perioperative patients.

Dr. Prielipp is Section Head, Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, NC.