Team-Based Process Improvement: The Core of Best ICU Practices

2015 - 6 December - Quality Improvement
This article discusses a Society-produced document that updated guidelines produced in 2001 that concentrated on best practices for critical care delivery.

In the July 2015 issue of Critical Care Medicine, the article, “Critical Care Delivery: The Importance of Process of Care and ICU Structure to Improved Outcomes: An Update From the American College of Critical Care Medicine Task Force on Models of Critical Care,” revisited recommendations for critical care delivery and processes as enumerated in guidelines (“Critical Care Delivery in the Intensive Care Unit: Defining Clinical Roles and the Best Practice Model”) produced by the Society of Critical Care Medicine in 2001. Those recommendations stated, in part, that model intensive care units (ICUs) should: be intensivist-led; be directed by ICU teams under a “closed” format in which the team takes ownership of all aspects of patient care; allow ICU physicians to be available for medical and administrative tasks without competing clinical responsibilities; require that ICU physicians and nurses be credentialed for critical care; include critical care pharmacists and full-time respiratory care practitioners; and have multidisciplinary governance.

Fourteen years later, the Task Force on Models of Critical Care found those recommendations fundamentally sound but worthy of further clarification and refinement. Task force co-chair, Andrew J. Patterson, MD, PhD, FCCM (who is currently the Executive Vice Chair of the University of Nebraska’s Department of Anesthesiology), discussed the key points and importance of these refinements with Critical Connections.

CC: What distinguishes the conclusions in the 2015 update from those found in the 2001 guidelines?
Patterson: The 2001 document offered practice model guidelines. The 2015 publication is an update of those guidelines. There has not been enough data gathered to completely revise the 2001 guidelines.

CC: The 2015 update outlined key revisions/clarifications, as detailed below. First, the task force discussed the 2001conclusion that “an intensivist-led, high-performing, multidisciplinary team dedicated to the ICU is an integral part of effective care delivery.” Did you find this to still hold true?
Patterson: The team approach to critical care delivery is still considered most important, because it builds in redundancies that keep things from falling through the cracks, and different individuals bring their expertise to bear. The consensus continues to be that a multidisciplinary team is most effective. Synchronization between team members is also important. What’s new in 2015 is the acknowledgement that it’s not always necessary to have around-the-clock intensivist coverage in the ICU.

CC: Second, the task force stated that “process improvement is the backbone of achieving high-quality ICU outcomes.” What do you see on the horizon for process improvement?
Patterson: There is broad agreement that the best way institutions can improve ICU care is to have clearly defined processes in place.  Hospitals and health systems are sharing their processes more now than in the past.  They are less proprietary about how they do things, and that’s being combined with an emphasis on standardization throughout the industry. As processes are shared more and more, standardization will become the norm.

CC: The task force also determined that “standardized protocols, including care bundles and order sets, facilitate measurable processes and outcomes which can be modified and improved as needed. The importance of measurement cannot be overemphasized.” Explain how the task force reached this conclusion.
Patterson: Guidelines and protocols are designed to be universal in scope.  In addition, they are carefully vetted and peer-reviewed.  Several studies published after 2001 suggest that guidelines and protocols are beneficial, in part, because they encourage processes and generate results that can be measured, evaluated over time, and compared.
CC: Finally, the 2015 update stated that “institutional support for measurement must be provided in order to optimize the success of process improvement efforts.” Can you explain further?
Patterson: The idea is that institutions and healthcare systems need to reward healthcare professionals for participating in process improvement. Clinicians should get credit and financial reward for participating in these activities. These activities should be considered no less important than continuing medical education.

CC: What role does the tele-ICU play in the future of the above recommendations?

Patterson: Tele-ICU has developed significantly since 2001, and it has forced us to look at what “presence” means in the ICU. Although there are certainly benefits of full-time, on-site dedicated intensivists, they are not always available around the clock.  There is now evidence that tele-ICU improves patient outcomes in some instances and that it can effectively become an extension of the full-time intensivist model.  For example, tele-ICU appears to be useful in rural and remote locations.  That being said, we do need more data before definitive conclusions with regard to tele-ICU can be made.

CC: Given these recommendations, how do you envision the ideal ICU of the future?
Patterson: The ideal ICU of the future will depend on the patient population, resources and personnel available.  I would expect, for example, big differences between an ideal urban trauma center ICU and an ideal rural Nebraska medical center ICU.

CC: What are the biggest challenges to implementing these recommendations?
Patterson: Money. There has been a tension within healthcare institutions about finances and reducing costs. I believe we can have ICUs that are both clinically effective and cost effective.

CC: What takeaways can clinicians gain from this update to improve their own daily practice?
Patterson: Clinicians should participate in multicenter trials on process improvement. It’s challenging to reward them for participation, but the best information will come from big data sets (repositories).  That means clinician participation will be essential. The more physicians participate, the better—and the more useful the data.