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President's Message: Quality Improvement in the ICU

It has been a pleasure and a privilege to represent the Society of Critical Care Medicine (SCCM) at many different critical care meetings around the world. While you might anticipate that the issues facing clinicians in different regions of the globe would differ by region, there is instead overwhelming commonality. We all face similar issues such as patient care space, staffing, electronic health record documentation burden, medication availability, and patient and clinician safety. Each of these issues impacts the quality of care that we can provide to inpatients; many also exert far-reaching effects in the outpatient setting as well. Regardless of where you practice around the globe or the extent of resources that are available, we share the common challenge of trying to improve patient care quality as one means of improving outcomes. Delivering high-value, high-quality care at the lowest appropriate cost has become a goal for many clinicians and health systems around the world. Indeed, this theme was the focus of SCCM’s immediate Past President Jerry J. Zimmerman, MD, PhD, FCCM, with his inspiring slogan “Less is More.” Zimmerman has shared that message around the world, and I have seen the durable interest in pursuing high-value care as a global initiative.

From its inception, SCCM has embraced improving the quality of patient care, initially focused on those needing critical care. You are all familiar with SCCM’s mission statement, which is to provide the highest-quality care for all critically ill and injured patients. This mission addresses vast numbers of patients. For example, about 6 million patients are admitted to ICUs in just the United States every year, and at least 15% of them require mechanical ventilation. Intensivist-led teams are at the forefront of evaluating, measuring, and improving quality and safety wherever critical care is provided. Each member of the team makes important contributions to that process.

Several years ago, as part of SCCM’s enduring efforts in enhancing quality, we assembled an accomplished group of academic leaders in critical care medicine (ALCCM). Their initial charge was to explore how existing and emerging issues impact the structure and function of critical care organizations. The ultimate goal was to help improve how critical care organizations deliver care as a key driver of improved patient care quality. One of the initial articles published by ALCCM was “Critical Care Organizations: Business of Critical Care and Value/Performance Building,” which provided a road map and key features to be considered when planning a value-based care program.1 A more recent publication by ALCCM detailed the existing workforce and how current staffing influences both workload and burnout. They note the importance of enhanced team communication and reduction of practice variation as being integral to improved patient outcomes.2 Interwoven in this process is support around compensation for resource shortages such as medications. SCCM’s Clinical Pharmacy and Pharmacology Section continually updates its web-based guide to support high-quality patient care during periods of drug shortages.

The structure and function of SCCM are organized and coordinated across seven business lines. The quality and safety line houses some of SCCM’s biggest programs. The Surviving Sepsis Campaign (SSC), ICU Liberation, and guidelines programs anchor this business line. The SSC has been instrumental in changing the face of sepsis care worldwide. Curating and generating high-quality evidence has led to iterative guidelines employed worldwide. These guidelines are accompanied by implementation guides—bundles—that set guideposts for achieving high-quality care. Importantly, the SSC, as a quality program, is a team event derived from SCCM’s partnership with the European Society of Intensive Care Medicine. Both the guidelines and the bundles have been effective in improving survival from sepsis and septic shock. Recent data from New York State documented that rapid antibiotic administration and adherence to all of the elements of the three-hour bundle directly improved survival rates.3

The SSC is not the only program that effectively uses the bundle approach to improve outcomes and enhance care quality. SCCM’s ICU Liberation program and the ABCDEF bundle demonstrate similar success at improving quality and survival. Survival increases as the care team increasingly complies with elements of the ABCDEF bundle; the greatest enhancement in survival was noted when the team used all of the bundle elements.4 These findings were replicated in a more recent study in which decreases in delirium, mechanical ventilation days, and ICU and hospital lengths of stay were accompanied by improved survival.5 There may even be a dose-related impact of bundle elements as benefits accrue even with partial compliance. The most recent study noted an increase in patient-reported pain, underscoring that opportunities remain for further quality improvement.

The American College of Critical Care Medicine (ACCM) is responsible for the guidelines that SCCM produces. These evidence-based guidelines cover all aspects of critical care medicine. The guideline process is robust in employing professional librarian support and world-class methodologists to acquire and assess the evidence on which the guidelines rest. Reflecting SCCM’s team-based approach to quality, the guidelines also benefit from expert input from other organizations with whom SCCM partners. Where sufficient evidence does not exist to warrant a guideline, the ACCM offers other quality guidance in the form of practice statements or consensus statements that reflect expert synthesis of current data to inform high-quality care in a financially responsible fashion.

The Choosing Wisely campaign, spearheaded by the American Board of Internal Medicine, focused on overuse of tests, treatments, and procedures that are of little benefit to patients but contribute to the high cost of healthcare. Professional societies were challenged to develop top five lists that patients and physicians should question. We participated in the initial Choosing Wisely Campaign as part of an initiative with the Critical Care Societies Collaborative (CCSC). The CCSC is made up of the American Association of Critical-Care Nurses, American College of Chest Physicians, American Thoracic Society, and SCCM. Together we developed five recommendations that would lead to higher quality and lower cost of care in the field of critical care (Table 1).6



Many elements within SCCM that support developing and delivering high-quality care also provide high value. SCCM depends on your innovation and dedication to continue to improve care quality and safety worldwide. I encourage you to seek ways to continue the focus on this important effort both in your local institution and on the national level with the Society. You never know what important improvements in patient care will be discovered. Be the ripple of change.
 

References 

  1. Leung S, Gregg SR, Coopersmith CM, et al; Academic Leaders in Critical Care Medicine Task Force of the Society of Critical Care Medicine. Critical care organizations: business of critical care and value/performance building. Crit Care Med. 2018 Jan;46(1):1-11. 
  2. Pastores SM, Kvetan V, Coopersmith CM, et al; Academic Leaders in Critical Care Medicine (ALCCM) Task Force of the Society of Critical Care Medicine. Workforce, workload, and burnout among intensivists and advanced practice providers: a narrative review. Crit Care Med. 2019 Apr;47(4):550-557. 
  3. Seymour CW, Gesten F, Prescott HC, et al. Time to treatment and mortality during mandated emergency care for sepsis. N Engl J Med. 2017 Jun 8;376(23):2235-2244. 
  4. Barnes-Daly MA, Phillips G, Ely EW. Improving hospital survival and reducing brain dysfunction at seven California community hospitals: implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Crit Care Med. 2017 Feb;45(2):171-178. 
  5. Pun BT, Balas MC, Barnes-Daly MA, et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med 2019 Jan;47(1):3-14. 
  6. Halpern SD, Becker D, Curtis JR, et al; Choosing Wisely Taskforce; American Thoracic Society; American Association of Critical-Care Nurses; Society of Critical Care Medicine. An official American Thoracic Society/American Association of Critical-Care Nurses/American College of Chest Physicians/Society of Critical Care Medicine policy statement: the Choosing Wisely® Top 5 list in critical care medicine. Am J Respir Crit Care Med. 2014 Oct 1;190(7):818-826.