Patient safety in intensive care units

Dear Medical Staff Leader:

The Wall Street Journal has done it again. After publishing an article several weeks ago addressing best practices for reducing surgical infection rates, the newspaper last week (September 25, 2003)published an article addressing best practices in the intensive care unit (ICU). As was the previous article, the article on ICUs is worth reading. If you haven't seen it, ask your library to make copies of this story available. You may even want to post both articles in a public place, such as the medical staff lounge, to encourage discussion among medical staff members.

The message of the surgical infection rate article (discussed by Hugh Greeley in the September, 18, 2003 issue of Medical Staff Leader Connection) was that following established guidelines with discipline and consistency can reduce surgical infections by 40% to 60%. The message of last week's ICU article is that we are still learning best practices for treating ICU patients.

Referencing ground-breaking VHA and IHI initiatives, the article identifies improvements that may decrease ICU mortality rates by 20%. According to the article, U.S. hospitals admit 5 million ICU patients a year, and these patients experience a 10% mortality rate, which translates into 500,000 patients. A 20% reduction in mortality would save 100,000 lives annually.

One of the article's findings, which should not surprise any of us who have worked in ICUs, is that we often fail to follow established procedures. One ICU that engaged in the VHA improvement initiative followed all the ventilator guidelines only 25% of the time. After initiating improvements, they comply with the guidelines more than 90% of the time.

The article also referenced the best practice of involving families in the care of their loved ones. Extended visiting hours, even 24/7 visiting, appears to improve family involvement while potentially improving clinical outcomes. Involving families who ask the right questions and do the right things can reduce medical errors. The article identifies an "ICU Checklist" for family members. The questions on this checklist go directly to the heart of whether your ICU has adopted and implemented best practices, including evidence-based practices.

So what will you, a physician leader, do in response to this article? Is it business as usual, or will you use this article to stimulate discussion among the medical staff and perhaps even take action? The recommended best practices are challenging--expecting stringent compliance with approved guidelines and encouraging families to question the treatment we provide. Physicians will undoubtedly resist such changes with claims that guidelines are equal to "cookbook medicine" and interfere in the practice of medicine. Are such assertions correct or are these changes a sign of what's to come in medicine--taking steps to reduce the unacceptably high rate of patient injury and delayed healing?

Physicians may also assert that establishing guidelines can lead to plaintiff attorneys' claims that not following the guidelines constitutes negligent care. Does that mean we shouldn't establish guidelines, or does it mean we should develop systems and processes to ensure we follow approved guidelines consistently?

Use this article to get a debate about these issues going within your medical staff. It's a great contribution you can make as a medical staff leader.

That's all for this week.

All the best,

Rick Sheff, MD