Intensive Care Unit without walls: Seeking patient safety by improving the efficiency of the system

doi:10.1016/j.medin.2014.02.001

Medicina Intensiva

Volume 38, Issue 7, October 2014, Pages 438-443

https://doi.org/10.1016/j.medin.2014.02.001 Get rights and content

Abstract

The term “ICU without walls” refers to innovative management in Intensive Care, based on two key elements: (1) collaboration of all medical and nursing staff involved in patient care during hospitalization and (2) technological support for severity early detection protocols by identifying patients at risk of deterioration throughout the hospital, based on the assessment of vital signs and/or laboratory test values, with the clear aim of improving critical patient safety in the hospitalization process.

At present, it can be affirmed that there is important work to be done in the detection of severity and early intervention in patients at risk of organ dysfunction. Such work must be adapted to the circumstances of each center and should include training in the detection of severity, multidisciplinary work in the complete patient clinical process, and the use of technological systems allowing intervention on the basis of monitored laboratory and physiological parameters, with effective and efficient use of the information generated. Not only must information be generated, but also efficient management of such information must also be achieved.

It is necessary to improve our activity through innovation in management procedures that facilitate the work of the intensivist, in collaboration with other specialists, throughout the hospital environment. Innovation is furthermore required in the efficient management of the information generated in hospitals, through intelligent and directed usage of the new available technology.

Resumen

El término «UCI sin paredes» se refiere a una innovadora estrategia de tratamiento en cuidados intensivos que se basa en 2 elementos fundamentales: (1) colaboración de todo el personal médico y de enfermería implicado en la atención del paciente durante la hospitalización, y (2) apoyo tecnológico para protocolos de detección temprana de la gravedad identificando a los pacientes en situación de riesgo de deterioro en el hospital a partir de la evaluación de las constantes vitales y/o los resultados de las pruebas analíticas, con el claro objetivo de mejorar la seguridad de los pacientes críticos durante el proceso de hospitalización.

En la actualidad puede decirse que todavía queda un importante trabajo por hacer en cuanto a la detección de la gravedad y la detección precoz en pacientes en situación de riesgo de disfunción orgánica. Este trabajo deberá adaptarse a las circunstancias de cada centro e incluir formación para la detección de la gravedad, el trabajo multidisciplinario en el conjunto del proceso clínico del paciente y el uso de sistemas tecnológicos que permitan la intervención a partir de la monitorización de parámetros fisiológicos y analíticos, con un uso eficiente y eficaz de la información generada. No solo debe generarse información sino que también es necesario que esta se gestione de manera eficaz.

Es necesario mejorar nuestra actividad mediante la innovación en los procedimientos de gestión que facilitan la labor del intensivista, en colaboración con otros especialistas, en el entorno hospitalario. Además, se requiere innovación para gestionar de forma eficiente la información generada en los hospitales a partir del uso inteligente y eficiente de las nuevas tecnologías disponibles.

Section snippets

Problem: why has the model of ICU without walls emerged?

The objective of Intensive Care Medicine, as defined by the international societies of Intensive Care Medicine in the Santander 2012 statement,² is to provide critically ill patients with medical care tailored to their needs, of high quality and as safe as possible. Intensive Care Medicine is one of the main elements in modern healthcare systems – Intensive Care Units (ICUs) being in increasing demand, and with an important healthcare cost impact. It is believed that in the United States more

Solution: early detection of severity

Working methods are thus required to allow the early detection of acute and potentially acute patients in any location within the hospital, with intervention in the early stages of the disease before damage becomes established. Such measures may comprise direct admission to the ICU, or diagnostic and/or therapeutic intervention in the ward where the patient is located, with protocolized close follow-up. Moreover, it is clear that the best results are obtained from collaboration among

Our solution: the ICU without walls project^1,48

Given this background, in our center we decided to develop an Intensive Care Medicine management system fundamented upon critically ill patient safety throughout the hospitalization process. It establishes a strategic focus on “early detection of the critically ill patient outside the ICU”, which refers to the identification of patients at risk outside the Unit, and is based on the recognition, diagnostic orientation and early treatment of acute patients, in collaboration with other clinical

Conclusions

At this time it can be affirmed that there is still important work to be done in the detection of severity and early intervention in patients at risk of organ dysfunction. This work must be adapted to the circumstances of each center and must include training in the detection of severity, multidisciplinary work in the global patient clinical process, and the use of technological systems for intervention referred to laboratory parameters and the monitoring of physiological parameters – with

Conflict of interest

The authors declare no conflicts of interest.

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One solution could be the electronic charting of early warning scores to improve the accuracy, reliability and availability of patients’ vital signs. There is a drive within healthcare systems to improve the efficiency of information management in hospitals, through integration and intelligent use of new technology (Gordo and Abella, 2014). A number of software packages have become available to address this need.
Early warning scores are widely used to identify deteriorating patients. Whilst their ability to predict clinical outcomes has been extensively reviewed, there has been no attempt to summarise the overall strengths and limitations of these scores for patients, staff and systems. This review aims to address this gap in the literature to guide improvements for the optimization of patient safety.
A systematic review was conducted of MEDLINE^®, PubMed, CINAHL and The Cochrane Library in September 2016. The citations and reference lists of selected studies were reviewed for completeness. Studies were included if they evaluated vital signs monitoring in adult human subjects. Studies regarding the paediatric population were excluded, as were studies describing the development or validation of monitoring models. A narrative synthesis of qualitative, quantitative and mixed- methods studies was undertaken.
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Early warning scores are known to have good predictive value for patient deterioration and have been shown to improve patient outcomes across a variety of specialties and international settings. This is partly due to their facilitation of communication between healthcare workers.
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Early warning scores provide the right language and environment for the timely escalation of patient care. They are limited by their intermittent and user-dependent nature, which can be partially overcome by automation and new continuous monitoring technologies, although clinical judgment remains paramount.
Five-Year Trends of Critical Care Practice and Outcomes
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Changes of admission source also suggest that more patients are monitored on stepdown and postanesthesia care units and transferred to ICUs when interventions are required. These trends occur at a time when reports of an “ICU without walls concept”20 appeared that encourages out-of-ICU monitoring for patients who do not require an ICU intervention. Following these trends is of interest because they may be redefining critical illness.21
Longitudinal analyses of large, detailed adult critical care datasets provide insights into practice trends and generate useful outcome and process benchmarks.
Data representing 991,571 consecutive critical care visits to 160 US adult ICUs from 2009 to 2013 from the eICU Research Institute clinical practice database were used to quantitate patient characteristics, APACHE IV–based acuity predictions, treatments, and outcomes. Analyses for changes over time were performed for patient characteristics, entry and discharge locations, primary admission diagnosis, treatments, adherence to consensus ICU best practices, length of stay (LOS), and inpatient mortality.
We detected significant trends for increasing age, BMI, and risk of mortality, higher frequency of admission from an ED and stepdown unit, and more frequent hospital discharge to substance abuse centers and skilled nursing facilities. Significantly more patients were admitted for sepsis, emphysema, coma, congestive heart failure, diabetic ketoacidosis, and fewer were admitted for asthma, unspecified chest pain, coronary artery bypass graft, and stroke care. The frequency of noninvasive mechanical ventilation and adherence to critical care best practices significantly increased, whereas the duration of renal replacement therapies, frequency of transfusions, antimicrobial use, critical care complications, LOS, and inpatient mortality decreased.
Analyses of patients, practices, and outcomes from a large geographically dispersed sample of adult ICUs revealed trends of increasing age and acuity, higher rates of adherence to best practice, use of noninvasive mechanical ventilation, and decreased use of antimicrobials, transfusions, and duration of renal replacement therapies. Acuity-adjusted LOS and in hospital mortality decreased.
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The RRT at the investigated institution was implemented in 2009 and was composed of an intensive care physician and physical therapist. The RRT operated in handling the requests for treatment of code events in the adult patient wards and also as an ICU-without-walls model.7 One of the functions of the RRT was the performance of daily assessments (in the morning and afternoon) of critically ill patients who were not admitted to the intensive care unit (ICU) due to lack of available beds.
To compare readmission rates to the intensive care unit (ICU) before and after the implementation of a rapid response team (RRT), and to identify risk factors for readmission.
A quasi-experimental before–after study was carried out.
A University Hospital.
All patients discharged from the ICU from January to December 2008 (control group) and from January 2010 to December 2012 (intervention group).
Implementation of an RRT.
The data included demographic parameters, diagnoses upon admission, ICU readmission, APACHE II, SOFA, and TISS 28 scores, and routine daily assessment by an RRT of patients discharged from the ICU.
During the study interval, 380 patients were analyzed in the period prior to the implementation of the RRT and 1361 after implementation. There was a tendency toward decreased readmission rates one year after RRT implementation. The APACHE II score and SOFA score at ICU discharge were independent factors associated to readmission, as well as clinical referral to the ICU.
The RRT intervention resulted in a sustained decrease in readmission rates one year after implementation of this service. The use of a specialized team in health institutions can be recommended for ICU survivors.
Comparar las tasas de reingreso en la UCI antes y después de la implementación de un equipo de respuesta rápida (RRT) e identificar los factores de riesgo para la readmisión.
Estudio cuasiexperimental before-after.
Hospital universitario.
Todos los pacientes que fueron dados de alta de la UCI de enero a diciembre de 2008 (grupo control) y de enero 2010 a diciembre 2012 (grupo intervención).
Implementación de un RRT.
Los datos incluidos demográfica, los diagnósticos de ingreso, readmisión UCI, APACHE II, SOFA y TISS 28 puntuación y de evaluación de los pacientes dados de alta de la UCI por un TSR.
Durante el período de estudio, 380 pacientes fueron analizados en el período anterior a la implementación de la RRT y 1,361 después de la implementación. Hubo una tendencia a disminuir las tasas de reingreso después de un año de la implementación de un RRT. APACHE II y SOFA de alta de la UCI fueron factores independientes asociados a la readmisión, así como lo tipo de paciente médico.
La intervención del RRT resultó en una reducción sostenida de las tasas de reingreso un año después de la implementación de este servicio. El uso de un equipo especializado en instituciones de salud puede ser recomendado para los pacientes supervivientes de la UCI.

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Point of viewIntensive Care Unit without walls: Seeking patient safety by improving the efficiency of the systemUnidad de cuidados intensivos sin paredes: buscando la seguridad del paciente mediante la mejora de la eficiencia del sistema

Abstract

Resumen

Section snippets

Problem: why has the model of ICU without walls emerged?

Solution: early detection of severity

Our solution: the ICU without walls project1,48

Conclusions

Conflict of interest

Med Intensiva

Crit Care Clin

Med Intensiva

Crit Care Clin

Med Intensiva

Med Intensiva

Resuscitation

Resuscitation

Surgeon

Resuscitation

Resuscitation

Med Intensiva

Patient-centered care for the critically ill

Critical care medicine in the United States 2000–2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

Crit Care Med

Clinical review: international comparisons in critical care – lessons learned

Crit Care

Intensive medicine in Spain

Med Intensiva

Refusal of intensive care unit admission due to a full unit: impact on mortality

Am J Respir Crit Care Med

After-hours discharge from intensive care increases the risk of readmission and death

Anaesth Intensive Care

Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study

Crit Care

Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome

Crit Care

The association between ICU readmission rate and patient outcomes

Crit Care Med

Intensive care unit readmissions in U.S. hospitals: patient characteristics, risk factors, and outcomes

Crit Care Med

Sepsis incidence and outcome: contrasting the intensive care unit with the hospital ward

Crit Care Med

Clinical risk conditions for acute lung injury in the intensive care unit and hospital ward: a prospective observational study

Crit Care

Point of view
Intensive Care Unit without walls: Seeking patient safety by improving the efficiency of the systemUnidad de cuidados intensivos sin paredes: buscando la seguridad del paciente mediante la mejora de la eficiencia del sistema

Our solution: the ICU without walls project^1,48