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Intensive Care Units are often susceptible to danger, risky procedures, or mismanagement of care. As such, it is essential to establish clear and traceable care quality indicators which will allow hospital staff to react accordingly. Additionally, it will benefit medical boards in planning better care programs and solutions to risk-high environments within medical facilities. Some of these care quality indicators include rates of unplanned extubations within specific hospitals as well as on a national scale.
The rate of unplanned extubations within Intensive Care Units is an evident indicator of the safety and care of a healthcare organization. Unplanned extubations, or UEs, are classified as accidental or self-extubation. Cases of accidental extubation refer to patients experiencing involuntarily-induced effects during nursing care or medical procedure. In the current research, a definite rate has not been found, as incidences vary from 0.3% to 35.8% in different studies (Lucchini, 2018). Self-extubation occurs when the patient disrupts the medical procedure themselves.
ICUs are settings with a likely high risk of danger and familiarity with potential harm in relation to patients. Much of the negative effects may stem from interference with the provided treatment such as self-removed support or monitoring equipment on a varied scale of invasiveness. Such actions can sway the medical consequences, each with its own severity and danger to the patient’s wellbeing. As such, a substantial portion of the care’s quality is indicated by incidences of positive or negative outcomes. Patients are not the only group affected by possible mishaps, as nurses are often the ones that bear significant responsibility. Some of their tasks include managing and protecting the patients from injury and maintaining the integrity of hospital equipment and devices. In cases of unplanned extubation, a part of the concern is also focused on preserving the quality of endotracheal tubes. Thus, in the cases of unplanned extubation, both self and accidental, the quality of care is observed through the nurse’s ability to react according to an incidence, with emphasis on the patient’s safety and the preservation of life-saving equipment.
Further, other quality care indicators regarding UEs focus on the clear relation between accidental or self-extubation and increased nosocomial pneumonia, increased reintubation, and, in some cases, even death. As accidental extubations are often the results of errors that happen during a patient’s change in position, or tracheal tube conduct and placement, the nursing staff are often responsible for incidents. At the same time, self-extubation may be caused by lacking surveillance, or failure to notice signs of the patient’s readiness to be weaned off mechanical ventilation, or total removal. However, in most studies, it has been noticed that self-extubations are the most common with 50% to a 100% of ICU unplanned extubations being self-caused (Nair, 2017). There are also a number of qualitative data that reveal risk factors that impact nurses and other hospital staff. These include the absence or unavailability of physical restraints, a nurse-patient ratio of 1-to-3, excursions outside of the ICU, insufficient sedation, bedside radiography, and the effects of the night shift on hospital staff as well as the patients.
It has been assessed that nosocomial infections are a common obstacle during hospital or ICU stays. The lungs are the site of the most frequent infections among patients with sepsis. The mortality rate in relation to ventilator-acquired pneumonia (VAP) was concluded to be between 24% and 50%, though some settings had reached a very worrying 78% (Nair, 2017). Nosocomial infections can be prevented, and measure taken to do it can reflect on the quality indicator of VAP rates.
Cases of VAP as quality indicators currently affect hospital staff, including leaders or authorities of medical facilities, by urging them to improve the overall quality and lower costs. This can be seen in certain efforts, such as the Joint Commission’s proposal to compel hospitals to meet certain patient safety goals before receiving accreditation.
Other advised methods of monitoring the quality of care through VAP rates include setting and meeting general benchmarks. Benchmarking is not new to private sectors and businesses but is an emerging tactic within the medical field. In the case of measuring VAP rates, it would be essential to ascertain and analyze risk factors, the comparison of preventative measures, contrast differing clinical or microbiological processes, the comparison of true incidence rates, analysis of procedures, treatments, and selected antibiotics, and the result and consequence of each administered option. Additionally, quality can be monitored through enhanced surveillance systems and technology, the activity of administrative support, the assistance and motivation provided to the healthcare staff, and reactions and assessments from the public or media.
Though the indicators above may establish a clear image of the quality of care in certain establishments, not all of them are as measurable or reliable as quality indicators are expected to be. One definition of quality indicators summarizes them as information that identifies levels of adherence to a specific, standardized target in a way that is simple, confirmed, reliable, and can be reproduced in a hospital setting. In the case of VAP, the patients are affected through their hospital stay and the severity of their infection, and the outcome of it. The working staff is affected when VAP rates are measured as quality indicators throughout the process of the patient’s medical care. For instance, the staff can be assessed on their ability to comply with guidelines, and capability to recommend methods of prevention, diagnosis, and treatment for VAP. Further, the quality indicator can be as specific as possible and in the case of VAP, this can mean that the staff must be equipped to accurately isolate methicillin-resistant Staphylococcus aureus carriers, and administer elective intubation with correct timing, perform adequate sedatives, and monitor the modalities of ventilation. National organizations such as the National Quality Forum also hold stakes in the assessment of quality and cite result measures such as trend identification, effective mitigation models, operations, and positive financial indicators such as reduced bed days in the ICU cost cuts to patients, payers, and hospital expenses.
The length of stay is another factor in determining the quality of care within an ICU. The length of a patient’s stay is determined by a variety of factors that may not always pertain to the quality of care within medical facilities. However, there have been indications of negatively-skewed care quality found in relation to lacking numbers of ICU beds, unavailability of fellows or specialists in training, full-time ICU nurses or practitioners, and recurring 100% bed occupancy (Verburg, 2021). As such, a shift of any of the previous indicators does not only affect the care the patient receives and the staff provides but also the additional costs to the establishments in case of mismanagement or need for additional resources.
The analysis of care quality within hospitals through the use of indicators is essential for the growth and improvement within specific facilities and for national or international standards as well. Though unplanned extubation, VAP, and length of stay are only a fragment of the factors that can be used to determine the quality of care, they are vital and should be monitored through a reliable and measurable system.
References
Lucchini, A., Bambi, S., Galazzi, A., Elli, S., Negrini, C., Vaccino, S., Triantafillidis, S., Biancardi, A., Cozzari, M., Fumagalli, R., & Foti, G. (2018). Unplanned extubations in general intensive care unit: A nine-year retrospective analysis. Acta Biomed, 89(7-S), 25-31. Web.
Nair, N., B., & Niederman, M., S. (2017). Using ventilator-associated pneumonia rates as a health care quality indicator: A contentious concept. Seminars in Respiratory and Critical Care Medicine, 38(3), 237-244. Web.
Verburg, I. M. W., Holman, R., Dongelmans, D., Jonge, E., & de Keizer, N. (2018). Is the patient length of stay associated with intensive care unit characteristics? Journal of Critical Care, 43, 114-121. Web.
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