Hints for Residents in the Egleston PICU on Quality Questions:
EVERY morning on EVERY patient while rounding there will be a set of 'Quality' questions asked, (depending on fellow or attending preference these may be asked before or after medical rounding on each specific the patient). These are questions that help to reduce iatrogenic risks that can occur during care of critically ill patients.
1. Medical record number?: Document out loud
Rationale: a sort of 'time out' to be sure we are collecting data on the correct patient
2. New admission since the previous morning? If so was this a readmission of patient who was discharged
Rationale: Bounce-backs to the unit suggest something was missed at ICU/floor transition
3. Hyperglycemia risk/treatment?: Is the patient at risk for ICU hyperglycemia (MV, pressors, CRRT) and if so is s/he on our "Hyperglycemia protocol" and does s/he have hyperglycemia and if so are they being treated with insulin?
Rationale: Hyperglycemia is associated w/ poor ICU outcomes and aggressive management appears to improve outcomes
4. Braden Q score?: This is a measure of patient activity and status which predicts risk for skin breakdown, ulcers, and sores. Higher the number, lower the risk. With a level off <16 make sure measures are discussed to lower risk - i.e turning and correct mattresses and good nutrition.
Rationale: Skin pressure sores in immobilized are a significant problem and cost
5. Invasive apparatuses?: Does a patient have and/or need - CVLs (document # and type), art lines, foley catheters, endotracheal tube. Remove any invasive equipment they do not need.
Rationale: These greatly increase the risk of hospitalized acquired infections (including blood stream infections, ventilated acquired pneumonia, and urinary tract infections.)
6. Meds and lab schedule review: Self explanatory
Rationale: In busy units, meds and labs needed change. Eliminating unneeded meds, changing meds to PO/NG when able, and reducing labs draws improves care (fewer entries into a central line as an example) and lessens costs.
7. Ventilator associated pneumonias (VAP) prevention in intubated patients: a series of questions and interventions to reduce the chance of VAP.
-Ulcer (GI) prophylaxis - H2 blockers, feeder
à Rationale: Reflux and aspiration of acidic gastric fluid contributes to VAP
-Head of bead up (at 30 degree or more)
Rationale: Propping up the head in appropriate patients makes aspiration less likely
-DVT prophylaxis: venous thromboses can break off, lodge in lungs and be a nidus of infections contributing to VAPs.
Rationale: Preventing DVTs by heparin, stockings or SCD may lower VAP risk.
8. Sedation "holidays"?: In patients receiving sedation/analgesia infusions, were the drips stopped and restarted (at a lower dose) the previous day? (hint: ask nurse and look in drip rate to 0 in patient summary area in Epic)
Rationale: A daily break and restarting at a lower dose of analgesia/ in most patients can facilitates appropriate dosing, weaning and help with an suitable level of sedation.