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Driving clinical best practice through a provincial audit and feedback approach: Alberta's ICU Delirium Initiative
CCCF Academy. Morrissey J. 11/12/19; 283364; EP56
Jeanna Morrissey
Jeanna Morrissey
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ePoster
Topic: Quality Assurance & Improvement

Morrissey, Jeanna RN MN1, Samantha L. Bowker, PhD1, 2, Selvi Sinnadurai RN1 'on behalf of the Critical Care Strategic Clinical Network
Affiliations: 1Critical Care Strategic Clinical Network TM, Alberta Health Services, Alberta, Canada; 2Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta


Introduction: Critical care in Alberta is delivered by 17 adult intensive care units and 3 pediatric units all operating within the integrated health system of Alberta Health Services. In 2018, there were 92,473 ICU patient-days, with an average stay of 5.2 days. An estimated 42% (>5,400) of intensive care unit (ICU) patients/year experienced ICU delirium.  A review of delirium prevention and management practices in Alberta found large variation in care delivery. Subsequently, the Critical Care Strategic Clinical NetworkTM (CCSCN) and critical care community identified this as a priority area, resulting in the Provincial ICU Delirium Initiative.
Objectives: The objective of the Provincial ICU Delirium Initiative was to reduce practice variation and establish a standardized, provincial approach to implementation of evidence-based pain, agitation, and delirium (PAD) best practices in critical care in Alberta.
Method: The Alberta Provincial Adult ICU-Delirium Framework was developed using a collaborative approach with involvement from all 17 adult ICUs.  A comprehensive measurement and reporting framework was established based on the Society of Critical Care Medicine's 2013 PAD guidelines that included 32 provincial and locally customizable metrics to improve delirium care. The provincial framework provided front line clinicians in each adult ICU with standards of care recommendations, clinical practice expectations, and corresponding metrics and performance targets, thus, providing the foundation for incorporating delirium prevention and management into everyday clinical practice.  A provincial audit and feedback system was designed to enable bedside charting and performance monitoring, consistent with care recommendations. This was leveraged through eCritical Alberta, which is a provincial ICU clinical information and analytics system which captures data on all patients admitted to an ICU in Alberta. Guidelines and recommendations for PAD best practices were embedded into everyday documentation using automated reminders for care and assessments, in addition to guiding tools to support clinical decision making.
Results: We observed a 10% reduction in patient days experiencing delirium in critically ill adult patients, (32.4% in Sept-Nov 2017 and 22.9% Jan-Mar 2019) and substantial improvements in delirium screening in both adult (40% improvement since 2015) and pediatric (52% improvement since 2016). Compliance with every 4 hour pain assessments increased by 35% and 10% in the pediatric and adult populations, respectively. There was also a 15% improvement in compliance with every 4 hour agitation and sedation assessments in adults and established this new practice in pediatric ICUs.
Conclusion: As a result of Alberta's ICU Delirium Initiative, critically ill patients in Alberta receive a more consistent standard of care for delirium prevention and management, which is in line with best practice recommendations. Leveraging a provincial critical care information system to provide audit and feedback has enabled clinicians in Alberta to integrate delirium best practices and has contributed to a reduction in the amount of delirium among critically ill patients. Reporting of unit-based performance has provided unique insight into understanding the provincial lens of practice and has provided momentum for further improvement.


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References:

  1. eCritical Alberta. Tracer Reports Alberta Health Services: Critical Care SCN, Alberta Health Services; 2019
  2. Canadian Institute for Health Information (CIHI). Care in Canadian ICUs – Data Tables. https://www.cihi.ca/en/search?query-all=intensive+care&Search+Submit= 2016
  3. Critical Care Strategic Clinical Network (CC SCN)., Alberta Health Services. . https://www.albertahealthservices.ca/scns/page9437.aspxAccessed March 28, 2019
  4. Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e73.
ePoster
Topic: Quality Assurance & Improvement

Morrissey, Jeanna RN MN1, Samantha L. Bowker, PhD1, 2, Selvi Sinnadurai RN1 'on behalf of the Critical Care Strategic Clinical Network
Affiliations: 1Critical Care Strategic Clinical Network TM, Alberta Health Services, Alberta, Canada; 2Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta


Introduction: Critical care in Alberta is delivered by 17 adult intensive care units and 3 pediatric units all operating within the integrated health system of Alberta Health Services. In 2018, there were 92,473 ICU patient-days, with an average stay of 5.2 days. An estimated 42% (>5,400) of intensive care unit (ICU) patients/year experienced ICU delirium.  A review of delirium prevention and management practices in Alberta found large variation in care delivery. Subsequently, the Critical Care Strategic Clinical NetworkTM (CCSCN) and critical care community identified this as a priority area, resulting in the Provincial ICU Delirium Initiative.
Objectives: The objective of the Provincial ICU Delirium Initiative was to reduce practice variation and establish a standardized, provincial approach to implementation of evidence-based pain, agitation, and delirium (PAD) best practices in critical care in Alberta.
Method: The Alberta Provincial Adult ICU-Delirium Framework was developed using a collaborative approach with involvement from all 17 adult ICUs.  A comprehensive measurement and reporting framework was established based on the Society of Critical Care Medicine's 2013 PAD guidelines that included 32 provincial and locally customizable metrics to improve delirium care. The provincial framework provided front line clinicians in each adult ICU with standards of care recommendations, clinical practice expectations, and corresponding metrics and performance targets, thus, providing the foundation for incorporating delirium prevention and management into everyday clinical practice.  A provincial audit and feedback system was designed to enable bedside charting and performance monitoring, consistent with care recommendations. This was leveraged through eCritical Alberta, which is a provincial ICU clinical information and analytics system which captures data on all patients admitted to an ICU in Alberta. Guidelines and recommendations for PAD best practices were embedded into everyday documentation using automated reminders for care and assessments, in addition to guiding tools to support clinical decision making.
Results: We observed a 10% reduction in patient days experiencing delirium in critically ill adult patients, (32.4% in Sept-Nov 2017 and 22.9% Jan-Mar 2019) and substantial improvements in delirium screening in both adult (40% improvement since 2015) and pediatric (52% improvement since 2016). Compliance with every 4 hour pain assessments increased by 35% and 10% in the pediatric and adult populations, respectively. There was also a 15% improvement in compliance with every 4 hour agitation and sedation assessments in adults and established this new practice in pediatric ICUs.
Conclusion: As a result of Alberta's ICU Delirium Initiative, critically ill patients in Alberta receive a more consistent standard of care for delirium prevention and management, which is in line with best practice recommendations. Leveraging a provincial critical care information system to provide audit and feedback has enabled clinicians in Alberta to integrate delirium best practices and has contributed to a reduction in the amount of delirium among critically ill patients. Reporting of unit-based performance has provided unique insight into understanding the provincial lens of practice and has provided momentum for further improvement.


Image

References:

  1. eCritical Alberta. Tracer Reports Alberta Health Services: Critical Care SCN, Alberta Health Services; 2019
  2. Canadian Institute for Health Information (CIHI). Care in Canadian ICUs – Data Tables. https://www.cihi.ca/en/search?query-all=intensive+care&Search+Submit= 2016
  3. Critical Care Strategic Clinical Network (CC SCN)., Alberta Health Services. . https://www.albertahealthservices.ca/scns/page9437.aspxAccessed March 28, 2019
  4. Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med. 2018;46(9):e825-e73.
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