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Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors t...
Most Intensive Care Units (ICU) collect comprehensive data relating
to patient demographics, diagnoses and complications and some use this
information to benchmark and guide quality improvement activities aimed at
improving patient outcomes and reducing iatrogenic complications. Ayas
et. al. are to be commended for using routine information they collect in
an attempt to identify trends and possible contributing factors to one of
the potential complications related to insertion of Central Venous
Catheters (CVCs), development of a pneumothorax. Their retrospective
review did not confirm their suspicions that the incidence of pneumothorax
would increase with the introduction of new trainees to their area, which
is surprising, however they have suggested that decreased supervision as
the ICU rotation progresses may contribute to this.
CVCs are widely used in ICUs around the world, and pneumothoraces are a
significant potential complication of insertion of CVCs into the internal
jugular and subclavian veins (SCV). There is high level evidence to
support the insertion of CVCs into neck veins, particularly the SCV, as
opposed to femoral veins to reduce the incidence of blood stream
infections that contribute to significant morbidity and mortality, and
increased length and cost of hospital stay.1
Sheretz et. al. demonstrated that providing targeted training for
physicians in relation to methods to reduce infection related to vascular
device insertion resulted in improved knowledge and retention that
translated into practice. In their study, compliance with evidence based
procedures improved and resulted in a reduction in the incidence of CVC
bloodstream infections. They provided a detailed cost-benefit analysis of
their training program that supports such an approach to improving quality
and safety of patient care.2
Ault described an approach to training inexperienced practitioners that
used tissue models for practice, the use of ultrasound devices, a focus on
use of large drapes and improved sharps handling that resulted in improved
accuracy and safety of CVC insertion.3 Ayas et. al. refer to the use of
ultrasound guidance to assist in CVC placement as being sporadic in their
study settings, which could contribute to the trends they are identifying,
however the evidence to support the routine use of such devices is to date
not strong.4
The only training method referred to by Ayas et. al. is supervision by
more experienced practitioners in the clinical field. Perhaps they could
consider introducing more formalized training, as described above, to
reduce the incidence of pneumothorax and other complications related to
CVC insertion for their patients. The routine data they are currently
collecting could assist in assessing the efficacy of such an approach.
Ros MacLeod, BN, Grad Cert CCN, Grad Dip Nursing, Nurse Unit Manager, ICU,
Western Health, Footscray, Australia, Ros.MacLeod@wh.org.au
References:
1. O’Grady, N. P., Alexander, M., Dellinger, E. P., Gerberding, J.L.,
Heard, S. O., Maki, D. G., Maur, H., McCormick, R. D., Mermel. L.A.,
Person, M. L., Raad, I. I., Randolph, A., Weinstein., R. A.. Guidelines
for the Prevention of Intravascular Catheter-Related Infections. National
Center for Infectious Diseases. 2002.
www.cdc.gov/mmwr/preview/mmwrhtml/rr5110al.htm
2. Sherertz, R. J., Ely, E., Wesley M. D., Westbrook, D. M., RN, Gledhill,
K. S., Streed, S. A., Kiger, B., Flynn, L., Hayes, S., Strong, S., Cruz,
J., Bowton, D. L., Hulgan, T. & Haponik, E. Education of Physicians-in
-Training Can Decrease the Risk for Vascular Catheter Infection. Annals of
Internal Medicine: 2000: 132(8): 641-648.
3. Ault, M. J. The Use of Tissue Models for Vascular Access Training:
Phase 1 of the Procedural Safety Initiative. Academic Emergency Medicine.
2007: 14(1):13.
4. Stone, M.B. Identification and correction guide wire malposition during
internal jugular cannulation with ultrasound. Journal of the Canadian
Association of Emergency Physicians. 2007:p(2):131.
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program h...
It has been well recognized internationally that hospitals are not as
safe as they should be. In order to redress this situation, health care
services around the world have turned their attention to strategically
implementing robust patient safety and quality care program to identify
circumstances that put patients at risk of harm and then acting to prevent
or control those risks
In my hospital the patient safety program has been implemented for 10
months. During the implementation period, the team continuously
encouraging all the staffs for actively reporting. The self assessment
result for patient safety activities was 77% (using hospital accreditation
criteria). The team has 2 weekly meeting agenda for discussing and
reviewing the incident reporting.
During theses 10 months, the team has received 45 cases of incident
reporting. The members of team actively collect the data by interviewing
the medical staffs from various facilities.
Most of the cases are in category of “near miss”, and “adverse events”.
The data showed that most of the incident are related to drug/ blood
products and medical equipment. Root cause analysis of several cases
showed that inadequate communication and inappropriate team working are
the main causes of the incident.
The effort for promoting patient safety and reducing error
The team and hospital leader continuously encouraging the medical staffs
for incident reporting.
The interesting finding is 29% of the incident reporting come from the
patients and family.
The article from Dr. Wasson, et.al. is very interesting. The use of
information technology will make the reporting system easier, faster, and
enabling of early identification. The online system can sure that the
system will be working in 24 hours a day. Appropriate action can be taken
for preventing further injury. The other important thing is to educate the
patients and family for identifying the adverse events, and report the
adverse events immediately.
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replicati...
Recently Neuhauser and Dias raised an important question [1]: are
randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized
replicatable theory. Otherwise it is a scientific house without
foundation” and argue that RCTs comparing drugs cannot be replicated for
two reasons: (1) after a decade or two the control arm has changed and (2)
replication may be considered unethical if the original trial showed a
difference. Thus it is tempting to draw the conclusion that the authors
suggest that RCT should not be used when the effect of a new drug is to be
tested.
Why is it so important that an experiment can be replicated? Say drug
B is shown to be superior to drug A, and later drug C is shown to be
superior to drug B. Then, who really cares whether the experiment
comparing drug A and B can be replicated or not?
The authors’ claim that RCTs cannot be replicated may be challenged.
If the conditions for the control arm has changed then the intervention
arm conditions are likely to have changed in parallel over time. Then we
expect to be able to replicate the findings. But we have no way of knowing
this. In fact, given that the same drug is used over the years, it is
unethical not to replicate the experiments regularly, according to
paragraph 6 in the introduction to the Helsinki Declaration
(www.wma.net/e/policy/b3.htm).
We agree with the authors that statistical process control (SPC) has
an important role to play in medicine [2]. But we feel that the use of SPC
for the comparison of drugs is quite risky due to the potential for the
introduction of all kinds of bias [2,3]. Another reason why SPC may be
inferior to RCTs is that the application of SPC requires the processes
studied to be brought in statistical control prior to the intervention
[2]. This may not be possible to achieve because the patient mix may vary
over time. It may be argued, then, that statistical risk adjustment may
take care of this problem. However, it is well known that this approach is
fraud with problems [2,3]. By contrast, the attainment of statistical
control is not an issue in the case of RCTs, precisely due to the random
assignment of patients to the intervention groups.
References
1. Neuhauser D, Dias M. Quality improvement research: are randomized
trials necessary? Qual Saf Health Care 2007; 16:77-80.
2. Winkel P, Zhang NF. Statistical Development of Quality in Medicine.
John Wiley and Sons Inc, 2007; 1 – 263.
3. Deeks JJ, Dinnes J, D’Amico R, Sowdon AJ, Sakarovitch C, Song F,
Petticrew M, Altman DG. Evaluating non-randomised intervention studies.
Health Technol Assess 2003;7:1-173.
Most Intensive Care Units (ICU) collect comprehensive data relating to patient demographics, diagnoses and complications and some use this information to benchmark and guide quality improvement activities aimed at improving patient outcomes and reducing iatrogenic complications. Ayas et. al. are to be commended for using routine information they collect in an attempt to identify trends and possible contributing factors t...
It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care program to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks In my hospital the patient safety program h...
Recently Neuhauser and Dias raised an important question [1]: are randomised clinical trials (RCT) necessary in quality improvement?
They conclude that “RCTs need to be embedded in generalized replicatable theory. Otherwise it is a scientific house without foundation” and argue that RCTs comparing drugs cannot be replicated for two reasons: (1) after a decade or two the control arm has changed and (2) replicati...