Staffing Determines ICU Patient Safety

1/28/2002

From: Katie Lundberg of Society of Critical Care Medicine, 847-827-7502; or e-mail, klundberg@sccm.org

SAN DIEGO, Jan. 28 -- "Management decisions that are made regarding staffing significantly impacts patient outcomes in the Intensive Care Unit (ICU)," according to John Hoyt, MD, FCCM, a leading expert in reducing medical errors.

"Most patients admitted to the ICU suffer some potentially life-threatening event. We need to focus on the systems of care to reduce the risk of adverse events," says Dr. Hoyt, director of the intensive care unit at Mercy Hospital in Pittsburgh, and clinical professor of anesthesiology and critical care medicine at the University of Pittsburgh.

"The greatest impact on patient outcome is ICU staffing. It's not a drug or a therapy we order for a patient. It's a management decision about how care is going to be organized," added Dr. Hoyt who spoke today at a Society of Critical Care Medicine press briefing in conjunction with the 31st Annual Critical Care Congress in San Diego.

"ICU patients are particularly vulnerable to errors because they are critically ill, and the system is highly complex" explains Dr. Hoyt. "For instance, the risk of a medication error is directly related to how many medicines are prescribed. ICU patients take approximately twice as many medications as patients who are in other parts of the hospital. Intensivists clearly have an obligation and an opportunity to significantly improve care."

Former astronaut Charles "Pete" Conrad Jr. died in 1999 as a result of a medical error following a motorcycle crash in California. His wife Nancy is now a patient safety advocate. "Care is a partnership. There is a difference between error and harm. The problems related to patients safety are truly an enormous opportunity to improve the quality of care," she says.

Be a Proactive Patient Patients and families can take an active role in ensuring ICU safety. Dr. Hoyt recommends asking the following questions before an emergency situation occurs:

-- Do intensivists (critical care physicians) provide care? If they do, a patient is three times less likely to die. -- What is the nurse-to-patient ratio? This impacts risk of complications and length of stay. The risk for several pulmonary complications doubles when an ICU nurse cares for three or more patients. -- What is the pharmacist's involvement? Having a pharmacist in the ICU reduces medication errors.

Preventing Medical Mistakes "Our knowledge of ICU medical safety is still young and far from mature. Looking at how the organization of care impacts patient outcome is an entirely new science. Intensive care is leading the way. We found that some of these organizational or system factors have perhaps the biggest impact on mortality. But, we still have more to learn about how to optimally organize. However, we do know enough to begin to help consumers make a decision," says Dr. Hoyt. He recommends a three-point framework: 1)Improve safety and prevent errors, 2) if this is not possible, make the error visible and, 3) if harm does occur, mitigate the harm.

In addition to patient advocacy, safety experts are improving the systems to prevent errors. One safeguard is the refitting of the nitrous oxide tubes to prevent them from connecting to oxygen tubing, thus preventing patients from getting low blood oxygen. Another is removing the concentrated form of potassium chloride from the units. Because unintentional overdoses are usually deadly, making much lower concentrations available prevents fatal overdose.

Safety experts also propose types of visual warn signs to help avoid medical errors. One proposal it to put a clip or a mark on a pulmonary artery catheter that will alert healthcare works when the catheter has been inserted far enough. Inserting a catheter too far into the heart is not an uncommon medical error that may result in death.

Another proposal involves epidural pain medication, which must be connected with an epidural catheter. Connecting it intravenously is a potentially deadly mistake. "Until we can move to the first level where it will be physically impossible to connect the epidural to the I.V. line, we can help preclude potential errors by utilizing visual warnings. In my ICU we put a big orange sticker on the epidural catheter that says 'epidural' so the warning will be noticed before a mistake happens," Dr. Hoyt illustrates.

The Society of Critical Care Medicine is the leading professional organization dedicated to ensuring excellence and consistency in the practice of critical care medicine. With more than 9,500 members worldwide, the Society is the only professional organization devoted exclusively to the advancement of multidisciplinary, multi-professional intensive care through excellence in patient care, professional education, public education, research and advocacy. Members of the Society include intensivists, critical care nurses, critical care pharmacists, clinical pharmacologists, respiratory therapists and other professionals, which may include technicians, social workers, dieticians and members of the clergy.