Quality and Safety: What Have We Learned?

Communication is key when it comes to improving quality and safety in intensive care, according to Todd Dorman, President, Society of Critical Care Medicine, and Professor and Vice Chair Critical Care, Johns Hopkins University. “We need to create a culture where mistakes will be identified”, he said.

Speaking at the Global Tracheostomy Collective meeting at the European Society of Intensive Care Medicine in Milan this week, Dorman contrasted where intensive care was in the 1990s to now, to show how far it has progressed.

Intensive Care in the 1990s

• Central line associated bloodstream infections (CLABSI) were acceptable.
• Ventilator-associated pneumonia (VAP) was expected.
• Sepsis was treated haphazardly.
• ICU services were poorly organised if at all. Close to 80% of adults were managed by primary care physicians.
• Nobody had heard of indicators.
• Autocratic hierarchy ruled the roost.
• Generally poor understanding of quality and safety.

Intensive Care Now

• CLABSI IS reduced and VAP redefined.
• There are sepsis bundles.
• More than 50 percent of adults are cared for by a high intensity staffing model.
• There is a recognition that communication failure is a major contribution.
• Interprofessional education is growing.

The traditional approach to improving quality and safety was to solve problems using people and money, and to implement policies and rules, reorganise and assign blame. But this is not the solution, because problems are latent, said Dorman. It is system failure that leads to adverse events, and these failures arise from managerial and organisational decisions or lack of decisions.  

The culture in safe organisations is committed to no harm. Organisations need to encourage open communication, and focus on systems not people. In hierarchies it’s not a decision problem as such, but how decisions are made that’s the problem. “We need to get away from autocracy and autocratic decision making”, said Dorman.

We have learned there are safe systems and that both leadership and culture are important, he added. Tools that facilitate compliance are important. Checklists get a bad rap, observed Dorman. They don’t tell you what to do, but are tools to facilitate memory and are not a sign of weakness. They facilitate team discussions and can be customised to local environments. If you are using a checklist, you are communicating as a team and that’s important.

Looking ahead, the future includes big data, networks for postintensive care, and programmes such as the Society of Critical Care Medicine's ICU Liberation for pain, agitation and delirium.

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