ICU Self Assessment

Provision of excellent ICU services requires a continuous commitment to self-examination and improvement. Self assessment falls into three categories:

1. Assessment of the hospital's ability to provide ICU care and at what level of service.
2. Assessment of the hospital's resources and the referral systems (Regional Referral Networks) required to properly care for critically ill patients.
3. Assessment of and continuous monitoring of resources and outcomes as part of ongoing improvement and quality efforts.

Ability to Provide High Quality, Safe Care

Caring for the most critically ill patients requires a complex system of staffing, infrastructure and supply resources. It is no longer appropriate to assume every hospital should provide this type of care. Hospitals should assess their ability to provide ICU care and what level of care they can safely provide. Hospitals should determine if their ICUs meet the criteria established by the Society of Critical Care Medicine for ICUs. This assessment will help hospitals identify which patients need to be referred elsewhere and the resources required at the facility to which patients are referred. It will also help hospitals identify gaps in their resources that they need to address in order to safely provide ICU care. Components of this assessment include:

• Determine Level I or Level II or Step-Down care based on the descriptions developed by the Society of Critical Care Medicine. The MH&SC physician Staffing Guideline apply to both Level I and Level II units. 25
• Determine what measures are needed to bring their units to their target Level of care as defined by the Society of Critical Care Medicine.

Assessing Hospital Resources and Referral Systems

Hospitals need to have a clear understanding of their ICU capabilities and any limitations. In hospitals where all ICU protocols are not present, the hospital needs to have a plan in place for transferring patients to more appropriate facilities. The components of this assessment should be shared publicly as they will become the foundation of Regional Referral Networks. (link this)

This assessment includes:

• Types of patients admitted
• Referrals to other facilities and why
• Referral patterns based on affiliation agreements among members of a health system or other integrated systems of care
• Ability to provide comprehensive medical, surgical and nursing specialty and subspecialty care
• Access to radiology, laboratory and other resources to care for complex cases within the hospital
• Local circumstances related to health care resources
• Geographic considerations
• Evaluation of current referral practices and gaps in specialty and subspecialty care and development of a referral plan. Each hospital's evaluation and plan will be used as a part of the Regional Referral Networks for complex cases activity.

Monitoring of Resources and Outcomes as Part of Ongoing Improvement and Quality Efforts

Michigan hospitals should be working toward an environment where every hospital monitors its performance and participates in collaborative monitoring activities with hospitals statewide. By establishing a standard system of measuring performance and developing a statewide database, hospitals can learn from each other and more quickly incorporate best practices.

Data needs to be collected and converted into information to be analyzed by the multidisciplinary team. Hospitals should immediately put in place safety reporting systems that collect, review and analyze the following information:

• Mortality and morbidity
• Trend data to identify potential process or system issues, such as: was surgical case selection appropriate, were complications related to length of stay, were there any inappropriate admissions, and did complications affect mortality?
• Adverse events and near misses
• Outcomes: ICUs need to continuously monitor the following attributes, using run charts and other analysis tools to track trends:
• Length of hospital stay
• Length of ICU stay
• Charges
• Patient and family satisfaction
• Unadjusted mortality
• Unexpected readmissions (less than 24 hours)
• Infection rates
• Adverse drug events

Hospitals should develop and publicize reporting systems that allow employees to report safety problems or potential safety problems anonymously and confidentially.

Longer-term hospitals should implement:

• Risk adjustment for mortality
• Risk adjustment for morbidity

25 Society of Critical Care Medicine. (1999). Guidelines on critical care services and personnel: Recommendations based on a system of categorization into two levels of care. Crit Care Med. 27(2):422-426.

© 2004 Michigan Health and Safety Coalition