Why Focus on Intensive Care Units?

“Health care has safety and quality problems because it relies on outmoded systems of work. If we want safer, higher quality care, we will need to have redesigned systems of care.” Institute of Medicine. To Err is Human: Building a Safer Health System. 2

The widely publicized 1999 report by the prestigious Institute of Medicine provided an urgent wake-up call on the need for institutional efforts to improve patient safety. The IOM concluded that each year between 44,000 and 98,000 deaths result from preventable medical errors in the United States. The complexity and cost of care in the ICU (30 percent of acute care hospital costs, or $180 billion annually 3) make it a prime target for patient safety improvement activities. Why? The complexity of ICU care leads to adverse events and poorer patient outcomes than would be expected if the errors did not occur. Adverse events cost money to cover the cost of additional tests and procedures, additional lengths of stays, more medications and increased levels of disability.

In the last few years, many national organizations in addition to the Institute of Medicine have focused on ICU care. For example the Institute for Healthcare Improvement, the Joint Commission on the Accreditation of HealthCare Organizations, the National Quality Forum, and The Leapfrog Group have all chosen to focus on ICU because errors are common in this complex health care environment, making some of the most critically ill patients vulnerable to an adverse event.

A 1997 study in a large teaching hospital identified 45.8 percent of ICU patients as having experienced an adverse event; of which 17.7 percent were defined as “a serious adverse event” – meaning the event produced disability or death. 4 In a different study in the same year, the rate of preventable adverse drug events and potential adverse drug events in ICUs was 19 events per 1,000 patient days. 5

Most of these errors are due to problems related to the systems, processes and conditions of health care institutions rather than to the culpability of individual professionals. 6 For this reason, safety improvement activities should focus on creating systemic improvements in the structure, processes and outcomes of care. In the ICU, scientific evidence indicates that the single most important factor in improving the quality and safety of ICU care is using intensivists to manage the ICU unit. 7 Recent literature has shown that higher mortality rates exist in hospital ICUs that are not staffed by physician intensivists who are educated in critical care medicine. 8 Employment of intensivists, supplemented by other structural and process improvements, leads to improved outcomes of care AND significant cost savings.

2 Institute of Medicine. (2001). Crossing the Quality Chasm. Washington, DC: National Academy Press.

3 Pronovost, Peter J. A Passion for Quality, Pg 2, Accelerating Change Today (A.C.T.) September 2002

4 Andrews, Lori B; Stocking, Carol; Krizek, Thomas; et al. An Alternative Strategy for Studying Adverse Events in Medical Care. Lancet. 349:309-313, 1997.

5 Cullen , David J.; Sweitzer, Bobbie Jean; Bates, David W.; et al. Preventable Adverse Drug Events in Hospitalized Patients: A Comparative Study of Intensive Care and General Care Units. Crit Care Med. 25 (8) 1289-1297, 1997.

6 Making a Science of Patient Safety. John Hopkins University School of Medicine, Baltimore MD. Accelerating Change Today (A.C.T.) Pg 4. September 2002

7 National Quality Forum. Background, Summary, and Set of Safe Practices.

8 Pronovost PJ, Waters H, Dorman T. (2001). Impact of critical care physician workforce for intensive care unit staffing. Curr Opin Crit Care. 7(6):456-459.

© 2004 Michigan Health and Safety Coalition