Special Feature
Risk Management in the ICU
By Stephen W. Crawford, MD, CPHRM, Medical Director, CIGNA LIFESOURCE Transplant Network, Bloomfield CT, is Associate Editor for Critical Care Alert.
Dr. Crawford is a consultant for Cubist Pharmaceuticals, and is on the speaker's bureau for Ortho Biotech.
It has been said that "medicine is a science, patient care is an art and healthcare is a business." To that end, physicians wear three hats, and must possess a broad range of skills to perform their jobs effectively. This demand is acutely evident in the tasks of an intensive care unit (ICU) director. In this article, I will explain why the specific behaviors and skills of intensivists make them particularly suited to performing as risk managers within their institutions. In fact, in order to be an effective intensivist, one must be a risk manager.
According to the Society of Critical Care Medicine, critical care is a "multi-professional healthcare specialty that cares for patients with acute, life-threatening illness or injury." This definition does not seem to differentiate the ICU from the emergency medicine department. The major difference seems to be in the duration of treatment in each unit. While each deal with acute, life-threatening illness or injury, the ICU is unique in dealing with these issues over days and weeks. In this timeframe, specific problems arise that are seen nowhere but the ICU; for example, the management of acute respiratory failure over days and weeks in the setting of multi-organ dysfunction.
A Risky Place To Be
The ICU is a place of increased risk relative to many in the hospital. Many ICUs report an average mortality rate of about 20%, in part due to the critical nature of many of the illnesses and a prevalence of patients with marginal physiological reserve. While I am aware of few specific data, it seems that there are three broad categories of causes of death in the ICU. Some patients die of progression of underlying incurable illness. Other patients die with ineffectively or inadequately treated and potentially curable illness. Lastly, the remaining patients die as complications of the treatments. This is particularly vexing, because, of the procedures we perform in the ICU, many (most?) hold more potential for harm than likelihood of benefit. The list of procedures likely to harm is longer than that of interventions likely to save life on a daily basis.
Thus, one of five patients in our ICU will die, either due to or with diseases without effective treatment, or due to the treatments themselves. From the perspective of the patient and family, neither of these is a "good" alternative.
So what are we really doing in the ICU? Voltaire (1694-1778) stated, "The art of medicine consists in amusing the patient while nature cures the disease." Similarly, the goal of the ICU is to be supportive of those patients capable of recovery, while we are careful to not kill them. We are truly Hippocratic in our approach of primum non nocere.
In many respects, the intensivist treats many of the same diseases and performs many of the same procedures as physicians elsewhere. What distinguishes the intensivist is a philosophical approach to patient care and the acuity of the situations.
The intensivist is by necessity compulsive in performing routine examinations on a daily basis. The approach to treatment is often simplified by considering individual organs systematically and devising plans for each individually. In keeping with William Osler's admonition, "Absolute diagnoses are unsafe, and are made at the expense of conscience," the intensivist often assumes that all diagnoses are incorrect and that all treatments are inappropriate.1 This caution leads to a continual reassessment of the patient. Lastly, the intensivist eschews surprises and believes that nothing should happen to a patient that was not predicted. This requires constant vigilance, assessment of risk factors, and an understanding of disease processes and complications of treatments. Thus, intensive care medicine is a matter of degree and philosophy. It is medicine practiced intensively and with intensity.
Why is the ICU a Liability Minefield?
The ICU is a very risky place, not only for the patient but also for medical liability. First, from the viewpoint of the patient and family the fact that one is in the ICU is rarely a 'good' thing. Admission to the ICU is frequently associated with unexpected injury or accident, major surgery or catastrophic illness: something has "gone wrong."
Second, from the viewpoint of a plaintiff's attorney many of the functions in the ICU have clearly defined standards of care. While standardization may be a benefit to patient safety, failure to strictly adhere to recommended protocols increases the medical liability for the ICU director. In the event of an adverse event, it is relatively easy to confirm whether the standards defined by the Society of Critical Care Medicine, the Leapfrog Group, and the Institute for Healthcare Improvement (IHI), have been followed.
These standards include:
- Ventilator bundle
- Central line bundle
- Glycemic control
- Prophylaxis against deep venous thrombosis
- Stress ulcer prophylaxis
The Leapfrog Group is an initiative driven by organizations that buy health care who are working to initiate breakthrough improvements in the safety, quality and affordability of healthcare for Americans. They have identified hospital quality and safety practices that are the focus of its health care provider performance comparisons and hospital recognition and reward.
Among these current initiatives are:
- Computer physician order entry
- Evidence-based hospital referral
- ICU staffing by intensivists
These initiatives are endorsed by national organizations that possess substantial credibility. The effect is to make these de facto 'standards of quality care.' There is a substantial risk that the arguments of plaintiff's attorneys will result in widespread implementation of these measures independent of any patient safety benefit they may have.
Specific ICU Risk Management Issues
Let's start with the Leapfrog Group's ICU "staffing by intensivists" proposal. They call it ICU Physician Staffing (IPS), and state that adhering to it reduces ICU mortality by 40%.2 This model is benefited by a "closed" staffing model in the ICU. I will not argue the potential impact of instituting the IPS model. However, there are significant problems with widespread implementation of the model, given the limited numbers of intensivists available and the large number of ICU beds to cover in the United States. In addition, most intensivists bring to the ICU a standard method of practice. It is possible that the decline in mortality observed with IPS was primarily the effect of standardization of ICU practices and not of the consistent availability of an intensivist. This is important to determine, since the financial and staffing impacts of protocol standardization are far less than those of implementing the IPS model. Regardless, failure to staff the ICU with critical care qualified staff whenever possible presents a liability risk.
Informed consent in the ICU is a cause for concern. In distinction to many surgical procedures, consent for procedures in the ICU is frequently obtained in times of critical illness, with urgency, and thus in times of stress for patients and families. Patients are often unable to participate in decision-making, and surrogates are sought for the consent. Add to that the unpredictable hours in which consent for urgent procedures is obtained, and the need for "telephone consent" from surrogates who are not present in the ICU, and this is clearly fraught with professional liability concerns.
One possible solution for the dilemma of consent in the ICU is to adopt the procedures used in the operating suite. Most surgeons obtain consent for all the procedures they anticipate they may need to do before beginning surgery. Similarly, "blanket" consent for the usual and expected ICU procedures covering a specific period of time can be obtained at the time of admission to the ICU.
Charting and writing orders are often done after the fact in a busy ICU. There is no "flight data recorder" in the ICU as there is in commercial airliners. Charting by both physicians and nursing staff is done 'in summary' after many events have occurred. The charting is not linear, and because it is done from memory, it is not comprehensive. In urgent situations, physician orders are frequently verbal, and are recorded in the chart at a later time and from memory. Telephone orders require a 'read back' to the physician by the staff member accepting the order to confirm correct receipt. Many of the problems with verbal orders in the ICU can be lessened by the habit of 'say back.' All verbal orders should be repeated by the staff to the physician from whom they were heard to confirm correct understanding.
Additional areas of risk exist in the ICU. One of these is the method of stocking medications. Unit-dose stocking decreases the likelihood of error compared to bulk stocking. Also, the presence of a pharmacist in the ICU appears to reduce medication errors.
Each new electronic device in the ICU increases the number of alarms that staff needs to monitor. Sources of new alarms can be myriad and include ventilators, CPAP and BiPAP machines purchased by the Respiratory Therapy Department. Constant attention to staff orientation and training is required in order to maintain a safe ICU environment. This training is particularly important for temporary staffing, such as nurse 'travelers,' physician house staff, and personnel who work in various locations in the hospital (respiratory therapy, physical therapy, nutritionists, etc.) Multidisciplinary Staffing Rounds can be utilized for training a wide range of staff on ICU protocols, alarms and procedures.
The Intensivist as Risk Manager
The ICU is a place of substantial risk. In addition, the management of the ICU is critical to the efficient functioning of the hospital. Flow of patients through the ICU is often a choke point for patient care. Prompt admission of patients from the Emergency Department and the timeliness of the Operating Room schedule depend on the availability of beds in the ICU. Every effort to minimize length of stay in the ICU can impact medical care throughout the facility. Therefore, efficiency in risk management is important.
The primary role of a hospital risk manager is to protect the assets of the institution.3 These assets are financial, property and staff. This protection is done by analyzing potential risks, devising risk reduction strategies and mitigating damage once an adverse event occurs. Intensivists, by inclination and training, are accustomed to analyzing risks and stratifying interventions on the basis of the risks. It is what we do routinely in order to prevent complications in the ICU. Prevention becomes the major function in the ICU. We are adept at modifying damage in the event of complications, usually because there is a plan already in place. Intensivists become experts in minimizing liability to patients and proficient in the appropriate choice and timing of interventions to minimize the extent of injury/damage. Thus, the actions of an effective intensivist are similar to those of the risk manager.
The IHI and Leapfrog Group are developing standards of care, in part due to the concerns for patient safety. More and more, procedures and care in the ICU are being driven by protocols. Adherence to these protocols may decrease complications, and more than likely can also decrease the professional liability damage if adverse events do occur.
There should be a natural collaboration between the ICU director and the hospital risk management department. The inclinations of the ICU director are precisely those of a successful healthcare risk manager. Moreover, the goals of the ICU director are perfectly in line with those of the risk manager. That is, both are preeminently concerned with the identification of risks, the prevention of adverse events, and the mitigation of consequences. Ideally, the ICU director will initiate prospective collaborations with the risk management office and develop lines of communication. These efforts should result in more proactive patient safety programs and improved quality of care throughout the institution due to the merging of the skills of multiple disciplines. Importantly, the risk management office can assist with education regarding professional liability that will assist the ICU staff to more confidently perform their duties and assure compliance with regulatory agencies, such as JCAHO.
References
- Bean RB, Bean WB. Sir William Osler, Aphorisms from his Bedside Teachings and Writings. Springfield, IL: Charles C. Thomas Company; 1961.
- Pronovost PJ, et al. Physician Staffing Patterns and Clinical Outcomes in Critically Ill Patients: A Systematic Review. JAMA. 2002;288:2151-2162.
- Carroll R, ed. Risk Management Handbook for Health Care Organizations. Chicago, IL: American Hospital Publishing Inc; 2005.
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