Critical Care Plus: Eight ICU Core Measures Move Forward
By Julie Crawshaw, Critical Care Plus Editor
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is pilot testing 8 of the 11 standardized intensive care core measures initially put forth for public comment. The ICU core measures are JCAHO’s latest move in the ORYX initiative to integrate performance measurement into the accreditation process. Core measures permit comparisons of performance in hospitals across the nation.
JCAHO is working with the Leapfrog Group, a consortium of Fortune 500 companies committed to improving patient safety, and other interested parties to reach agreement on a set of consensus performance measures for intensive care provided in hospitals.
"When Leapfrog came out more than a year ago with the standard that intensivists provide better care, we were a little concerned that the standard might be used as a proxy for outcomes and direct processes of care," says Jerod Loeb, JCAHO vice president for research and performance measurement. "That’s why we decided to partner with Leapfrog to get a little more precision into measuring issues around ICU outcomes instead of just using a metric of how many intensivists a hospital has."
Loeb says that these measures will be used in the context of already existing accreditation activities that cover a variety of other aspects of health care, including a group of 600+ standards designed to reduce the risk of bad things happening in hospitals.
"These measures are not JCAHO’s final word on ICU metrics," Loeb says. "They will change over time in accordance with changing clinical and scientific literature."
Subjective Measures Not in Pilot Test
Nancy Lawler, RN, BSN, JCAHO’s associate project director says that the 15-member advisory panel began its work by consolidating 45 measures into the 11 that were posted for public comment. The eight measures now being pilot tested constitute less than one-fifth of those originally proposed.
One of the measures not going forward involved optimal pain management. "The major issue was lack of consensus on pain scale to be used," Lawler says. "There are lots of valid pain scales, and no one wanted us to dictate which one they had to use."
Another measures thrown out concerned family satisfaction, for which no agreed-upon survey tool was available. "This measure scored rather low on how the data would be used because it’s based on subjective information," Loeb notes. "We’re not saying satisfaction isn’t important, just that we don’t have a tool to measure it."
Lawler says that 41.9% of the 1600 respondents were nurses, 30% were physicians and of those 77.4% were board-certified or board-eligible in critical care medicine. Well-qualified audience lent credibility to the comments received.
Lawler adds that the final set contains individual performance measures interrelated and designed to help other stakeholders, such as government agencies and business communities, assess the overall care provided in an ICU.
Measures are a First for Care Setting
Loeb observes that the ICU measures mark an important change for the Joint Commission. "Until this point all the measure sets and core measure complements we have come up with have addressed physical conditions," Loeb says. "This is the first time a set of measures has been proposed that address a setting of care."
He adds that the conflict between using hospitalists and intensivists in the ICU is an issue JCAHO will ultimately have to address. "There’s a fair amount of data that strongly suggests a link between the training of the physicians practicing in the ICU setting and patient outcomes," he says. "The problem is that there’s a much greater demand than supply for intensivists and it’s an economic issue for many hospitals because the costs of having an intensivist present on a 24/7 basis."
The ICU core measures recommended for initial pilot testing are:
- Ventilator Associated Pneumonia (VAP) Prevention
- Appropriate Peptic Ulcer Disease (PUD) Prophylaxis
- Appropriate Deep Vein Thrombosis (DVT) Prophylaxis
- Appropriate Sedation
- Central Line-Associated Bloodstream Infection (BSI) rate by type of ICU
- Intensive Care Unit (ICU) Length of Stay (LOS) by type of ICU
- ICU Mortality (Risk Adjusted)
- Use of Intensivists
Overall Reception to Measures Less than Positive
Loeb describes reception to the measures as "less than positive" but says the negativity has little to do with the notion that what gets measured gets managed and everything to do with "don’t make me do yet another unfunded mandate." He says the response is hardly surprising in the current healthcare environment with its escalating cost and workforce pressures.
"We’re trying to come up with a set of measures that will be fairly simple, have a great bearing on positive outcomes for ICU patients, be beneficial from a quality improvement standpoint and also provide information for interested stakeholders," Loeb says. "The measures are complementary to the existing standards. You can’t look at them as singular tools used for decision-making-they are one in a large armamentarium of information gathered for accreditation."
Loeb says the ICU measures mark an important change for the Joint Commission. "Until this point all the measure sets and core measure complements we have come up with have addressed physical conditions," he observes. "This is the first time a set of measures has been proposed that address a setting of care."
Loeb describes an ICU a setting that sucks up enormous resources and stresses that the proposed measures are not intended as a panacea for stopping death in the ICU. He quotes Ian Morrison, president of the Institute for the Future, who said, "The Scots believe that death is imminent. Canadians believe that death is inevitable. But Americans believe that death is optional."
Technology to the Rescue
Loeb expects that at some point technology will become the white knight that overworked and understaffed ICUs need. "We’re fast approaching a time when monitoring patients from afar using boarded intensivists and giving input to the care giving staff is routine," he notes.
He anticipates that measures for end-of-life care will be the next additions to the core set. Loeb expects that advisory panel member Mitchell M. Levy, MD, FCCM, FCCP, medical director of MICU at Rhode Island Hospital/Providence, will bring forth an end-of-life proposal when the end-of-life project he heads for the Robert Wood Johnson Foundation is complete. "We need to think about end-of-life care, but right now we don’t have good, well-tested measures," Loeb says. "Within six months I expect we’ll have some meat on these bones." (For more information contact Jerod Loeb or Nancy Lawler at [630] 792-5920.)
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is pilot testing 8 of the 11 standardized intensive care core measures initially put forth for public comment.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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