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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 5  |  Page : 260-270

Quality indicators and improvement measures for pediatric intensive care units

Department of Pediatric Intensive Care, Rainbow Children's Hospital, Hyderabad, Telangana, India

Date of Submission21-Jun-2020
Date of Decision23-Jul-2020
Date of Acceptance01-Aug-2020
Date of Web Publication14-Sep-2020

Correspondence Address:
Dr. Farhan Shaikh
Rainbow Children's Hospital, Banjara Hills, Hyderabad, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_100_20

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Quality and patient safety is an integral part of pediatric critical care. Quality indicators (QIs) or key performance indicators (KPIs) are crucial to measure various aspects of quality and patient safety in pediatric intensive care. If we want a system which gives us reproducible results, it is crucial that various aspects of structure, process, and outcomes in that system are measurable and reproducible. It is crucial that the data used for measurements are accurate and they are analyzed using appropriate tools, and the KPIs/QIs calculated from the data are appropriately validated. These QIs/KPIs should be compared to the “accepted” international or national benchmarks on a periodic basis so that the team of doctors, nurses, and administrators are aware of the performance of their unit. In India, there are no national benchmarks available to compare the QIs/KPIs of our pediatric intensive care units (PICUs), and there is a dearth of such benchmarks for PICUs at international level too. In this review article, we aim to discuss the various aspects of data collection, data validation, and measurement of some important QIs of a PICU. We have also tried to gather some international benchmarks for some important QIs, which can be used by PICUs for their comparisons. Eventually, the best thing will be to develop a national database from various PICUs across India so that a national benchmark is created.

Keywords: Key performance indicators, pediatric intensive care unit, quality and patient safety in pediatric intensive care, quality indicators

How to cite this article:
Shaikh F. Quality indicators and improvement measures for pediatric intensive care units. J Pediatr Crit Care 2020;7:260-70

How to cite this URL:
Shaikh F. Quality indicators and improvement measures for pediatric intensive care units. J Pediatr Crit Care [serial online] 2020 [cited 2023 Jun 8];7:260-70. Available from: http://www.jpcc.org.in/text.asp?2020/7/5/260/295011

  Introduction Top

Providing medical care to a patient with latest gadgets and the most updated scientific knowledge is the most obvious practice in any pediatric intensive care unit (PICU).

In this endeavor, the treating team often tends to ignore the other crucial aspect of critical care, which is providing care with utmost attention to patient safety and high quality.

In the last two decades, there is increased public awareness, media attention, and legal intercession in the way health care functions. There is also a growing insistence from health insurance companies to bring transparency, accountability, and cost-effectiveness in health-care system.

In this chapter, we shall discuss the important aspects of quality indicators (QIs) and their appropriate utilization in the implementation of quality and patient safety practices.

The Institute of Medicine (IOM) report[1] on safety revealed that there is a health-care safety crisis. Their data indicated that approximately 44,000 to nearly 100,000 patients die annually in US hospitals due to error.[1]

This was equal to one Jumbo Jet plane crashing every 2nd day!

Moreover, these were the data from one developed country; the scenario in a developing country would be unimaginable!!

Apart from developing and monitoring of QIs, there are many other tools to improve quality and patient safety in intensive care units, which are beyond the scope of the present article.

In this article, we shall restrict our discussion on different types of QIs, which can be used in a PICU, and various means of collecting reliable data so that the calculated QIs in turn are meaningful.

  “Quality Indicators” and “Benchmarking” Top

The IOM has defined health-care quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”[1]

This definition insists that the services provided in health-care industry should be audited and various standards of services must be “measured.”

These measurable components of health-care service are known as “quality indicators” or “key performance indicators.”

These QIs should be compared with nationally or internationally accepted QIs, known as “benchmarks,” to understand “the degree to which health services for individuals and populations match with the desired health outcomes and are consistent with the current professional knowledge.”

“QIs” help in the assessment of the quality of service provided; analyze the various outcomes of intervention, treatment, and adverse events (AEs); audit various managerial and therapeutic processes; and thus help explore opportunities for further improvement.

Concept of “Benchmarking”

Benchmarking is a technique in which an organization measures its performance against that of the reputed organizations, determines how those organizations achieved their performance levels, and uses the information to improve its own performance. Subjects that can be benchmarked include strategies, operations, and processes.

  Role of “Quality Indicators in Pediatric Intensive Care Unit” Top

PICU is a potentially dangerous place in terms of patient safety and quality of care.

PICU care is unique because:

  • Sick patients vary depending on their age, size, and the underlying medical conditions
  • There are many complex invasive and noninvasive procedures involved
  • There is continuous usage of high-risk medications in complex dosing and frequency regimes, and there is constant use of complex lifesaving equipment and
  • There is a complex interaction between technology and potentially erring humans.

Thus, it is very important to device reliable methodologies to identify important areas, where quality of care can be measured (QIs) and analyzed and reliable corrective and preventive actions can be planned accordingly.

  How to Select Appropriate Quality Indicators for Pediatric Intensive Care Unit Care? Top

The simplest approach is to follow the Donabedian's[2] model of “structure,” “process,” and “outcome.”

  1. Structure: This encompasses facility attributes:

    • Layout of the PICU in terms of its location in the hospital and utilization of available space
    • Overall infrastructure (physical lighting, air quality, water quality, and available workforce [nurses (nurse: patient ratio), number of doctors, etc.])
    • Available equipment (ventilators, cardiac monitors, syringe pumps, hemodialysis and/or continuous renal replacement therapy [CRRT] machine, extracorporeal membrane oxygenation [ECMO], etc.)
    • Medical gas supply, electricity supply (including availability of adequate backup supply of gas, water, and electricity)
    • Availability of isolation and quarantine facilities
    • Efficient and effective air-handling system
    • Effective fire safety system
    • Efficient water and electricity supply and utilization
    • Presence of infection control nurse (ICN)
    • Presence of clinical pharmacist.

  2. Process: This includes various aspects of patient care:

    • Open versus closed PICU system
    • 24-h intensivist presence
    • Identifying patients by two identifiers
    • Process of pain assessment and management
    • Process of prescription audits and prevention of prescription and administration errors
    • Turnaround time for availability of blood products
    • Turnaround time for availability of important lab results
    • Response time for short and long transports by hospital ambulance
    • Standardized procedures are followed to adhere to various infection control activities (adhering to hand hygiene, adhering to “bundle” approach to prevent ventilator-associated pneumonia [VAP], Central line associated blood stream infection (CLA-BSI) and catheter-associated-urinary tract infection [CA-UTI], adhering to antibiotic stewardship, etc.)
    • Standardized protocols being followed to manage various clinical conditions (using clinical guidelines and algorithms in the management of diabetic ketoacidosis, dengue hemorrhagic fever, acute respiratory distress syndrome, septic shock, etc.)
    • Emphasis on patient- and family-centered care
    • Emphasis on excellent communication between doctors and nurses
    • Standardized process to address breakdown of equipment, gas supply, and electricity failure
    • The treating team following standard procedures during admission, discharge, death, or left against medical advice situations
    • Process to manage “nonavailability of bed” situation
    • Process to handle grievances of patient's family members
    • Process for managing patient's family request for organ donation

    “Process” also includes ensuring the well-being and safety of the treating team:

    • Process for selection of adequately qualified staff for the PICU
    • Process for induction training and education of newly joined doctors and nurses
    • Process for handling complaints and grievances of the PICU staff (doctors and nurses)
    • Process of ensuring prompt response following a needlestick injury
    • Process preexposure prophylaxis of health-care workers
    • Process of ensuring adequate number of doctors and nurses per shift
    • Process of ensuring adequate ongoing training and education of the doctors and nurses
    • Training of hospital staff in fire and nonfire emergencies (including handling of difficult/violent family members, child abduction, and disaster management).

  3. Outcome: This includes various clinical, nonclinical, or administrative aspects of patient care:

  4. Clinical outcomes:

    • Mortality rate (MR)
    • Average length of PICU stay
    • Average ventilator days
    • Survival rates of patients on high-frequency oscillatory ventilation (HFOV) or ECMO or CRRT therapy
    • Survival of postliver transplant patients, or postcardiac surgery patients, etc.

    Nonclinical outcomes:

    • Patient satisfaction survey reports
    • Number of admissions per month and per year
    • Average PICU bed occupancy
    • PICU utilization rate
    • PICU equipment utilization rate

    In addition to the above-mentioned Donabedian's approach of “structure,” “process,” and “outcome,” certain other QIs which are useful are derived from two important aspects of care delivery, namely (a) improvement based and (b) accountability based.

    1. “Improvement-” based quality indicators include:

      • Return to PICU within 48 h
      • Incidence of iatrogenic pneumothorax
      • Percentage of unplanned extubation (UE)
      • Incidence of re-intubation
      • Adverse drug reactions
      • Antibiotic stewardship-related indices.

    2. “Accountability-” based quality indicators include:

      • Incidents of medication errors (including prescription, dispensing, and administration errors)
      • Safe injection practices
      • VAP rate
      • Catheter-related bloodstream infection (CRBSI) rate/catheter-associated-bloodstream infection (CA-BSI) rate
      • CA-UTI rate
      • Surgical-site infection (SSI) rates
      • Percentage of adherence to hand hygiene
      • Incidence of pressure sores
      • Fall from bed
      • Incident of sentinel events
      • Equipment breakdown
      • Deviation from standardized protocols
      • Air and water quality monitoring
      • Fire safety
      • Disaster preparedness
      • Outbreak management.

Some examples of the commonly used QIs with their benchmark are as follows:


PICU MR = (total number of deaths/total number of PICU admissions in the same period) × 100

This gives a rough guide to the death rate in a unit; however, they are not “adjusted” with the disease severity.

2. Standardized mortality rate (SMR)

SMR = (observed MR/risk-adjusted expected rate) × 100

Risk-adjusted MR can be calculated from various severity scoring systems such as PRISM-3 or PIM-2. The scoring is as follows:

  • = 100 – Hospital's MR and the expected average rate are the same
  • > 100 – Hospitals' MR is higher than the expected average MR
  • <100 – Hospitals' MR is lower than the expected average MR
  • Higher SMR does not necessarily mean that the hospital is unsafe, as this is a snapshot method and simultaneous assessment of other QIs must be done to draw a logical conclusion. Single parameter-based judgment on performance level is not advocated.[3]

3. Unplanned extubation

The incidence of UE is reported in two ways. The first approach divides the number of UE by the number of ventilated patients (percentage). This calculation is confounded by the possibility of disproportionate rates of ventilated patient turnover. Adopting this first method, intensive care units that have a high number of short-term ventilations would have lower incidences of UE because the denominator of the formula would be large; therefore, to avoid this confounding possibility, Little et al.[4] recommended calculating incidence as a function of the number of UE per 100 intubation days. This model incorporates the concept of days at risk for UE and allows comparisons among different PICUs.

(no. of UEs/no. of intubation days) × 100

Studies conducted within the past 20 years indicate that UE occurs with a rate of 0.11[5] to 2.7[6] events/100 intubation days. A multicentric study conducted to examine extubation failure in 16 PICUs revealed UE rate of 1.02/100 intubation days.[7]

4. Incidence of re-intubation

Accidental extubation and subsequent re-intubation can lead to prolonged stay, longer ventilation, and higher nosocomial pneumonia and mortality.

(no. of re-intubations within 48 h of extubation/total no. of extubation) × 100

Benchmark: 12%[8]

  • Too low re-intubation rate hints toward very conservative ventilation strategy
  • Too high rate signifies aggressive extubation policy and poor sedation/analgesia or extubation planning.

5. Incidence of decubitus (pressure) ulcer

Prolonged uninterrupted pressure over bony prominences causes necrosis and ulceration.

Depending on tissue damage, ulcers are classified into four stages.

  • Stage 1 indicates superficial color change
  • Stage 2 represents partial-thickness skin loss
  • Stage 3 denotes full-thickness skin loss
  • Stage 4 denotes deep and extensive tissue damage involving muscle, tendon, or bone.

Hip and buttock sores represent 67% of all pressure sores.

(No. of pressure ulcers/no. of patients admitted) × 1000


(No. of pressure ulcers/no. of patients admitted) × 100

Benchmark: 17%–24% in PICU population[9] and 3%–11% or 18–22/1000 patient-days in some other studies.[10]

6. Average length of stay (LOS) in PICU

Total occupied bed days/number of patients in a given time frame (weekly/monthly/yearly)

The total duration of hours and days in which patients are treated in the unit with midnight bed occupancy is taken for the calculation of numerator.

Calculation of “mean” overestimates LOS, as outliers in both ways erroneously influence the calculation.

Calculating the median of LOS can avoid this problem.

If calculated and analyzed properly and stratified on the basis of diseases and underlying clinical conditions, this can be a sensitive parameter to analyze the quality of care provided for various clinical conditions, discharge process in PICU, and mortality/morbidity pattern of the unit.

7. Readmission in PICU within 48 h:

The Society of Critical Care Medicine's QI Committee has ranked this indicator as the top indicator for judging ICU quality.

(no. of readmitted patients/total no. of patients managed in the ICU) × 100

Benchmark: 4%[8]

Zero readmission rate over few months reflects a conservative approach; this will increase LOS in ICU causing risk of nosocomial infection, iatrogenic complications, and nonavailability of beds for the deserving patients.

A higher readmission rate indicates premature decision to shift out patients, and such units should adopt sound discharge planning and discharge criteria to prevent readmissions within 48 h.

8. Incidence of fall from bed:

A fall can be accidental or anticipated in a patient with risk factors (sedation, neurodeficit, etc.). Accidental fall can cause injuries, prolonged stay, and patient dissatisfaction.

(No. of patient falls/total no. of patient-days in the same period) × 100

Benchmark: 0%[8]

9. Medication errors:

Medication errors can be of prescription, administration, dispensing, monitoring, and transcription errors.

Medication error rate = (no. of error/no. of bed days) × 1000

Median of 24.1/1000 patient-days in neonatal/pediatric ICUs

Wrong dose: 105.9 errors/1000 patient-days in the ICU.[11]

A Dutch study used a passive observer to determine the frequency and causes of drug administration errors in the ICUs of two hospitals. A 33% error rate was observed, with wrong administration technique as the leading type of error.

The investigators determined that the systems for operating the ICUs made a difference in the rate of errors. The ICU with full-time intensive care physicians and approved pharmacy protocols for drug administration had fewer errors (21.5% vs. 70.2%).

This factor and other system issues, such as staffing on certain days (errors were observed more frequently on a Monday) and lack of familiarity with nursing protocols on nasogastric (NG) administration of medication, were suggested as interventions to improve medication safety.[12]

10. AEs/error rate

Patients in PICU are at high risk for complications due to their underlying medical conditions, various invasive procedures, use of high-risk medications, and technology-based interventions.

As per the IOM report,[1] nearly half (45%) of the AEs are preventable.

AEs/error rate = (no. of error/no. of bed days) × 1000

11. Needlestick injury rate

Needlestick injuries can cause transmission of blood-borne pathogens. Needlestick injury can occur due to lack of awareness in safe handling of sharps (syringe needles, recapping of needles, suture needles, etc.) and their safe disposal.

Needlestick injury rate = (no. of incidences of needlestick injuries/patient-days in that period) × 100

The aim is to keep the incidence of needlestick injuries to 0% by better training and awareness of staff and sound biomedical waste segregation practices.

12. Infection control quality indicators

Nosocomial infection causes direct and indirect impact on the mortality and morbidity in the PICU patients.

Nearly 80% of the nosocomial infection in any hospital belong to the following four main categories:

  • VAP
  • CA-UTI
  • SSI.

12a. VAP

VAP refers to nosocomial pneumonia occurring 48 h or more after the initiation of invasive mechanical ventilation. Centers for Disease Control and Prevention (CDC) criteria (PNU 1, PNU2, and PNU3 categories: CDC Device-associated module, 2017) are used to identify VAP.

Indian studies have shown VAP rates ranging from 15% to 45%. The incidence rates of VAP are higher in developing countries with limited resources.[13]

(no. of patients diagnosed as VAP as per CDC criteria [PNU1, PNU2, or PNU3]/no. of ventilator days) × 1000 days.[14]

12b. CA-BSI or CRBSI

CRBSI remains the most common nosocomial infection in pediatric ICUs, resulting in significant morbidity, mortality, and added health-care costs.

Very few studies expressing CRBSI data in terms of device utilization frequencies as denominator are available in India and other developing countries.

(no. of CLABSI/no. of central line-days) × 1000

For surveillance purposes, CA-BSI is used rather than CR-BSI as the diagnostic criteria, as CR-BSI criteria are more stringent.[15]

CA-BSI rates are higher in developing countries than that of the developed countries due to various factors. A study by Parameswaran et al. from a tertiary care center in South India shows the incidence of CRBSI as 8.75/1000 catheter-days.[16]

12c. CA-UTI:

Urinary tract infections diagnosed after 48 h of urinary catheterization are included in the numerator.

(no. of UTI/no. of catheter-days) × 1000

An incidence of 2–5/1000 catheter-days is reported in many studies.[17]

12d. Hand hygiene audit (percentage of adherence)

(No. of missed moment/no. of available opportunities) × 100

The unit should strive to keep the compliance above 80%

Individual moments from the WHO recommended that “five moments” of hand hygiene should also be audited individually. The data can be interpreted using the Pareto chart to understand the most commonly missed moments.

13. Percentage of transfusion reactions:

Every transfusion of blood product should be monitored for transfusion reaction. Transfusion reactions can be analyzed using the following formula:

(No. of transfusion reactions/no. of transfusions administered) × 100

The aim should be to keep this rate at 0%.

14. Bed occupancy rate:

(No. of inpatient days in a given month/no. of available bed days in that month) × 100

The no. of inpatient days is calculated by multiplying the number of patients admitted during the study period with the number of days the patients were kept in PICU.

The no. of available bed days is calculated by multiplying the number of beds in PICU with the total number of days (if calculating bed occupancy for a month, then multiply by 30 and if for 1 year, then multiply by 365).

This indicator helps hospital management in planning resources.

15. Nurse: patient ratio

Based on our experience and unit practice, a safe ratio between patients and nurses can be as follows:

  • For very sick patient (ventilated patients on high-ventilator settings, multiple inotropes, HFOV, CRRT, or ECMO, etc.): 1 patient: 2 nurses
  • For sick patients (ventilated on moderate settings, those on continuous positive airway pressure (CPAP)/high-flow nasal cannula (HFNC) with severe distress, on multiple inotropes): 1 patient: 1 nurse
  • For moderately sick patients (on CPAP/HFNC but stable, hemodynamically stable, etc.): 2 patients: 1 nurse
  • For stable patients (on low-flow oxygen or room air, feeding on NG or direct oral feeds,): 3 patients: 1 nurse

  Attributes of Quality Indicators Top

The key to continuous quality improvement is availability of reliable and robust data.

A clear understanding of availability and limitations of the data is crucial in developing strong and reliable QIs.

The inaccuracy in the data can be due to:

  • Passive or “voluntary reporting” of various incidents, which is the most common method of data collection, carries inherent risk of underreporting and thus, erroneous data[18]
  • Erroneous data collection can also be due to inexperience or lack of knowledge of the person who is collecting the data, in that particular process. If the person collecting the data does not have knowledge in that domain, the data collection can be erroneously collected or wrongly interpreted
  • Errors in data entry due to human and/or machine errors
  • Errors in coding due to human factors or lack of training, etc.
  • Inability to adjust the data depending on the severity of illness
  • Possibility of incomplete data collection. For example, if data were collected for some other purpose and then decided to use them for calculating QI or safety parameter, there is a risk of data being incomplete as it was originally not collected for this purpose.

  Data Validation for Reliable Data Collection Top

Voluntary reporting of AEs is the most commonly used method for data collection in health care. However, voluntary reportings have been shown to capture only 2%–8% of all harms.[18]

One more commonly utilized method is direct observation and detailed chart reviews.

This method requires workforce and is labor intensive. Although more reliable than voluntary reporting, it too carries the risk of personal bias and personal interpretation errors.[19]

Doctors, nurses, and coordinators working within the PICU can also be trained and made “quality champions,” “infection control champions,” and “medication safety champions,” who help the quality team, ICNs, and clinical pharmacists in their audits and data validation.

Data validation can be done through various indirect means. For example, an “interdepartmental cross audits can be a useful tool for data validation. Quality champions, infection control champions, and medication safety champions of one department can be sent to other departments for auditing, for example, a trained team from neonatal intensive care unit audits pediatric intensive care and vice versa. This provides opportunity for “peer review” and validation of data collected by the regular auditing team.

One more effective strategy, known as the “trigger tool,” has been found to be superior to voluntary occurrence reports and conventional unfocused chart review in the identification of AEs.[20]

David C. Stockwell and his team[18] used a novel pediatric-specific list of triggers and found 40 harms/100 admissions among children hospitalized at six large freestanding children's hospitals. Nearly one-half of the harm was deemed preventable.[2],[15],[16] One of the every four pediatric admissions in their study had at least one identified harm. They found trigger tools far superior to voluntary reporting in detecting harm.[18]

A trigger is defined as an occurrence, prompt, or flag found on review of the medical chart that triggers further investigation to determine the presence or absence of an AE.

AEs are defined as an injury, large or small, caused by the use (including nonuse) of a drug, test, or medical treatment.

Harm is defined as an unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment, or hospitalization or that results in death.[19]

Some examples of “trigger tools” are:

  • Using “Pediatric Ventilator-Associated Events (PedVAE) to screen for the possibility of VAP
  • Use of naloxone in PICU patients should trigger the team to investigate for opioid-related AE
  • Any positive blood culture in a patient after 48 h of insertion of a central line should trigger investigation for the possibility of CA-BSI
  • Any patient receiving intravenous antihistaminic (Pheniramine) and/or hydrocortisone during or immediately after transfusion of a blood product should trigger an investigation for possible transfusion reaction which could have been missed in the “voluntary reporting” system
  • Return to PICU in 48 h should trigger to investigate any lacunae in the discharge process
  • LOS in PICU longer than the usual trend of the unit for a particular medical condition should trigger to investigate for any iatrogenic complication (iatrogenic infections, air leaks, pressure sores, adverse drug reactions, etc.).

The Institute for Healthcare Improvement has come up with a list of global trigger tools which can be used for capturing reliable data and add more value to the calculated QIs.[21]

Various units can device their own trigger tools to capture their data.

  Analysis and Presentation of Data Top

The data which are collected by various methods (voluntary reporting, auditing of patient records, use of trigger tools, patient feedbacks, managerial reports, etc.) are converted into “QIs” by using various formulas/calculators. These QIs are then presented in graphical or pictorial format for better visual appeal and understanding.

For example, analysis of AEs can be done in different ways as follows:

  • AEs/1000 patient-days
  • AEs/100 admissions; and
  • Percent of admissions with an AE.

“AEs/1000 patient-days” is the traditional measure and is the recommended measure to track the harm rate over time.

Data should be presented in a run chart [Figure 1] with “AEs/1000 patient-days” on the Y-axis and time in 2-week increments on the X-axis.
Figure 1: A run chart showing incidence of pressure sores/1000 patient-days, in a pediatric intensive care unit over 1 year. There is reduction in incidence from September due to implementation of some quality improvement measures

Click here to view

“AEs/100 admissions” is another presentation of rate. It provides a more easily understood representation of harm. Data should be presented in a run chart similar to “AEs/1000 patient-days.”

It should be noted that the conversion from “AEs/1000 days” to “AEs/100 admissions” simply entails a switch from the number of patient-days (1000) to records reviewed (admissions).

“Percent of admissions with an AE” is a convenient way to present the information to lay persons, although it diminishes the number of events because some patients may have more than one AE during a hospital stay. Thus, it is less sensitive to improvement than the two rate measurements.

In addition to the run chart representations, the team can present categories of harm in a “bar chart” in order to depict the volume of harm in each category.

Data are also often presented by the “type of AEs.” The types of events have commonly been defined as infections, medications, and procedural complications.

Hospitals find this categorization to be useful in prioritizing areas for improvement in work.

The Pareto chart [Figure 2] is one useful tool which depicts the “80:20” rule (80% of the events are due to 20% of the causes).
Figure 2: Pareto chart utilizing 80:20 rule (80% of the events are due to 20% of the causes). In this chart, we can see Moment #1 and Moment #5 are the most commonly missed moments out of the WHO's Five Moments of hand hygiene

Click here to view

  Implementation of Quality and Patient Safety Improvement Methods Top

The Plan-Do-Study-Act (PDSA) cycle is a simple yet effective tool for continuous quality improvement.[22]

Once a team has set an aim, assembled appropriate team, and “Planned” a workflow, they will start the work (Do), and after some time period they will make an re-assessment (Study) whether their strategy is leading to an improvement or not, if the target is still not achieved or partially acheived, the team shall start the work with some appropriate changes in strategy once again (Act). The same cyckle of Plan, Do, Study and Act will repeat.

The PDSA cycle [Figure 3] is shorthand for testing a change – by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.
Figure 3: Plan-Do-Study-Act cycle

Click here to view

  Quality and Patient Safety Is a Continuous “team” Effort. Top

The entire team of PICU (doctors, nurses, technicians, housekeeping staff, and administrative staff) forms the “quality team.”

An ICN performs various infection control-related audits (hand hygiene audits, adherence to various infection prevention bundles such as VAP bundle, CABSI bundle, and CAUTI bundle) and surveillance activities (water quality, air quality, and surveillance swabs on regular intervals). The ICN is also responsible for ensuring that all health-care staff had received prophylactic immunization (hepatitis B vaccine, H1N1 prevention vaccine, etc.).

The ICN also ensures that adequate isolation measures (air-borne/droplet/contact isolations) are followed for patients in need of isolation in PICU.

The ICN is also actively involved in continuous training and education of doctors and nurses in infection control activities, personal protection, needlestick injury, etc.

Clinical pharmacists perform daily prescription audits, ensure appropriate labeling of medications and appropriate dilution of infusions, and ensure that inappropriate drug combinations are avoided.

Clinical pharmacists also check the crash trolleys and medication trolleys for sound inventory control and appropriate segregation of medications in different categories (look-alike drugs, sound-alike drugs, high-risk drugs, narcotics, emergency drugs, etc.).

Clinical pharmacists are also involved in the training and education of nurses in safe medication practices.

A quality executive from the department of quality will be involved in collecting data and performing document audits and audits of various “structure-,” “process-,” and “outcome-” related parameters on a daily basis. He/she maintains the data and shares the data with the physicians and nurses on regular intervals. The quality executive also maintains an “events report” register in collaboration with the PICU in-charge nurse. This register keeps record of all AEs and events which deviated from the routine process. This register is an important source of data which is used for the calculation of various QIs.

The in-charge nurse of a PICU is a crucial link between PICU physicians (consultants and resident doctors), PICU nurses, ICNs, clinical pharmacists, housekeeping staff, biomedical engineering staff, maintenance engineering staff, human resources department, and hospital's operations and management division.

The in-charge nurse of a PICU maintains optimum patient: nurse ratio, ensures training and education of the PICU nurses, and ensures that all PICU equipment are calibrated and are in sound working condition.

The in-charge nurse should carry a “checklist” to ensure the availability of emergency drugs, airway equipment, and other lifesaving equipment (ventilators, cardiac monitors, defibrillators, etc.).

The PICU in-charge nurse ensures efficiency in:

  • Structured hand overs between nurses
  • Monitoring patients' vital parameters and their accurate entry in patients' medical records
  • Taking complete patient consents
  • Monitoring patients' pain, sedation, and analgesia
  • Screening of various risk factors (e.g., pressure sores, thrombophlebitis, and falls from bed) at regular intervals
  • Implementation of various “checklists” to implement patient safety activities (e.g., VAP bundle, CABSI bundle, CA-UTI bundle, head injury bundle, and septic shock management bundle).

The PICU consultants must carry one “huddle round” in the morning to discuss new admissions in the previous day, any patient-related clinical care issues, and any other events from PICU.[23]

Consultants, fellows, and residents in the PICU should meet once in a week and discuss the important events of the previous week such as cancellation of procedures, refused admissions, delayed PICU shift outs, delayed procedures, and readmission in 48 h.

The resident doctor can adopt “checklists” for various clinical conditions (e.g., septic shock management checklist, diabetic ketoacidosis checklist, and trauma care checklist).

The team of doctors should use standardized communication tools (e.g., ISBAR) and “structured” hand-off tools while exchanging patient information at the time of change of shift.[24]

The entire team of PICU staff (medical and paramedical staff) should meet once in a month to discuss all the QIs, patient feedbacks, and patient safety-related events.

  Summary Top

  • Quality and patient safety is everybody's business!
  • The entire team should work in a blame-free atmosphere where audits are carried out with the sole aim of improving quality and safety and not finding faults or blame individuals
  • In resource-limited setups with shortage of workforce, sometimes, it may not be possible to recruit designated ICN, clinical pharmacists, or quality executives. In such a scenario, these responsibilities can be shared among the doctors and nurses of the PICU
  • Daily morning huddles and regular meetings on weekly and monthly intervals should be planned to ensure that PDSA cycle is maintained.

Future directions

The QIs of PICU should be compiled over months and years. The data should be shared between various units with an aim for eventual development of regional benchmarking and eventually national benchmarking.

These benchmarks will provide a direction to the PICUs across the country, who are in pursuit of perfection in critical care delivery to sick children.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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