ICU QA

Part A: Universal Critical Care QA (Applicable to 08, 12, 13, 14, 15)

These are the "Big 4" HAI Indicators mandatory for NABH 6th Edition.

1. VAP (Ventilator Associated Pneumonia) Rate:

   • Formula: (Number of VAP cases / Total Ventilator Days) x 1000.

   • Bundle Compliance: Head end elevation (30-45°), Daily sedation vacation, Peptic ulcer prophylaxis, DVT prophylaxis, Oral care with Chlorhexidine.

2. CLABSI (Central Line Associated Blood Stream Infection) Rate:

   • Formula: (Number of CLABSI cases / Total Central Line Days) x 1000.

   • Bundle Compliance: Maximal barrier precautions during insertion, Chlorhexidine skin prep, Daily review of line necessity.

3. CAUTI (Catheter Associated Urinary Tract Infection) Rate:

   • Formula: (Number of CAUTI cases / Total Urinary Catheter Days) x 1000.

   • Bundle Compliance: Closed drainage system, Bag below bladder level, Daily hygiene.

4. SSSI (Surgical Site Infection):

   • Specific for CVTS/Neuro: Monitoring deep organ space infections.

Part B: General ICU Outcome & Safety Indicators

Applicable to MDCCU, CCU, CVTS ICU, PICU, NICU.

1. SMR (Standardized Mortality Ratio):

   • Indicator: Observed Mortality vs. Predicted Mortality.

   • Tools: APACHE II or SOFA Score (Adults), PIM/PRISM (Paediatrics), SNAPPE (Neonates).

   • Interpretation: SMR > 1.0 means more patients are dying than expected (Quality Issue).

2. Re-admission to ICU:

   • Indicator: Patients discharged to ward but returning to ICU within 48 hours.

   • Significance: Indicates premature discharge or poor ward care.

3. Re-intubation Rate:

   • Indicator: Patients requiring re-intubation within 48 hours of extubation.

   • Significance: Failure of "Weaning Protocol."

4. Pressure Ulcer (Bed Sore) Incidence:

   • Indicator: New sores developing > 24 hours after admission (exclude sores present on admission).

   • Audit: Braden Scale assessment compliance per shift.

5. Restraint Compliance:

   • Audit: Documentation of "Reason for Restraint," "Consent," and "2-hourly release/checks" for neuro-agitated patients.

Part C: Unit-Specific QA Framework

08. MDCCU (Multi-Disciplinary / Medical Critical Care)

Focus: Sepsis and Multi-Organ Failure.

• Sepsis Bundle Compliance: % of patients receiving the "Hour-1 Bundle" (Lactate, Blood Cultures, Broad-spectrum Antibiotics, Fluids).

• Deep Vein Thrombosis (DVT) Prophylaxis: % of eligible patients receiving Heparin/LMWH or Pneumatic Compression.

• Hypoglycemia Rate: Episodes of Glucose < 70 mg/dL (Insulin infusion safety).

09, 10, 11. HDU / NHDU / Cardiac HDU

(Note: NHDU assumed as Neuro HDU. HDUs are step-down units).

• Unplanned Upgrade to ICU:

  • Indicator: Patients in HDU deteriorating and needing transfer back to ICU/Ventilator.

• Early Warning Score (EWS) Compliance:

  • Audit: Use of MEWS/NEWS scores to detect deterioration early.

• Fall Rate:

  • Indicator: High risk here as patients are mobilizing.

• Specific for NHDU (Neuro):

  • GCS Monitoring Accuracy: Audit of nursing logs vs. resident assessment.

  • Dysphagia Screening: Swallow test passed before oral feeding (Stroke safety).

• Specific for Cardiac HDU:

  • Anticoagulation Education: Documented counseling for Warfarin/Acitrom (INR targets) before discharge.

  • Post-Sheath Removal Complications: Hematoma or bleeding at femoral/radial site.

12. NICU (Neonatal ICU)

Focus: Extreme Fragility & Developmental Care.

• Neonatal Hypothermia on Admission:

  • Indicator: % of babies arriving with Temp < 36.5°C (transport quality issue).

• Retinopathy of Prematurity (ROP) Screening:

  • Indicator: 100% screening of eligible pre-terms (Weight < 2000g or GA < 34 weeks).

• Necrotizing Enterocolitis (NEC) Rate:

  • Indicator: Incidence of NEC > Stage 2.

• Unplanned Extubation:

  • Significance: Very high risk in neonates due to short trachea; critical safety metric.

• Antibiotic Stewardship:

  • Indicator: "Days of Therapy" (DOT) per 1000 patient days. (Avoid overuse of Meropenem/Vancomycin).

13. PICU (Paediatric ICU)

Focus: Medication Safety & Resuscitation.

• Medication Error Rate (Weight-Based):

  • Audit: Check doses against patient weight (mg/kg).

• IV Infiltration / Extravasation:

  • Indicator: Severity grading of skin injury due to IV leaks (Paediatric veins are fragile).

• Paediatric Early Warning Score (PEWS):

  • Audit: Response time to high PEWS score.

• Pain Assessment:

  • Audit: Use of age-appropriate scales (FLACC for non-verbal, Wong-Baker faces for older kids).

14. CCU (Coronary Care Unit)

Focus: MI Management & Arrhythmia.

• Door-to-Needle / Balloon Time: (Shared with ER, but managed by CCU).Discharge Medication Bundle:

  • Indicator: % of MI patients discharged on Aspirin, Beta-Blocker, Statin, and ACE-I/ARB (unless contraindicated).

• Arrhythmia Management:

  • Indicator: Time to defibrillation for in-unit cardiac arrests (Target < 2 mins).

• Alarm Fatigue Audit:

  • Process: Checking if alarm limits are customized (e.g., HR limit set to 50-120, not default 60-100).

15. CVTS ICU (Post-Op Cardiac Surgery)

Focus: Post-Bypass Recovery.

• Fast-Track Extubation:

  • Indicator: % of uncomplicated CABG/Valve patients extubated within 6-8 hours.

• Re-exploration Rate:

  • Indicator: Return to OT for bleeding/tamponade.

• Mediastinitis (Deep Sternal Infection) Rate:

  • Indicator: Serious HAI specific to this unit.

• Post-Op Renal Failure (AKI):

  • Indicator: % of patients requiring new Dialysis post-surgery.

Part D: Implementation Checklist for Critical Care HODs

Daily Rounds:

1. "FAST HUGS BID" Checklist:

   • Feeding, Analgesia, Sedation, Thrombo-prophylaxis.

   • Head-up, Ulcer prophylaxis, Glucose control, Spontaneous breathing trial.

   • Bowel care, Indwelling catheter removal, De-escalation of antibiotics.

2. Line Day Count: Nursing In-charge must confirm: "Do we still need this Central Line/Foley?" (If no, remove immediately to reduce infection risk).

Monthly Audits:

1. Hand Hygiene Audit: "Secret shopper" observing doctors and nurses for the 5 moments.

2. Antibiotic Stewardship: Review of "Justification Forms" for restricted antibiotics (Colistin/Tigecycline).

3. Blood Culture Contamination: If > 3%, re-train staff on sterile collection technique.

Equipment QA:

1. Ventilator Calibration: Flow sensor and Oxygen cell calibration.

2. Defibrillator Load Test: Daily discharge test (30 Joules) recorded in logbook.

Summary of Documentation for Accreditation (NABH)

For all these sections, you need to maintain:

1. The Quality Manual: Defining the formulas.

2. The Registers: Where raw data is entered daily.

3. The Analysis Reports: Monthly bar charts/trend lines showing performance vs. benchmarks.

4. Corrective and Preventive Action (CAPA): Documenting what you did when a target was missed (e.g., "VAP rate spiked in June -> Conducted Suctioning Training").