High Quality cardiac ICU, a framework for discussion
Dr Tim Palfreman (Leeds)
This is not simply a wish list. All of the items or options listed below are
already present in one or more of the ICU’s in which I have recently worked,
and there is no reason why these cannot be implemented elsewhere.
Addressing these aspects of structure, process and outcome measurement
would form a comprehensive 5 year plan for quality improvement in a cardiac
ICU.
Structure
 Capacity (level 3 and 2 beds, co-location vs separate HDU)
 ICU physical environment
o Size of bed spaces
o Storage
o Designed for infection control
o ICS standards
 Nursing staff:
o Full establishment
o Skill mix (cost pressures to reduce this)
o Specialist nurses eg practice development and staff
development
o Education/ courses
 Ancillary staff
o HCA’s
o Ward clerks
o Dedicated cleaner
 Medical staff:
o Cardiac anaesthetists vs intensivists (including nonanaesthetists)
o Rota: whole week, half week, day at a time
o Dedicated consultant cover > 15 PA’s per week (required for
advanced ICM trainees)
o Qualifications in ICM
o 24/7 availability of TOE
 Equipment:
o Clinical information system
o Modern ventilators etc
o Specialist kit immediately available for:
 Difficult airway
 Transvenous pacing
 Sternotomy
 Bronchoscopy
o Capnography at every bed space
o Line insertion trolley
 Supporting services:
o Daily radiology and microbiology rounds on the ICU
o Daily pacing checks by pacing technicians
o Immediate access to interventional cardiology, general surgery,
nephrology, neurology, gastroenterology, SALT, etc
D:\116093741.doc

o Ability to provide short-term VAD support
Management structure:
o Formal links with ICU users: surgeons, cardiologists, etc
o Formal links with other ICU’s in the Trust
o Unit clinical governance and operational meetings
 Involvement of all intensivists
 Scorecards with key quality and operational indicators
Process
 Closed vs shared model of care
 Multi-disciplinary ward rounds:
o Intensivist
o Surgeon
o Nurse
o Physiotherapist
o Pharmacist
 Documentation:
o Admission
o Daily assessment
o Discharge
o Consent
o Integrated pathways
 Clinical guidelines and protocols
o Insulin infusion
o PAC management
o IABP management
o Management of pacing wires
o Routine post-operative care
o etc
 Routine audit
o Hand hygiene
o CVC management
o Urinary catheter management
o Ventilator care bundle
o Matching Michigan
o Prescribing standards
o Antimicrobial use
o C. Diff
o MRSA bacteraemias
o Surgical site infections
o Glycaemic control
o etc
 Safety culture
o List of triggers for incident reporting
o Root cause analysis of significant incidents
o Mortality review (modified Birmingham death reporting form)
 Education:
o Induction for every new trainee
o Mandatory training
 Hand hygiene
D:\116093741.doc

 Scrub technique
 Blood products
 MRSA, C. diff
o Weekly educational meeting (as per syllabus)
o Journal club
o Formal educational supervision
o Accreditation for training advanced ICM trainees
Appraisal and revalidation
o Covers ICM as well as cardiac anaesthesia
Potential Outcome Measures
 Mortality
 Surgical site infections
 Catheter related blood stream infections
 Drug resistant organism infections (including MRSA)
 C. difficile infections
 Chest reopening rate on ICU
 Unplanned extubation
 Reintubation rate
 Readmission within 48 hrs of discharge
 Serious untoward incidents
 Length of stay
 Cancellations
 Economic indicators
 Patient satisfaction
 Family satisfaction
 Research output
 Role of ICNARC and cardiac surgical databases
Role of the ACTA ICU group
o Setting standards
o Sharing data for benchmarking
o Sharing clinical guidelines and best practice
o Sharing innovation
o Involvement in guidelines produced by others eg ICS, SCTS
D:\116093741.doc