hồi sức

1. Hồ Thị Quỳnh Duyên
Lê Hữu Thiện Biên
EVALUATION OF NURSING CARE
QUALITY IN A ICU

2. Introduction
Nursing care plays an important role in patient
outcome
Poor nursing care may increase morbidity and
mortality
Nursing care quality is more important for ICU
patients
 Higher illness severity
 Completely depend on healthcare personnel

3. Introduction
Nursing care quality depends on
 Patient severity
 Patient to nurse ratio
 Nursing skill mix
Nursing quality indicators
 Length of stay, mortality
 Postoperative pain
 Pressure ulcer
 Self-extubation
 Nosocomial infections

4. Introduction
Nguyễn Văn Thông (2010) in stroke unit
 UTI 6%, pressure ulcer 4%
 Did not clarify: indicators definitions, nurse staffing
 May not be suitable to generalize for heterogenous
population such as ICU patients
Our study goals
 Assess nursing care quality in our ICU using ANA
quality indicators
 Compare our nursing quality to available reference
 Demonstrate our nurse staffing

5. Materials and method
Longitudinal observational study 11/2011-
11/2012
Mixed ICU
Inclusion criteria
 Patients stay ≥ 48 hrs
 Level of care using VN ministry of health guides
Nurse modeling
 8 hours shift
 Nursing skill measured by: academic degree, year of
experience

6. Materials and method
Patient to nurse ratio = number of
patient/number of nurse per shift
Nursing quality indicators
 Pressure ulcer
 Patient fall
 Physical restraint
 Medication errors
 Hospital acquired pneumonia
 Hospital acquired UTI

7. Nursing quality
indicator definition
Pressure ulcer
 The National Pressure Ulcer Advisory Panel criteria
 Stage I-IV
 Incidence=patient with pressure ulcer/all patient
Patient fall
 Unplanned fall to the floor with and without injury
 Self-reported by in-charge nurse
 Rate=number of fall/1000 patient-day

8. Nursing quality
indicator definition
Physical restraint
 Any limb restraint
 Self-reported by in-charge nurse
 Incidence=patient with physical restraint/all patient
Medication errors
 Including: wrong medication, wrong dose, wrong
route, missed dose
 Self-reported by in-charge nurse
 Indidence=number of medication error/1000 patient-
day

9. Nursing quality
indicator definition
Hospital acquired pneumonia
 According to CDC definition
 Incidence=patient with HAP/all patient
 Patient with pneumonia on admission will not be
counted as HAP during ICU stay
Hospital acquired UTI
 According to CDC definition
 Incidence=patient with HAUTI/all patient
 Patient with UTI on admission will not be counted as
HAUTI during ICU stay

10. Results
102 patients
 Age: 70,4  13,3
 Length of stay: 7,0  4,9 ngày
Underlying diseases
 Respiratory failure: 37,3%
 Shock: 20,6%
 Neurologic diseases 16,7%
 Complicated surgery: 13,7%
 Others : 11,8%
Level of care
 Level 1: 68,6%
 Level 2: 9,8%
 Level 3: 21,6%

11. Nursing quality indicators
Pressure ulcer: 7.8%
Patient fall: 1.4/1000 patient-day
Physical restraint: 1%
Medication errors: 11.1/1000 patient-day
(3.9% orders)
HAP: 2%
HAUTI: 11.8%

12. Nurse staffing
Patient to nurse ratio: 2.38  0,66
Year of experience: 7.3  5.9
Academic degree
 Associate degree in nursing: 80%
 Bachelor degree in nursing: 20%

13. Pressure ulcer
Nguyễn Văn Thông
(VN)
4% - Without risk factors of pressure
ulcer: (1) patient age, (2) LOS, (3)
immobility
Reilly (Hoa kỳ) 8,4% US-ICU
Chitpakdee (Thailand) 0-10,8% Highest prevalence of pressure
ulcer in most severe patient
Our result 7,8% -Most patient with level 1 of care,
-High immobility due to underlying
disease, sedation

14. Patient fall
Lake (Res Nurs Health 2010;33:413)
 Rate 1,38  2,79/1000 patient-day
 Predisposing factor: nursing hours per day
Our result
 1.4/1000 patient-day
 Not high fall rate, although patient:nurse ratio than
recommended
 Most patients were sedated and reduced fall rate

15. Physical restraint
Eser (Turkish ICU)
 By nurse interview: 81,7%
 In medical record: 32,2%
physical restraint is common in ICU but often
unnoticed
Our result: 1%
 Very low rate, not concordance with low rate of fall
 Self-reported may not show accurate rate of physical
restraint

16. Medication errors
Valentin 2009 113 Europe
ICUs
74/100
patient-day
-24 hrs observation
-Medication errors:
wrong drug, wrong
dose, wrong time,
wrong route, missed
dose
Jennane 2011 1 Morocco ICY 19/1000
patient-day
Chúng tôi 11,1/1000
patient-day
-Self-reported
-Medication errors:
wrong drug, wrong
dose, wrong route,
missed dose

17. Nosocomial infections
Laupland 2005 Multi ICUs HAUTI 6,5% (9,6/1000
patient-day)
Alps 2004 Multi ICUs -HAP 6,8%
-LOS 3,9 day
Chúng tôi Mixed ICU -HAUTI 11,8%
-HAP 2%
-LOS 7 ngày

18. Nosocomial infections
Needleman (NEJM 2002;346:1717): staffing of
RN hours from 25th to 75th percentile
 Rate of UTI decrease 9%
 Rate of HAP decrease 6.4%
Our patient:nurse ratio 2.38, it must decrease to
achieve a lower rate of UTI
HAP was unexplaindable low, may due to many
patient had pneumonia on admission (66.7%)
and these pts were assumed not to have HAP
during ICU stay

19. Patient to nurse ratio
Important factor for nursing quality
 2:1= pt without MV
 1:1= pt with MV
Kane (Medical care 2007;45:1195): increase 1
patient to patient:nurse ratio
  HAP 7%
  Self-extubation 45%
Cho (J Clin Nurs 2009;18:1729)
 Nurse self-evaluate
 Quality of care increase when P:N ratio 32
 Year of experience 4.9 (our 7.3)

20. Limitations
Self-report method may not demonstrate
accurate of incidence (patient fall, medication
errors)
Did not evaluate hours of nursing care, nurse
workload, varied nursing care by shift (night vs
non-night shift)

21. Conclusion
Reveal some nursing quality indicators n a VN
ICU, compared to India standards
 Acceptable: patient fall, physical restraint, medication
errors
 Lower than standard: pressure ulcer, UTI
Patient:nurse ratio higher than recommended
guidelines, but similar to Korean ICU
Suggestions
 lower patient:nurse ratio 2
 Use objective method to evaluate indicators
(medication erros)
 Evaluate nursing quality by shift