SJ Mackenzie, Consultant Anaesthetist, The Royal Infirmary of Edinburgh
Some, perhaps many, Intensive Care Units review patients who die in order to assess their management, monitor quality and learn lessons for the future. There are obvious limitations to reviewing your own practice however.
External peer review of case notes could help improve clinical ICU practice.
Case Note Review was discussed in the early days of SICS audit and was included in the current CRAG funding application.
A small group (David Wright, John Kinsella, Mark Worsley, Simon Mackenzie, Roger White, Fiona MacKirdy) was asked to develop a proposed system which now requires wider consideration.
To implement a system of anonymous, external case note review in Scottish Intensive Care Units. This would be similar, but not identical, to SASM.
Anonymity for both unit and reviewer.
Review selected deaths, not all deaths. The WardWatcher database could be used to identify patients for case note review in an objective manner. This would allow review to focus on particular groups of patients and to vary these from time to time. Possible groups suggested have included ‘low risk’, medium risk, age <50, readmissions, short and long length of stay, particular diagnoses, post-ICU deaths.
Use the WardWatcher database to generate part of report form. This could be done both locally (for internal review if desired) and centrally. Ask the responsible consultant to comment on whether they thought there were any adverse events (on paper, not computer).
Structured review of case note by external assessor. Comments should be dispassionate and reviewers will be encouraged to provide evidence for any criticisms made. Feedback to responsible consultant.
The only additional field in the dataset would be ‘Was treatment withdrawn?’ The workload of reviewing depends on the number of cases selected and the number of reviewers. Careful planning to minimize load on SICS staff.
The format of these is important to ensure that the objective of improving quality is achieved.
A survey of the structure and process of renal replacement therapy in Scottish Intensive care units.
J S Noble, J Ross, F N MacKirdy, J C Howie, S J Mackenzie.
INTRODUCTION: An increasing number of Scottish intensive care units (ICU) are providing renal replacement therapy (RRT). We examined the structure and process of this developing service.
METHODS: The study took the form of an interview carried out by a research nurse using a structured questionnaire. The interviewee was if possible, the consultant who had most involvement with renal support in that unit. In addition, the amount of RRT activity that took place between July 1998 and June 1999 was determined from the SICSAG database.
RESULTS: Nineteen Scottish units provided RRT at the time of the survey and of these 7 were teaching hospitals. There were 7542 admissions to these ICUs for this time period. The mean age was 58.2 years, the mean ICU length of stay was 4.35 days and the mean APACHE II score was 19. In 390 (5.17%) of these admissions, RRT was administered. The median admission was 327.5mmol/l. The patients received a mean 6.6 days of RRT. Mechanical ventilation was required in 85.8% of cases and 79% received inotropic support. RRT was first administered most commonly on day 2. The mean length of ICU admission for RRT patients was 12.6 days.
Only three of these units ran the RRT by protocol, six used standard practice and ten had no standard practice. Four units audited complications of RRT. Six interviewees recalled 1-3 incidents of major haemorrhage on RRT during the previous three years. RRT is prescribed by the renal physician and intensivist on nine units, by the intensivist alone on nine units and by the renal physician alone on one unit. Following optimum fluid loading if oligo-anuria persists, 8 units employ dopamine, 14 employ frusemide, 4 employ mannitol and one uses combined infusions of aminophylline and frusemide. The reasons given were ease of fluid management, reversal of renal failure, renal protection and conversion to renal failure with an output.
In four units intermittent haemodialysis (IHD) is the main RRT technique employed on ICU (estimated 60,70,80,100% of workload respectively). Other than one unit that employs continuous haemodiafiltration in an estimated 60% of cases, continuous (CVVH) or intermittent haemofiltration (IVVH) provides the majority of RRT in the remainder. The specific reasons given for the predominance of technique were mainly logistical and to a lesser extent clinical. The trend in RRT has been towards increased or stable levels of IVVH, CVVH and IHD. However two units estimated that they were using less IHD.
There is no consistent central venous access site favoured across the Scottish units. Nutritional therapy is largely unaffected by the onset of ARF and the need for RRT. Heparin is still the most frequently prescribed anticoagulant for RRT because it is perceived as cheap and effective. If thrombocytopenia supervenes, epoprostenol is employed in 7 units and low molecular weight heparin in 2.
CONCLUSIONS: In Scottish units the predominant RRT treatment modalities vary widely. In the absence of formal protocols there is a diversity of clinical practice.
Financial support from GlaxoWellcome
SICSAG Meetings reports