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Background The number and efficacy of indicators used to monitor and improve the quality of care in Intensive Care Units (ICU) is debatable. This study aimed to select a consensus-based core set of indicators for effective quality improvement in the ICU. Methods A Delphi study with a panel of intensivists, ICU nurses, and former ICU patients or relatives ( n  = 34) from general, teaching, and academic hospitals. Panelists completed a questionnaire in which they scored 69 preselected quality indicators on relevance using a nine-point Likert scale. Indicators were categorized using the rated relevance score into: ‘accepted, ‘equivocal’ and ‘excluded’. Questionnaire results were discussed in focus groups to reach consensus on the final set. Results Response rates for the questionnaire and focus groups were 100 and 68%, respectively. Consensus was reached on a final set of 17 quality indicators including patient reported outcome measures (PROMs) and patient reported experience measures (PREMs). Other quality indicators relate to the organization and outcome of ICU care, including safety culture, ICU standardized mortality ratio, and the process indicator ‘learning from and improving after serious incidents’. Conclusions ICU clinicians and former patients and relatives developed a consensus-based core set of ICU quality indicators that is relatively short but comprehensive and particularly tailored to end-users needs.

Quality indicators are registered to monitor and improve the quality of care. However, the number and effectiveness of quality indicators is under debate, and may influence the joy in work of physicians and nurses. Empirical data on the nature and consequences of the registration burden are lacking. The aim of this study was to identify and explore healthcare professionals' perceived burden due to quality registrations in hospitals, and the effect of this burden on their joy in work. A mixed methods observational study, including participative observations, a survey and semi-structured interviews in two academic hospitals and one teaching hospital in the Netherlands. Study participants were 371 healthcare professionals from an intensive care unit (ICU), a haematology department and others involved in the care of elderly patients and patients with prostate or gastrointestinal cancer. On average, healthcare professionals spend 52.3 minutes per working day on quality registrations. The average number of quality measures per department is 91, with 1380 underlying variables. Overall, 57% are primarily registered for accountability purposes, 19% for institutional governance and 25% for quality improvement objectives. Only 36% were perceived as useful for improving quality in everyday practice. Eight types of registration burden were identified, such as an excessive number of quality registrations, and the lack of usefulness for improving quality and inefficiencies in the registration process. The time healthcare professionals spent on quality registrations was not correlated with any measure of joy in work. Perceived unreasonable registrations were negatively associated with healthcare professionals' joy in work (intrinsic motivation and autonomy). Healthcare professionals experienced quality registrations as diverting time from patient care and from actually improving quality. Registering fewer quality indicators, but more of what really matters to healthcare professionals, is key to increasing the effectiveness of registrations for quality improvement and governance. Also the efficiency of quality registrations should be increased through staffing and information and communications technology solutions to reduce the registration burden experienced by nurses and physicians.

ObjectivesThe number of indicators used to monitor and improve the quality of care is debatable and may influence professionals’ joy in work. We aimed to assess intensive care unit (ICU) professionals’ perceived burden of documenting quality indicator data and its association with joy in work.DesignCross-sectional survey.SettingICUs of eight hospitals in the Netherlands.ParticipantsHealth professionals (ie, medical specialists, residents and nurses) working in the ICU.MeasurementsThe survey included reported time spent on documenting quality indicator data and validated measures for documentation burden (ie, such documentation being unreasonable and unnecessary) and elements of joy in work (ie, intrinsic and extrinsic motivation, autonomy, relatedness and competence). Multivariable regression analysis was performed for each element of joy in work as a separate outcome.ResultsIn total, 448 ICU professionals responded to the survey (65% response rate). The overall median time spent on documenting quality data per working day is 60 min (IQR 30–90). Nurses spend more time documenting these data than physicians (medians of 60 min vs 35 min, p<0.01). Most professionals (n=259, 66%) often perceive such documentation tasks as unnecessary and a minority (n=71, 18%) perceive them as unreasonable. No associations between documentation burden and measures of joy in work were found, except for the negative association between unnecessary documentations and sense of autonomy (β=−0.11, 95% CI −0.21 to −0.01, p=0.03).ConclusionsDutch ICU professionals spend substantial time on documenting quality indicator data they often regard as unnecessary. Despite the lacking necessity, documentation burden had limited impact on joy in work. Future research should focus on which aspects of work are affected by documentation burden and whether diminishing the burden improves joy in work.

Background The Airway, Breathing, Circulation, Disability and Exposure (ABCDE) approach is a universal, priority-based approach for the assessment and treatment of critically ill patients. Although the ABCDE approach is widely recommended, adherence in practice appears to be suboptimal. The cause of this non-compliance is unknown. As knowledge is a prerequisite for adherence, the aim of this study was to assess healthcare professionals’ knowledge of the ABCDE approach. Methods A cross-sectional study was conducted at the Radboud University Medical Center, the Netherlands. A digital multiple-choice assessment tool of the ABCDE approach was developed by an expert panel through a mini-Delphi method and validated by performing test item statistics and an expert-novice comparison. The validated test was sent to healthcare professionals (nurses, residents and medical specialists) of the participating departments: Anaesthesiology, Paediatrics, Emergency Department and the Neonatal, Paediatric and Adult Intensive Care Units. Primary outcome was the test score, reflecting individual level of knowledge. Descriptive statistics, regression analysis and ANOVA were used. Results Test validation showed a Cronbach’s alpha of 0.71 and an expert-novice comparison of 91.9% (standard deviation (SD) 9.1) and 72.4% (15.2) respectively ( p  < 0.001). Of 954 eligible participants, 240 filled out the questionnaire. The mean (SD) test score (% of correct answers) was 80.1% (12.2). Nurses had significantly lower scores (74.9% (10.9)) than residents (92.3% (7.5)) and medical specialists (88.0% (8.6)) ( p  < 0.001). The Neonatal Intensive Care Unit (75.9% (12.6)) and Adult Intensive Care Unit (77.4% (11.2)) had significantly lower scores than Paediatric Intensive Care Unit (85.6% (10.6)), Emergency Department (85.5% (10.4)) and Anaesthesiology (85.3% (10.6)) ( p  < 0.05). Younger participants scored higher than older participants (−0.30% (-0.46;-0.15) in test score/year increase in age). Conclusion Scores of a validated knowledge test regarding the ABCDE approach vary among healthcare professionals caring for critically ill patients. Type of department, profession category and age had a significant influence on the test score. Further research should relate theoretical knowledge level to clinical practice. Tailored interventions to increase ABCDE-related knowledge are recommended.

Insufficient sleep burdens critically ill patients, optimizing sleep may enhance patient's outcomes. Current assessment methods may unnecessary burden patients. Therefore, a single numeric rating score was validated for sleep assessment. First, two cross-sectional measurements on two separate days, from cooperative patients from 19 centers assessed their sleep sufficiency, the numeric rating score (NRS) and the Richards Campbell Sleep Questionnaire (RCSQ). Assessments were compared using a Bland Altman plot. A NRS cut-off was determined using regression analysis. Second, daily sleep assessment was implemented and monitored single center for a year. Multicenter, 194 patients assessed sleep quality, of which 53% was rated as sufficient. Mean (±SD) difference between RCSQ and NRS-Sleep using Bland-Altman analysis was 0.25 (±1.21, 95% limits of agreement −2.12 to 2.62). The optimal cut-off was >5. Single center, 1603 patients ranked 4532 ICU nights of sleep, of which 71% was sufficient; median NRS was 6 [IQR 5–7]. A single numeric rating score for sleep is interchangeable for the RCSQ score for assessment of sleep quality. Optimal cut-off is >5. Use of a numeric rating score for sleep is a practical way to evaluate and monitor sleep as perceived by patients in daily ICU practice. •Insufficient sleep burdens critically ill patients, optimizing sleep may enhance patient's outcomes.•Current assessment methods may unnecessary burden patients.•A single numeric rating score for sleep (NRS-Sleep) is interchangeable for the RCSQ score for assessment of sleep quality.•An optimal NRS-Sleep cut-off for sufficient sleep is >5.•Use of the NRS-Sleep is a practical way to evaluate and monitor sleep as perceived by patients in daily ICU practice.

BackgroundThe number of quality indicators for which clinicians need to record data is increasing. For many indicators, there are concerns about their efficacy. This study aimed to determine whether working with only a consensus-based core set of quality indicators in the intensive care unit (ICU) reduces the time spent on documenting performance data and administrative burden of ICU professionals, and if this is associated with more joy in work without impacting the quality of ICU care.MethodsBetween May 2021 and June 2023, ICU clinicians of seven hospitals in the Netherlands were instructed to only document data for a core set of quality indicators. Time spent on documentation, administrative burden and joy in work were collected at three time points with validated questionnaires. Longitudinal data on standardised mortality rates (SMR) and ICU readmission rates were gathered from the Dutch National Intensive Care registry. Longitudinal effects and differences in outcomes between ICUs and between nurses and physicians were statistically tested.ResultsA total of 390 (60%), 291 (47%) and 236 (40%) questionnaires returned at T0, T1 and T2. At T2, the overall median time spent on documentation per day was halved by 30 min (p<0.01) and respondents reported fewer unnecessary and unreasonable administrative tasks (p<0.01). Almost one-third still experienced unnecessary administrative tasks. No significant changes over time were found in joy in work, SMR and ICU readmission.ConclusionsImplementing a core set of quality indicators reduces the time ICU clinicians spend on documentation and administrative burden without negatively affecting SMR or ICU readmission rates. Time savings can be invested in patient care and improving joy in work in the ICU.

To select a consensus-based set of relevant and feasible indicators for monitoring and improving the quality of regional ICU network collaboratives. A three-round Delphi study was conducted in the Netherlands between April and July 2022. A multidisciplinary expert panel prioritized potentially relevant and feasible indicators in two questionnaire rounds with two consensus meetings between both rounds. The RAND/UCLA appropriateness method was used to categorize indicators and synthesize results. A core set of highest ranked indicators with consensus-based levels of relevance and feasibility were finally tested in two ICU networks to assess their measurability. Twenty-four indicators were deemed as relevant and feasible. Seven indicators were selected for the core set measuring the standardized mortality rate in the region (n = 1) and evaluating the presence, content and/or follow-up of a formal plan describing network structures and policy agreements (n = 3), a long-term network vision statement (n = 1), and network meetings to reflect on and learn from outcome data (n = 2). The practice tests led to minor reformulations. This study generated relevant and feasible indicators for monitoring and improving the quality of ICU network collaboratives based on the collective opinion of various experts. The indicators may help to effectively govern such networks. •This article describes the findings of a three-round Delphi study.•Twenty-four indicators were deemed relevant and feasible for monitoring the quality of ICU collaboratives.•These indicators can be used to govern regional ICU collaboratives.•Further research is needed to ensure effective and long-term use of the indicators.

IntroductionAround 1 in every 10 patients is harmed in health care and more than 3 million deaths occur annually due to unsafe care. In low-to-middle income countries, as many as 4 in 100 people die from unsafe care; more than half of patient harm (1 in every 20 patients) is preventable [WHO, 2021]. In intensive care units (ICUs), a severe or potentially detrimental error occurs on average twice a day [Donchin, 1995]. In 2009, as part of a series of actions to raise the awareness of both professionals and the public on the issue of patient safety, European Society of Intensive Care Medicine (ESICM) initiated a task force with the aim of improving the safety and quality of care provided to critically ill patients. This task force developed a directive for change that was signed by 57 national and international critical care organisations in the Vienna Declaration [Moreno, 2009]. Moreover, there was a follow-up of a series of ESICM-supported studies investigating the level of patient safety events in ICUs worldwide, which documented the scale of the problem [Valentin, 2009]. The current learning pathway builds on the outputs of previous projects undertaken by ESICM to support learning and research in patient safety.What you didIn 2023, the Taskforce launched the first edition of the Patient Safety Training and Research Program of the ESICM. This educational initiative targets intensivists, intensive care nurses, allied healthcare professionals and clinical pharmacists who wish to improve their knowledge and skills in the field of patient safety and who are members of the ESICM. The program includes a hybrid training programme to allow participants to acquire, apply and integrate knowledge and skills through:4 live virtual interactive sessions (LIS) about the history of safety research and implementation science; patient safety in the operating room; patient safety in the ICU; organizational concepts of patient safety centered interventions15 fellowships for candidates from 12 different countries who visits ‘best practice’ ICUs in Germany, France, and Italy)a research competition awarding 2 research initiatives with 10.000 euro awards)face to face case-based expert-led workshops: 35 participants (during the annual ESICM congress)This program is supported by an unrestricted educational grant from Philips; the program has not been influenced in any way by the sponsor.Carers are involved in the program which included a session on the Voice of the patient & family.What it meansLIS were found useful to extremely useful by 96% of a total of 475 registrations from 22 different (non-)European countries.Fellowships were found useful to extremely useful by 87% of the 15 participants and impactful for their clinical practice by 87% of the participants.Case Based Essentials were found useful in helping the participants to understand the basic concepts of patient safety and quality improvement.The overall conclusions show us that such an ICU patient safety program is useful and impactful in participants’ professional activity and therefore much needed to further improve clinical performance and patient care.Lessons LearntAn ICU multidisciplinary multimodal patient safety training & research program can be very effective and inspiring: virtual live sessions, on site fellowships at ‘best practice’ ICUs, awarding innovative research and live case-based interactive workshops facilitate ‘learning, teaching and research’ in patient safety.ReferencesGlobal patient safety action plan 2021–2030: towards eliminating avoidable harm in health care. Geneva: World Health Organization; 2021.Moreno RP, Rhodes A, Donchin Y. ESICM Patient safety in intensive care medicine: the Declaration of Vienna. Intensive Care Med. 2009 Oct;35(10):1667–72.Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med. 1995 Feb;23(2):294–300.Valentin A, Capuzzo M, Guidet B, et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study. BMJ 2009 Mar 12;338:b814.

Background: Quality indicators are registered to monitor and improve the quality of care. However, the number and effectiveness of quality indicators is under debate, and may influence the joy in work of physicians and nurses. Empirical data on the nature and consequences of the registration burden are lacking. The aim of this study was to identify and explore healthcare professionals’ perceived burden due to quality registrations in hospitals, and the effect of this burden on their joy in work. Methods: A mixed methods observational study, including participative observations, a survey and semi-structured interviews in two academic hospitals and one teaching hospital in the Netherlands. Study participants were 371 healthcare professionals from an intensive care unit (ICU), a haematology department and others involved in the care of elderly patients and patients with prostate or gastrointestinal cancer. Results: On average, healthcare professionals spend 52.3 minutes per working day on quality registrations. The average number of quality measures per department is 91, with 1380 underlying variables. Overall, 57% are primarily registered for accountability purposes, 19% for institutional governance and 25% for quality improvement objectives. Only 36% were perceived as useful for improving quality in everyday practice. Eight types of registration burden were identified, such as an excessive number of quality registrations, and the lack of usefulness for improving quality and inefficiencies in the registration process. The time healthcare professionals spent on quality registrations was not correlated with any measure of joy in work. Perceived unreasonable registrations were negatively associated with healthcare professionals’ joy in work (intrinsic motivation and autonomy). Healthcare professionals experienced quality registrations as diverting time from patient care and from actually improving quality. Conclusion: Registering fewer quality indicators, but more of what really matters to healthcare professionals, is key to increasing the effectiveness of registrations for quality improvement and governance. Also the efficiency of quality registrations should be increased through staffing and information and communications technology solutions to reduce the registration burden experienced by nurses and physicians.