Research & Quality

One of ICNSW 's main aims is to work with clinicians and key organisations to identify, address, and improve clinical practice in NSW ICUs. These webpages will highlight some of the issues that have been identified and are being addressed via various projects. There is a section dedicated to infection control, a highly important issue for intensive care practice. Other useful content includes a Resource Library for access to tools and practical information about various quality and safety projects and Weblinks to sites containing related or further information of interest.

ICNSW 's role in quality and safety research is reflected in two of its three main objectives:

  • promoting excellence in the standard of care in all NSW ICUs by providing a forum for the systematic analysis and assessment of information regarding the quality of care in NSW intensive care units.
  • facilitating an understanding of intensive care service provision including resources, workforce, patterns of demand including access issues, and other factors that may impact on the effective delivery of intensive care service in NSW.

Projects Overview

Quality and Safety projects undertaken by ICNSW include:

Exploring long term outcomes for intensive care patients

ICNSW in conjunction with ICSN Performance Working Group have identified the need to explore the longer term outcomes for hospitalised patients who received care in an intensive care unit for longer than 24 hours. A literature search revealed gaps in the evidence base including the combined effect of out of hours admissions and discharges to ICU along with other patient and service-level information on outcome, and the cause of death for patients who were deceased at 6, 12 and 24 months post-hospital discharge. This has not been explored previously within NSW.

The Performance Working Group agreed that determining the long term outcomes of intensive care patients and identifying the factors that contribute to long-term outcomes was a priority. Another area to be explored is how survival rates of ICU patients compare with the survival rates of other acute care hospital inpatients.

To progress this work, in June 2014 ICNSW submitted a formal data request to the ACI Health Economics and Evaluation Team for linking hospital inpatient data with fact-of-death data from the NSW Registry of Births, Deaths and Marriages and cause-of-death data from the Australian Bureau of Statistics.  A draft report was produced and tabled at a Performance Working Group meeting in September, 2014. The analysis for this piece of work is currently being revised and the included data updated. The findings could assist in the development of appropriate intensive care service models with the ultimate aim of improving patient outcomes.

The key objectives are to describe the:

  • proportion of patients discharged alive from hospital, where they were discharged to, and what factors were associated with survival
  • long term survival estimates of ICU patients post-hospital discharge and a matched patient cohort that never had an ICU stay
  • contributing factors to long term outcomes of ICU patients
  • ultimate cause of death for patients who are discharged from hospital alive.

Further information on this project will be shared once it becomes available.

Exploring data collection processes and data quality in NSW ICUs

The results of the first survey were presented in a poster at the 5th Australasian Conference on Safety and Quality in Health Care, Melbourne (2007) and as an oral presentation at the 1st International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care, Queenstown, NZ (2007). A paper detailing the results of the first survey was published in Critical Care & Resuscitation (December 2008- see reference in list below).

A follow-up survey to ICU directors was completed in 2008. The aims of this study were to:

  1. further evaluate the quality of data collected for and submitted to the ANZICS APD; and
  2. investigate the perceptions of NSW ICU directors in relation to issues pertaining to ICU data quality, reporting and usage, including the value that is placed on these issues at the local ICU level.

Process of care in NSW ICUs

This ongoing project involves the development, implementation and evaluation of a ’process of care’ checklist, designed to assist ICU clinicians with the delivery of daily care to their patients. A paper-based checklist pilot was completed and the results were presented as an oral presentation at the 1st Critical Care Conference in the Vineyards, Hunter Valley (2006), a poster presentation at the 4th Australasian Conference on Safety and Quality in Health Care, Melbourne (2006) and published in Anaesthesia and Intensive Care (June 2006- see list below).

Checklist validation work has been completed via a medical record audit, revealing a strong positive correlation between checklist responses and cares documented in the medical record. The results were published in Anaesthesia & Intensive Care (May 2013- see list below). Content development work for an electronic checklist to be delivered by a Palm PDA was completed via a comprehensive literature review and a modified - Delphi technique with senior ICU clinicians, to develop clear, concise checklist statements that were based on the latest clinical evidence and/or expert opinion. The results of this study were published in BMC Health Services Research (October 2013- see list below). This collective work was also presented at the 3rd International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care Conference, Queenstown (2009).

In determining the need for tools to assist clinicians in delivering essential processes of care in Australian and New Zealand ICUs, a point prevalence study was conducted. Results demonstrated variability in the delivery of identified cares both within and between ICUs. The results of this study have been presented, and were published in the September issue of Anaesthesia and Intensive Care (see reference list below).

The next phase of the research was a prospective before-after study evaluating the effect of implementing an electronic checklist in a tertiary ICU. A methods paper was presented at the 4th International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care conference, Creswick (2010). The results of this study were presented at the 35th Australian and New Zealand annual Scientific Meeting on Intensive Care conference, Melbourne (2010).

Publications or presentations arising include the following.

  • Hewson KM, Burrell AR. A pilot study to test the use of a checklist in a tertiary intensive care unit as a method of ensuring quality processes of care. Anaesth Intensive Care 2006; 34:322-328.
  • Hewson KM, Burrell AR. (2006) A pilot study to test the use of a checklist in a tertiary intensive care unit as a method of ensuring quality processes of care. Australasian Quality & Safety Conference
  • Hewson KM, Burrell AR. A pilot study to test the use of a checklist in a tertiary intensive care unit as a method of ensuring quality processes of care.Critical Care in the Vineyards
  • Hewson KM, Elliott D & Burrell AR Improving process of care in NSW ICUs through collaboration & innovation. UTS Health Research Showcase, 19-20 November 2008 [oral presentation]
  • Hewson KM & Burrell AR (2008) CTG Point prevalence study: process of care in ICU, 2nd International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care, Queenstown [oral presentation]
  • Hewson-Conroy K (2009) Development and validation of a 'process of care' checklist for intensive care units.3rd International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care, Queenstown [oral presentation].
  • Burrell A, Hewson-Conroy K, Elliott D, Seppelt I, Webb S (2009) Compliance with processes of care in the intensive care unit. 34th Australian and New Zealand Annual Scientific Meeting on Intensive Care Conference; Perth. [oral presentation: unpublished].
  • Hewson KM, Elliott D, Burrell AR (2010) Electronic checklist as a strategy for improving processes of care. 4th International Conference on Safety, Quality, Audit and Outcomes Research in Intensive Care, Creswick. [oral presentation]
  • Hewson-Conroy KM, Elliott D, Burrell AR. Quality and Safety in Intensive Care - A means to an end is critical. Australian Critical Care 2010; 23:109-129. Pub Med Link.
  • Hewson K, Elliott D, Burrell A (2010) Electronic checklist improves care delivery in tertiary intensive care unit. 35th Australian and New Zealand Annual Scientific Meeting on Intensive Care Conference; Melbourne. [oral presentation].
  • Hewson-Conroy KM, Burrell AR, Elliott D, Webb SAR, Seppelt IM, Taylor CB, Glass P. Compliance with processes of care in Intensive Care Units in Australia and New Zealand – a point prevalence study. Anaesthesia & Intensive Care, 2011; 39: 926-935.
  • Conroy KM, Elliott D, Burrell AR. Validating a process-of-care checklist for intensive care units. Anaesthesia & Intensive Care, 2013; 41(3): 342-348.
  • Conroy KM, Elliott D, Burrell AR. Developing content for a process-of-care checklist for use in intensive care units: a dual-method approach to establishing construct validity. BMC Health Services Research, 2013; 13:380. http://www.biomedcentral.com/1472-6963/13/380
  • Conroy K, Elliott D, Burrell T. Evaluating an electronic checklist as a strategy for improving processes of care. In: 7th International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care Conference Handbook; 2013 Jul 29-31; Sydney, NSW.
  • Conroy KM, Elliott D, Burrell AR. Testing the implementation of an electronic process-of-care checklist for use during morning medical rounds in a tertiary intensive care unit: a prospective before-after study. Annals of Intensive Care, 2015; 5:20. http://annalsofintensivecare.springeropen.com/articles/10.1186/s13613-015-0060-1

The most recent oral presentation and peer-reviewed publication shared the key findings of a prospective before-after intervention study testing the implementation of an e-checklist for use by physicians on the medical ward round. Compliance with routine processes of care improved over time and there was very good concordance between checklist responses and actual delivery of care (measured by research nurses during post-ward round audit) offering evidence in support of the validity of the tool. The process-of-care checklist is recommended for use during ward rounds in NSW ICUs. Aspects of this work are being used to inform current and future initiatives e.g. eRIC.

The Clinical Handover in ICU Workshop Report (28 October 2013) was prepared by Karena Conroy on behalf of the ANZICS Safety and Quality Committee. The report summarises information shared at a workshop on clinical handover in the ICU held at the 7th International Conference on Safety, Quality, Audit and Outcomes Research in Intensive Care (SQAO), in Sydney on 29 July 2013. The aim of the workshop was to draw on the collective experience and knowledge of the workshop attendees to consider how ICUs can achieve the prescribed actions outlined in National Safety and Quality Health Service Standards Clinical Handover (Standard 6). A number of recommendations for how ICUs can address this standard have been made and will be disseminated to NSW ICUs in the near future.

ICU Safety Culture

A pilot of the implementation of the Safety Attitudes Questionnaire (SAQ) to assess the perceived culture of safety in a tertiary ICU was completed and results were presented to the ICU and at the 1st International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care, Queenstown, NZ (2007). This has led to a joint ACCCN and ANZICS Safety & Quality Committee study which was conducted in 10 Australian ICUs. Results were published in the American Journal of Critical Care (February 2013, see reference list below).

Publications or presentations arising

  • Chaboyer W, Chamberlain D, Hewson-Conroy K, Grealy B, Elderkin T, Brittin M, McCutcheon C, Longbottom P, Thalib L. Safety culture in Australian intensive care units: Establishing a baseline for quality improvement. American Journal of Critical Care, 2013; 22(2):93-102.
  • Hewson KM (2007) Assessing the safety culture in a tertiary ICU 1st International Conference on Safety, Quality, Audit & Outcomes Research in Intensive Care, Queenstown [oral presentation]
  • Hewson KM (2008) Assessing the safety culture in a tertiary ICU. Australasian Quality & Safety Conference

Suggested reading/Useful links:

  • The University of Texas Center of Excellence for Patient Safety Research and Practice Owner of copyright to the Safety Attitudes Questionnaire (SAQ) and Safety Climate Survey (SCS). Contains survey tools, tracking forms, user guides, instructions and technical report.
  • WHO Patient Safety Research 2012: A Guide for Developing Training Programs. This guide outlines the core skill and knowledge-based competencies that professionals at various levels of expertise may wish to acquire to conduct effective patient safety research and improvement efforts.

ICU Indicators

The former ICNSW Quality Group advised the ANZICS Safety & Quality Committee on the indicators to be put to the ACHS for ICU indicators in 2007. ICU data items have been developed by ICNSW in conjunction with the Data Management Committee for inclusion in a minimum dataset for reporting by ICU Data Managers. ICNSW continues to work in conjunction with ANZICS on the development of ICU quality indicators for Australia and New Zealand.

ICNSW has had significant input into the 'NSW Intensive Care Services Quality Indicator Reporting Background Paper' that has been developed in response to recommendations made by the Independent Pricing and Regulatory Tribunal (IPART) after a review of health services in regard to efficiency, cost and clinical quality. The final IPART report was issued in July 2010 and can be accessed at IPART - Publications. Forty recommendations in total were made regarding areas for improvement. Recommendation 38 was related specifically to 'measuring care and/or outcomes in ICUs'.

ICNSW has completed a literature review on the topic of ICU occupancy - its definition, measurement, benchmarking and use as a quality indicator. This work was initially conducted to help inform statewide planning, and has since been published in Australian Critical Care (2013).  NSW ICU occupancy data is reported in real-time via the Critical Care Resource System (CCRS).

Publications or presentations arising:

  • Tierney LT, Conroy KM. Optimal occupancy in the ICU: A literature review. Australian Critical Care. 2014 May; 27(2):77-84. doi: 10.1016/j.aucc.2013.11.003. Epub 2013 Dec 27.

The Optimal Occupancy in the ICU: A literature review (18 June 2014) was written by Karena Conroy in order to provide an executive summary of the detailed literature review that was published in Australian Critical Care. The recommendations made in this report have been endorsed by the ICSN Executive Committee. The recommended method for calculating occupancy is:

Optimal Occupancy

Units are encouraged to interact with CCRS to ensure accuracy of bed availability. Importantly, CCRS is still the only tool available that allows calculation of exit block hours. Exit block is an ACHS indicator and a Key Performance Indicator for NSW Health and LHD Chief Executives. Occupancy and exit block are important to the measurement of unit activity, and the consideration of resource allocation. If you would like more information, please contact Hardeep Singh at ICNSW .


If there is something you think is relevant and appropriate for this page please contact the ICNSW team.