Multimodal strategies to improve APACHE II score documentation

Background

The APACHE II score is used widely in the ICU setting. In our phase I study [1], APACHE II scores collected by an expert research coordinator and two research clerks were reliable (intraclass correlation coefficient = 0.90, lower 95% confidence interval [L-95% CI] = 0.85). However, we found substantial variability in the Chronic Health Index (CHI) (0.67, L-95% CI = 0.53) and Glasgow Coma Scale, verbal component (GCS-V) (0.42, L-95% CI = 0.25). To improve the reliability of the APACHE II score, we conducted phase II, aimed at changing the behaviour of ICU clinicians who are involved in documenting the APACHE II score in practice.

Objective

To educate ICU clinicians regarding two specific components of the APACHE II score with suboptimal reliability: CHI and GCS-V.

Design

An educational quality improvement interventional project.

Population

ICU clinicians, primarily bedside nurses.

Methods

We convened a combined clinical and administrative working group. In-person meetings, conference calls, and electronic communication were used to generate ideas for strategies that would efficiently serve our objective.

Results

We implemented multimodal strategies to try to improve ICU clinicians' knowledge of, and compliance with, documentation of CHI and GCS-V. Strategies were: re-structuring the Clinical Information System Carevue (Philips, Andover, MA, USA), in-service education, use of local opinion leaders, reminders, audit and feedback, and support from the ICU Working Group (MDs, Allied Health professionals, bedside RNs, RN manager, RN educator, RN informatician [RNI]) who approved an improved CHI policy. We reconfigured the Carevue workstation screens to improve the visibility of CHI. In-services were conducted by an ICU educator and RNI. Education focused on the CHI components, GCS-V domain in intubated patients, and expectations for documentation of these items. As local opinion leaders, RNs (manager and charge nurses) prompted bedside nurses to complete chronic health documentation for all new admissions. We provided written information sheets, electronic resources, and computer-generated electronic reminders at RN workstations and on Carevue. The RNI provided regular, informal audit and feedback to bedside RNs to reinforce timely documentation.

Conclusions

These diverse methods were delivered over 1 year, were multiply redundant to maximize the chance of behaviour change, were led by an integrated team of clinical and administrative managers, and were well accepted. We will next proceed to phase III, a formal re-evaluation of the reliability of the APACHE II score in our institution.