Quality Improvement Activity

Below is a selection of Quality Improvement Projects undertaken within Cardiff Critical Care...


A Nurse-Led Quality Improvement Project Using Driving Pressure to Reduce Ergotrauma and Optimise Ventilation. [Sam Tavern and Jade Cole, 2022].

Accepted to the intensive care society meeting state of the art. June 2023.

Introduction: Over the last two decades there has been a drive to raise health standards by empowering nursing professionals to expand their skills. Advanced clinical, leadership and research tasks are now common for nurses, and the Quality Improvement (QI) project discussed here builds upon many of these advancements (1).

Simultaneously, Intensive Care Unit (ICU) Patients with Acute Respiratory Distress Syndrome (ARDS) have been identified as an important area of research. This cohort has much higher mortality and morbidity than the general ICU patient, and correct measurement and optimisation of Driving Pressure (ΔP) has been suggested as a means of improving these outcomes (2,3).


Primary Objective - Improve patient safety through the routine measurement, assessment, and interpretation of ΔP.

Secondary Objective – Empower nurses to create and deliver a QI programme that can be validated and used as a template for future Quality and Safety projects.

Methods: The interventions discussed took place in the 37 bed General ICU of a tertiary hospital and involved all levels of nursing and medical staff.

A Plan, Do, Study, Act (PDSA) template was used to formulise the QI processes, with repeated PDSA cycles used to feedback and improve the project (4). SMART Goals and ideas around Sustainable Change were also included (5). These were; Promotion of the ΔP project with posters and social media, identification of ΔP Champions who are advocates for the project, and the presentation of ΔP theory and practice to groups of 30-40 nurses.

To validate the project a detailed audit trail had to be initiated. Elements of this were; a large survey of ΔP compliance across the nursing staff before any teaching had occurred, individual written feedback, and surveys pre/post teaching.

Results: Before the teaching 29% of respondents said they knew how to measure ΔP, and after the teaching this number rose to 100%. Pre-training 73% of nurses said they could not identify the basic principles of Mechanical Power. Post-training only 3% could still not describe this theory, with 8% remaining unsure.

Qualitative feedback has been obtained from nurses who have been through the training. Prominent themes that emerged from this were; Nursed found the ‘blended’ nature of the learning package was effective, nurses thought the delivery of the teaching was very effective, and learners found the use of small group drop-ins very helpful.

Conclusions: This initial dataset suggests the programme has made good progress and has the potential to accomplish its aims. The nurse-led aspect has been received with enthusiasm and could be used as a template for further nurse-led initiatives if validated. Nurses reported a large increase in their knowledge around ΔP and it is hoped this continues as the project expands.


1. Adam S. Critical care nursing. Oxford University Press; 2017.

2. Amato MBP, Meade MO, Slutsky AS, Brochard L, Costa ELV, Schoenfeld DA, et al. Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine. 2015;372(8):747–55.

3. Gattinon L, Carlesso E. Acute respiratory failure and acute respiratory distress syndrome. Oxford Medicine Online. 2018;

4. Webb AR. Handbook of Intensive Care Organization and Management. Covent Garden, London: Imperial College Press; 2016.

5. 1000 Lives Improvement 2014. The Quality Improvement Guide: The Improving Quality Together Edition. Cardiff: 1000 Lives Improvement


Analysis of Quality Metrics Relating to the Intubation of Covid-19 patients on a General ICU  [Anne Frawley, lucy Hoarde, James Lavers, 2022]

Introduction: Most modern healthcare systems are striving to improve patient outcomes in an evidence-based manner. Increasingly, performance metrics are seen as key tools for accurately measuring and improving patient outcomes and healthcare value (Shah 2019). However, in order to achieve better outcomes, process measures need to be identified. Process measures are evidence-based, best practices metrics that can be measured and thus, used to identify if outcomes are being met. Good process measures can improve patient outcomes by reducing the amount of variation in care delivery. During the Covid-19 pandemic, vast quantities of data were generated while managing ARDS on the ICU. Furthermore, there was as a concomitant evolution of treatment strategies, which made it exceedingly difficult to identify processes that were actually improving patient outcomes.

Objectives:- The aim of our quality improvement project was to promote standardised high quality care for intubated Covid-19 patients by identifying potential quality indicators and trends in their management. It is our intention to expand on this work to report metrics on all severe acute respiratory failure patients.

Methods: - 15 process metrics surrounding the early care of intubated of Covid-19 patients were selected via a consultant led review process and a literature review in an effort to identify markers of quality surrounding intubation on our ITU. The variables selected included: - P/F ratio 24 hours pre-intubation, CPAP duration prior to intubation, Recording intubation location, Enhanced thromboprophylaxis prescribed, Permissive hypercapnia, Driving pressure documented, prone position and paralysis initiated if P/F ratio was less than 20 kPa, Echo post intubation.

Results: Data surrounding the intubation of Covid-19 patients was collected over an 11 week period between September and November 2021. The data was collected in a standardised fashion from patient notes and nursing notes, then stored in an excel file. Our data showed more than half the patients admitted were either intubated on the ward or immediately following arrival onto our ICU, possible indicating a delay in admitting Covid-19 patients. Our data also demonstrated heterogeneity of duration in CPAP prior to intubation which may also indicate delayed intubation for these patients (Vaschetto et al. 2021)

Conclusions:  Our data demonstrated a reasonable degree of heterogeneity in our approach to the early care of intubated Covid-19 Patients. Areas of concern highlighted were the number of patients intubated on the ward or immediately upon arrival to ITU, rather than admitting prior to deterioration (most likely due to bed pressure) and variation in post intubation respiratory sampling between invasive and non-invasive broncheoalveolar lavage. Ongoing PDSA cycling are in progress to refine the data collection processes and reporting for all severe acute respiratory failure patients.

Shah, A., 2019. Using data for improvement. BMJ, 364, p.189. Available at: http://www.bmj.com/permissionsSubscribe:http://www.bmj.com/subscribehttp://www.bmj.com/. 

Vaschetto, R. et al., 2021. Outcomes of COVID-19 patients treated with continuous positive airway pressure outside the intensive care unit. ERJ Open Research, 7(1), pp.00541–02020. Available at: https://openres.ersjournals.com/content/7/1/00541-2020 [Accessed February 24, 2022]. 

[Submitted to ICS SOA 2022]


Implementation of Neuron Specific Enolase (NSE) for Multimodal Prognostication after Cardiac Arrest [Olivia Don, Olivia Hayward, Maximilian Balogac, 2022]

Introduction:  Approximately 2/3 of patients surviving critical care admission and experiencing coma, following an out of hospital cardiac arrest (OHCA) will die of hypoxic-ischaemic brain injury. Withdrawal of life sustaining treatment following poor neurological outcome occurs in >66% of OHCA and 25% of in-hospital cardiac arrests. Prognostication is complex, using a multimodal approach of clinical, biochemical, radiographical and neurophysiological tests.   

The 2021 guidelines from the European Resuscitation Council and European Society of Intensive Care surrounding post resuscitation care highlight the role of NSE as part of this process. 

NSE is a protein biomarker released from neurons following injury, with high levels suggestive of neuronal cell damage. It has been recommended as a predictor of poor neurological outcome following cardiac arrest.  

The adoption of this recommendation was the focus of this QI project. 

Objective:  Agreeing a local protocol for the use of NSE in neuro-prognostication, and auditing adherence via plan-do-study-act (PDSA) cycling in a South Wales ICU.

Method:   A literature review and discussion and agreement with local biochemistry services were the first steps in the production of a NSE neuro-prognostication protocol. A proforma was introduced, with testing recommended at 48 and 72 hours post return of spontaneous circulation (ROSC). It was presented at a departmental quality and safety (Q&S) meeting and agreed upon prior to its implementation.

As part of the first PDSA cycle, ICNARC data was used to identify all post-cardiac arrest patients admitted to ICU in the previous 30 days. A notes and electronic blood results system review was performed to assess time of ROSC, NSE sample times and results, and patient outcomes. Compliance with NSE protocol and proforma completion were reviewed.

Results:   In this first PDSA cycle, 8 sets of patient’s records were examined. In 3, NSE was not sent due to early neurological recovery, or resuscitation being ceased. Of the remaining 5; NSE was sent correctly at 48 hours in one case and none at 72 hours. In 2 of 5, the proforma had been filled out, although these patients died before the first sample was taken.  2 patients had samples rejected by the laboratory; one patient had 6 samples taken at variable timepoints and the other experienced sample haemolysis, from failure to alert the laboratory of sample taking.

Conclusion: This PDSA cycle revealed that NSE sampling compliance was increasing but had not achieved a satisfactory standard. This was likely due to a lack of awareness of the new protocols and proformas. Barriers identified to the implementation are the dissemination of information to a large unit with changing work force and the time lag to feedback audit cycles.   

The results were presented at a departmental Q&S meeting and feedback distributed via nursing and trainee social media/WhatsApp groups. 

Educational resources (see below) were produced and distributed to all staff groups. Further work on improving PDSA feedback is ongoing via the employment of a data manager to improve methods. A second cycle is in progress to assess if these interventions have improved awareness and accuracy of NSE sampling. 

[Submitted to ICS SOA 2022]


Critical care dietetic outcomes during the first wave of the COVID-19 pandemic by RJ Prichard, SC Evans and AL Jukes, Cardiff and Vale University Health Board, Cardiff

Introduction: The COVID-19 pandemic led to a surge in patients being admitted to the Intensive Care Unit (ICU) and increased dietetic input was required. To meet this demand, non-ICU dietitians were upskilled and service changed from 5 to 7-days.

Objectives: To analyse changes in nutritional outcomes during the COVID-19 pandemic, and how changes to the dietetic service impacted upon dietetic outcomes.

Methods: Data was collected for all ICU patients under dietetic care with COVID-19 between 22/03/2020 and 04/06/2020. Total patient cohort equalled 66. Data was collected until patients were discharged or passed away. All data was analysed using descriptive statistics, and an independent t-test was used to compare COVID-19 feed delivery to previous feed delivery data. Ethical approval was not required.

Results: Of the 66 patients, 62 required enteral nutrition (EN). Feeding was commenced within 48 hours of ICU admission in 92% of patients. Average percentage feed delivery was 82.4% for energy and protein. A total of 60% of patients were initially started on a fluid restricted feed for fluid balance or due to being proned. A total of 50% of patients continued with a fluid restricted feed, 44% received a protocol 1kcal/ml high-protein feed and 6% a peptide or renal feed. Prokinetics were required in 35% of patients. A total of 3% of patients required parenteral nutrition. Of the 70% discharged from ICU alive, 70% were receiving EN at the time of discharge.

Conclusions: A number of barriers to maintaining high standards of patient outcomes arose at the onset of the COVID-19 pandemic. These included disruptions to MDT working, challenges in undertaking face-to-face assessments and an increased caseload and footfall - thereby increasing the demand for ICU trained Dietitians. Despite these barriers, this service evaluation demonstrates that percentage feed delivery remained relatively stable when compared to the pre-COVID 2020 audit (n = 35). An independent-samples t-test showed there was no significant difference in the scores for pre-COVID (M = 85%, SD = 13.4) and COVID (M = 82.4%, SD = 16.8) samples; t(180) = -0.81, p = .42. This is despite 36% of patients requiring proning during COVID vs. 0% pre-COVID, and increased gastrointestinal intolerance evidenced by 35% of patients requiring prokinetics vs. 29% pre-COVID. These factors eliminated the ability to utilise ‘catch-up’ feeding, which in normal circumstances optimises feed delivery. This suggests that changes in dietetic provision, allowed more prompt management of nutritional issues and facilitated the maintenance of the pre-existing high standards of nutritional care. Achieving this degree of feed delivery necessitated adapting feeding regimens to best meet the patient needs and in the absence of dietetic input it is unlikely these feeding strategies would have been utilised.

The COVID-19 pandemic presented challenges to every aspect of the healthcare sector; and reinforced the importance of multidisciplinary teams guiding patient care in the absence of evidence-based guidelines. This service evaluation demonstrates that forward-planning can assure that patient care need not be compromised

[Submitted to ICS SOA 2021]


Innovation of Eye Care of the critically ill patient within ICU  [Coles et al, 2021]

QI Team: Victoria Coles, Louise Ludlam, Sophie McClure, Debbie Davies and Katie Hook

Motivation: - Quality improvement (QI) is a systemic multi-dimensional approach to ensure the care provided by health professionals is safe, effective, person-centred, timely, efficient and equitable. (The Health Foundation 2013) Within critical care, standards are set by organisations to provide up to date good quality care to all patients.  

The problem: - The author identified an increase in eye injuries during the Covid 19 pandemic within ICU requiring ophthalmology intervention.  Eye injury ranged from minor injuries to severe, and complications were exacerbated due to workload and greater number of inexperienced staff. 

The Intensive Care Society (ICS) endorsed a guideline to prevent eye injury and increase education surrounding the subject. Variability is still significantly affected in practice with the authors unit demonstrating a low compliance compared to ICS standards of >90% compliance. 

The study design: - Ocular surface disease is common within the authors practice with 20–42% of patients developing corneal epithelial defects (Johnson & Rolls 2014). Cases highlighted as ‘avoidable harm’ within the authors area of practice could have been prevented with a standardised approach to care. Despite the high number of patients effected by this issue there is a severe lack of education and documentation surrounding eye care within ITU.  

The team implemented structured educational guidance and documentation to improve compliance within ITU to reach ICS standards. Measured compliance through 3/6/12 monthly audit  

Prediction and results: - Aim of study was to increase unit compliance to ICS standards of >90% compliance. First 3 monthly audits identified a significant increase in compliance. 6 monthly audits achieved compliance. Current aim is to continue to achieve 100% compliance within the ICU.  

Conclusion: - The study identified a significant problem in ICU that was causing avoidable patient harm. The results of this QI project are generalisable to other areas by increasing patient safety and staff education on the potential harm of ineffective eye care within ICU.  

Early data collection identifies high compliance despite the Covid-19 pandemic. More research and work are needed to develop and raise awareness eye care in the critically ill. (292) 

Submitted to BACCN 2021


Intensive care society. 2020. Eye care in the intensive care. Available at: unithttps://www.rcophth.ac.uk/wp-content/uploads/2020/04/Eye-Care-in-the-Intensive-Care-Unit-2020.pdf 

Johnson, K & Rolls, K. 2014. Eye Care for Critically Ill Adults, Version 2. Chatswood, NSW: Agency for Clinical Innovation, pp.1–43. 

The Health Foundation. 2013. Quality improvement made simple. 



Chlorhexidine bathing compliance to reduce unit acquired infections [Peters et al, 2021]

QI Team: Shiela Capulso, Christy Viliruz, Gigi Enriquez, Jo Peters.

The purpose of the quality improvement project was to increase the compliance of chlorhexidine (CH) bathing to 90% in a large ICU in a tertiary UK hospital 

CH bathing can be beneficial in preventing colonisation and infection with healthcare associated pathogens in critical care, although compliance should be monitored. Unit acquired bacteraemia had increased in our ICU as shown in our Intensive Care National Audit & Research Centre (ICNARC) data. This project was to ensure high compliance with CH bathing to minimise the risk of these infections. CH bathing is recommended in the Guidelines for the Provision of Intensive Care Services.  

The team followed SMART criteria to plan and support the project. The use of PDSA cycles was used to assess and maximise compliance with daily CH washes in eligible patients. Audits were carried out during the course of day shifts when patient bathing is usually undertaken. The number of patients who received CH baths and those who did not was recorded as well as reasonwhy in those who did not. The data was collected and reviewed each week by the team followed with solutions for non-compliance being discussed and implemented.  

Over the course of the project, compliance in CH bathing increased to achieve our aim although this was not a steady increase with several challenges encountered. There was a lack of awareness especially among new staff, issues with access to resources and changes in nursing priorities. The PDSA actions included increased education, improved documentation and ensured access to CH wipes throughout the unit.  

The ability to flag high bacteraemia rates via ICNARC was a successful trigger to improve CH bathing in our organisation. The use of PDSA cycling was successful in improving CH bathing compliance. The authors will continue auditing routinely to ensure standards are maintained.   

Submitted to BACCN 2021


Donskey, C.J. and Deshpande, A. 2016. ‘Effect of chlohexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature’, American Journal of Infection Control, 44, Suppl2, e17-e21. [Online] Available at: https://www.ajicjournal.org/article/S0196-6553(16)00200-5/fulltext  

Faculty of Intensive Care Medicine2019. Guidelines for the Provision of Intensive Care Services. [Online] Available at: https://www.ficm.ac.uk/sites/default/files/gpics-v2.pdf 


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