232 / Intensive Care Unit without walls

the PSP
Type of Patient Safety Practice Safe
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Early Warning
Health IT
Topic of the reported practice
Patient safety system
Aim and the benefit of the Patient Safety Practice
The usual patient flow in a hospital center leads critical patients to be admitted to the Intensive Care Unit (ICU), independently of their previous location in the emergency room, a conventional hospital ward, or operating room. Following clinical improvement, the patients are moved to a conventional hospital ward where they remain until their clinical recovery allows discharge from hospital. On the other hand, if the clinical condition worsens again, repeat admission to the ICU may prove necessary.

However, what would happen if we were able to identify patients at risk, before critical worsening, when they are still in the emergency area or in a conventional hospital ward? Anticipated clinical management of these patients at risk surely would exert a favorable influence upon their clinical course and prognosis. In this context, if the clinical condition were serious enough, the required admission to Intensive Care would take place earlier, thereby avoiding unnecessary delays in treatment. In contrast, and as a particularly important aspect, if the clinical condition of the patient allows diagnostic reorientation or the intensification of therapeutic measures, it might be possible to achieve clinical improvement without having to move the patient to Intensive Care – with the added advantage of improving management of the available healthcare resources. Therefore, while the medical care of critical patients centers on the ICU, it can be extended beyond such Units, constituting a continuous process throughout the length of patient hospital stay.

Description of the Patient Safety Practice

Based on the above considerations, in our center we have developed an Intensive Care management system or model fundamented on the safety of critical patients throughout the hospitalization process. The operation of this system is schematically represented in Figure 1. Specifically, the guiding principle of the system is the “Early detection of seriously ill patients outside the Intensive Care unit”. This refers to the identification of patients at risk outside the ICU, and is based on the identification, diagnostic evaluation and early treatment of seriously ill patients, in collaboration with other clinical specialties and independently of the place or ward where the patients are hospitalized.

Implementation of the model has been sequential in our center, based on consensus with the hospital management and all the Departments implicated in the care of these patients – fundamentally the Department of Internal Medicine, the Emergency Department, and the Department of General Surgery. An analysis has been made of the results of each of the steps taken, since introduction of the model in 2008:

1.- Introduction of emergency care codes in diseases where treatment is time-dependent:

•    Sepsis code
•    Acute coronary syndrome code
•    Cardiopulmonary resuscitation code

2.- Detection of risk patients in the Emergency Department.

3.- Follow-up of patients discharged from the ICU with a risk of poor posterior clinical evolution in the hospital ward.

4.- Development of a software application for laboratory test identification.

5.- Expansion of the activity to the entire hospital.

We have created an electronic alarm system defining the laboratory test indicators of severity used to detect potentially seriously ill patients with disease conditions in which rapid intervention can improve the prognosis and reduce the development of complications and thus the associated healthcare costs (acute or exacerbated chronic respiratory failure, severe sepsis, ischemic heart disease, and severe heart failure).

An efficiency study was made of these indicators, establishing working target limits for each of the variables. In collaboration with the Information Systems Department of the hospital, it has been possible to download all the requested laboratory test data in the hospitalization or emergency settings in the previous 24 hours from our information system, which is linked to the laboratory test management system. A software application in turn is applied to the downloaded data to identify all those tests in which some indicator or variable exceeded the predefined limits or cutoff points – generating a file with the altered parameter, the time of extraction and corresponding value, and identification of the patient and location within the center.


We have evaluated the results of the ICU Without Walls Project, based on a quasi-experimental before-after study, establishing comparisons with standards found in hospital centers of a similar level. These results have been analyzed in terms of both health and economical terms, and reveal the following:

1.- High survival among the patients covered by the program (over 95%), with the need for admission to the ICU in only a small proportion of these individuals.
2.- Increased availability of beds in the ICU for the programmed admission of patients undergoing high risk surgery. Considering a reduction in mean ICU stay of 1.36 days versus the standards in hospitals of similar level, and registering about 500 admissions a year, we can estimate the increase in maximum available stays to be 600.
3.- Change in the emergency care model, whereby part of the emergency activity targeted to patients at risk becomes programmed activity.
4.- Reduction by 50% of the situations of in-hospital cardiopulmonary resuscitation.
5.- Significant reduction in mean stay and mortality in the ICU, to levels below those of the standards referred to the degree of patient severity and found in other centers of similar characteristics.
6.- Taking into account only the shortening of mean stay in the ICU, the economical impact in terms of savings or cost-treatment opportunity for other patients is close to 700,000 euros a year.
7.- The entire process has been implemented without using any resources other than the availability and dedication of the personnel participating in the project. There have been no contracted services or any direct material expenditures.

Attachment of relevant written information and/or photos, as appropriate
There is no specified text here
Effectiveness of the Patient Safety Practice
Degree of implementation of reported practice
Yes, fully
Level of implementation of reported practice
Institution level
Specific and measurable outcome for the reported practice were defined
A baseline measurement before implementation of the reported practice was obtained
A measurement after full implementation of the reported practice was obtained
Evaluation of a “positive” effect of the reported practice on Patient Safety
The evaluation showed improvements in Patient Safety outcomes
Type of before-and after evaluation
Both/mixed (qualitative and quantitative)
Enclosure of a reference or attachment in case of published evaluation’s results




Health care context where the Patient Safety Practices was implemented
Successful implementation of this Patient Safety Practice in other health care settings than above stated
Specification of implementation in another health care setting(s)
There is no specified text here
Successful implementation’s level  of this Patient Safety Practice across settings
There is no specified text here
Involved health care staff
Patient Involvement
Direct service user’s involvement as integral part of this Patient Safety Practice
Specification of the service users or their representatives’ involvement in the implementation of this Patient Safety Practice
Point of time in which service user or their reprasentatives’ involvement takes place
During the development of the Patient Safety Practices$During evaluation of the Patient Safety Practices
Active seeking of service users’ opinion, feedback, experience, etc. as integral part of this Patient Safety Practice
Short description of the service users’ level of involvement
Consultation, such as asking for information
Public accessibility of information regarding this Patient Safety Practice to patients and citizens/service users
List of sources where public information is accessible









Implementation of the Patient Safety Practice
Existing collaboration with other countries or international organisations related to implementation of this Patient Safety Practice
Problems encountering in the implememntation course of this Patient Safety Practice like lack of motivation, no management support, etc.
List of the most prevelent difficulties encuntered during implementation of this Patient Safety Practice
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List of the most prevalent drivers for a successful implemetation of this Patient Safety Practice
Motivated staff
Use of any specific incentives to enhance motivation while implementing this Patient Safety Practice
Description of used incentives, if any.
There is no specified text here
Existence of support or approval by the clinical or hospital management or any other hihg level authority in the implementation process of this Patient Safety Practice
Costs of the Patient Safety Practices
Completion of cost calculation related to this Patient Safety Practice
Not relevant
Total number of person days required to implement this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total number of person days required for training as preparation for implementation of this Patient Safety Practice
Clinical staff:
External consultants:
Support staff:
Managerial staff:
Not relevant:
Total cost in Euro of specific equipment (machines, software, communications supplies, etc.) needed to support implementation of this Patient Safety Practice
There is no specified text here
Associated cost with a work reduction or foregoing in order to deliver this Patient Safety Practice
There is no specified text here