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(Chest. 2005;128:3773-3774.)
© 2005 American College of Chest Physicians

Probabilistic Risk Assessment and Performance Index Applications for the ICU

Kelvin K. Shiu, DO, PhD and Mark J. Rosen, MD, FCCP

Beth Israel Medical Center, New York, NY

Correspondence to: Kelvin K, Shiu, DO, PhD, Pulmonary and Critical Care, First Ave. and 16th Street, Beth Israel Medical Center, New York, NY

To the Editor:

Dr. Garland provided a comprehensive review of the interplay of medical, technical, administrative, social, and economic issues facing ICU organization and management.1 He is to be congratulated for reminding the medical community of the concept of an integrated system approach to unraveling the complex and interdependent factors that influence patient care in the ICU. Standard analytical tools employed for quality assessment such as root cause analysis are simply inadequate. Probabilistic risk assessment (PRA) is a systematic and comprehensive methodology widely applied in other industries to evaluate undesirable outcomes such as risk, and PRA may be a promising tool for assessment of adverse events in the ICU.2345 PRA entails constructing the chronology of a scenario and a "fault tree" of occurrences that could lead to a specific adverse outcome. By analysis of the likelihood of each contributor to the adverse event, one could quantify the likelihood of that outcome occurring and focus efforts on modifying each of these events. Results from PRA would also provide a quantitative basis for specific event rates and for overall system performance over time.

The need for serious discussions of ICU performance metrics is overdue. We gauge the "health" of financial or business entities by measurements like price-to-earnings ratio, equity, debt load, or cash on hand. Similarly, we monitor the integrity of engineering systems by their failure rates, reliability, recovery rate, and level of redundancy. The performance measures described by Dr. Garland are good first steps toward arriving at community consensus; others may propose alternatives. The ultimate test would depend on the usefulness of these measurements in improving care in the ICU.

References

  1. Garland, A. (2005) Improving the ICU. Chest 127,2151-2179[Abstract/Free Full Text]
  2. Preliminary probabilistic exposure and risk assessment for children who contact chromated copper arsenate (CCA) treated wood and play sets and decks and CCA containing soil around these structures 2004 Environmental Protection Agency. Washington, DC:
  3. US Nuclear Regulatory Commission 1975 Reactor Safety Study: an assessment of accident risks in US commercial nuclear power plants 1975 US Nuclear Regulatory Commission. Washington, DC: WASH-1400, NUREG-75/014
  4. Battles, JB, Kanki, BG The use of socio-technical probabilistic risk assessment at AHRQ and NASA. International Conference on Probabilistic Safety Assessment and Management, June 11–18, 2004 2004 Springer-Verlag. Berlin, Germany:
  5. Shiu KK, Rosen MJ. Application of risk assessment model in ICU adverse events [abstract]. Proc Am Thorac Soc 2005; A429




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