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The association between outcome-based quality indicators for intensive care units.

ABSTRACT: PURPOSE:To assess and improve the effectiveness of ICU care, in-hospital mortality rates are often used as principal quality indicator for benchmarking purposes. Two other often used, easily quantifiable, quality indicators to assess the efficiency of ICU care are based on readmission to the ICU and ICU length of stay. Our aim was to examine whether there is an association between case-mix adjusted outcome-based quality indicators in the general ICU population as well as within specific subgroups. MATERIALS AND METHODS:We included patients admitted in 2015 of all Dutch ICUs. We derived the standardized in-hospital mortality ratio (SMR); the standardized readmission ratio (SRR); and the standardized length of stay ratio (SLOSR). We expressed association through Pearson's correlation coefficients. RESULTS:The SMR ranged from 0.6 to 1.5; the SRR ranged from 0.7 to 2.1; and the SLOSR ranged from 0.7 to 1.3. For the total ICU population we found no significant associations. We found a positive, non-significant, association between SMR and SLOSR for admissions with low-mortality risk, (r = 0.25; p = 0.024), and a negative association between these indicators for admissions with high-mortality risk (r = -0.49; p<0.001). CONCLUSION:Overall, we found no association at ICU population level. Differential associations were found between performance on mortality and length of stay within different risk strata. We recommend users of quality information to take these three outcome indicators into account when benchmarking ICUs as they capture different aspects of ICU performance. Furthermore, we suggest to report quality indicators for patient subgroups.

SUBMITTER: Verburg IWM

PROVIDER: S-EPMC5999279 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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The association between outcome-based quality indicators for intensive care units.

Verburg Ilona W M IWM de Jonge Evert E Peek Niels N de Keizer Nicolette F NF

PloS one 20180613 6

<h4>Purpose</h4>To assess and improve the effectiveness of ICU care, in-hospital mortality rates are often used as principal quality indicator for benchmarking purposes. Two other often used, easily quantifiable, quality indicators to assess the efficiency of ICU care are based on readmission to the ICU and ICU length of stay. Our aim was to examine whether there is an association between case-mix adjusted outcome-based quality indicators in the general ICU population as well as within specific ...[more]

PMID: 29897994

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Project description:BACKGROUND:Outcome data on fluid therapy in critically ill patients from randomised controlled trials may be different from data obtained by observational studies under "real-life" conditions. We conducted this prospective, observational study to investigate current practice of fluid therapy (crystalloids and colloids) and associated outcomes in 65 German intensive care units (ICUs). In total, 4545 adult patients who underwent intravenous fluid therapy were included. The main outcome measures were 90-day mortality, ICU mortality and acute kidney injury (AKI). Data were analysed using logistic and Cox regression models, as appropriate. RESULTS:In the predominantly post-operative overall cohort, unadjusted 90-day mortality was 20.1%. Patients who also received colloids (54.6%) had a higher median Simplified Acute Physiology Score II [25 (interquartile range 11; 41) vs. 17 (7; 31)] and incidence of severe sepsis (10.2 vs. 7.4%) on admission compared to patients who received exclusively crystalloids (45.4%). 6% hydroxyethyl starch (HES 130/0.4) was the most common colloid (57.0%). Crude rates of 90-day mortality were higher for patients who received colloids (OR 1.845 [1.560; 2.181]). After adjustment for baseline variables, the HR was 1.666 [1.405; 1.976] and further decreased to indicate no associated risk (HR 1.003 [0.980; 1.027]) when it was adjusted for vasopressor use, severity of disease and transfusions. Similarly, the crude risk of AKI was higher in the colloid group (crude OR 3.056 [2.528; 3.694]), after adjustment for baseline variables OR 1.941 [1.573; 2.397], and after full adjustment OR 0.696 [0.629; 0.770]), the risk of AKI turned out to be reduced. The same was true for the subgroup of patients treated with 6% HES 130/0.4 (crude OR 1.931 [1.541; 2.419], adjusted for baseline variables OR 2.260 [1.730; 2.953] and fully adjusted OR 0.800 [0.704; 0.910]) as compared to crystalloids only. CONCLUSIONS:The present analysis of mostly post-operative patients in routine clinical care did not reveal an independent negative effect of colloids (mostly 6% HES 130/0.4) on renal function or survival after multivariable adjustment. Signals towards a reduced risk in subgroup analyses deserve further study. Trial registration ClinicalTrials.gov Identifier: NCT01122277, registered May 11th, 2010.

Project description:BackgroundAssessment of preparedness of weaning has been recommended before extubation for mechanically ventilated patients. We aimed to understand the association of a structured assessment of weaning preparedness with successful liberation.MethodsWe retrospectively investigated patients with acute respiratory failure who experienced an extubation trial at the medical intensive care units of a medical center and compared the demographic and clinical characteristics between those patients with successful and failed extubation. A composite score to assess the preparedness of weaning, the WEANSNOW score, was generated consisting of eight components, including Weaning parameters, Endotracheal tube, Arterial blood gas analysis, Nutrition, Secretions, Neuromuscular-affecting agents, Obstructive airway problems and Wakefulness. The prognostic ability of the WEANSNOW score for extubation was then analyzed.ResultsOf the 205 patients included, 138 (67.3%) patients had successful extubation. Compared with the failure group, the success group had a significantly shorter duration of MV before the weaning attempt (11.2 ± 11.6 vs. 31.7 ± 26.2 days, p < 0.001), more with congestive heart failure (42.0% vs. 25.4%, p = 0.020), and had different distribution of the types of acute respiratory failure (p = 0.037). The failure group also had a higher WEANSNOW score (1.22 ± 0.85 vs. 0.51 ± 0.71, p < 0.001) and worse Rapid Shallow Breathing Index (93.9 ± 63.8 vs. 56.3 ± 35.1, p < 0.001). Multivariate logistic regression analysis showed that a WEANSNOW Score = 1 or higher (OR = 2.880 (95% CI [1.291-6.426]), p = 0.010) and intubation duration >21 days (OR = 7.752 (95% CI [3.560-16.879]), p < 0.001) were independently associated with an increased probability of extubation failure.ConclusionAssessing the pre-extubation status of intubated patients in a checklist-based approach using the WEANSNOW score might provide valuable insights into extubation failure in patients in a medical ICU for acute respiratory failure. Further prospective studies are warranted to elucidate the practice of assessing weaning preparedness.

Project description:IntroductionExtensive antibiotic use makes the intensive care unit (ICU) an important focus for antibiotic stewardship programs. The aim of this study was to develop a set of actionable quality indicators for appropriate antibiotic use at ICUs and an implementation toolbox, which can be used to assess and improve the appropriateness of antibiotic use in the treatment of adult patients at an ICU.MethodsA four round modified-RAND Delphi procedure was used. Potential indicators were identified by a multidisciplinary panel of 15 Dutch experts, from international literature and guidelines. Using an online survey, the identified indicators were rated on three criteria: relevance, actionability and feasibility. Experts discussed and rated the indicators for the second time during a face-to-face consensus meeting. During a final consensus meeting the toolbox was developed, containing potential barriers and improvement strategies which were identified using a validated checklist by Flottorp et al., and if available also containing supporting material.ResultsThe first round resulted in 24 potential indicators. After the final meeting a set of three process indicators, one structure indicator and one quantity metric remained: 1) perform at least two sets of blood cultures before start of empirical systemic therapy; 2) perform therapeutic drug monitoring in patients treated with vancomycin or aminoglycosides; 3) perform surveillance cultures if selective digestive or oropharyngeal decontamination is applied at the ICU; 4) biannual face-to-face meetings between ICU and microbiology staff in which local resistance rates are discussed; and 5) quantitative antibiotic use at the ICU expressed in days of therapy (DOT). The toolbox contains 24 unique barriers and 37 improvement strategies.ConclusionsOur study identified a set of four actionable quality indicators and one quantity metric, together with an implementation toolbox, to improve appropriate antibiotic use at ICUs.

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The association between outcome-based quality indicators for intensive care units.

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The association between outcome-based quality indicators for intensive care units.

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