Qualitative review of intensive care unit quality indicators,☆☆

https://doi.org/10.1053/jcrc.2002.33035Get rights and content

Abstract

Purpose: The purpose of this study was to (1) conduct a systematic review of the literature to identify interventions that improve patient outcomes in the intensive care unit (ICU); (2) evaluate potential measures of quality based on the impact, feasibility, variability, and the strength of evidence to support each measure and to categorize these measures as outcome, process, access, or complication measures; and (3) select a list of candidate quality measures that can be broadly applied to improve ICU care. Methods: We identified and independently reviewed all studies in Medline (1965-2000) and The Cochrane Library (Issue 3, 2001) that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill adults; and intervention: process or structure measure that was associated with improved patient outcomes: morbidity, mortality, complications, errors, costs, length of stay (LOS), and patient reported outcomes. Studies were grouped into categories by the type of outcome that was improved by the intervention. Potential quality measures were evaluated for: impact on morbidity, mortality, and costs; feasibility of the measure; and variability in the measure. We evaluated the strength of evidence for each intervention used to improve outcomes and using the Delphi method, assigned an over-all recommendation for each quality measure. Results: A total of 3,014 citations were identified. Sixty-six studies that met selection criteria reported on a variety of interventions that were associated with improved patient outcomes. We identified 6 outcome measures: ICU mortality rate, ICU LOS greater than 7 days, average ICU LOS, average days on mechanical ventilation, suboptimal management of pain, and patient/family satisfaction; 6 process measures: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator-associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis, and appropriate deep venous thrombosis prophylaxis; 4 access measures: rate of delayed admissions, rate of delayed discharges, cancelled surgical cases, and emergency department by-pass hours; and 3 complication measures: rate of unplanned ICU readmission, rate of catheter-related blood stream infections, and rate of resistant infections. Conclusions: Further work is needed to create operational definitions and to pilot test the selected measures.The value of these measures will be determined by our ability to evaluate our current performance and implement interventions designed to improve the quality of ICU care. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Study selection criteria

We sought to identify and review all studies that provide a potential measure of quality of ICU care and that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill patients, and intervention: a process (what we do to patients) or structure (how we deliver care) measure that was associated with improved patient outcomes: including morbidity, mortality, complications, error, costs, length of stay (LOS), and

Study selection and characteristics

We identified 3,014 citations from the electronic search. Of these, we rejected 2,948 (98%) after re-view of the abstracts because they did not meet our selection criteria. Sixty-six studies met selection criteria, with 99% agreement in the selection of eligible articles between reviewers. These studies reported on a variety of interventions. These results, and the potential indicators, are summarized in Table 1.

. Studies meeting inclusion criteria

Outcome EvaluatedStudy DesignIntervention Studied

Conclusions

The ability to measure quality of care is becoming increasingly important. Patients and purchasers are beginning to make health care purchasing decisions based on quality of care. We have conducted an informal review of the literature and identified several potential ICU quality indicators. This study advances the science of ICU quality measures by moving beyond risk-adjusted mortality and providing a framework for developing a rigorously evaluated set of quality measures.

Controversy exists

Acknowledgements

The authors would like to acknowledge Firouzeh Manuchehri for help on the logic critique and evaluation of the indicators and for providing feedback during the conduct of the study. The authors would also like to thank Sherrie Solomon for her assistance during the preparation of the manuscript.

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    Supported by a grant from the Volunteer Hospitals of America, Inc. S.M.B. and P.J.P. are supported in part by a clinician scientist award from The Johns Hopkins University.

    ☆☆

    Address reprint requests to Sean M. Berenholtz, MD, Department of Anesthesiology/CCM, The Johns Hopkins University, 600 N. Wolfe St, Halsted 842, Baltimore, MD 21287.

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