Prospectively Defined Indicators to Improve the Safety and Quality of Care for Critically

Prospectively defined indicators to improve the safety and quality of care for critically ill patients.A report from the task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM).

Electronic Supplementary Material

A Rhodes, RP Moreno, E Azoulay, M Capuzzo, JD Chiche, J Eddleston, R Endacott,P Ferdinande, H Flaatten, B Guidet, R Kuhlen, C León-Gil, MC Martin Delgado, P Metnitz, M Soares, C Sprung, JF Timsit, A Valentin on behalf of the Task Force on Quality and Safety of the European Society of Intensive care Medicine (ESICM).

The European Society of Intensive Care Medicine has formally endorsed this manuscript.

A Rhodes

Department of Intensive Care Medicine

St George’s Healthcare NHS Trust and University of London

London SW17 0QT

T: +44 208 725 5699

RP Moreno

Unidade de Cuidados Intensivos Polivalente

Hospital de St. António dos Capuchos

Centro Hospitalar de Lisboa Central, E.P.E.

Lisboa

Portugal

E Azoulay

Service de Réanimation Médicale

Hôpital Saint-Louis, Université Paris 7

1 Avenue Claude Vellefaux, 75010 PARIS

M Capuzzo,

Department of Surgical, Anaesthetic and Radiological Sciences.

Section of Anaesthesiology and Intensive Care,

University Hospital of Ferrara,

Corso Giovecca 203, 44100 Ferrara,

Italy

JD Chiche,

Réanimation Médicale -Hôpital Cochin

27 Rue du Faubourg St Jacques

75679 Paris Cedex 14-

France

J Eddleston,

Consultant in Intensive Care Medicine & Anaesthesia

Central Manchester University Hospitals NHS Foundation Trust

Manchester Royal Infirmary

Oxford Road

Manchester, M13 9WL

R Endacott

Professor of Critical Care Nursing,

Faculty of Health,

University of Plymouth,

8 Portland Villas, Drake Circus

PLYMOUTH PL4 8AA

P Ferdinande,

Surgical and Transplantation ICU

University Hospital Gasthuisberg

Leuven,

Belgium

H Flaatten,

Professor & Medical director

ICU

Haukeland University Hospital

Bergen, Norway

B Guidet,

Assistance Publique - Hôpitaux de Paris, Hôpital Saint-Antoine,

service de réanimation médicale, Paris, F-75012, France;

UPMC Univ Paris 06

Inserm, Unité de Recherche en Épidémiologie Systèmes d’Information et

Modélisation (U707), Paris, F-75012, France

R Kuhlen,

HELIOS Kliniken GmbH Geschäftsführer Medizin

Friedrichstrasse 136, 10117 Berlin

C León-Gil,

Servicio de Cuidados Críticos y Urgencias

Hospital Universitario de Valme

Ctra.Cádiz,

Sevilla,

Spain

MC Martin Delgado,

Hospital de Torrejón

Director Intensive Care Unit

C /Mateo Inurria, s/n

28850 Torrejón de Ardoz, Madrid

Tel.: 91 488 66 24 – 91 488 66 25

Spain

P Metnitz,

Medical Director ICU 13i1

Dept. of Anesthesia& General Intensive Care

AKH Wien - Medical University of Vienna

Vienna,

Austria

M Soares,

IDOR - D'Or Institute for Research and Education

Rua Diniz Cordeiro, 30 – 3º andar

Botafogo - Rio de Janeiro - RJ –

Brazil

CEP: 22281-100

C L Sprung,

Director, General Intensive Care Unit

Hadassah Hebrew University Medical Center

PO Box 12000

Jerusalem, Israel 91120

JF Timsit,

Responsable Médical Clinique Réanimation Médicale (PMAC)

Director of the Medical I.C.U.

University Grenoble 1, Teaching hospital Albert Michallon, BP 217,

38043 GRENOBLE CEDEX 9,

France

A Valentin

Medical Director, General and Medical ICU

Rudolfstiftung Hospital

Juchgasse 25

A-1030 Wien

Austria

Correspondence to:

A Rhodes

Department of Intensive Care Medicine

St George’s Healthcare NHS Trust and University of London

London SW17 0QT

T: +44 208 725 5699

Part 1. Specific Details of Indicators

1. Intensive Care Unit (ICU) fulfils national requirements.

Name of Indicator / Intensive Care Unit (ICU) fulfils national requirements to provide Intensive Care.
Dimension / Safe, effective, equitable
Justification / The designation of a unit as an ICU results in standard resource allocation and reporting mechanisms.
Formula / Yes or No
Explanation of terminology / Designation as an ICU distinguishes the unit from other critical care settings with lower acuity such as high dependency or intermediate care.
Population / The Unit
Type / Structure
Source of data / National Intensive Care Board or Government Directive
Standard / Yes

2. 24-hour availability of a consultant level Intensivist

Name of Indicator / 24-hour availability of a consultant level Intensivist
Dimension / Safe, effective, patient-centred, efficient, equitable
Justification / The immediate availability of an Intensivist in the ICU 24 hours per day guarantees the quality of care, decreasing morbidity and mortality and reducing length of stay of critically ill patients.
If the consultant is not resident on the unit then there must be residentmedical expertize sufficient to initiate resuscitation and organ support 24 hours per day and the consultant must be immediately available to return to the bedside whenever required.
Formula / Number of days with the immediate availabilityto the ICU of an Intensivist for 24 hours per day x 100/365.
Units / Rate in %
Explanation of terminology / •Intensivist: physician that is a certified as an intensive care medicine specialist, excluding specialists in training.
•Immediate availability is considered necessary seven days a week, 24 hours per day.
Population / All days of the year during the period reviewed.
Type / Structure
Source of data / Human Resources Department and Duty Rosters
Standard / 100%
References / Pronovost PJ, et al Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review [1]
Vincent JL. Need for intensivists in intensive-care units [2].

3. Presence of adverse incident reporting system.

Name of Indicator / Adverse event reporting system
Dimension / Safe
Justification / Adverse events are common in the field of medicine and are related to significant mortality and morbidity, as well as increased stays and costs. In order to reduce the rates of adverse events and to therefore improve the quality of care provided, the rates and specific types of these events need to be understood. One way of achieving this is for each unit to have a specific monitoring system in place that record the events that take place for each patient.
Formula / The presence of a system for notifying and registering AE in the ICU
Units / Yes or No
Explanation of terminology / System for notifying and registering AE:

Must be voluntary and anonymous
Must make it possible for any professional to notify an AE
Must provide a mechanism for regular feedback to the clinical teams.

Patients reviewed: All
Population / Hospital registers
Type / Process
Source of data / ICU Registers
Standard / 100%
References / Wu AW, et al. ICU incident reporting systems.[3]
Needham DM, et al A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS).[4]
Pronovost PJ et al. Toward learning from patient safety reporting systems.[5]
Winters BD et al. Improving patient safety reporting systems[6].
Zhan C et al. Administrative data based patient safety research: a critical review[7]
Holzmueller CG et al. Creating the web-based intensive care unit safety reporting system [8].
Valentin A et al. Errors in administration of parenteral drugs in intensive care units: multinational prospective study [9].

4. Presence of routine multi-disciplinary clinical ward rounds

Name of Indicator / Presence of routine multi-disciplinary clinical ward rounds
Dimension / Effective, patient-centred, efficient, equitable
Justification / The presence of routine multi disciplinary clinical ward rounds in the ICU guarantees the quality of care, decreasing mortality and stay among critical patients.
Formula / Number of days with the multi-disciplinary clinical rounds x 100 / 365
Units / Rate in %
Explanation of terminology / Multi-disciplinary: the presence of both nursing and medical staff.
Clinical round: bedside review of every patient on the ward
Population / All days of the year during the period reviewed.
Type / Process
Source of data / Proforma
Standard / 100%
References / Rothen HU et al. Variability in outcome and resource use in intensive care units [10].
Kim MM, et al. The effect of multidisciplinary care teams on intensive care unit mortality.[11].

5. Standardized Handover procedure for discharging patients

Name of Indicator / Standardized Handover procedure for discharging patients
Dimension / Effective, efficient
Justification / Every patient should have on discharge from the Intensive Care Unit a standardized documentation of the reasons for admission, the diagnoses made, the on-going problems and the issues that need to be resolved. This list should include an explanation of why long term drugs have been stopped and why new drugs have been started and for how long they should be continued. This documentation should form part of the routine patient record and should be available to all clinical teams caring for the patient post discharge from the ICU.
Formula / Number of patients discharged from the ICU with a documented standardized handover x 100 / Number of patients discharged from the ICU
Units / Rate in %
Explanation of terminology / The description of the diagnoses made should be with a recognized system of classifying disease groups. This may differ even between regions within countries according to local regulations and practices.
Population / All patients discharged from the ICU during the period reviewed.
Type / Process
Source of data / Clinical record
Standard / 100%
References / Pickering BW et al. Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover[12].
Catchpole KR et al. Patient handover from surgery to intensive care: using Formula 1 pit stop and aviation models to improve safety and quality [13].
Bell CM et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases [14].
Khan JM et al. Going home on the right medications: prescription errors and transitions of care [15].

6. Reporting and analysis of Standardized Mortality Ratio (SMR)

Name of Indicator / Reporting and analysis of Standardized Mortality Ratio (SMR)
Dimension / Safety, Effective
Justification / Raw mortality is not a good indicator of quality, as it does not take into consideration the differences in case mix or severity of illness. The use of a standardized mortality ratio (SMR) calculated from an appropriately calibrated severity of illness score enables comparative auditing controlling for the severity of illness as evaluated by a given mortality prediction model. Comparison of a unit’s SMR against other similar institutions in a benchmarking project enables reflective practice, audit and quality improvement processes to be performed.
Formula / The SMR should be reported to either a local, regional or national database at least on a quarterly basis with feedback being given with regards the unit’s results in comparison to the larger dataset.
Units / Yes or No
Explanation of terminology / •Observed hospital mortality: number of patients admitted to the ICU that die in the hospital/number of patients admitted to the ICU per unit of time
•Expected hospital mortality: arithmetic sum of the individual probabilities of death for each patient admitted to the ICU according to the severity score/no. of patients admitted to the ICU
•Standardized mortality: mortality adjusted for severity; different predictive models can be used (APACHE II-III, MPM I-II, SAPS I-II-III, ICNARC Model) but must be related to the specific region
•This indicator is based on the comparison of the results with those predicted by the model.
•All predictive indices of risk of death refer to hospital mortality.
Population / All patients admitted to the ICU during the period reviewed.
Exclusion criteria are:
• readmissions
Type / Outcome
Source of data / Unit records
References / Moreno RP et al. Characterizing the risk profiles of intensive care units[16].
Poole D External validation of the Simplified Acute Physiology Score (SAPS) 3 in a cohort of 28,357 patients from 147 Italian intensive care units[17].

7. Intensive Care re-admission rate within 48 hours of ICU discharge.

Name of Indicator / Intensive Care re-admission rate within 48 hours of ICU discharge.
Dimension / Safe, Efficiency and patient-centred.
Justification / A high early readmission rate suggests poor ICU discharge decision-making. It can be caused by discharges occurring before the patient is ready for ward based care, incorrect use of ward care, and deficient hand-over to staff taking over the care and responsibility of the patient.
Readmission is generally associated with increased hospital stays, increased consumption of resources, and greater morbidity and mortality. It is mainly explained by residual organ dysfunction/failure at ICU discharge, requiring consequently a high nursing workload.
Formula / Number of unscheduled readmissions < 48 hours x 100/ Number of patients discharged from the ICU
Units / Rate in %
Explanation of terminology / Unscheduled readmission: Readmission due to unforeseen causes (not planned); whether related or not and regardless of where the patient spent the last 48 hours.
Population / All patients discharged from the ICU during the period reviewed. Exclusion criteria:

Death in the ICU
Discharges with orders to withhold further life support
Discharges with pre-planned readmission scheduled before 48 hours

Type / Outcome
Source of data / ICU Register
Standard / 4%
References / Angus DC Grappling with intensive care unit quality--does the readmission rate tell us anything? [18].
Task Force of the American College of Critical Care Medicine. Guidelines for intensive care unit admission, discharge, and triage. [19].
Metnitz PGH et al Critically ill patients readmitted to intensive care units--lessons to learn? [20]
Rosenberg AL et al. Patients readmitted to ICUs: a systematic review of risk factors and outcomes [21].

8. Rate of central venous catheter related blood stream infection.

Name of Indicator / The rate of central venous catheter related blood stream infection.
Dimension / Safe and effective
Justification / The use of central venous catheters (CVC) is indispensable in the treatment of critically ill patients. Infection is one of the most important complications of CVC use andbacteraemia due to CVC are the main cause of nosocomial bacteraemia in ICUs. Although the real impact has not been well established, mortality is estimated at 10% and can increase ICU stay by 5-8 days.
Formula / No. of episodes of bacteremia due to CVC x1000 days CVC / Total no. of days CVC
Explanation of terminology / BSI: Laboratory-confirmed bloodstream infection
1 positive blood culture for a recognized pathogen
or
Patient has at least one of the following signs or symptoms: fever (>38°C.), chills, or hypotension
and
2 positive blood cultures for a common skin contaminant (from 2 separate blood samples, usually within 48 hours).
skin contaminants = coagulase-negative staphylococci, Micrococcus sp., Propionibacterium acnes, Bacillus sp., Corynebacterium sp.
- Catheter-related: the same micro-organism was cultured from the catheter or symptoms improve within 48 hours after removal of the catheter.
Population / All days of CVC in patients discharged after having spent > 24 hrs in the ICU during the period reviewed.
•Exclusion criterion: peripherally inserted CVC
Type / Outcome
Source of data / Clinical records
Standard / Four episodes per 1,000 days CVC
References / Chittick P et al. Recognition and prevention of nosocomial vascular device and related bloodstream infections in the intensive care unit [22].
Dendle C et al. Staphylococcus aureus bacteraemia as a quality indicator for hospital infection control [23].
Pronosvost P et al. An intervention to decrease catheter-related bloodstream infections in the ICU [24].
Pronovost P et al. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study [25].
Lucet JC et al. Infectious risk associated with arterial catheters compared with central venous catheters[26].

9. Rate of unplanned extubations.

]

Name of Indicator / The rate of unplanned endotracheal extubations.
Dimension / Safe
Justification / Unplanned extubation is associated with a high rate of re-intubation and with increased risk of nosocomial pneumonia and death.
Formula / The number of tubes or tracheal cannulas accidentally removed × 1000/sum of the time that each tube remained placed.
Explanation of terminology / Unplanned extubation is defined as a premature removal of the endotracheal tube by action of the patient (i.e. deliberate self-extubation) or premature removal during nursing care and manipulation of the patient (i.e. accidental extubation).
Population / All days of intubation of patients that require ventilatory support through an endotracheal tube during the period of review.
Type / Outcome
Source of data / Clinical records
Standard / 10 episodes per 1000 days intubation
References / Vassal T et al. Prospective evaluation of self-extubations in a medical intensive care unit [27].
Esteban A et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study[28].
Chevron V et al. Unplanned extubation: risk factors of development and predictive criteria for reintubation[29].
Penuelas O et al. Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation. [30]
de Groot RI et al. Risk factors and outcomes after unplanned extubations on the ICU: a case-control study. [31]
List of indicators (combined from documents)

PLANNING, ORGANIZATION, AND MANAGEMENT

1 Observed, predicted and Standardized mortality rate

2 Observed, predicted and Standardized use of resources (LOS)

3 Regular participation in a regional, national or international Case Mix Programme (CMP).

4 Average (and median) length of stay for survivors and non-survivors

5 Average (and median) length of mechanical ventilation

6 Bed occupancy rate in the ICU

7 Rates of cancellation of scheduled surgery

8 Inappropriate or precipitated discharge from the ICU (nights, weekends)

9 Incidence of Delayed discharge from the ICU

10 Incidence of delayed admission to the ICU

11 Unscheduled readmission to the ICU within 48 hours of ICU discharge

12 Perceived quality survey at discharge from the ICU for patients and families

13 Formal process for discharge handover of information from the ICU

14 Staff orientation plan in the ICU

15 ICU fulfils national requirements to be an Intensive Care Unit

16 Presence of an intensivist in the ICU 24 hrs/day

17 Routine multi-disciplinary Clinical rounds

18 handovers for changes in shift

19 Handover for discharging patients

20 Access to relevant medical sources in electronic format

21 Complication rate related to central venous catheter insertion

22 Adverse events register

23 Incidence of medication errors

24 Protocol for the insertion and management of nasogastric tubes

25 Appropriate bronchial aspiration

26 Protocol for endotracheal tube cuff pressure monitoring

27 Monitoring alarms management

28 Incidence of accidental falls

29 Compliance with hand-washing protocols

30 Accidental removal of intravascular catheters

31 Incidence of pressure sores

32 Availability of special labelling of concentrated electrolyte solutions

33 Incidence of barotrauma

34 Ventilator circuit change at 7 days

35 Serious complications during prone position in ARDS

36 Limited alveolar plateau pressure in invasive mechanical ventilation

37 Avoidance of zero end expiratory pressure in mechanical ventilation (ZEEP)

38 Use of capnometry for all intubations

39 Semirecumbent position in patients undergoing invasive mechanical ventilation

40 Local policies for changing heat-and-moisture exchangers / circuits

41 Prevention of thromboembolism

42 Rate of unplanned extubation

43 Reintubation within 48 hours of planned extubation

44 Early implementation of non invasive mechanical ventilation in COPD

45 Laryngoscope dysfunction

46 Rate of bacteraemia related to central venous catheter