Quality indicators in critically ill patients

Introduction

Quality indicators are working tools that permit measurement of the medical care provided. They can provide warning signs and identify problems or improvements and departures from standard care.

Objectives

The Spanish Society of Intensive Care and Coronary Units (SEMICYUC) developed a Strategic Plan that included the drawing up of quality indicators for key processes in the care of critically ill patients.

Materials and methods

Over a 2-year period, the 14 working groups of the SEMICYUC drew up a consensual list of 120 quality indicators. The methodology was coordinated and supervised by the Avedis Donabedian Foundation (FAD). The initial phase was the definition of the process and identification of the most important aspects according to priority criteria. The design phase consisted of the description of the various sections of the indicator in order to ensure its validity and reliability (definition, dimension, justification, formula, explanation of terms, population, type, data sources, standard and commentaries). All these process were based on the best scientific evidence available and expert opinion.

Results

A total of 120 quality indicators, covering all areas and dimensions of intensive care medicine, were drawn up. Of these, 20 were considered important enough to recommend their monitoring in all ICUs: (1) Early administration of acetylsalicylic acid (ASA) in acute coronary syndrome. (2) Early reperfusion techniques in acute coronary syndrome with ST elevation. (3) Semirecumbent position in patients with invasive mechanical ventilation. (4) Prevention of thromboembolic disease. (5) Surgical intervention in head trauma with epidural and/or subdural hematoma. (6) Monitoring of intracranial pressure (IPC) in severe head trauma with pathological CAT. (7) Pneumonia associated with mechanical ventilation. (8) Early management of sepsis/septic shock. (9) Early enteral nutrition. (10) Prophylaxis of gastrointestinal hemorrhage in patients with invasive mechanical ventilation. (11) Adequate sedation. (12) Management of analgesia in nonsedated patients. (13) Inadequate transfusion of blood concentrates. (14) Real donors. (15) Compliance with hand-washing protocol. (16) Information for the families of ICU patients. (17) Therapeutic limitations. (18) Survey of perceived quality at discharge from the ICU. (19) Round-the-clock presence of intensive care specialists in the ICU. (20) Register of adverse effects.

With respect to the type of indicator included: five were structural, 79 were procedural and 36 were concerned with results. The principal quality dimensions evaluated in the indicators were: risk (53); effectiveness (42); adaptation (25); efficiency (10); satisfaction (seven); continuity of care (three) and accessibility (one), although the majority evaluated more than one dimension of quality.

Conclusion

This project led to the drawing-up of 120 quality indicators of the key processes in the care of the critically ill patient. Twenty basic indicators were identified that we consider should be monitored in all ICUs, with the other indicators depending on the case mix. According to these indicators, the dimensions monitored with greatest frequency are risk and effectiveness.