Qualitative review of intensive care unit quality indicators.
OBJECTIVE
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.
Berenholtz
Sean M
SM
Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University Schools of Medicine and Hygiene and Public Health, Baltimore, MD 21287, USA.
Dorman
Todd
T
Ngo
Koni
K
Pronovost
Peter J
PJ
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D001803:Blood Transfusion / Q000706:statistics & numerical data; D017723:Drug Utilization Review; D019317:Evidence-Based Medicine; D017721:Hospital Costs; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000592:standards*; D007902:Length of Stay; D017063:Outcome Assessment, Health Care; D010043:Outcome and Process Assessment, Health Care; D019984:Quality Indicators, Health Care; D014481:United States / Q000453:epidemiology; D020246:Venous Thrombosis / Q000517:prevention & control
D000319:Adrenergic beta-Antagonists; D000900:Anti-Bacterial Agents