Monitoring the evolutionary process of quality: risk-adjusted charting to track outcomes in intensive care.
OBJECTIVE
To present graphical procedures for prospectively monitoring outcomes in the intensive care unit.


METHODS
Observational study: risk-adjusted control chart analysis of a case series.


METHODS
Tertiary referral adult intensive care unit: Princess Alexandra Hospital, Brisbane, Australia.


METHODS
A total of 3398 intensive care unit admissions from January 1, 1995, to January 1, 1998.


CONCLUSIONS
Risk-adjusted process control charting procedures for continuous monitoring of intensive care unit outcomes are proposed as quality management tools. A modified Shewhart p chart and cumulative sum process control chart, using the Acute Physiology and Chronic Health Evaluation III model mortality prediction for risk adjustment, are presented. The risk-adjusted p chart summarizes performance at arbitrary intervals and plots observed against predicted mortality rate to detect large changes in risk-adjusted mortality. The risk-adjusted cumulative sum procedure is a likelihood-based scoring method that adjusts for estimated risk of death, accumulating evidence from outcomes of all previous patients. It formally tests the hypothesis of a change in the odds of death. In this application, we detected a decrease from above to predicted risk-adjusted mortality. This was temporally related to increased senior staffing levels and enhanced ongoing multidisciplinary review of practice, quality improvement, and educational activities. Formulas and analyses are provided as appendices.
Cook
David A
DA
Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Australia.
Steiner
Stefan H
SH
Cook
Richard J
RJ
Farewell
Vern T
VT
Morton
Anthony P
AP
D000328:Adult; D003627:Data Interpretation, Statistical; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000592:standards* / Q000706:statistics & numerical data; D016013:Likelihood Functions; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D011793:Queensland / Q000453:epidemiology; D020379:Risk Adjustment / Q000379:methods*