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Quality Indicators: The Use of Metrics in Critical Care Medicine

  • Sergio L. Zanotti CavazzoniEmail author
Chapter

Abstract

The healthcare landscape is undergoing significant changes. An important movement toward value-based payments has heightened the focus on quality and cost. The intensive care unit (ICU) is characterized by high acuity, high resource utilization, and unwanted variability in the application of evidence-based treatments. These characteristics make the ICU a prime target for improvement programs focused on quality and safety. In this chapter, we discuss the basic paradigm of value in healthcare based on the relationship of quality and cost. We review the three domains utilized to assess quality in healthcare (structure, process, and outcome). In addition, we examine the essential characteristics required for good quality metrics in the ICU. A good quality metric in critical care should be important, valid, reliable, responsive, interpretable, and feasible. Factors to consider in assuring success when implementing quality metrics in the ICU include clear purpose, inclusion of the multidisciplinary team, and a structured approach to setting priorities. In the chapter, we review examples of quality metrics that meet these requirements and are specific to the ICU. Creating surrogates and overinterpretation of results falling in the trap of the law of small numbers are potential pitfalls to avoid. Critical care leaders must understand these fundamental principles in order to successfully utilize quality metrics and accurately assess quality of care and most importantly to create value for our patients.

Keywords

Value Quality Safety Metrics Intensive care unit 

References

  1. 1.
    O’Brien JM, Kumar A, Metersky ML. Does value-based purchasing enhance quality of care and patient outcomes in the ICU? Crit Care Clin. 2013;29(1):91–112.  https://doi.org/10.1016/j.ccc.2012.10.002.CrossRefPubMedGoogle Scholar
  2. 2.
    Murphy DJ, Ogbu OC, Coopersmith CM. ICU director data: using data to assess value, inform local change, and relate to the external world. Chest. 2015;147(4):1168–78.  https://doi.org/10.1378/chest.14-1567.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Institute of Medicine (US) Committee on Quality of Health Care in America. To err is human: building a safer health system. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington, DC: National Academies Press; 2000. http://www.ncbi.nlm.nih.gov/books/NBK225182/. Accessed 21 Sept 2019.
  4. 4.
    Halpern NA, Pastores SM. Critical care medicine beds, use, occupancy, and costs in the United States: a methodological review. Crit Care Med. 2015;43(11):2452–9.  https://doi.org/10.1097/CCM.0000000000001227.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Hewson-Conroy KM, Burrell AR, Elliott D, et al. Compliance with processes of care in intensive care units in Australia and New Zealand—a point prevalence study. Anaesth Intensive Care. 2011;39(5):926–35.  https://doi.org/10.1177/0310057X1103900520.CrossRefPubMedGoogle Scholar
  6. 6.
    Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694–700.  https://doi.org/10.1097/01.ccm.0000171609.91035.bd.CrossRefPubMedGoogle Scholar
  7. 7.
    Myers EA, Smith DA, Allen SR, Kaplan LJ. Post-ICU syndrome: rescuing the undiagnosed. JAAPA. 2016;29(4):34–7.  https://doi.org/10.1097/01.JAA.0000481401.21841.32.CrossRefGoogle Scholar
  8. 8.
    Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–8.  https://doi.org/10.1001/jama.260.12.1743.CrossRefPubMedGoogle Scholar
  9. 9.
    Martinez EA, Donelan K, Henneman JP, et al. Identifying meaningful outcome measures for the intensive care unit. Am J Med Qual. 2014;29(2):144–52.  https://doi.org/10.1177/1062860613491823.CrossRefPubMedGoogle Scholar
  10. 10.
    Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001. http://www.ncbi.nlm.nih.gov/books/NBK222274/. Accessed 21 Sept 2019
  11. 11.
    Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit quality improvement: a “how-to” guide for the interdisciplinary team. Crit Care Med. 2006;34(1):211–8.  https://doi.org/10.1097/01.ccm.0000190617.76104.ac.CrossRefGoogle Scholar
  12. 12.
    Dimick JB, Pronovost PJ, Heitmiller RF, Lipsett PA. Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection. Crit Care Med. 2001;29(4):753–8.  https://doi.org/10.1097/00003246-200104000-00012.CrossRefPubMedGoogle Scholar
  13. 13.
    Horn E, Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Crit Care Med. 2006;34(3 Suppl):S46–51.  https://doi.org/10.1097/01.CCM.0000199990.68341.33.CrossRefPubMedGoogle Scholar
  14. 14.
    Manthous C, Nembhard IM, Hollingshead AB. Building effective critical care teams. Crit Care (Lond Engl). 2011;15(4):307.  https://doi.org/10.1186/cc10255.CrossRefGoogle Scholar
  15. 15.
    Rhodes A, Moreno RP, Azoulay E, et al. 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). Intensive Care Med. 2012;38(4):598–605.  https://doi.org/10.1007/s00134-011-2462-3.CrossRefPubMedGoogle Scholar
  16. 16.
    Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients: a systematic review. JAMA. 2002;288(17):2151–62.  https://doi.org/10.1001/jama.288.17.2151.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Vincent JL. Need for intensivists in intensive-care units. Lancet (Lond Engl). 2000;356(9231):695–6.  https://doi.org/10.1016/S0140-6736(00)02622-2.CrossRefGoogle Scholar
  18. 18.
    Pronovost PJ, Thompson DA, Holzmueller CG, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305–15.  https://doi.org/10.1016/j.jcrc.2006.07.001.CrossRefPubMedGoogle Scholar
  19. 19.
    Wu AW, Pronovost P, Morlock L. ICU incident reporting systems. J Crit Care. 2002;17(2):86–94.CrossRefGoogle Scholar
  20. 20.
    Needham DM, Thompson DA, Holzmueller CG, et al. A system factors analysis of airway events from the Intensive Care Unit Safety Reporting System (ICUSRS). Crit Care Med. 2004;32(11):2227–33.  https://doi.org/10.1097/01.ccm.0000145230.52725.6c.CrossRefPubMedGoogle Scholar
  21. 21.
    Kim MM, Barnato AE, Angus DC, Fleisher LA, Fleisher LF, Kahn JM. The effect of multidisciplinary care teams on intensive care unit mortality. Arch Intern Med. 2010;170(4):369–76.  https://doi.org/10.1001/archinternmed.2009.521.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Yoo EJ, Edwards JD, Dean ML, Dudley RA. Multidisciplinary critical care and intensivist staffing: results of a statewide survey and association with mortality. J Intensive Care Med. 2016;31(5):325–32.  https://doi.org/10.1177/0885066614534605.CrossRefPubMedGoogle Scholar
  23. 23.
    Catchpole KR, de Leval MR, McEwan A, Pigott N, Elliott MJ, McQuillan A, MacDonald C, Goldman AJ. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth. 2007;17:470–8.CrossRefGoogle Scholar
  24. 24.
    Kahn JM, Angus DC. Going home on the right medications: prescription errors and transitions of care. JAMA. 2011;306(8):878–9.  https://doi.org/10.1001/jama.2011.1209.CrossRefPubMedGoogle Scholar
  25. 25.
    Moreno RP, Hochrieser H, Metnitz B, Bauer P, Metnitz PGH. Characterizing the risk profiles of intensive care units. Intensive Care Med. 2010;36(7):1207–12.  https://doi.org/10.1007/s00134-010-1852-2.CrossRefPubMedGoogle Scholar
  26. 26.
    Poole D, Rossi C, Anghileri A, et al. External validation of the Simplified Acute Physiology Score (SAPS) 3 in a cohort of 28,357 patients from 147 Italian intensive care units. Intensive Care Med. 2009;35(11):1916–24.  https://doi.org/10.1007/s00134-009-1615-0.CrossRefPubMedGoogle Scholar
  27. 27.
    Angus DC. Grappling with intensive care unit quality—does the readmission rate tell us anything? Crit Care Med. 1998;26(11):1779–80.  https://doi.org/10.1097/00003246-199811000-00008.CrossRefPubMedGoogle Scholar
  28. 28.
    Nates JL, Nunnally M, Kleinpell R, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research. Crit Care Med. 2016;44(8):1553–602.  https://doi.org/10.1097/CCM.0000000000001856.CrossRefPubMedGoogle Scholar
  29. 29.
    Rosenberg AL, Watts C. Patients readmitted to ICUs∗: a systematic review of risk factors and outcomes. Chest. 2000;118(2):492–502.  https://doi.org/10.1378/chest.118.2.492.CrossRefPubMedGoogle Scholar
  30. 30.
    Chittick P, Sherertz RJ. Recognition and prevention of nosocomial vascular device and related bloodstream infections in the intensive care unit. Crit Care Med. 2010;38(8 Suppl):S363–72.  https://doi.org/10.1097/CCM.0b013e3181e6cdca.CrossRefPubMedGoogle Scholar
  31. 31.
    Pronovost PJ, Watson SR, Goeschel CA, Hyzy RC, Berenholtz SM. Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis. Am J Med Qual. 2016;31(3):197–202.  https://doi.org/10.1177/1062860614568647.CrossRefPubMedGoogle Scholar
  32. 32.
    Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35(1):56–62.  https://doi.org/10.1086/674384.CrossRefPubMedGoogle Scholar
  33. 33.
    Vassal T, Anh NG, Gabillet JM, Guidet B, Staikowsky F, Offenstadt G. Prospective evaluation of self-extubations in a medical intensive care unit. Intensive Care Med. 1993;19(6):340–2.  https://doi.org/10.1007/bf01694708.CrossRefPubMedGoogle Scholar
  34. 34.
    Peñuelas Ó, Frutos-Vivar F, Esteban A. Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation. Crit Care (Lond Engl). 2011;15(2):128.  https://doi.org/10.1186/cc10049.CrossRefGoogle Scholar
  35. 35.
    Harris M, Tayler B. Don’t let metrics undermine your business. Harv Bus Rev. 2019. https://hbr.org/2019/09/dont-let-metrics-undermine-your-business. Accessed 21 Sept 2019.
  36. 36.
    Tversky A, Kahneman D. Belief in the law of small numbers. Psychol Bull. 1971;76(2):105–10.  https://doi.org/10.1037/h0031322.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Sound Critical Care, Sound PhysiciansTacomaUSA

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