Quality Management in the
ICU
Mazen Kherallah, MD, FCCP
Chairman, Critical Care Department
King Faisal Specialist
Hospital & Research Center
Quality Management Issues
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•
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APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
Individual Functions
Quality
Administration
Ancillary
service
Others
Clinical
service
Interaction: Links
Quality
Administration
Ancillary
service
Others
Clinical
service
Order
Quality
Ancillary
service
Clinical
service
Others
Administration
Group Function
Quality
Ancillary
service
Clinical
service
Others
Facility
Quality Indicators
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•
•
•
•
•
•
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•
Length of stay
Unscheduled return to OR
Readmission rate to ICU
Reintubation rate
Medication errors
Blood utilization rates
Infectious complication rate
Inappropriate empiric antimicrobial coverage
Iatrogenic pneumothorax rate
Quality Management
Quality Management Issues
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•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
BOX B
Age
Points
<
>
<
<
<
<
<
<
<
<
<
<
<
<
N=
A
Date/Time
Primary diagnosis
Admission
Secondary diagnoses
Specific conditions
Referring Hospital
Referring Service
Readmission
Neutropenia
No
h
Different diagnosis
Transplant
h
CRF
COPD
> h
Same diagnosis
APACHE II
/Treatment Days
ETT/Site
Trach. Canula
Ventilator
Central line/Site
Swan Ganz/Site
Arterial line/Site
Foley catheter
Quinton catheter/Site
CRRT
Intermittent HD
ICP/Ventriculostomy
NIV
/Line
Catheter
Date
Special Procedure
Infection
Medication error
Adverse drug reaction
Transfusion reaction
Reintubation within h
Self extubation
Description
Events
Procedure complication
Outcome
Discharge
Death
Date
LOS
Functional Status Dependent
Non-ambulatory
Independent
Ambulatory
Ventilator days
Central catheter days
Foley catheter days
Expected
Non-expected
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
s
100
L
N
V
80
M
M
60
M
M
40
S
V
M
20
S
0
P
2
1
3
5
7
9 11 13 15 17 20 24 26 29 32 45 63
5
Length of Stay
7
Count
1
0
2
0
2
1
5
9
3
0
0
0
Length of Stay
LOS
Benchmark
.
Lukas
KFSH
Sepsis
Seizure
50
Renal Tr
Renal-tr
40
Post-op
Others
30
ICB
GI Bleed
20
GI bleed
APACHE II
ESLD
10
ARF II
ARF I
0
ARF
0
20
Length of Stay
40
60
80
100
14
12
10
8
6
4
2
0
ARF
ARF II
ARF I
Diagnosis
GI bleed
ESLD
GI Bleed
ICB
Post-op
Others
Renal Tr
Renal-tr
Sepsis
Seizure
100
Alive
80
Dead
60
Alive
Alive
Alive
40
Dead
Dead
20
Alive
Alive
Alive
Alive
Dead
Dead
Alive
Alive
Alive
Alive
Alive
Alive
0
-20
N=
3
47
ARF
17
4
ARF II
ARF I
Diagnosis
11
1
GI bleed
ESLD
18
ICB
GI Bleed
22
59
1
Post-op
Others
12
3
Renal Tr
Renal-tr
53
Sepsis
Seizure
Sepsis LOS
Benchmark
.
PROWESS
KFSH
100
Alive
80
Dead
60
Alive
Alive
Alive
Alive
Dead
Dead
Dead
Alive
Alive
Alive
Dead
Alive
40
Dead
Alive
20
Dead
Alive
Dead
Alive
Alive
Alive
Dead
Alive
Dead
Alive
Dead
Alive
Alive
Alive
0
-20
N=
20
1
98
40
23
69
Cardioth
med
Med
Neuro
Oncology
Surg
Referring service
Length of Stay
100
80
60
40
ICU Mortality
20
Dead
0
Alive
0
10
APACHE II
20
30
40
50
Length of Stay
100
80
60
40
Transfer
20
yes
0
no
0
10
APACHE II
20
30
40
50
100
80
60
40
CR-BSI
20
1
0
0
0
10
APACHE II
20
30
40
50
Length of Stay
100
80
60
40
VAP
20
1
0
0
0
10
APACHE II
20
30
40
50
e
N
e
i
e
n
m
a
m
V
1
6
1
7
5
3
9
V
1
100
Alive
80
Dead
60
Alive
Alive
40
Alive
Dead
Dead
Dead
Alive
Dead
20
0
-20
N=
141
Ventilated
Ventilator
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
Patients Re-admitted to ICU
Bars show percents
75%
50%
25%
94%
6%
n=235
n=16
no
yes
0%
Re-admission to ICU
Patients Re-admitted to ICU
Benchmark
International
KFSH
Patients Re-admitted to ICU
14
12
10
8
6
4
Count
2
0
no
Readmission in 24hr
yes
Patients Re-admitted to ICU
12
10
Re-admission diagnos
8
Missing
Sepsis
6
SAH/spas
4
GI Bleed
Aspirati
Count
2
ARF II
0
ARF I
No
Yes
Readmission with same diagnosis
Patients Re-admitted to ICU
3.5
3.0
Re-admission diagnos
2.5
Missing
2.0
Sepsis
1.5
SAH/spas
GI Bleed
1.0
Aspirati
Count
.5
ARF II
0.0
ARF I
1
2
4
6
8
15
16
18
20
23
LOS on floor before readmission
29
34
100
Alive
80
Dead
60
Alive
Alive
Alive
40
Dead
Dead
Dead
Alive
Alive
Alive
Dead
Dead
Alive
Alive
Alive
Alive
Dead
Alive
Dead
20
Alive
0
-20
N=
235
16
no
yes
Re-admission to ICU
60
50
Dead
Dead
Alive
Dead
Alive
Dead
40
Dead
30
20
APACHE II
10
0
-10
N=
235
16
no
yes
Re-admission to ICU
Patients Re-admitted to ICU
3
Mortality
Alive
Dead
Bars show counts
Count
2
1
0
1
2
4
6
8
15
16
18
20
23
29
LOS on floor before readmission
34
ARF I
ARF II
Aspirati
APACHE II
40

Dead
30


Alive
Alive

Alive

20

10
Alive
Alive
0
GI Bleed
SAH/spas
Sepsis
APACHE II
40

30
Dead

20


10

Alive
Dead

Alive

Dead

Dead

Dead
Dead
Alive

Alive
0
1
2
4
6
8 15 16 18 20 23 29 34
1
2
4
6
8 15 16 18 20 23 29 34
1
2
4
6
8 15 16 18 20 23 29 34
LOS on floor before readm ission
LOS on floor before readm ission
LOS on floor before readm ission
Mortality of Re-admitted Patients
M
No
Yes
o
r t a
e
l
o
iv
a
t
R
n
C
5
0
5
t
o
%
%
%
%
R
y
C
9
7
6
%
%
%
%
R
T
C
4
7
1
%
%
%
%
R
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
Per
days or per
devices
number of
Device-Associated Infectious Rates
.
.
.
.
.
.
.
CR-BSI
Patient-Days
VAP
Device-Days
.
.
CR-UTI
Device-Number
Device-Associated Infection Rates
Medical/Surgical ICU
Benchmarked with NNIS 1995-2001
Denominator: Device-Days
.
.
.
.
.
.
.
.
.
CR-BSI
NNIS/Major teaching
VAP
NNIS/All others
CR-UTI
KFSH
NIC, Trend
CR-BSI
VAP
CR-UTI
st Qtr
nd Qtr
rd Qtr
VAP
E.Coli
Stenotro
Serratia
Pseudomo
MSSA
CR-BSI
Klebsiel
Yeast
MRSE
Pseudomo
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
pi
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Im
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Va
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of
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DDD’s
April-May
June-July
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
Inappropriate Empiric Antibiotic
Coverage
8.2%
Total
Appropriate
Inappropriate
Causes of Inappropriateness
•
•
•
•
•
•
MDR pseudomonas(1)
ESBL E. Coli (1)
Sensitive pseudomonas(1)
Aeromonas (1)
Stenotrophomonas (1)
Yeast (1)
Quality Management Issues
•
•
•
•
•
•
•
APACHE II
Length of Stay
Patients re-admitted to ICU
Nosocomial infections in ICU
Antibiotic utilization
Inappropriateness of empiric antibiotic coverage
Mortality review
ICU Mortality Rates
Predicted
Observed
SMR: Standardized Mortality Ratio: < 1
.
%
%
.
%
%
%
%
%
.
.
%
%
%
%
%
%
0-5
%
%
%
%
%
6-10 11-15 16-20 21-25 26-30 31-35 >35
Hospital Mortality of ICU patients
%
.
.
%
.
.
.
ICU Mortality
Hospital Mortality
Hospital Mortality Rates
Predicted
Observed
SMR >1
.
%
%
.
%
%
%
%
SMR: Standardized Mortality Ratio:%< 1
.
.
%
%
%
%
%
0-5
%
%
%
%
%
%
6-10 11-15 16-20 21-25 26-30 31-35 >35
Mortality of Patients Receiving Prolonged
Mechanical ventilation (>2 days)
.
%
.
.
%
%
.
.
.
.
.
.
.
KFSH
ICU Mortality
KFSH
Hospital Mortality
Univ. of Pittsburgh
2-Month Mortality
Armando J et al. Chest2002;121:549-558
Mortality as per Diagnosis
%
.
.
.
.
.
%
%
%
%
.
.
%
%
.
%
ARF
ARF I ARF II ESLD
GI
Bleed
%
ICB
PostOp
%
%
Renal Seizure Sepsis Others
Tx
Mortality as per Referring Service
Cardiothoracic
Medicine
Neurosurgery
Oncology
Surgery
Age Distribution
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Age Distribution and Referring
Service
Medicine
Surgery
Cardiothoracic
Oncology
Neuroscience
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Years
Distribution of APACHE
II/Terminal Illness on Arrival to
ICU
Advanced malignancy
ESLD
Brain death
Severe brain injury
End-stage lung disease
6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48
APACHE II score
Quality Issues
Potentially preventable
Possibly preventable
No quality issues
Poor respiratory care, early ICU discharge
Failure to recognize life threatening disease
Delayed diagnosis
15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90
Years Questionable procedure indication
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