Page 39 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

8 PART 1: An Overview of the Approach to and Organization of Critical Care

quality metrics, once stated that “running a company on visible figures should not be used to address quality. An example of a measurement
alone” is one of the seven deadly sins of management. However, to that is reliable is the measurement of time to reaching target cooling
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demonstrate improvement or to detect deviations from the expectations, temperature after cardiac arrest. The time zero (hospital arrival) and
metrics are needed. the time of goal temperature can be clearly defined and abstracted from
Governments, regulators, clinicians, insurance companies, and charts. On the other hand, VAP rates are less reliable. A study compar-
patients may need different quality measures or the same measures ing the identification of VAPs by two experienced providers, using the
presented in different ways. Unfortunately, quality indicators are often CDC VAP definition, observed a twofold variation in the total numbers
selected based on convenience, feasibility, or politics rather than valid- of VAP. Based on these data, twofold increases or decreases in VAP rates
ity. In this chapter, we will try to define what the ideal characteristics could be simply due to variation in interpretations of the CDC VAP
of quality metrics should be and apply these principles to the current definition. 5
metrics proposed for intensive care medicine.
https://kat.cr/user/tahir99/
Actionable: An indicator is only helpful if the users and managers
of the outcomes and processes are able to take actions based on the
INDICATORS information gained. For example, although long-term health-related
■ CHARACTERISTICS quality of life in ICU survivors is an important outcome, it is a poorly
actionable quality measure as the determinants of this outcome are
An ideal indicator would have the following key characteristics: (1) specific poorly understood and may not be primarily determined by practices
and sensitive to the process or outcome being measured; (2) measurable in the ICU. On the other hand, an indicator that provides ICU man-
based on detailed definitions so that indicators are comparable; (3) actionable agers with compliance rates for SBTs may be immediately actionable
so that the they can lead to specific interventions to improve quality; if unacceptable. In some circumstances, indicators may be selected
(4) relevant to clinical practice and based on available scientific evidence; due to a misinterpretation of research and may not be achievable.
and (5) timely so that the information is reported to the interested parties in For example, a single-center randomized controlled trial observed a
a way that can motivate change (see Table 2-1). 4 reduction in mortality for patients with severe sepsis or septic shock
when treatment was guided by central venous saturation. Some
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Specific and Sensitive: Indicators share the same properties as diag- groups have decided to use the proportion of patients who have
nostic tests: sensitivity and specificity. Sensitivity is the ability of central venous saturation higher than 70% in the first 6 hours as a
a test to identify true positives. For example, a sensitive indicator quality marker. This is flawed. The clinical trial did not study achiev-
for ventilator-associated pneumonia (VAP) should identify patients ing a central venous saturation of 70%, but trying to achieve it. Some
who actually have VAP. An indicator that measures a process of care, patients will never achieve it, due to individual characteristics, while
such as compliance with daily interruption of sedation, should iden- others will get there regardless of the treatment provided. A hospital
tify patients who have received that treatment. On the other hand, might look like a poor quality center with low rates of “achieving 70%
specificity should also be high; therefore, patients who do not have central venous saturation” simply because their patient population is
VAP should not be identified by the measure and patients who did particularly old or sick. The correct quality metrics would be compli-
not receive an interruption of sedation should be properly coded. ance with processes of care used to achieve the goal, for example,
Perfectly accurate quality measures do not exist; however, as long as the proportion of patients with low central venous saturations that
a test is measurable, then comparisons of different units and of the received protocol guided treatment in the first 6 hours.
same unit over time become feasible.
Relevant: Indicators need to be based on evidence that they lead to
Measurable: The parameter must be measurable in a reliable and valid improved outcomes and that the outcomes themselves are relevant. An
way by different observers and over time. Subjective definitions such indicator must be accepted by the main stakeholders, including patients,
as “if patient is in shock” are too broad to allow for adequate measure- families, clinicians, hospital managers, policy makers, and service buy-
ments; a better way is to have clear definitions, based on observable ers. For health care providers, indicators that are based on available
parameters, such as “if systolic blood pressure is below 90 mmHg for scientific evidence are preferred in relation to indicators selected accord-
at least 1 hour.” For example, the proportion of ventilated patients ing to nonscientific criteria or availability. Using indicators that do not
receiving a spontaneous breathing trial (SBT) is not adequate to con- have sound resonance from stakeholders is bound to be received with
trol the process, as many patients may not undergo an SBT because resistance and either disregarded or subjected to data manipulation in
they have contraindications. Therefore, metrics should clearly specify conscious or unconscious ways. A good example is the use of nighttime
the population that is eligible for measurement. discharges as a quality metric. Although one study demonstrated an
Reliability implies that repeated measurements will provide the same association of nighttime discharges with mortality in the ICU, its exter-
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results. An indicator that gives different results for the same population
nal validity is threatened by differences in health care systems, and dif-
ferent ICUs may not demonstrate the same association. In this situation,
it would be difficult to convince stakeholders that nighttime discharge is
TABLE 2-1 The Ideal Quality Indicator (SMART) a good quality indicator when local data demonstrate its safety.
Characteristic Definition
Timely: To be helpful in influencing decisions, indicators must be
Sensitive and specific The ability of the indicator to detect true positives and true available in time to allow for actions. Learning that an ICU’s rate of
negatives. compliance with a daily interruption of sedation protocol was low
Measurable Validity and reliability. An indicator should measure what it 6 months ago is less helpful than observing monthly compliance to
is intended to measure (validity) and should be reproducible allow for more immediate actions to be taken. Outcome-based quality
(reliability). Clear instructions for inclusion and exclusion indicators, such as mortality and infection rates, frequently fail this
criteria, as well as objective parameters are essential. item as ICUs require a long-time frame to have enough numbers of
events to allow for an accurate description of the population.
Actionable The indicator can be modified by actions taken from the
stakeholders. ■
Relevant The indicator is based on scientific evidence. TYPES OF INDICATORS
Indicators can be measured and reported in various ways. A rate-based
Timely The indicator is available in a timely manner to allow for indicator uses data about events that are expected to occur with some
interpretation and corrective actions.
frequency. These can be expressed as proportions or rates (proportions

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