Page 45 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

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

TABLE 2-3 Selected Process of Care Quality Indicators
Validated Outcome
Process of Care Mortality Resource Utilization Other Suggested Quality Indicator
Continuous aspiration of subglot- No effect No effect Reduced VAP rates Proportion of eligible patients using
tic secretions (CASS) 147 CASS
Daily assessment of readiness to Decreased when combined with Decreased LOS and LMV NA Proportion of ventilated patients
wean 148 sedation interruption 149 assessed for readiness to wean
DVT Prophylaxis 150 NA NA Reduced DVT rates Proportion of eligible patients using
DVT prophylaxis
Early antibiotics in septic shock 151 Decreased NA NA Median time to antibiotic administra-
tion after hypotension
Early enteral nutrition 152,153 Decreased (meta-analysis of small NA Reduced pneumonia rates Proportion of eligible patients receiv-
trials) 152 ing early enteral nutrition
No effect (cluster RCT) 153
Early goal directed therapy 6 Decreased No effect on LOS or LMV NA Proportion of severe sepsis/septic
shock patients monitoring central
venous saturation in the first 6 hours
of admission
Head of bed elevation 154-156 No effect No effect Reduced VAP rates by 50% (results Proportion of eligible patients with
driven by a single small trial, n =86 ) head of bed elevated >30°
156
Hypothermia after cardiac Decreased NA No effect on pneumonia or sepsis Median time to achieve temperature
arrest 157-158 <34°C in eligible patients or proportion
of patients achieving target tempera-
ture within 6 hours of cardiac arrest
Stress ulcer prophylaxis 159 No enteral feeding NA No enteral feeding Proportion of eligible patients using
• No effect • Decreased risk of SU stress ulcer prophylaxis
Enteral feeding Enteral feeding
• Increased • No effect on SU
• Increased risk of pneumonia
Protective lung ventilation 127 Decreased Increased ventilator-free Decreased nonpulmonary organ Proportion of eligible patients using
days failure low tidal volume ventilation
Sedation interruption 160 Decreased when coupled with Decreased LOS and LMV NA Proportion of eligible patients receiv-
spontaneous breathing trial 149 ing a daily interruption of sedation

to higher mortality, morbidity, and cost. In the United States, Medicare 24 hospitals in the United States show that by using two different defini-
will not reimburse providers for the treatment of hospital-acquired tions of CR-BSIs, rates can change up to sixfold. In Australia, medical
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infections and they are more frequently presented in public reports. charts from six hospitals participating in a statewide surveillance system
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However, VAPs are notoriously difficult to diagnose, which impedes for CR-BSI were reviewed. Their results were impressive: Sensitivity of
their use as a concrete and reproducible quality indicator. Up to a third the reported cases was 35% and specificity was 87%, with a high false-
of patients diagnosed with VAP are found to have no evidence of such in negative rate, where more than 50% of the CR-BSIs could be missed. 143
autopsy studies, on the other hand, up to one-quarter of patients who Based on the above data, it can be concluded that VAP and CR-BSIs
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die without a VAP diagnosis are found to have evidence of pneumonia share common problems that make them problematic quality indicators:
at autopsy. Physicians’ frequently err when diagnosing VAP because (1) definition is not sensitive or specific; (2) there is large interobserver
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signs and diagnostic findings are shared with a multitude of commonly variability and potential for subjectivity in the diagnosis; (3) events are
encountered ICU situations: Fever, secretions, leukocytosis, and a new rare enough that even if definitions were sensitive and specific it would
radiographic infiltrate can be seen in conditions as diverse as pulmo- take a long time to collect enough cases to allow for identification of
nary embolism, atelectasis, pulmonary edema, acute lung injury, and improvement or worsening; and (4) benchmarking between institutions
pulmonary contusion. Using a model that took into account the uncer- should, but frequently does not, account for case-mix differences.
tainty of clinical findings both from VAP and some of these commonly There are many additional potential outcome measures that might be
encountered conditions, investigators demonstrated that VAP rates explored for critical care. Approximately one in five deaths in the United
could vary from 6% to 31%, in spite of a known prevalence of 10%. States occur in or after admission to an ICU. It may be clear very
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Not only are the findings nonspecific, but the assessment of key points early that these deaths are unavoidable and evidence-based processes of
such as secretions, worsening gas exchange, and radiographic infiltrates care may be withheld so some quality metrics may miss the quality of
is quite subjective and prone to interobserver variability. It is difficult care provided to these patients. Markers of good end-of-life care in the
5
to demonstrate if recent decreases in VAP rates being published in the ICU are being developed and could be deployed. Patient and family
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literature represent differences in interpretation of the diagnostic criteria satisfaction with health care is a recognized marker of quality and there
as opposed to a real decrease in VAP rates. are validated instruments for use in the ICU. Like other measures,
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CR-BSIs are also being increasingly tracked as a quality measure and satisfaction does not necessarily correlate with other domains of quality
suffer the same limitations as VAP. For example, observational data from but can be valuable information. Markers of staff retention, burnout,

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