1. Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China 2. Department of Medical Administration, National Health Commission of the People’s Republic of China, Beijing 100044, China 3. Intensive Care Unit, The People’s Hospital of Zizhong, Neijiang 641000, China 4. Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences & School of Basic Medicine, Peking Union Medical College, Beijing 100730, China 5. Information Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
This study aimed to explore key quality control factors that affected the prognosis of intensive care unit (ICU) patients in Chinese mainland over six years (2015−2020). The data for this study were from 31 provincial and municipal hospitals (3425 hospital ICUs) and included 2 110 685 ICU patients, for a total of 27 607 376 ICU hospitalization days. We found that 15 initially established quality control indicators were good predictors of patient prognosis, including percentage of ICU patients out of all inpatients (%), percentage of ICU bed occupancy of total inpatient bed occupancy (%), percentage of all ICU inpatients with an APACHE II score ≥15 (%), three-hour (surviving sepsis campaign) SSC bundle compliance (%), six-hour SSC bundle compliance (%), rate of microbe detection before antibiotics (%), percentage of drug deep venous thrombosis (DVT) prophylaxis (%), percentage of unplanned endotracheal extubations (%), percentage of patients reintubated within 48 hours (%), unplanned transfers to the ICU (%), 48-h ICU readmission rate (%), ventilator associated pneumonia (VAP) (per 1000 ventilator days), catheter related blood stream infection (CRBSI) (per 1000 catheter days), catheter-associated urinary tract infections (CAUTI) (per 1000 catheter days), in-hospital mortality (%). When exploratory factor analysis was applied, the 15 indicators were divided into 6 core elements that varied in weight regarding quality evaluation: nosocomial infection management (21.35%), compliance with the Surviving Sepsis Campaign guidelines (17.97%), ICU resources (17.46%), airway management (15.53%), prevention of deep-vein thrombosis (14.07%), and severity of patient condition (13.61%). Based on the different weights of the core elements associated with the 15 indicators, we developed an integrated quality scoring system defined as F score=21.35%×nosocomial infection management + 17.97%×compliance with SSC guidelines + 17.46%×ICU resources + 15.53%×airway management + 14.07%×DVT prevention + 13.61%×severity of patient condition. This evidence-based quality scoring system will help in assessing the key elements of quality management and establish a foundation for further optimization of the quality control indicator system.
. [J]. Frontiers of Medicine, 2023, 17(4): 675-684.
Longxiang Su, Xudong Ma, Sifa Gao, Zhi Yin, Yujie Chen, Wenhu Wang, Huaiwu He, Wei Du, Yaoda Hu, Dandan Ma, Feng Zhang, Wen Zhu, Xiaoyang Meng, Guoqiang Sun, Lian Ma, Huizhen Jiang, Guangliang Shan, Dawei Liu, Xiang Zhou, on behalf of China-NCCQC. Evaluation of ICUs and weight of quality control indicators: an exploratory study based on Chinese ICU quality data from 2015 to 2020. Front. Med., 2023, 17(4): 675-684.
Percentage of ICU patients out of all inpatients (%)
1.60 (1.00, 2.62)
1.61 (1.06, 2.58)
1.62 (1.06, 2.55)
1.67 (1.05, 2.71)
1.6 (1.02, 2.60)
1.67 (1.06, 2.61)
0.224*
Percentage of ICU bed occupancy of total inpatient bed occupancy (%)
1.08 (0.74, 1.69)
1.18 (0.77, 1.86)
1.2 (0.78, 1.9)
1.27 (0.78, 2.100)
1.27 (0.81, 2.00)
1.33 (0.84, 2.07)
< 0.001
Percentage of all ICU inpatients with an APACHE II score ≥ 15 (%)
63.13 (38.48, 82.62)
58.79 (33.50, 80.00)
59.95 (35.09, 78.7)
57.5 (33.12, 76.61)
58.01 (33.30, 77.15)
58.79 (34.99, 76.23)
< 0.001
Procedural indicators
Three-hour SSC bundle compliance (%)
83.33 (60.91, 98.26)
83.33 (60.00, 100.00)
87.5 (63.16, 100.00)
91.17 (68.00, 100.00)
89.79 (67.37, 100.00)
90.21 (70.09, 100.00)
< 0.001
Six-hour SSC bundle compliance (%)
87.88 (53.33, 100)
66.67 (35.94, 12.00)
72.73 (40.00, 100.00)
77.63 (47.62, 100.00)
78.95 (47.96, 100.00)
80 (50.00, 100.00)
< 0.001
Rate of microbe detection before antibiotics (%)
86.21 (61.69, 97.85)
83.55 (50.28, 98.37)
82.35 (51.85, 97.14)
90.38 (68.62, 100.00)
90.28 (69.95, 100.00)
91.67 (71.43, 100.00)
< 0.001
Percentage of drug DVT prophylaxis (%)
–
–
–
21.03 (7.61, 41.22)
25.14 (8.77, 51.49)
26.07 (9.05, 52.13)
< 0.001
Percentage of mechanical DVT prophylaxis (%)
–
–
–
35 (6.9, 63.420)
52.44 (14.38, 87.78)
53.66 (16.91, 89.19)
< 0.001
Percentage of unplanned endotracheal extubations (%)
1.15 (0.31, 2.95)
1.33 (0.24, 4.24)
1.5 (0.25, 4.35)
1.65 (0.22, 4.61)
1.19 (0.00, 3.45)
1.03 (0.00, 3.03)
< 0.001
Percentage of patients reintubated within 48 h (%)
1.78 (0.63, 4.11)
1.76 (0.43, 4.61)
1.92 (0.49, 4.56)
1.86 (0.47, 4.44)
1.95 (0.62, 4.23)
1.7 (0.45, 3.85)
0.061*
Unplanned transfers to the ICU (%)
3.02 (1.00, 7.59)
2.62 (0.58, 8.16)
–
5.45 (1.41, 17.35)
4.66 (1.19, 14.63)
4.63 (1.08, 14.85)
< 0.001
48-h ICU readmission rate (%)
0.93 (0.41, 1.92)
0.95 (0.29, 2.32)
0.93 (0.27, 2.06)
1.02 (0.29, 2.24)
1 (0.30, 2.04)
0.9 (0.24, 1.94)
0.100*
VAP (per 1000 ventilator days)
11.33 (5.81, 21.24)
11.33 (4.15, 24.71)
10.65 (4.05, 25.00)
8.2 (2.80, 18.90)
6.8 (2.30, 15.20)
5.6 (1.60, 11.9)
< 0.001
CRBSI (per 1000 catheter days)
1.59 (0.15, 3.47)
1.33 (0.00, 3.89)
1.2 (0.00, 3.60)
1 (0.00, 2.90)
0.8 (0.00, 2.40)
0.6 (0.00, 2.00)
< 0.001
CAUTI (per 1000 catheter days)
2.06 (0.77, 4.81)
2.03 (0.48, 5.07)
2 (0.70, 5.30)
1.9 (0.50, 4.70)
1.7 (0.40, 3.80)
1.4 (0.40, 3.40)
< 0.001
Outcome indicator
In-hospital mortality (%)
10.82 (5.91, 18.94)
8.25 (3.98, 15.38)
8.39 (4.21, 15.68)
8.57 (4.19, 15.27)
8.11 (3.75, 15.46)
8 (3.75, 14.32)
< 0.001
Tab.1
Fig.1
Item
Coef.
Std. Err.
z
P
[95% Conf. Interval]
Percentage of ICU patients out of all inpatients (%)
?0.03
0.07
?0.39
0.70
?0.16
0.10
Percentage of ICU bed occupancy of total inpatient bed occupancy (%)
0.82
0.81
1.02
0.31
?0.76
2.41
Percentage of all ICU inpatients with an APACHE II score ≥ 15 (%)
?0.25
0.18
?1.41
0.16
?0.60
0.10
Three-hour SSC bundle compliance (%)
1.45
0.19
7.83
0.00
1.09
1.81
Six-hour SSC bundle compliance (%)
0.23
0.80
0.29
0.77
?1.33
1.80
Rate of microbe detection before antibiotics (%)
2.36
0.18
13.22
0.00
2.01
2.71
Percentage of drug DVT prophylaxis (%)
3.19
0.33
9.76
0.00
2.55
3.83
Percentage of mechanical DVT prophylaxis (%)
7.49
0.42
17.84
0.00
6.67
8.32
Percentage of unplanned endotracheal extubations (%)
?1.49
1.01
?1.47
0.14
?3.47
0.49
Percentage of patients reintubated within 48 h (%)
?0.10
0.12
?0.81
0.42
?0.33
0.14
Unplanned transfers to the ICU (%)
0.02
0.15
0.13
0.90
?0.28
0.32
48-h ICU readmission rate (%)
0.75
0.14
5.51
0.00
0.48
1.02
VAP (per 1000 ventilator days)
?0.05
0.06
?0.85
0.39
?0.16
0.06
CRBSI (per 1000 catheter days)
?0.43
0.06
?6.60
0.00
?0.55
?0.30
CAUTI (per 1000 catheter days)
?0.22
0.04
?5.21
0.00
?0.31
?0.14
In-hospital mortality (%)
?0.10
0.05
?1.85
0.07
?0.21
0.01
Tab.2
Fig.2
Elements
Variance
Difference
Percentage
Cumulative
Weight
Element 1: nosocomial infection management
2.05853
0.32549
0.1372
0.1372
21.35%
Element 2: compliance with the guidelines for the SSC campaign
1.73304
0.05045
0.1155
0.2528
17.97%
Element 3: ICU resources
1.68259
0.18503
0.1122
0.3649
17.46%
Element 4: airway management
1.49755
0.14138
0.0998
0.4648
15.53%
Element 5: DVT prevention
1.35617
0.04406
0.0904
0.5552
14.07%
Element 6: severity of patient condition
1.31211
0
0.00875
0.6427
13.61%
Tab.3
Fig.3
Element 1: nosocomial infection management
Element 2: compliance with the guidelines for the SSC campaign
Element 3: ICU resources
Element 4: airway management
Element 5: DVT prevention
Element 6: severity of patient condition
Uniqueness
Percentage of ICU patients out of all inpatients (%)
0.1259
?0.0051
0.8256*
?0.0154
?0.0774
?0.1007
0.2862
Percentage of ICU bed occupancy out of total inpatient bed occupancy (%)
0.0366
?0.0125
0.8378*
0.0356
0.0642
0.0377
0.2897
Percentage of all ICU inpatients with an APACHE II score ≥ 15 (%)
?0.1015
0.0412
?0.186
0.0034
0.5105
0.4829*
0.4596
Three-hour SSC bundle compliance (%)
?0.0178
0.9251*
?0.0163
0
0.0349
?0.0223
0.1419
Six-hour SSC bundle compliance (%)
?0.014
0.9228*
0.0019
?0.0116
0.0331
0.0055
0.147
Percentage of drug DVT prophylaxis (%)
?0.0031
0.0486
0.1044
?0.0133
0.6786*
0.0561
0.5229
Percentage of mechanical DVT prophylaxis (%)
0.0218
0.0787
?0.0395
?0.0266
0.7302*
?0.0573
0.4546
In-hospital mortality (%)
?0.0126
?0.0849
?0.1889
?0.04
0.1583
0.7052
0.4329
Percentage of unplanned endotracheal extubations (%)
0.0745
0.003
0.0409
0.8463*
?0.0128
0.0443
0.2744
Percentage of patients reintubated within 48 h (%)
0.0448
?0.0169
?0.0134
0.8557*
?0.013
?0.0083
0.2651
Unplanned transfers to the ICU (%)
0.1014
0.0681
0.1771
0.1083
?0.231
0.6103*
0.5162*
48-h ICU readmission rate (%)
0.3601
?0.0384
0.3359
0.143
?0.0869
0.4237*
0.5485*
VAP (per 1000 ventilator days)
0.8652*
?0.0342
0.1006
0.0206
0.0203
0.0295
0.2384
CRBSI (per 1000 catheter days)
0.7924*
0.008
?0.0757
0.1045
?0.0061
?0.0455
0.3533
CAUTI (per 1000 catheter days)
0.7113*
?0.0188
0.2328
0.0381
?0.0524
0.078
0.4293
Tab.4
Fig.4
Variable
Nosocomial infection management
Compliance with SSC guidelines
ICU resources
Airway management
Prevention of DVT
Severity of patient condition
Percentage of ICU patients of all inpatients (%)
?0.047
0
0.508
?0.034
0.011
?0.072
Percentage of ICU bed occupancy of total inpatient bed occupancy (%)
?0.107
?0.012
0.539
0.007
0.105
0.024
Percentage of all ICU inpatients with an APACHE II score ≥ 15 (%)
?0.045
0
?0.067
0.007
0.32
0.33
Three-hour SSC bundle compliance (%)
0.01
0.537
?0.008
0.004
?0.033
0
Six-hour SSC bundle compliance (%)
0.009
0.536
0.004
?0.006
?0.037
0.023
Percentage of drug DVT prophylaxis (%)
0.005
?0.015
0.113
0.016
0.523
?0.034
Percentage of mechanical DVT prophylaxis (%)
0.051
?0.003
0.02
0.017
0.565
?0.132
In-hospital mortality (%)
?0.024
?0.044
?0.102
?0.061
0.029
0.543
Percentage of unplanned endotracheal extubations (%)
?0.041
0.004
?0.001
0.577
0.028
?0.022
Percentage of patients reintubated within 48 h (%)
?0.046
?0.009
?0.032
0.59
0.031
?0.064
Unplanned transfers to the ICU (%)
?0.033
0.07
0.087
0.014
?0.237
0.503
48-h ICU readmission rate (%)
0.099
?0.002
0.159
0.031
?0.074
0.314
VAP (per 1000 ventilator days)
0.451
?0.007
?0.061
?0.062
0.053
?0.044
CRBSI (per 1000 catheter days)
0.435
0.017
?0.168
0.009
0.028
?0.101
CAUTI (per 1000 catheter days)
0.34
0.005
0.042
?0.046
?0.007
0.015
Tab.5
Hospital level
Tertiary comprehensive
Tertiary specialized
Secondary comprehensive
Secondary specialized
Tertiary specialized
?0.51 (1.000)
Secondary comprehensive
?3.23 (0.000)
?2.71 (0.001)
Secondary specialized
?7.43 (0.010)
?6.92 (0.039)
?4.21 (1.000)
Tab.6
1
M Garrouste-Orgeas, JF Timsit, A Vesin, C Schwebel, P Arnodo, JY Lefrant, B Souweine, A Tabah, J Charpentier, O Gontier, F Fieux, B Mourvillier, G Troché, J Reignier, MF Dumay, E Azoulay, B Reignier, J Carlet, L Soufir. Selected medical errors in the intensive care unit: results of the IATROREF study: parts I and II. Am J Respir Crit Care Med 2010; 181(2): 134–142 https://doi.org/10.1164/rccm.200812-1820OC
pmid: 19875690
2
PH van der Voort, SN van der Veer, ML de Vos. The use of indicators to improve the quality of intensive care: theoretical aspects and experiences from the Dutch intensive care registry. Acta Anaesthesiol Scand 2012; 56(9): 1084–1091 https://doi.org/10.1111/j.1399-6576.2012.02687.x
pmid: 22490006
3
A Rhodes, RP Moreno, E Azoulay, M Capuzzo, JD Chiche, J Eddleston, R Endacott, P Ferdinande, H Flaatten, B Guidet, R Kuhlen, C León-Gil, Delgado MC Martin, PG Metnitz, M Soares, CL Sprung, JF Timsit, A Valentin. 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
pmid: 22278594
4
B Ray, DP Samaddar, SK Todi, N Ramakrishnan, G John, S Ramasubban. Quality indicators for ICU: ISCCM guidelines for ICUs in India. Indian J Crit Care Med 2009; 13(4): 173–206 https://doi.org/10.5005/ijccm-13-4-173
pmid: 20436688
5
SM Berenholtz, T Dorman, K Ngo, PJ Pronovost. Qualitative review of intensive care unit quality indicators. J Crit Care 2002; 17(1): 1–12 https://doi.org/10.1053/jcrc.2002.33035
pmid: 12040543
H He, X Ma, L Su, L Wang, Y Guo, G Shan, HJ He, X Zhou, D Liu, Y Long, Y Zhao, S Zhang. Effects of a national quality improvement program on ICUs in China: a controlled pre-post cohort study in 586 hospitals. Crit Care 2020; 24(1): 73 https://doi.org/10.1186/s13054-020-2790-1
pmid: 32131872
8
B. Thompson. Exploratory and Confirmatory Factor Analysis. Washington, DC: American Psychological Association, 2004
9
MM Levy, RP Dellinger, SR Townsend, WT Linde-Zwirble, JC Marshall, J Bion, C Schorr, A Artigas, G Ramsay, R Beale, MM Parker, H Gerlach, K Reinhart, E Silva, M Harvey, S Regan, DC Angus. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010; 36(2): 222–231 https://doi.org/10.1007/s00134-009-1738-3
pmid: 20069275
10
L Wang, XD Ma, HW He, LX Su, YH Guo, GL Shan, X Zhou, DW Liu, Y; China National Critical Care Quality Control Center group Long. Analysis of factors influencing 3- and 6-h compliance with the surviving sepsis campaign guidelines based on medical-quality intensive care unit data from China. Chin Med J (Engl) 2021; 134(14): 1747–1749 https://doi.org/10.1097/CM9.0000000000001362
pmid: 33496465
11
R Manoucheri, MJ Fallahi. Adherence to venous thromboprophylaxis guidelines for medical and surgical inpatients of Teaching Hospitals, Shiraz-Iran. Tanaffos 2015; 14(1): 17–26
pmid: 26221148
12
KC Parikh, D Oh, C Sittipunt, H Kalim, S Ullah, SK Aggarwal, VA Investigators. Venous thromboembolism prophylaxis in medical ICU patients in Asia (VOICE Asia): a multicenter, observational, cross-sectional study. Thromb Res 2012; 129(4): e152–e158 https://doi.org/10.1016/j.thromres.2012.01.012
pmid: 22326367
13
Y Fan, F Gao, Y Wu, J Zhang, M Zhu, L Xiong. Does ventilator-associated event surveillance detect ventilator-associated pneumonia in intensive care units? A systematic review and meta-analysis. Crit Care 2016; 20(1): 338 https://doi.org/10.1186/s13054-016-1506-z
pmid: 27772529
14
L JiaH YuJ LuY ZhangY CaiY LiuX Ma. Epidemiological characteristics and risk factors for patients with catheter-related bloodstream infections in intensive care unit. Zhonghua Yi Xue Za Zhi (in Chinese) 2015; 95(9): 654–658
pmid: 25976044
15
D Peng, X Li, P Liu, M Luo, S Chen, K Su, Z Zhang, Q He, J Qiu, Y Li. Epidemiology of pathogens and antimicrobial resistanceof catheter-associated urinary tract infections in intensivecare units: a systematic review and meta-analysis. Am J Infect Control 2018; 46(12): e81–e90 https://doi.org/10.1016/j.ajic.2018.07.012
pmid: 30174256
16
B Anna. Costello JWO. Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis. Pract Assess, Res Eval 2005; 10(1): 1–9 https://doi.org/10.7275/jyj1-4868
17
DG Altman. Practical Statistics for Medical Research. London: Chapman & Hall/CRC, 1991
CA Chrusch, CM Martin, TQIC Project. Quality improvement in critical care: selection and development of quality indicators. Can Respir J 2016; 2016: 2516765 https://doi.org/10.1155/2016/2516765
pmid: 27493476
21
ML de Vos, SN van der Veer, WC Graafmans, NF de Keizer, KJ Jager, GP Westert, PH van der Voort. Implementing quality indicators in intensive care units: exploring barriers to and facilitators of behaviour change. Implement Sci 2010; 5(1): 52 https://doi.org/10.1186/1748-5908-5-52
pmid: 20594312
A Donabedian. A founder of quality assessment encounters a troubled system firsthand. Interview by Fitzhugh Mullan. Health Aff (Millwood) 2001; 20(1): 137–141 https://doi.org/10.1377/hlthaff.20.1.137
pmid: 11194834
25
O KumpfJP BraunA BrinkmannH BauseM BellgardtF BloosR DubbC GreimA KaltwasserG MarxR RiessenC SpiesJ WeimannG WöbkerE MuhlC Waydhas. Quality indicators in intensive care medicine for Germany—third edition 2017. Ger Med Sci 2017, 15: Doc10. doi: 10.3205/000251.28794694
26
S Valiani, R Rigal, HT Stelfox, J Muscedere, CM Martin, P Dodek, F Lamontagne, R Fowler, A Gheshmy, DJ Cook, AJ Forster, PC Hébert. An environmental scan of quality indicators in critical care. CMAJ Open 2017; 5(2): E488–E495 https://doi.org/10.9778/cmajo.20150139
pmid: 28637683
27
CF Christiansen, MH Møller, H Nielsen, S Christensen. The Danish Intensive Care Database. Clin Epidemiol 2016; 8: 525–530 https://doi.org/10.2147/CLEP.S99476
pmid: 27822095
