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Frontiers of Medicine

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Front. Med.    2024, Vol. 18 Issue (2) : 315-326    https://doi.org/10.1007/s11684-023-1014-x
Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients—the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019
Wei Cheng1, Jieqing Chen2, Xudong Ma3, Jialu Sun6, Sifa Gao3, Ye Wang4, Longxiang Su1, Lu Wang1, Wei Du1, Huaiwu He1, Yujie Chen1, Zunzhu Li1, Qi Li1, Jianhua Sun1, Hongbo Luo1, Jinbang Liu1, Guangliang Shan5, Bing Du3, Yanhong Guo3, Dawei Liu1(), Chang Yin6(), Xiang Zhou1,2(), on behalf of the China National Critical Care Quality Control Center – the ECMO quality improvement action (EQIA) study1
1. Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100730, China
2. Information Center Department/Department of Information Management, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing 100730, China
3. Department of Medical Administration, National Health Commission of the People’s Republic of China, Beijing 100044, China
4. School of Population Medicine and Public Health, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
5. Department of Epidemiology and Biostatistics, Institute of Basic Medicine Sciences, Chinese Academy of Medical Sciences (CAMS) & School of Basic Medicine, Peking Union Medical College, Beijing 100730, China
6. National Institute of Hospital Administration, National Health Commission of the People’s Republic of China, Beijing 100044, China
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Abstract

This cohort study was performed to explore the influence of intensive care unit (ICU) quality on in-hospital mortality of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO)-supported patients in China. The study involved all V-V ECMO-supported patients in 318 of 1700 tertiary hospitals from 2017 to 2019, using data from the National Clinical Improvement System and China National Critical Care Quality Control Center. ICU quality was assessed by quality control indicators and capacity parameters. Among the 2563 V-V ECMO-supported patients in 318 hospitals, a significant correlation was found between ECMO-related complications and prognosis. The reintubation rate within 48 hours after extubation and the total ICU mortality rate were independent risk factors for higher in-hospital mortality of V-V ECMO-supported patients (cutoff: 1.5% and 7.0%; 95% confidence interval: 1.05–1.48 and 1.04–1.45; odds ratios: 1.25 and 1.23; P = 0.012 and P = 0.015, respectively). Meanwhile, the V-V ECMO center volume was a protective factor (cutoff of ≥ 50 cases within the 3-year study period; 95% confidence interval: 0.57–0.83, odds ratio: 0.69, P = 0.0001). The subgroup analysis of 864 patients in 11 high-volume centers further strengthened these findings. Thus, ICU quality may play an important role in improving the prognosis of V-V ECMO-supported patients.
Keywords veno-venous extracorporeal membrane oxygenation      in-hospital mortality      high-volume centers      quality control      intensive care unit capacity parameters     
Corresponding Author(s): Dawei Liu,Chang Yin,Xiang Zhou   
Just Accepted Date: 28 September 2023   Online First Date: 22 November 2023    Issue Date: 27 May 2024
 Cite this article:   
Wei Cheng,Jieqing Chen,Xudong Ma, et al. Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients—the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019[J]. Front. Med., 2024, 18(2): 315-326.
 URL:  
https://academic.hep.com.cn/fmd/EN/10.1007/s11684-023-1014-x
https://academic.hep.com.cn/fmd/EN/Y2024/V18/I2/315
Fig.1  Changes in patient number and in-hospital mortality of V-V ECMO-supported patients from 2017 to 2019. The number of V-V ECMO cases increased over time (n = 386 in 2017, n = 719 in 2018, and n = 1458 in 2019), whereas the in-hospital mortality rate decreased (32.4% in 2017, 29.4% in 2018, and 27.4% in 2019). V-V ECMO, veno-venous extracorporeal membrane oxygenation.
Fig.2  Slope chart of associations of etiology, treatment, and complications with in-hospital mortality of V-V ECMO-supported patients. From 2017 to 2019, the in-hospital mortality rate showed a trend of decreasing year by year. Specifically, this included V-V ECMO-supported patients with respiratory failure, with severe pneumonia, with ARDS, with bacterial pneumonia, with fungal pneumonia, receiving CRRT, receiving blood transfusion, complicated with bacteremia, and complicated with MODS. Other factors showed an upward trend followed by a downward trend and vice versa. Square dot, etiology-related diagnosis. Circular dot, treatment. Triangular dot, complications. V-V ECMO, veno-venous extracorporeal membrane oxygenation; ARDS, acute respiratory distress syndrome; CRRT, continuous renal replacement therapy; MODS, multiple organ dysfunction syndrome; HIE, hypoxic–ischemic encephalopathy; ICH, intracerebral hemorrhage; bacteremia, bloodstream infection; hemoptysis, respiratory tract bleeding.
Fig.3  Patient-related factors significantly associated with in-hospital mortality of V-V ECMO-supported patients. V-V ECMO support due to lung cancer diagnosis, complication with intracranial hemorrhage, hypoxic-ischemic encephalopathy, MODS, kidney injury, coagulation disorder, bacteremia, and shock was independently correlated with increased in-hospital mortality. By contrast, diagnosis with ARDS, age of 21–30 years, and hospital location in a middle GDP region were protective factors. V-V ECMO, veno-venous extracorporeal membrane oxygenation; MODS, multiple organ dysfunction syndrome; ARDS, acute respiratory distress syndrome; OR, odds ratio; 95% CI, 95% confidence interval; GDP, gross domestic product.
Fig.4  A priori algorithm-based association rules between patient factors and in-hospital mortality of V-V ECMO-supported patients from 2017 to 2019. The association between patient factors and in-hospital mortality of 2563 V-V ECMO-supported patients was explored through a priori algorithm-based association rules. The strength of the correlation degree was indicated by the width of the ribbon, with a stronger association being associated with a wider ribbon. In accordance with the rule that a positive correlation was present between patient factors and in-hospital mortality and divided by the threshold of ≥ 200 cases, the following seven factors were confirmed to be associated with in-hospital mortality of V-V ECMO-supported patients: received CRRT (n = 640), received blood transfusion for hemorrhage (n = 601), received noninvasive ventilation (n = 599), underwent CPR (n = 597), complicated with bacteremia (n = 286), complicated with kidney injury (n = 274), and complicated with coagulation disorder (n = 268). V-V ECMO, veno-venous extracorporeal membrane oxygenation; CRRT, continuous renal replacement therapy; CPR, cardiopulmonary resuscitation.
Indicators Categories All patients (N) In-hospital mortality n (%) P¥
Quality control indicators
Proportion of ICU in total inpatients (%) < 1.5 655 208 (31.8) 0.045
≥ 1.5 1796 496 (27.6)
Proportion of ICU in total inpatient bed occupancy (%) < 1.2 513 151 (29.4) 0.655
≥ 1.2 1966 559 (28.4)
Proportion of Apache II score > 15 in all ICU patients (%) < 60 1554 429 (27.6) 0.115
≥ 60 781 240 (30.7)
3-h SSC bundles compliance rate (%) < 90 1204 310 (25.8) 0.002
≥ 90 1099 346 (31.5)
6-h SSC bundle compliance rate (%) < 80 976 238 (24.4) 0.0002
≥ 80 1320 417 (31.6)
Microbiology detection before antibiotics (%) < 80 490 139 (28.4) 0.960
≥ 80 1917 546 (28.5)
Unplanned endotracheal extubation rate (%) < 1.3 1813 527 (29.1) 0.739
≥ 1.3 603 171 (28.4)
Reintubation rate within 48 h (%) < 1.5 1375 367 (26.7) 0.007
≥ 1.5 983 313 (31.8)
Rate of unplanned transfer to ICU (%) < 2.5 1025 290 (28.3) 0.932
≥ 2.5 1230 350 (28.5)
ICU readmission rate within 48 h (%) < 1 1388 387 (27.9) 0.371
≥ 1 998 295 (29.6)
VAP incidence rate (per 1000 ventilator days) < 10 2060 588 (28.5) 0.506
≥ 10 411 124 (30.2)
CRBSI incidence rate (per 1000 line days) < 1.7 1878 533 (28.4) 0.585
≥ 1.7 582 172 (29.6)
CAUTI incidence rate (per 1000 line days) < 1.5 1456 388 (26.7) 0.008
≥ 1.5 1004 317 (31.6)
ICU mortality rate (%) < 7 1156 300 (26.0) 0.004
≥ 7 1316 410 (31.2)
ICU capacity parameters
Volume of centers (3 years’ total cases of V-V ECMO) < 50 1699 523 (30.8) 0.0009
≥ 50 864 212 (24.5)
ICU patient-to-bed ratio < 40 1030 314 (30.5) 0.155
≥ 40 1468 409 (27.9)
Severe ICU patient-to-bed ratio < 30 1819 508 (27.9) 0.159
≥ 30 511 159 (31.1)
Intensivist-to-bed ratio < 0.3 235 65 (27.7) 0.670
≥ 0.3 2291 664 (29.0)
Nurse-to-bed ratio < 1.5 313 80 (25.6) 0.169
≥ 1.5 2213 649 (29.3)
Intensivist-to-ICU patient ratio < 15 1514 449 (29.7) 0.325
≥ 15 981 273 (27.8)
Intensivist-to-severe ICU patient ratio < 20 557 176 (31.6) 0.074
≥ 20 1781 493 (27.7)
Tab.1  Comparison of in-hospital mortality of V-V ECMO-supported patients between hospitals with different qualities
Univariate Multivariate
OR 95% CI P OR 95% CI P
Quality control indicators
Proportion of ICU in total inpatients (≥ 1.5%) 0.86 0.73–1.02 0.0841 0.85 0.71–1.01 0.065
Proportion of ICU in total inpatient bed occupancy (≥ 1.2%) 0.95 0.77–1.18 0.6531 0.87 0.70–1.09 0.226
Proportion of Apache II score > 15 in all ICU patients (≥ 60%) 1.09 0.95–1.27 0.2257 1.10 0.95–1.28 0.207
3-h SSC bundles compliance rate (≥ 90%) 1.07 0.81–1.41 0.6493 0.97 0.72–1.32 0.862
6-h SSC bundle compliance rate (≥ 80%) 1.02 0.92–1.13 0.7167 1.13 0.83–1.55 0.446
Microbiology detection before antibiotics (≥ 80%) 1.01 0.81–1.25 0.9600 0.96 0.76–1.20 0.709
Unplanned endotracheal extubation rate (≥ 1.3%) 0.97 0.79–1.18 0.7400 1.04 0.84–1.28 0.745
Reintubation rate within 48 h (≥ 1.5%) 1.24 1.05–1.47 0.0115 1.25 1.05–1.48 0.012
Rate of unplanned transfer to ICU (≥ 2.5%) 1.01 0.84–1.21 0.9321 1.03 0.86–1.25 0.743
ICU readmission rate within 48 h (≥ 1%) 1.09 0.91–1.30 0.3711 1.11 0.92–1.33 0.285
VAP incidence rate (≥ 10‰) 1.08 0.86–1.36 0.5062 1.03 0.92–1.14 0.620
CRBSI incidence rate (≥ 1.7‰) 1.08 0.57–2.04 0.8136 1.05 0.55–2.03 0.876
CAUTI incidence rate (≥ 1.5‰) 1.23 1.04–1.45 0.0141 1.18 1.01–1.39 0.043
ICU mortality rate (≥ 7%) 1.25 1.06–1.47 0.0076 1.23 1.04–1.45 0.015
ICU capacity parameters
Volume of ECMO centers (3 years’ cases of V-V ECMO ≥ 50) 0.75 0.63–0.90 0.0016 0.69 0.57–0.83 0.0001
ICU patient-to-bed ratio (≥ 40) 0.94 0.83–1.06 0.3120 0.94 0.83–1.07 0.334
Severe ICU patient-to-bed ratio (≥ 30) 1.08 0.93–1.25 0.3256 1.13 0.95–1.35 0.172
Intensivist-to-bed ratio (≥ 0.3) 1.07 0.79–1.44 0.6699 1.06 0.78–1.45 0.701
Nurse-to-bed ratio (≥ 1.5) 1.09 0.91–1.32 0.3362 1.05 0.91–1.21 0.543
Intensivist-to-ICU patient ratio (≥ 15) 0.91 0.77–1.09 0.3255 0.95 0.85–1.07 0.399
Intensivist-to-severe ICU patient ratio (≥ 20) 0.88 0.74–1.04 0.1420 0.85 0.71–1.02 0.090
Tab.2  Univariate and multivariate analyses of association between quality indicators and in-hospital mortality of all V-V ECMO-supported patients
High-volume centers(V-V ECMO ≥ 50 cases) Low-volume centers(V-V ECMO < 50 cases) P
N = 11 N = 307
Quality control indicators (median, IQR)
Proportion of ICU in total inpatients (%) 3.88 (1.92, 4.96) 1.8 (1.22, 3.19) 0.023
Proportion of ICU in total inpatient bed occupancy (%) 3.15 (1.99, 3.95) 1.64 (1.06, 2.54) 0.006
Proportion of patients with Apache II score ≥ 15 in all ICU patients (%) 35.7 (19.5, 62.3) 52.9 (35.3, 72.0) 0.065
3-h SSC bundles compliance rate (%) 90.9 (79.9, 100) 90.7 (77.9, 100) 0.909
6-h SSC bundle compliance rate (%) 87.9 (63.0, 98.3) 83.2 (67.1, 98.5) 0.932
Microbiology detection before antibiotics (%) 97.4 (85.6, 100) 94.6 (80.3, 100) 0.334
DVT prophylaxis rate (%) 30.9 (17.3, 42.4) 34.1 (15, 60.2) 0.632
Unplanned endotracheal extubation rate (%) 0.39 (0.08, 0.9) 0.87 (0.26, 1.99) 0.095
Reintubation rate within 48 h (%) 0.77 (0.02, 2.03) 1.64 (0.8, 2.89) 0.045
Rate of unplanned transfer to ICU (%) 3.85 (1.47, 8.03) 3.1 (0.97, 10.5) 0.927
ICU readmission rate within 48 h (%) 0.58 (0.28, 1.48) 0.9 (0.43, 1.48) 0.355
VAP incidence rate per 1000 ventilator days (‰) 3.74 (1.81, 4.7) 5.39 (2.66, 9.37) 0.127
CRBSI incidence rate per 1000 lines days (‰) 1.09 (0.53, 2.25) 0.98 (0.42, 1.91) 0.636
CAUTI incidence rate (%) per 1000 lines days (‰) 0.93 (0.47, 2.32) 1.29 (0.5, 2.66) 0.671
ICU mortality rate (%) 6.56 (2.15, 11.12) 7.71 (3.99, 12.8) 0.262
Capacity parameters (median, IQR)
ICU patient-to-bed ratio 49.7 (39.8, 61.1) 38.6 (28, 56.9) 0.043
Severe patient-to-bed ratio 17.1 (12.7, 28.2) 19.4 (11.9, 30.1) 0.628
Intensivist-to-bed ratio 0.63 (0.47, 0.81) 0.54 (0.4, 0.7) 0.300
Nurse-to-bed ratio 2.63 (1.84, 3.24) 2.05 (1.53, 2.52) 0.037
Intensivist-to-ICU patient ratio 13.7 (5.53, 16.9) 13.7 (9.45, 20.0) 0.482
Intensivist-to-severe ICU patient ratio 37.8 (24.7, 45.3) 26.9 (18.5, 40.5) 0.196
Tab.3  Comparison of capacity parameters and quality control indicators in high- and low-volume V-V ECMO centers*
B SE Wald OR 95% CI P
Quality control indicators
Proportion of ICU in total inpatients 0.166 0.052 10.3 1.18 1.067–1.306 0.001
6-h SSC bundle compliance rate 0.015 0.004 13.52 1.015 1.007–1.023 < 0.0001
Microbiology detection before antibiotics −0.028 0.01 7.338 0.972 0.952–0.992 0.007
Reintubation rate within 48 h −0.332 0.075 18.37 0.725 0.625–0.84 < 0.0001
ICU mortality rate 0.198 0.035 33.02 1.219 1.14–1.305 < 0.0001
ICU capacity parameters
ICU patient-to-bed ratio −0.015 0.003 21.48 0.985 0.979–0.991 < 0.0001
Intensivist-to-severe ICU patient ratio −0.034 0.012 7.275 0.967 0.944–0.991 0.007
Nurse-to-severe ICU patient ratio 0.016 0.005 9.688 1.016 1.006–1.026 0.002
V-V ECMO related complications
Intracerebral hemorrhage 0.703 0.357 3.89 2.021 1.004–4.065 0.049
Hypoxic–ischemic encephalopathy 0.776 0.305 6.47 2.174 1.195–3.954 0.011
Multiple organ dysfunction syndrome 0.845 0.187 20.49 2.33 1.615–3.357 < 0.0001
Coagulation disorder 0.913 0.183 24.97 2.491 1.741–3.562 < 0.0001
Bacteremia 0.523 0.181 8.300 1.687 1.182–2.407 0.004
Tab.4  Multivariate analysis of association between quality indicators and in-hospital mortality of V-V ECMO-supported patients in high-volume centers
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