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Quality Indicators in Critical Care

Article · October 2019

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Austin Critical Care Journal

Editorial

Quality Indicators in Critical Care

Bilotta F1*, Nato CG1, Falegnami A2 and Pugliese structural/organization-related, i.e. the attributes of the settings in
F1 which care is provided (personnel, facilities etc.); process-related, i.e.
1
Department of Anaesthesia and critical care, University the activities of the practitioner and how are accomplished; outcome-
of Rome, Italy
related, i.e. the change in health status of the patient [11].
2
Department of Mechanical and Aerospace Engineering,
University of Rome , Roma , Italy Because of this considerable heterogenicity in critical care’s QIs, a
*Corresponding author: Bilotta F, Department rational selection is extremely complex and controversial and indeed
of Anesthesia and critical care, Policlinic Umberto I, only a small number of quality indicators with strong supporting
University of Rome, La Sapienza, Roma, Italy. 00199 Via evidence could be considered for adoption into clinical practice [12].
Acherusio 16 Roma Italy
In 2012 the European Society of Intensive Care Medicine
Received: October 10, 2019; Accepted: October 17,
2019; Published: October 24, 2019 (ESICM) selected on the basis of available literature 111 QIs and
chose –according arbitrary an expert opinion- 9 QIs criteria: 3
Editorial structural (if ICU fulfills national requirements, presence of 24-h
consultant level intensivist and adverse event reporting system); 2
Quality indicators (QIs), sometime indicated as “performance process (presence of routine multi-disciplinary clinical ward rounds
indicators”, were first introduced in 1970 in the USA in order to and standardized handover procedure for discharging patients); 4
asses in a reproducible and objective way the performance of higher outcome (ICU readmission <48h, rate of unplanned extubations, the
education institutions and are now widely used by corporates rate of central venous catheter-related blood stream infection and
and public utility management to evaluate various aspects from standardized mortality ratio) to be tested for quality of care and better
production to customer satisfaction [1,2]. When appropriately used, patients outcome [13].
QIs can contribute to increase quality of goods and services, customer
satisfaction and to improve cost effectiveness [2]. “Structural/organization QIs” are generally defined at political
level and often are limited by the availability of economic resources,
In medicine, according to the US agency for healthcare research thus allowing little room for doctors and medical personnel to intervene
and quality, QIs are: “standardized, evidence-based measures of health in their selection [5]. “Outcome QIs”, when measured to evaluate the
care quality that can be used with readily available hospital inpatient ICU performance are frequently biased by case load criteria, thus
administrative data to measure and track clinical performance and inducing the paradox of better outcome in those unit that poorly
outcomes” [3]. Accordingly, medical QIs can address 4 aspects of define admission criteria [6,10]. “Process QIs” are often in the range
clinical practice: prevention, intended to evaluate hospital admissions of individual commitment and professionalism. Those “process QIs”
that might have been avoided; inpatients-treatment, which include proposed by ESICM (presence of routine multi-disciplinary clinical
mortality indicators, utilization indicators, and volume indicators; ward rounds and standardized handover procedure for discharging
patient safety, to identify potentially avoidable safety events; pediatric- patients), can certainly contribute to improve the delivered quality of
treatment, to address safety issue specifically for the children care care, but seems rather to relate to structural/organizational features
[3,4]. Appropriate selection of medical QIs is complex and depends rather than actual “process control” [11].
on the setting and the purpose they are intended to be used for, this
is even more complex in critical care medicine where “case load” As possible “process QIs” it is important to focus on specific aspect
(selection of patients admitted), “structural” features (technology and of the clinical management in ICUs like: titration of the continuous
staffing) and the role of each individual “professionalism” (quality and infusion vasoactive drugs, expressed by the ratio between the number
commitment) play a substantial role [5-7]. An alternative paradigm of hours of infusion and the delivered changes in dosing; optimal O2
for QIs is resilience engineering, a fairly novel discipline, envisioning administration avoiding hyper or hypoxia, expressed by the values of
the need for more systemic approach in settings such as critical care PaO2; adequate nutrition and blood glucose management, expressed
departments [8]; for example, a set of systemic indicators have been by blood glucose concentration (BGC) and hours from first nutrition;
proposed to match structural needs (e.g. management pressure) and also clinical research activity (as number of research protocol
with process issues (e.g. communication deadlock among personnel ongoing and year/publication) can possibly be included among “ICU
involved) [9]. process QIs” [14].

In the last decade, 13 countries (Australia/NZ, Austria, Canada, The use of short acting vasoactive drugs (dopamine, nitrates,
Denmark, Germany, India, Ireland, Netherland, Norway, Scotland, etc.), that are among the most used and abused drugs in critical care
Spain, Sweden and UK) have published a list of nationally qualified [15], can provide a meaningful indicator of delivered quality of care
critical care QIs in order to optimize resources utilization in healthcare and be used as QIs: to reach and to maintain a clinically defined
[10]. Various and different QIs have been listed (from the 7 of Norway hemodynamic endpoint during the stay in ICU can influence survival
to the 58 of UK) that include substantial differences on variables and complications rate of treated patient, and considering the inter-
and typology; for example QIs are categorized into 3 major groups: individual variability in response to vasoactive drugs and the evolving

Austin Crit Care J - Volume 6 Issue 1 - 2019 Citation: Bilotta F, Nato CG, Falegnami A and Pugliese F. Quality Indicators in Critical Care. Austin Crit Care
ISSN 2379-8017 | www.austinpublishinggroup.com J. 2019; 6(1): 1027.
Bilotta et al. © All rights are reserved
Bilotta F Austin Publishing Group

clinical conditions it is of paramount importance to clearly define a 5. Bilotta F, Pizzichetta F, Rosa G. Cost containment and poor-quality materials:
an unusual cause of failure in central venous indwelling catheter placement.
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Crit Care Med. 2007; 35: 2002-2003.
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subarachnoid hemorrhage. Curr Opin Anaesthesiol. 2014; 27: 489-493.
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