ICU quality and management tools

ICU Quality and Management Tools.Intensive care unit (ICU) is one of the major component of the current health care system. The advances in supportive care and monitoring resulted in significant improvements in the care of surgical and clinical patients. Nowadays aggressive surgical therapies as well as transplantation are made safer by the monitoring in a closed environment, the surgical ICU, in the post-operative period. Moreover, the care and full recovery of many severely ill clinical patients as those with life-threatening infections occurs as a result of intensive care.

However, despite many significant advances in various fields as mechanical ventilation, renal replacement therapy, antimicrobial therapy and hemodynamic monitoring this increased knowledge and the wise use of such technology is not available for all patients. Shortage of ICU beds are an important issue, however even when ICU beds are available significant variability in treatment and in the adherence to evidence-based interventions do not occur.

Monitoring ICU quality

Several studies demonstrate that nonadherence to established standards are related to poor outcomes. Only about half of Americans receive the care that is recommended for their clinical situations. Moreover, up to 30% receive inappropriate medical interventions. A day in the ICU costs around US$3,000, which is sixfold higher than those for non-ICU care. ICUs consume 20% of the total in-patient expenditures and only in the USA equaled $91 billion in 2001. Such figures are worrisome especially if one considers that ICU utilization is increasing rapidly.Thus it is reasonable to say that serious and sustained efforts to improve ICU performance are crucial.

Tools for ICU quality monitoring

Several measures of ICU performance have been proposed in the past 30 years. It is intuitive, and correct, to assume that ICU mortality may be a useful marker of quality. However, crude mortality rates does not take into consideration the singular aspects of each specific patient population that is treated in a certain geographic region, hospital or ICU. Therefore approaches looking for standardized mortality ratios that are adjusted for disease severity, comorbidities and other clinical aspects are often sought. Severity of illness is usually evaluated by scoring systems that integrates clinical, physiologic and demographic variables. Scoring systems are interesting tools to describe ICU populations and explain their different outcomes. The most frequently used are the APACHE II, SAPS II and MPM. However, newer scores as APACHE IV and SAPS3 have been recently introduced in clinical practice. More than only using scoring systems, one should search for a high rate of adherence to clinically effective interventions. Adherence to interventions as deep venous thrombosis prophylaxis, reduction of ICU-acquired infections, adequate sedation regimens and decreasing and reporting serious adverse events are essential and have been accepted as benchmarking of quality. The complex task of collecting and analyzing data on performance measures are made easier when clinical information systems are available. Although several clinical information systems focus on important aspects as computerized physician order entry systems and individual patient tracking information, few have attempted to gather clinical information generating full reports that provide a panorama of the ICU performance and detailed data on several domains as mortality, length of stay, severity of illness, clinical scores, nosocomial infections, adverse events and adherence to good clinical practice. Throughimplementing quality initiatives, increasing the quality of care and patient safety are major and feasible goals. Such systems are available for clinical use and may facilitate the process of care on a daily basis and provide data for an in-depth analysis of ICU performance.

References

* Gallesio AO, Ceraso D, Palizas F.Improving quality in the intensive care unit setting. Crit Care Clin. 2006 Jul;22(3):547-71
* Garland A. Improving the ICU: part 1. Chest. 2005 Jun;127(6):2151-64.
* Garland A. Improving the ICU: part 2. Chest. 2005 Jun;127(6):2165-79.
* McMillan TR, Hyzy RC. Bringing quality improvement into the intensive care unit. Crit Care Med. 2007 Feb;35(2 Suppl):S59-65.