A scoping review of registry captured indicators for evaluating quality of critical care in ICU.

Abstract

Background Excess morbidity and mortality following critical illness is increasingly attributed to potentially avoidable complications occurring as a result of complex ICU management [1–3]. Routine measurement of quality indicators through an EHR or registries are increasingly used to benchmark care and evaluate improvement interventions. However, existing Indicators of quality for intensive care are derived almost exclusively from relatively narrow subsets of ICU patients from high-income healthcare systems. The aim of this scoping review is to systematically review the literature on quality indicators (QIs) for evaluating critical care, identify QIs, map their definitions, evidence base, and describe the variances in measurement, and the reported challenges of implementation.Method We searched MEDLINE, EMBASE, CINAHL and the Cochrane libraries from the earliest available date through to January 2019. To increase sensitivity of the search, grey literature and reference lists were reviewed. Minimum inclusion criteria were a description of one or more QIs designed to evaluate care for patients in ICU captured through a registry platform- or Electronic Health Record (EHR) adapted for quality of care surveillance.Results The search identified 4780 citations. Review of abstracts led to retrieval of 276 full-text articles, of which 123 articles were accepted. 51 unique QIs in ICU were classified using the three components of health care quality proposed by the High Quality Health Systems (HQSS) framework. Adverse events including hospital acquired infections (13.7%) hospital processes (54.9%) and outcomes (31.4%) were the most common QIs identified. Patient reported outcome QIs accounted for less than 6%. Barriers to the implementation of QIs were described in 35.7% of articles and divided into operational barriers (51%) and acceptability barriers (49%).Conclusions Despite the complexity and risk associated with ICU care, there are only a small number of operational indicators used. Future selection of QIs would benefit from a stakeholder driven approach, whereby the values of patients and communities and the priorities for actionable improvement as perceived by healthcare providers are prioritised and include greater focus on measuring discriminable processes of care.

What intensive care registries can teach us about outcomes

“…Survival measures, most notably all-cause ICU mortality, are defined and captured with relative consistency across national and international critical care registry groups. [ 3 , 7 ]. ICU and hospital mortality are frequently captured, although some registries also include some “fixed-time” (30, 60-day) reports on vital status.…”

“…However, reporting of procedure-related deaths including those related to a complication of the procedure or treatment for a complication remain widely absent from the majority of registries. [ 7 ].…”

“…Although all registries use standardised mortality rates (SMRs), internationally they vary in both the models used and the time points at which they are applied. The most frequently used are those based on APACHE (II,III and IV) and SAPS (2 and 3) which are used by registries in Europe, South America, Japan, whilst well established registries such as ICNARC (UK) and the Australia and New Zealand registry (ANZICS) use their own scoring systems- developed and validated specifically for their populations (ANZROD and ICNARC mortality model, respectively) [ 7 , 11 , 12 ]. More recently in emerging LMIC ICU registries including those in Asia (India, Nepal, Sri Lanka and Pakistan) and Latin America (Brazil) work is underway to develop and validate simpler scoring systems (e.g Asian validation of E-TropICS and Brazilian validation of the SMS-ICU score); that reflect diagnosis and aetiologies more prevalent in such settings, and which attempt to increase score utility, and minimise data missingness.…”

“…A recently published review of registry reported indicators of quality-describes 51 different quality indicators, of which 20 were categorized as outcome events of interest. [ 7 ]. The most frequently reported events of interest focused on potentially avoidable adverse events such as healthcare associated infections (HCAIs), pressure sores, duration and complications of invasive mechanical ventilation, prolonged ventilation and unplanned readmission.…”

“…The most frequently reported events of interest focused on potentially avoidable adverse events such as healthcare associated infections (HCAIs), pressure sores, duration and complications of invasive mechanical ventilation, prolonged ventilation and unplanned readmission. [ 4 , 7 , 20 – 23 ]. Wide variation and inconsistency in collection, definition and reporting of such measures was described, hindering utility and interpretability of such outcomes.…”