Defining a High-Performance ICU System for the 21st Century: A Position Paper

Abstract

R, Artigas A, Strosberg M, Lemeshow S_ Defining a high-performance lCU system for the 21st century: a position paper.] Intensive Care Moo 1998; 13:195-205. In the fall of 1997 George D. Lundberg and]ohn E. Wennberg wrote an editorial in]AMA calling for comprehensh'e qualitl' improvement programs to become the drh-er of the American health care sl'stem. The suggestion came dUring the Second European Forum on Qualitl' Improvement in Health Care held in Paris, France, in April 1997 and was based on comments made bl' Donald Berwick. The concept was to focus on an organized response to problem identification and proposed solutions to improve patient care and protect the health of the public. Critical care medicine represents a large segment of health care and is undergoing dramatic changes during our managed care revolution. General lCU severity of illness models have been developed, tested, and shown to pro\'idc a useful estimate of hospital mortalitl' for populations of criticalll' ill patients. These systems have captured the imagination of clinical researchers and have become an integral component of a large number of publications as well as a part of manl' lCU databases. These risk adjustment severitl' models are remarkably robust for heterogeneous patient populations but the models have not been From the ·Center for Health Services Research, shown to validate well in new settings. We feel that by focusing on the episode of critical illness rather than each individual lCU admission and by going be}'ond the traditional acute hospital discharge to determine whether the patient lives or dies, we can bctter e\":lluatc critical carc systelll performance and cost-effectivcncss. The incentives for high quality/low cost should favor integrated comprehensive critical care delivery systems. Programs that score well should be identified as high quality and be honored as medallion level 1 lCUs. We challenge national and international critical care societies to e\":lluate and then debate the described definitions and recommendations as a call to action.In order to facilitate the study of outcomes in critical care medicine for the 21st century, it is important to better define what constitutes a high-performance leu system. leus do not function in isolation in the process of caring for an acute critical illness, and comparisons of leu mortality and length of stay are directly affected by the growing use of intermediate or step-down units and subacute or long-term ventilator facilities not necessarily linked to an leu or hospital. Measurement of system performance should include mortality, functional outcome, and resource consumption in the leU, intermediate care unit, and regular nursing units, as well as status beyond hospital discharge. Lundberg and Wennberg [II, based on a suggestion by Berwick, recently requested proposals that can provide directions for measuring the quality of major segments of our evolving health care system. We propose measuring quality of care for leu systems by focusing specifically on the first ...

Outcome prediction in critical care: the Mortality Probability Models

“…MPM 0 -III calibrates and discriminates well (AUROC ¼ 0.823) and addresses changes in the relationship of its variables to mortality that have developed over time. It also measures resource utilization when used in the Rapoport-Teres graph [18,30]. It involves the least amount of data collection among the general severity-ofillness models and does not require a diagnosis when calculating a predicted probability of mortality.…”

“…Because morbidities such as prolonged mechanical ventilation or acute renal failure occur more commonly than death, they can be attractive endpoints for analysis [30]. Unfortunately, there is little consensus on which morbidity outcomes should be reported or how they should be defined.…”

Quantifying Risk and Benchmarking Performance in the Adult Intensive Care Unit

“…The SMR reflects system-wide performance rather than just the ICU's contribution, and differences in the use of long-term facilities can bias the hospital mortality rate. Evaluating care delivered in a particular ICU must also consider when the episode of critical illness or ICU care begins [39]. Lead-time bias and other issues related to pre-ICU care may vary significantly across units and have measurable effect on outcome [40,41].…”

“…In-hospital mortality loses some meaning as an end point if a hospital system extensively transfers patients to other hospitals or long-term facilities. All models start the scoring clock at ICU admission, the time of which may be influenced by ICU bed availability or other conditions that vary locally [39]. Physiology may be better controlled⎯and ICU admission scores thus lower⎯in hospitals with rapid response teams.…”

When to customize a severity model

“…To accommodate this major change in medical practice and to better define when critical care starts, our research group has proposed focusing attention on the acute episode of critical illness rather than on each ICU admission [21]. A reasonable endpoint would be vital status at 90 days.…”