Quality Indicators For ICU: Indian Society of Critical Care Medicine 2009

Quality indicators for ICU
Indian Society of Critical Care Medicine

2009
Task force:
Dr. N. Rangnathan
Dr. N. Rungta
Dr. D. Govil
Dr. M. Munjal
Dr. A. Kulkarni
Dr. S. Nainan Myatra
Dr. J. Divatia
Dr. C. K. Jani
Foreword by chair:
Intensive Care has had a phenomenal growth since its inception during the Copenhagen
Poliomyelitis outbreak in 1952. Few specialities have grown with that much of pace as that of
Intensive Care in such a short period. True, its a ‗capital intensive‘ care but its saving lives
which otherwise would not have been possible and its even contributing with precision to
perception of future course of the disease and to instituting remedial measures well ahead of the
time, the patients require critical care therapies. Target oriented therapies and bundles are
becoming the preferred modalities for bettering the outcomes and there are definitive indications
that such therapies are helpful. Intensive therapy outcomes are constantly improving
notwithstanding the variations in deployment of processes, resources, drugs, consumables and
techniques in different ICUs. While disease outcomes are relatively easy to appreciate and
accounted for, intensive care outcomes are not so easy to do so because of the very nature of the
units and the way we practice it particularly in our country with a large number of open and very
few semi closed and even fewer closed units. In order to develop the right kind of unit and
practice optimum therapies for providing best quality treatment to our critically ill patients, we
need to develop appropriate key performance indicators which reflect the aspirations of patients,
relatives and intensivists.
Developing key performance indicators and monitoring, auditing and improving those parameters
is a dynamic process which requires standardization, improvement and innovation – the three
arms of any improvement process, may it be in industry or in service scenario. While
standardization means ‗removing the outliers‘ i.e. reducing the standard deviation, improvement
denotes gradual bettering of a parameter from the previous level with a degree of irreversible
consistency. Innovation is however, sporadic and often it requires a thinking cap which, while
maintaining the speed of standardization and improvement, quickly takes the parameters to a new
level. In Total Quality Management (TQM) parlance the first two are a part or product of Daily
Management and the last one is a part or product of Policy Management. While standardization
and improvement come with all-round participation in the unit, the innovation comes from a
particular individual or a section of the people connected with the unit.
Small improvements through small group activities (SGAs), previously known as Quality Circles,
are central to any improvement in a unit and brings about pride and involvement amongst the staff
in ICU. While isolated improvement activities are important to making the members engaged to
start with, institutionalizing these activities is the ultimate goal of the unit, for only that will
ensure a complete irreversibility of the process. The latter is possible if the problems are
constantly identified in the process/procedure and improvement initiatives are taken to address
those. Striving for results is extremely important and for that the team needs to identify and take
care of the ‗vital few‘ problems leaving the ‗trivial many‘; something like ‗triaging‘ in mass
casualty parlance.
Co-relating the improvement of the process/outcome parameter with the improvement activities is
important; if it does not match, then either one has not chosen the parameter properly, or the
parameter needs further development in form of precision and complexity or the ‗vital few‘
problems have not been properly identified. A constant engagement with the improvement
process is necessary on the part of the team. The parameter needs to be developed, validated and
revalidated in the same unit and in different units among the similar and dissimilar case mix
before it is finally accepted.
*********
Members’ details :
Dr B Ray : General Manager ( Medical Services ) Tata Main Hospital, Jamshedpur

drbray@tatasteel.com ;09234510648
Dr D P Samaddar : HOD Anaesthesia and Critical Care , Tata Main Hospital , Jamshedpur
drdpsamaddar@tatasteel.com ;9234551849
Dr S K Todi: Head of Medicine & Critical Care , AMRI , Kolkata

subhashtodi@vsnl.com ;09831202040
Dr George John : Professor of Medicine , Head division of Critical Care, CMC, Vellore
yokavi@yahoo.com ;09443626986
N Ramakrishnan : Director , Critical Care Services,Senior Consultant in Critical Care &

Sleep Medicine, Apollo Hospital , Chennai
icudoctor@gmail.com ;09840855115
Dr S Ramasubban: Director Critical Care , Apollo, Kolkata

drsuresh@hotmail.com ;09831740837
Preface
Background: Efficiency of any health care unit is judged by its quality indicators. However in our
country monitoring the outcome through quality indicators is not yet institutionalized because of many
reasons including the majority of ICUs being run as open or semi closed with unaccountable custodians.
Dependency on the key performance indicators practiced by the developed countries therefore becomes
inevitable wherever some degree of total quality management system is being adhered to. It is generally
seen that few of the hospitals in India attempt to evolve their own parameters either taking ideas from the
―established parameters‖ or from their experience in Indian hospitals. Some of the parameters when
pursued year after year do not express or reflect the aspirations of the intensivists. Selecting definitive
and sensitive quality indicators and forming a data base at national level, is therefore required. The
executive committee of Indian Society of Critical Care Medicine (ISCCM) , took a decision in the year
2008 to evolve Quality Indicators for ICUs in India and a task force was constituted under the convener
ship of Dr B Ray to give its report.
Objective: Primary objective is to select suitable quality indicators for Indian intensive care units.
Development of national data base and meaningful utilization of this data base is the final objective.
Parameters: Common performance parameters (nominators) along with certain basic parameters
(denominators) have been selected to find out quality indicators. Each indicator has been explained for
ease of understanding and uniformity of practice. Based on the selected parameters Dash Board for
monitoring the data has been developed.
Dash Board: Dash board includes the selected parameters which would be made available to
participating institutions for reporting to main body at pre decided intervals.
Caution and limitations: Very common parameters have been selected in this report. Acceptability and
utility of these parameters in the Indian scenario will have to be assessed over a period of time.
Accordingly parameters will be modified and may be few parameters have to be even discontinued if
those parameters do not reflect the outcome directly or indirectly.
Future steps: Addition and deletion of parameters as per need would be considered in future. This will
be done in phases after proper evaluation of monitored parameters. National data base generated by this
exercise can be released for public reporting at a later date. Institutions will also be in a position to
compare their performance with the national data base.
Approach by an Intensive Care Unit: These should be the guidelines and by no means a complete or
closed list. Once the parameters are put in place , monitored and audited at predetermined interval one
would surely find some improvement in the key performance indicators (KPIs) but by no standards that
alone should be construed as a successful exercise. The approach should be to minimize standard
deviation (prevent ―spikes‖on either direction) while improving the KPIs .It will be clearly appreciated
that the whole unit‘s involvement is essential to find out the bottlenecks in the process or functional areas
of any parameter and take remedial action through small group activities(SGAs) and self initiated
projects(SIPs). One would see a lot of Plan-Do-Check-Act (PDCAs) on the way to evolution of a
parameter.
Main Report
Index Page no.
1. Back ground ( Introduction ) : 1
2. Gathering the evidence: 1
3. Units 1
4. Objective 2
5. Parameters 2
6. Definition of Indicators 2-15
7. Dash board 16
8. Limitations and concerns 16
9. Future course 16-17
10. Recommendations 17
11. List of symbols 17-18
12. Acknowledgements 18
13. References (additional) 18-19
14. Annexure 20
Quality indicators in Critical Care : An overview 21-30
Patient safety 31-33
Quality indicators in Critical care : Personnel Development 34-36
Quality Process 37-44
Quality Indicators in Critical Care – Outcome Parameters 45-49
Q indicators : Infection Control 50-54

-1-
1.Background:
Quality orientation is an integral part of patient care. Best possible care at the institutional level is
not considered adequate in the present competitive environment. It should be visible, appreciated
and comparable. Total Quality Management therefore, is essential to judge the appropriateness
and effectiveness of medical care. Quality of service offered, result of intervention and treatment,
undesirable outcomes, and other managerial and treatment related processes can be analyzed to
define the scope of improvement. Quality indicators help in achieving these objectives. Health
care is becoming transparent and customer focussed. Patients and their relatives have the right to
know the standard of care and its cost.
It is therefore becoming more and more mandatory for the institution to monitor quality
indicators/parameters and compare their performance level with the national standard or
international bench marks. It gives an opportunity to the individual institution to improve its
quality of care through standardization of processes, procedures and treatment protocols.
Unfortunately, due to variety of reasons, performance levels are not monitored in India and
therefore a national data base does not exist for a meaningful comparison. Dependency on the
international data base, however not logical for Indian scenario, becomes inevitable in our
strategic planning of the service.
Indian Society of Critical Care Medicine (ISCCM) had taken the initiative in the year 2008 in its
executive body meeting to identify quality indicators for the ICUs which will help intensive care
units in India to judge their performance level and also compare with the national data base.
2. Gathering evidence:
Annexure :
1 Quality indicators in Critical Care : An overview Dr B Ray, Dr D P Samaddar
2 Patient safety Dr S K Todi
3 Personnel Development Dr Suresh
4 Quality of processes Dr George John, Dr N Ramakrishnan
5 Outcome Parameters Dr George John, Dr N Ramakrishnan
6 Infection Control Dr D P Samaddar
3. Units : Report is basically focused on adult mixed intensive care unit but wherever possible
for benchmarking other specified units‘ references have also been given (except Neonatal ICU ).
Abbreviations used for different specialized units are given below.( Table no. 1)
Table no.1
Unit Abbreviation
Burn BCU
Coronary CCU
Surgical cardiothoracic SCU
Medical MICU
Medical/surgical, major ,teaching M-S ICU major teaching
Medical/surgical, all others M- S ICU
Pediatric medical/surgical PICU
Neurological Neuro ( Med) ICU
Neurosurgical Neuro (Surg) ICU
Surgical SICU
Trauma TICU
-2-
4 . Objective:
1. Select very common parameters mainly focussing on the outcome (mortality and
morbidity), process, infection, communication, human resource and safety.
2. Generate national data base for comparison with international bench marks and provide
data to participating institutions at national level for comparison with national data base.
5. Parameters: Based on the objective of this report, common parameters with their
international bench marks have been selected to address different aspects of patient care
operational issues and human resource development. Certain basic data, which as such do not
reflect patient care but when used as denominators to the selected parameters, make the parameter
more sensitive and meaningful. Example of these denominators are: number of admissions , total
patient days in the unit( occupancy), ventilatory days, central venous and arterial line days,
urinary catheter days etc. In order to avoid confusion and ambiguity of interpretation, it is
essential that purpose and usefulness of selected parameters must be understood by the care
providers. All the selected parameters, therefore, are described under certain sub headings as
given in the table no. 2 along with explanation.
Table no. 2
Indicator Explanation
Description What does the parameter mean
Rationality Why should it be monitored
Formula for calculation How it should be calculated
Patient population For whom the parameter is collected
Source of data Where from the input will be collected
Type of parameter Linkage of parameter with the type of quality
Bench mark Common national or international standard
References Literature back up for the bench mark and background
information for the selected parameter
6.Definition of Parameters:
6.1 Mortality:
.
6.1.1 Standardized mortality rate ( SMR)
Indicator Standardized mortality rate ( SMR) or risk adjusted

mortality rate
Description Mortality rates are not often the indicators of performance even
if those are often referred to. However mortality rate related to
prior prediction is a sensitive indicator for comparison.SMR
allows comparison of actual performance of the institution with
predicted performance, based on the average mortality as
expressed by national or international data.
-3-
Rationality Risk of death varies with severity of disease state, age, and co-
morbid conditions. Crude mortality (overall mortality) therefore is
not a sensitive indicator. On the basis of influencing factors SMR
obviates limitation of crude mortality as data from a large pool of
patients with similar diagnoses and risk factors are analysed to get
expected mortality for that group of patients. Data can be obtained
from national records or international records. Mortality rate can be
obtained from predictive models such as APACHE , SAPS,MPM
etc.2 The SMR is a very useful parameter, often used to compare
outcomes in two or more groups under study. It also gives an
opportunity to individual ICU for improving the processes and
techniques.
Formula for calculation 1 Risk-adjusted Mortality 1
= Observed Rate/Risk-adjusted expected Rate (X100)
Observed rate = Actual death in ICU/ institution.
Risk adjusted expected rate = Predicted death rate by predictive
model
Interpretation 1 Equal to 100 — hospital's mortality rate and the expected
average rate are the same
>100 — hospitals mortality rate is higher than the expected
average mortality rate
<100 — hospitals mortality rate is lower than the expected
average mortality rate.
Higher SMR does not necessarily mean that hospital is unsafe as this
is a snapshot method and simultaneous assessment of other quality
indicators must be done to draw a logical conclusion. Single
parameter based judgment on performance level is not advocated. 2
Patient population All patients admitted to critical care units of different type
Source of data Hospital record for the observed mortality ( numerator)
Type of parameter Outcome
Bench mark If the 95% confidence interval of the SMR includes 1, the
performance is considered average. If the 95% CI *does not include
1, SMRs less than 1 and more than 1 are considered to show good
and poor performances, respectively.3
References 1. Available at : http://www.mayoclinic.org/quality/adjusted-
mortality.html
2. Available at: http://www.qhc.on.ca/body.cfm?id=565
3. Bekele Afessa ,Ognjen Gajic , Mark T. Keegan Severity of
Illness and Organ Failure Assessment in Adult Intensive
Care Units. Crit Care Clin 23 (2007) 639–658
-4-
6.2 Morbidity Parameters :

6.2.1. Iatrogenic Pneumothorax
Indicator Iatrogenic Pneumothorax

Description Procedure related pneumothorax
Rationality Associated mortality and morbidity, prolonged stay, cost
implications
Formula for calculation (Number of pneumothorax / Number of cases) X 1000
Patient population Intensive care
Source of data Hospital record
Type of parameter Morbidity, safety
Bench mark 0.83 per 1000 cases 1
5% ( interstitial emphysema/pneumothorax/
pneumomediastinum/subcutaneous emphysema)2
References 1.AHRQ national average .Sharp health care ,2007 Malcolm
Baldrige National Quality Award application 2007.
2.Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz

Moreno et al. Quality indicators in critically ill patients.
SEMICYUC work groups.1st edition May 2005.ISBN 6095974.
6.2.2 Incidence of Acute Renal Failure in noncoronary ICU :
Indicator Incidence of severe Acute Renal Failure in noncoronary ICU

Description Denovo acute renal failure requiring renal replacement therapy or
when urine output is < 200 mL in 12 h and/or marked azotemia
defined as a BUN level > 84 mg/dL) during patient‘s ICU stay .1
Rationality Renal failure increases possibility of death( 60.3%)
notwithstanding whether renal replacement therapy has been
initiated.1,2 Even a modest increase in the serum creatinine level
(0.3 to 0.4 mg per deciliter [26.5 to 35.4 mol per liter])
increases risk of death by 70% when compared to normal
creatinine levels.
Formula for calculation Number developed severe renal failure/Number managed in ICU
X 100
Patient population Nominator: Severe renal failure ( GFR < 10 ml/min.)4
developing in ICU (excluding chronic renal failure patients.)
Denominator : Patient managed in ICU in a given time frame.

Source of data ICU record
Type of parameter Outcome parameter
Bench mark Severe ARF 5.7% 1
10% patients develop ARF ( including Severe ARF) 4

-5-
References 1. Uchino, S, Kellum, JA, Bellomo, R, et al Acute renal failure

in critically ill patients: a multinational, multicenter study.
JAMA 2005;294,813-818.
2. Ramesh Venkataraman and John A. Kellum..Prevention of

Acute Renal Failure.Chest. 2007;131:300-308.
3. Chertow GM, Burdick E, Honour M, Bonventre JW, Bates

DW. Acute kidney in1 jury, mortality, length of stay, and
costs in hospitalized patients. J Am Soc Nephrol
2005;16:3365-70.
4. Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz

SEMICYUC work groups. First edition May 2005. ISBN
609- 5974
6.2.3. Decubitus ( Pressure) ulcer :
Indicator Decubitus ( Pressure) ulcer

Description Decubitus ulcer and pressure sore are synonyms. Decubitus is
derived from Latin word decumbere, means "to lie down. Since
pressure sore can develop from other positions, it is called
―Pressure sore‖.Prolonged uninterrupted pressure over bony
prominences causes necrosis and ulceration. Depending upon
tissue damage ulcers are classified in 4 stages.Stage 1 indicates
superficial colour change, stage 2 represents partial thickness
skin loss ,Stage 3: full thickness skin loss, and stage 4 denote
deep and extensive tissue damage involving muscle, tendon or
bone. Hip and buttock sores represent 67% of all pressure
sores.1,2
Rationality Annual cost of treatment in US exceds $1 billion .
Formula for calculation Number of pressure ulcers / Number of cases X 1000
Patient population Critically ill
Type of parameter Morbidity, Safety of patients
Bench mark 3 – 11% 1
22.71 / 1000 cases 3
References 1. Don R Revis. Decubitus Ulcers. E edicine October 25th, 2005.
2. Pressure care for pressure ulcer and ain therapy. National

Pressure Ulcer Advisory Panel (NPUAP) available at:
info@pressurecare.co.uk
3. AHRQ national average .Sharphealth care ,2007 Malcolm

Baldrige National Quality Award application 2007, page 34.
-6-
6.3 Operational Or Process Parameters :

6.3.1 Length of Stay :
Indicator Length of Stay (LOS)

Description Total hours and days patients managed in the unit with midnight
bed occupancy are more accurate than the number of calendar
days a patient spends in the ICU. Arithmetic mean overestimate
LOS, as outliers both ways influence the mean LOS very
adversely. Median of LOS can circumvent this problem. LOS is
also influenced by factors such as the availability of a
intermediary care, discharge practices, and mortality rates.
Appropriateness of using LOS as outcome measure is therefore
being reconsidered by Joint Commission on Accreditation of
Healthcare Organizations ( JCACHO).LOS properly stratified on
the basis of diseases and conditions and properly analysed could
be a sensitive parameter throwing up deficiency in process and
technique in ICU.
Rationality ICU beds are limited in any hospital. Rationalized use for needy
patients therefore is necessary. LOS is therefore used to assess
quality of care and resource utilization.
Formula for calculation Total occupied bed days / number of patients in a given time
frame (weekly,monthly /yrly)
Patient population All admitted patients in the unit
Source of data ICU data
Type of parameter Outcome measure
Bench mark Average LOS in year 2001 Norfolk General Hospital 2
4.36 days in general ICU;
2.43 days in vascular ICU

References 1. Tracy R. McMillan, MD; Robert C. Hyzy, Bringing quality
improvement into the intensive care unit Crit Care Med 2007;
35[Suppl.]:S59–S65).
2. Peter J. Pronovost ,Accelerating Change Today (A.C.T.)for

America‘s Health.. Editor Patricia Q. Schoeni © 2002 by the
National Coalition on Health Care and the Institute for
Healthcare Improvement. The Robert Wood Johnson
Foundation supported report
-7-
6.3.2 Compliance to protocol

Indicator Compliance to protocol
Description Selected guidelines , protocols, treatment bundles in the unit to
improve patient care, resource utilization, and reduce iatrogenic
complications.
Rationality Compliance to protocols, guidelines and treatment bundles are
expected to improve patient care. Compliance to protocol could be
absolute non compliance, partial or full (correct). Seventy percent
correct compliance had been reported by McMillan et al .1
Formula for calculation Number of time followed/ Number of time expected to follow X
100
Patient population All ICU patients
Source of data Audit report
Type of parameter Process parameter
Bench mark 90% 2
References 1. Tracy R. McMillan, MD; Robert C. Hyzy, Bringing quality
35[Suppl.]:S59–S65).
2. Peter J. Pronovost .Accelerating Change Today (A.C.T.)for
America‘s Health.. Editor Patricia Q. Schoeni © 2002 by the
National Coalition on Health Care and the Institute for Healthcare
Improvement. The Robert Wood Johnson Foundation supported report
6.3.3 ICU readmission rate
Indicator ICU readmission rate

Description Readmission to the ICU within 24 hrs of transfer during a single
hospital stay.This is an indicator of post ICU care.
Rationality A zero readmission rate reflects more defensive approach by ICU team
which increases LOS in ICU causing risk of nosocomial infection,
iatrogenic complications, and non availability of bed for the deserving
patients Higher mortality rate of 1.5 to 10 times that of controls and
higher length of stay at least twice that of control patients had been
documented .A higher readmission rate indicates premature decision
to shift out.
Formula for calculation (Number of readmitted patients/ Total patients managed in ICU ) X
100
Patient population All patients discharged from ICU in a time frame.(exclusion : death
in CCU)
Type of parameter Process, Safety of patients
Bench mark ICU readmission rates are around 5–6%1
4% 2
References 1 Tracy R. McMillan, MD; Robert C. Hyzy, Bringing quality
35[Suppl.]:S59–S65).
2. Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz
SEMICYUC work groups. First edition May 2005. ISBN 609- 5974
-8-
6.4 Error and patient Safety

Error is defined as ‗‗the failure of a planned action to be completed as intended or the use of a
wrong plan to achieve an aim‘‘ .1 additional ref Culture of safety is important considering the high
number of preventable deaths (44000 to 98000/ annum medical error related deaths had been
reported in USA).2 additional ref Brochure released by society of Critical Care Medicine, USA in
2004 had quoted very high incidence of medication errors which caused more than 770,000
injuries and deaths per year. 3 additional ref
Both patient safety and staff safety are important.
6.4.1 Patients’ fall rate

Indicator Patients’ fall rate
Definition An untoward event which results in the patient coming to rest
unintentionally on the ground or on other lower surface. 1
Rationality Fall could be accidental, anticipated physiological or
unanticipated physiological .This is a safety issue for a patient in
ICU. Accidental fall could lead to morbidity, prolonged stay and
customer dissatisfaction.
Formula for calculation 1 fall rate = (no. of falls/no. of bed days) x 1000
Patient population All patients
Type of parameter Safety and morbidity
Bench mark 2,3 8.46 falls per thousand bed days with an injury rate of 12.85% in
2000-012
Norton Hospital USA, 2008 Norton Healthcare statistics per

1000 in patient days of the unit. 3
Without injury With injury
ICU 2.10 0.22
Medical surgical 2.23 0.74
Medical 2.62 0.70
Surgical 2.02 0.37
References 1 Barnett, K. (2002) Reducing patient falls in an acute general

hospital. In Shaw, T. and Sanders, K. (Eds)Foundation of
Nursing Studies Dissemination Series.Vol. 1.
2. Karen Barnett. Mid Yorkshire Hospitals NHS Trust.Reducing
patients falls project .2001-02
3. Norton hospital USA2008 Norton Healthcare. Available at:
http://www.erlanger.org/quality/PatientSafety.asp
-9-
6.4.2 Medication error

Indicator Medication error
Description Medication error could be due to wrong prescription , dosing, and
due to communication gap ( verbal or written)
Rationality Medication errors occur at a mean rate of 19% in hospitalized
adults. The need for assessing ICU medication error
frequency is highlighted by the finding that 78% of the serious
medical errors that occurred in the ICU were attributed to
medications .More than 235,000 medication errors were reported
in 2003 in USA .At least 2% of these errors caused significant
patient harm (eg, injury requiring treatment, prolonged hospital
stay, and death.) 1
Formula for calculation Medication error rate = (no. of error /no. of bed days) x 1000
Patient population All patients in ICU
Type of parameter Patient safety
Bench marks 1, 2 1.Medication errors range from 1.2 to 947 per 1000 patient-days (
median of 105.9 per 1000 patient-days) in adult ICUs and Median
of 24.1 per 1000 patient days in neonatal/pediatric ICUs 1
2.Wrong dose : 105.9 errors per 1000 patient-days in ICU 2
References 1.Sandra Kane-Gill, Robert J. Weber. Principles and Practices of
Medication Safety in the ICU. Crit Care Clin 22 (2006) 273– 290
2.Herout PM, Erstad BL. Crit Care Med 2004;32(2):428– 32
Medication errors involving continuously infused medications in a
surgical intensive care unit..
6.4.3 Adverse events /error rate

Indicator Adverse events /error rate
Description Common ICU errors are related to treatment, procedure, ordering
or carrying out medication orders, reporting or communication,
and failures to take precautions or follow protocols.
Rationality Critically ill patients are at high risk for complications due to the
severity of medical conditions, complexity of treatments , poly
pharmacy, and technology based interventions. Nearly all ICU
patients suffer from potentially harmful events. Nearly half
(45%) of the adverse events are preventable.
Formula for calculation Adverse events/ error rate = (no. of error /no. of bed days) x 1000
Patient population All ICU patients
Source of data Medical record
Type of parameter Safety ( patient)
1
Bench mark The rates per 1000 patient-days for all adverse events,
preventable adverse events, and serious errors were 80.5, 36.2,
and 149.7, respectively. Among adverse events, 13% (16/120)
were life-threatening or fatal; and among serious errors, 11%
(24/223) were potentially life-threatening.
References 1. Jeffrey M. Rothschild, Christopher P. Landrigan, John W.
Cronin etal. The Critical Care Safety Study: The incidence and
nature of adverse events and serious medical errors in intensive
care Crit Care Med 2005; 33:1694 –1700
- 10 -
6.4.4 Needle stick injury rate

Indicator Needle stick injury rate
Description A penetrating stab wound from a needle (or other sharp objects) that
may or may not be associated with exposure to blood or other body
fluids.
1
Rationality Needlestick injuries can cause transmission of blood borne
pathogens. Needle stick injury can occur due to faulty handling of
needle syringe with needle, suture needle, recapping of needle, and
faulty disposal. Annual incidence ranges from 600,000 to 800,000
at global level. According to CDC estimate 385,000 needlestick
injuries occur annually in U.S. hospital settings. Approximately half
of those go unreported.2Although this is a minor injury ,
transmission of disease is a concern. Blood filled hollow bore needles
accounted for 63% of the needlestick injuries from June 1995 to July
1999.It is a preventable injury3 therefore adequate training to health
care provider is a must.
Formula for calculation Incidence per 10,000 venepunctures
Patient population All health care workers
Type of parameter Safety ( Health care worker)
2
Bench mark 0.94 per 10,000 venipunctures in the USA national rate.
References 1.Available at :
http://www.medterms.com/script/main/art.asp?articlekey=25492
2.Linda Rosenstock .Statement for the record on needlestick injuries
JUNE 22, 2000 Centers for disease control and prevention,
Department of Health and Human Services
http://www.hhs.gov/asl/testify/t000622a.html
3.American nurses‘ association‘s needle stick injury prevention
guide. Washington, D.C. 20024.www.NursingWorld.org.1-800-274-
4ANA.
6.4.5 . Reintubation rate

Indicator Reintubation rate
Description Reintubation within 48 hours of extubation.
Rationality Accidental extubation and subsequent reintubation can lead to
prolonged stay, longer ventilation and higher nosocomial pneumonia
and mortality.
Formula for calculation (Number reintubated/ Number extubated )X 100
Patient population ICU patients with endotracheal tube had undergone planned
extubation.
Type of parameter Morbidity, safety
Bench mark 12.2% 1, 12% 2
References 1 Tracy R. McMillan, MD; Robert C. Hyzy, Bringing quality
35[Suppl.]:S59–S65).
2 Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz
SEMICYUC work groups. First edition May 2005. ISBN 609- 5974.
- 11 -
6.5 Infection Control: Nosocomial infection has both outcome and financial implications.
Approximately 1.7 million infections, 99,000 deaths, and higher estimated annual expenditure of
$4.5 billion had been reported by centers for disease control and prevention in 2007. 4 additional ref
Most commonly monitored three variables : a) ventilator associated pneumonia , b) blood stream
infection and c) urinary tract infection rate were selected as quality indicators for this report.
NNIS surveillance 2002 shows that out of overall 13.04 overall infection rate / 1000 patient days
in adult and children intensive care unit , pneumonia, BSI and UTI rates were represented as 3.33
, 2.71 and 3.38 respectively. SSI (0.95) and others (2.67) represented the rest. Percentage wise
UTI, BSI, and Pneumonia incidence were 32, 14, 15 in the 2002 survey. 5 additional ref
6.5.1 Ventilator associated pneumonia (VAP): VAP is an important cause of morbidity and
mortality 6,7additional ref but difficulties encountered in diagnosis of VAP makes bench marking a
difficult proposition. Therefore its advantage as quality indicator is limited. Still hospitals in
United States report ventilator-associated pneumonia rates as an indicator of quality of care and
also for benchmarking due to the collective demand of legislators, tax payers, and advocates of
quality-of-care across .8 additional ref
Endotracheal aspirates with nonquantitative cultures had been advocated as the initial diagnostic
strategy. Common clinical criteria (e.g. fever, leukocytosis, purulent secretions, new or changing
radiographic infiltrate) have high sensitivity but suffer from relatively low specificity level. They
are most useful for initial screening for VAP and for selecting patients for invasive procedures,
such as BAL, that have sensitivities and specificities in the region of 80%.For ease of application
clinical and radiological diagnostic criteria are given in this report.
Indicator Ventilator associated pneumonia(VAP)

Description Ventilated patient developing new opacity and also fulfilling
criteria of VAP
Rationality Ventilator associated pneumonia increases morbidity and mortality. It
has cost implications as it increases days of ventilation. Reduction in
the incidence rate is desirable in ventilated patients. Reported crude
mortality rates in VAP exceed 50%, and the attributable cost of VAP
approaches $20,000.1
Diagnosis 2 Radiologic signs
>2 serial chest radiographs† with at least one of the following:
• New or progressive and persistent infiltrate
• Consolidation
• Cavitation
Clinical signs
at least one of the following:
• Fever (temperature >38 °C) with no other recognized cause
• Leukopenia (<4.0 X 109 cells/L) or leukocytosis (>12.0 X 109
cells/L)
• For adults > 70 y of age, altered mental status with no other
recognized cause
- 12 -
and > 2 of the following:

• New development of purulent sputum, change in character of
sputum, increased respiratory secretions, or increased
suctioning requirements.
• New-onset or worsening cough, or dyspnea, or tachypnea
• Rales or bronchial breath sounds.
Worsening gas exchange (e.g., oxygen desaturation ratio [PaO2–
FiO2] < 240, increased oxygen requirement, or increased ventilation
demand.
Formula for calculation # of patients with VAP
X 1000 days
# of days mechanically ventilated with endotracheal tube
Patient population All ventilated patients except neonatal intensive care patients
Source of data Hospital record of patient
Type of parameter Infection ,outcome, safety
Bench mark ( 1000
Burn 10.7
device days) NHSN 3
Coronary 2.5
Surgical cardiothoracic 4.7
Neurological 7.1
Neurosurgical 6.5
Surgical general 5.3
Trauma 9.3
Medical 2.5
Medical/surgical, major ,teaching 3.3
Medical/surgical, all others 2.3
Pediatric medical/surgical 2.1
INICC* 4 Overall in 98 ICUs of Latin America, Asia, Africa, and Europe 19.5
References 1. Safdar N, Dezfulian C, Collard HR, Saint S. Clinical and economic
consequences of ventilator-associated pneumonia: a systematic
review. Crit Care Med. 2005;33:2184-2193. (Abstract)
2. Horan T, Gaynes R. Surveillance of noscomial infections. In:
Mayhall C, ed. Hospital Epidemiology and Infection Control. 3rd
ed. Philadelphia: Lippincott Williams & Wilkins; 2004:1659-702.
3. Jonathan R. Edwards, Kelly D. Peterson, , Mary L. Andrus,
Margaret A. Dudeck et al . National Healthcare Safety Network
(NHSN) Report, data summary for 2006 through 2007, issued
November 2008.
4. Victor D. Rosenthal, Dennis G. Maki, Ajita Mehta et al.
International Nosocomial Infection Control Consortium report,
data summary for 2002-2007,issued January 2008. Am J Infect
Control 2008;36:627-37
* International Nosocomial Infection Control Consortium (INICC) surveillance study
- 13 -
6.5.2 Blood stream infection due to central line:
Indicator Blood stream infection due to central line

Description Blood stream infection rates = number of central line related
BSI per 1000 central line-days.
Rationality Bloodstream infection (BSI) had emerged as a major killer. The
estimated death caused by BSI was 26,250 deaths/ year and it is
ranked as the eighth leading cause of death in the United States.1
Formula for calculation Number of central line-associated BSI
X 1000
Number of central line-days
Patient population Adult
Type of parameter Infection , outcome,safety
Bench mark NHSN 2 Burn 5.6
Coronary 2.1
Neurosurgical 2.5
Surgical general 2.3
Trauma 4.0
Medical 2.4
Pediatric medical 1.0
Neurologic 1.2
References for Bench 1.. Wenzel RP, Edmond MB. The impact of hospital-acquired
mark bloodstream infections. Emerg Infect Dis 2001; 7:174-177.
2.Jonathan R. Edwards, Kelly D. Peterson, , Mary L. Andrus,
November 2008.
3.Victor D. Rosenthal, Dennis G. Maki, Ajita Mehta et al.
Control 2008;36:627-37.
6.5.3 Urinary catheter related infection

Indicator Urinary catheter related infection
Description Incidence of UTI per 1000 catheterized day in patients
catheterized in the unit but were not infected on the day of
catheterization.
Rationality Prevalence wise Urinary tract infection is most common. It
increase morbidity if not mortality, cost , and stay.
Formula for calculation Number of UTI
X 1000
Number of catheter days
Patient population All patients catheterized in the unit and were without infection
on day one of catheterization
- 14 -
Source of data Data collected in the unit

Type of parameter Infection , safety,Outcome
Bench mark1 Burn 7.7
Coronary 4.4
Neurosurgical 6.8
Surgical 4.1
Trauma 5.7
Medical 4.1
References 1.Jonathan R. Edwards, Kelly D. Peterson, , Mary L. Andrus,
November 2008.
2. Victor D. Rosenthal, Dennis G. Maki, Ajita Mehta et al.
Control 2008;36:627-37.
6.6 Human resource :

Adequate and competent staff can ensure delivery of quality oriented service. Therefore,
adequacy of human resource and its development are important issues. The unit should pay
attention to monitor attrition rate. Leader of the team should interact with internal, external
agencies, ICU staff to ensure delivery of predecided standard of care. Positive culture to
encourage innovation , autonomy, empowerment, safety, ethical standard, staff satisfaction,
should also be developed to achieve goal of the unit and the organization. Overall employees‘
satisfaction is advocated in this report.
6.6.1 Overall employee satisfaction

Indicator Overall employee satisfaction
Description Satisfaction level of the staff working in the hospital/unit.
Rationality Satisfied work force gives better output. Retention rate remains
high.
Formula for calculation On a 1 to 5 point scale where 1 represents lowest satisfaction and
5 indicates highest possible satisfaction.
Population Staff working in the unit
Source of data Employee satisfaction survey
Type of parameter Human resource
Bench mark 4 score best in class
References Sharp health care ,2007 Malcolm Baldrige National Quality
Award application 2007,
6.7 Customer focus: Perception of patients and their relatives about the care received is an
important determinant for forming public opinion. If care perceived is not good then it causes
customer (Patient, relatives) dissatisfaction. Patient and family‘s satisfaction level should never
be ignored and regular attempt to assess the gap between actual level of care (based on the survey
- 15 -
by health care provider and other quality parameters discussed above ) and perceived level of
care(customer dependent), should be made. Patient satisfaction is included for this report. In units
where most of the patients, due to their physical condition, are not in a position to give feedback,
relative‘s opinion can be taken.
6.7.1 Patient satisfaction ( Customer satisfaction)

Indicator Patient satisfaction
Description Patients‘ satisfaction is a perceived parameter by the patient.
Rationality Reflects performance of the hospital as perceived by patients
( customer )
Satisfaction of the customer is directly related to financial return

to the hospital and also reveals institutions credibility in the
population it functions. It also gives opportunity for
improvement.
Formula for calculation Survey can be conducted by external agency to eliminate bias or
on regular basis feedback forms can be collected for analysis.
Feedback forms should address areas such as :

admission/registration process, facilities, food, interactions with
nurses and physicians, discharge process, personal issues, overall
assessment of the care and other services
Feedback form with 10 point scale can be used where 10 is for

the best possible service. Patients give a rating for all the
questions. Overall mean (average) score for each service is
calculated from the rating given by each patient.
Patient population All patients admitted in ICU , who are capable of giving feed
back
Source of data Feedback forms
Type of parameter Customer focus :Perceived quality of service
Bench mark Satisfaction level to Physician‘s communication(always well
communicated?) = 80%, nurses‘ communication(always well
National average USA communicated?) = 74%, cleanliness(always clean) = 70%,noise
2008 (quiet at night ?)= 56%, Responsiveness(always responded ?) =
63%, Pain management(always well controlled?)=
68%,Communication about medicine ( always explained) = 59%,
Discharge information =80%,Will you recommend the hospital =
68%,Is it the best hospital? = 64%
Note: Methodology of collecting data influences the parameter

and therefore uniformity is essential.
References Available at :
http://www.erlanger.org/quality/PatientSatisfaction.asp
- 16 -
7. Dash board :
Based on the selected parameters, dash board has been prepared for systematic data entry of the
parameters. Participating centers are expected to use the dash boards and send the same to the central
body for review, analysis, and to collate available data for preparing national data base. Following
acceptance of this dash boards, formula for automatic calculation of performance parameter will be
incorporated. Annexure 7
8. Limitations and concerns:

1. Very common parameters have been selected in this report. Stress has been given on
mortality, morbidity, infection and safety of patients. Acceptability and utility of these
parameters in the Indian scenario will have to be assessed over a period of time.
2. Diagnosis of VAP is controversial. Clinical and radiological diagnostic criteria are given in
this report for ease of application in Indian scenario.
3. Compliance to protocols had not been given more importance because at initial stage
monitoring will be difficult in most of the units and therefore generation of corrupt data is
possible. Similarly only overall satisfaction of employees has been suggested in this report
even though satisfaction level can be judged by various means.
4. Certain institutions might have reservation in sharing their data base while due to lack of
logistic support many institutions might find difficulty in generating regular and meaningful
data.
5. Considering wide variability of practices and resource in Indian intensive care units, initial
data base might not represent actual level of care in quality oriented units in India.
6. Till national data base starts generating data specific to specialized units, comparison for such
units will be difficult.
7. All bench marks included in this report do not represent national bench marks. Whenever
national bench marks could not be found, bench marks have been taken from the figures given
in reputed journals but these could be different from the national averages.
8. All participating institutions might not be comfortable in monitoring all the suggested
parameters.
9. NICU related bench marks had not been mentioned in the report.
9. Future course of action (as suggested by this task force):
This report is only the beginning of the broad based objective of quality orientation in Indian
scenario. Future direction, therefore, is necessary to achieve its final objective.
9.1 Generation of national data base: Authenticity of data due to variable system of data
collection (manual vs electronic), variability of practice, infrastructure, support etc will be the
biggest challenge in forming a national data base. Institutions, therefore, will have to be selected
based on prefixed guidelines for contribution to national data base. Compliance to national level
guidelines, surveillance system, reporting frequency set by ISCCM and commitment to provide
correct data should be part and parcel of such guideline. Steps will be necessary to ensure data
collection, collation, stratification and analysis of data to make it meaningful for the end user.
Responsibility will have to be given to a central body / institution with adequate support to
accomplish this job on regular basis.
9.2 Data base for specialized units: This is a future consideration so that national data base is
available for units looking after specific subset of patients.
- 17 -
9.3 Inclusion and exclusion of parameters: Many new parameters will have to be included to
address the need of the intensive care units managing specific subset of patients and accordingly
national bench marks will have to be decided. All the institutions might not be willing to compare
their results against all the parameters selected at national level. Liberty should be given to the
institutions to select few optional parameters while monitoring mandatory parameters. Decision
will have to be taken to identify mandatory parameters. Utility of certain parameters over a
period of time might have to be questioned and decision to take them off dash board will have to
be taken from time to time. This happens when the unit appreciates that the parameters are not
helping any more in bringing a positive change.
9.4 Evaluation of Performance level: Institution can match their performance against the
national data base. While granting accreditation to institution for IDCC, fellowship in critical care
and inclusion as participating institution for the national data base , performance level of the
institution should be taken into consideration. National data base subsequently may be compared
with international bench marks.
9.5 Research , qualitative improvement: National data base can be used for improvement cycles
(―Plan – Do- Check - Act‖ i.e. PDCA) to bring qualitative improvement in the unit and even at
national level.
9.6 Public reporting: Public reporting should be the ultimate objective of the whole exercise so
that patient and their relatives can take a conscious decision while selecting an institution for its
offered services and performance levels. However, to prevent misuse of national data base and
inappropriate projection for boosting the image of the institution or financial gain for the
institution ; right to use the data base should be restricted .Public reporting should be allowed
only with prior approval of the ―ISCCM quality parameters body‖, which could be formed and
authorized to give such permission.
9.7 Audit system: Periodic auditing of institution interested in post doctoral course , contributing
data for national data base and public reporting of their performance against national data base
,should be done to maintain uniformity of standards set by ISCCM. Audit team should be formed
by the national body to address this issue. Methodology for auditing, scoring system and a cutoff
limit should be set for this purpose.
9.8 ISCCM quality parameters body : Formation of a team will be essential to address various
aspects related to maintaining , updating data, formation of audit team, audit schedule, auditing
system, training , amendments in national dash board, inclusion exclusion and modification of
parameter, and to address any dispute related to quality parameters.
9.9 Bench marks: Periodic amendment of bench marks given in this report will be necessary
with the availability of newer bench marks from developed countries and national data base.
10.Recommendations:
1. Following approval of this report, pilot implementation of advocated dash board in
selected few institutions is recommended with monthly updating of the dash board.
2. Based on the experience of the participating institution and central body while developing
the national data base , further amendments can be done.
3. Future steps suggested above can be considered in phased manner subsequently.
11 List of symbols:
Symbols Definitions
Agencies:
AHRQ Agency for Healthcare Research and Quality
JCAHO Joint Commission on Accreditation of Healthcare Organizations
NNIS National nosocomial infection surveillance system
CDC Center for disease control and prevention
- 18 -
Terminologies:
ISCCM Indian Society of Critical Care Medicine
SMR Standardized mortality rate
APACHE Acute physiology and chronic health evaluation
MPM Mortality prediction model
BUN Blood urea nitrogen
GFR Glomerular filtration rate
ARF Acute renal failure
LOS Length of stay
VAP Ventilator associated pneumonia
BSI Blood stream infection
UTI Urinary tract infection (catheter induced)
Units
ICU Intensive Care Unit
BCU Burn care unit
CCU Coronary care unit
SCU Surgical cardiothoracic unit
MICU Medical intensive care unit
M-S ICU major teaching Medical/Surgical , major , teaching intensive care unit
M- S ICU Medical/ surgical all others
PICU Pediatric intensive care unit
Neuro ( Med) ICU Neuro(medical) Intensive care unit
Neuro (Surg) ICU Neuro(Surgical) Intensive care Unit
SICU Surgical Intensive care unit
TICU Trauma Intensive care unit
12. Acknowledgement:
Task force members compliment national executive body for considering lack of quality
indicators and national data base as an important issue. It was an honor and privilege for the
members to be a part of this exercise which is first of its kind at national level and particularly in
the field of critical care. This is a humble beginning for a mammoth task waiting to be completed
.As chairman, I express my deepest gratitude to each member of the task force for his valuable
contribution in finalization of this report.
13. Additional references

1. Kohn L et al , Washington, DC: National Academy Pr.; 2000
2. To Err isHuman: Building a Safer Health System 1999 by Institute of Medicine (IOM)
3. Improving your ICU , Tips for better care. Society of Critical Care Medicine USA in
2004 Available at : info@sccm.org
4. The Center for Disease Control and Prevention estimates of health care associated
infections. Available at: http://www.cdc.gov/ncidod/dhqp/ hai.html. Accessed October 15,
2007
5. R. Monina Klevens, Jonathan R. Edwards, Chesley L. Richards et al Estimating Health
Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports /
March–April 2007 / Volume 122.
- 19 -
6. Daren Heyland ,Deborah Cook, Hamilton, ON , Peter Dodek, et al , The Canadian Critical
Care Trials Group, A Randomized Trial of Diagnostic Techniques for Ventilator-
Associated Pneumonia.NEJM.2006; 355:2619-2630
7. John Muscedere, Peter Dodek, Sean Keenan, Rob Fowler et. al. Comprehensive evidence-
based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and
treatment. - J Crit Care - 01-MAR-2008; 23(1): 138-47 (MEDLINE)
8. Michael Klompas, and Richard Platt. Ventilator-Associated Pneumonia—The Wrong
Quality Measure for Benchmarking Ann Intern Med. 2007;147:803-805.
********
- 20 -
Annexure:
1 Quality indicators in Critical Care : An overview Dr B Ray, Dr D P Samaddar
2 Patient safety Dr S K Todi
3 Personnel Development Dr Suresh Ramasubban
4 Quality of processes Dr George John, Dr N Ramakrishnan
5 Outcome Parameters Dr George John, Dr N Ramakrishnan
6 Infection Control Dr D P Samaddar

- 21 -
Annexure :1
Quality indicators in Critical Care : An overview
B Ray
D P Samaddar
Quality of care in medical practice in general and critical care in particular is the responsibility of
the care provider. Clinicians involved in providing the care therefore are morally and ethically
bound to enhance quality. Level of care varies among ICUs and within ICU. Even small
adjustments can significantly improve quality of care and patient outcome.1 Care before and after
improvement initiatives can be quantified provided attributes to measure the care are predefined.
Quantification of ICU performances, however, is a not an easy task because it depends on
multiple variables involving medical knowledge, ethics, economics, systems, engineering,
sociology, and philosophy. 2 Regular monitoring. of parameters is a labor intensive process.
Therefore, selection of quality indicators and prioritization should be done in such a way that
impact is maximum with minimum data collection.
Objective: Monitoring of quality indicators is done to identify level of care provided on a time
scale. Trend analyses of such data helps in quantifying the standard of care offered in the same
setup and compare the same with selected bench marks. Improvement initiatives are subsequently
taken, to bridge the gap between the levels offered and bench mark levels, as per need.
Whole issue of quality indicators in ICU will be discussed under two broad headings in this article
A: Conceptual basis
B. Selection and implementation of parameters
A: Conceptual basis of quality indicators: Quantification of parameters must have relevance to

patients, hospital and the society. Before selecting indicators it is therefore important to
understand the conceptual basis of quality in critical care.
Outcome parameter:
Success rate of the unit is of paramount importance. Basic reason of providing health care is to
improve outcome. Survival / mortality rate of the unit makes significant impact on the relatives of
the patients, hospital authority, and the general mass in that locality. Credibility of the unit is
judged to a great extent by its mortality statistics. 3. However, crude mortality is not a sensitive
parameter. If moribund and terminally ill patients mostly get admitted in the unit because
intensive care is being used as the dumping ground then mortality naturally will be higher.
Contrary to this higher success rate will be observed if unit manages patients who are mostly not
serious enough to deserve intensive care admission. Measuring the crude mortality rate therefore
can be misleading if it does not address changing patient profile.. 4 For better assessment mortality
should at least be correlated with severity status of the patients and disease state (case mix).2
Some scoring systems therefore should be in place to stratify severity status of the admitted
patients and link it with the outcome.
Morbidity indicators: Unanticipated developments or iatrogenic complications (examples given

in table No.1) indicate cost of poor quality (COPQ). Morbidities have important bearing on the
ultimate outcome, resource utilization, length of stay (LOS) and subsequent quality of life patient
enjoys. Monitoring of morbidity and steps taken to reduce the incidence helps in achieving the
primary goal of better outcome. LOS and better resource utilization are secondary objectives
which automatically get addressed to some extent with such approach.
- 22 -
Readmission and Length of stay: Judicious transfer of patients to ward is important to prevent
overstay. On the contrary overzealous and injudicious shifting can lead to readmission and
mortality. 1.5 to 10 time higher mortality and twice the length of stay (LOS) in readmitted
patients as compared to control patients have been documented in the literature. Premature
transfer can reduce ICU stay and expenditure 5 but at the cost of worse outcome. 6-8 LOS therefore
should also be correlated to ICU readmission within 24 hrs of transfer during a single hospital
stay. Reported ICU readmission rates are around 5–6% .9,10 Readmission rate of a given setup can
be compared with such bench mark data. Reduction in ICU readmission rate can be taken as
improvement initiative to reduce crude mortality.While doing so, a root cause analysis should be
done so that vital few causes are addressed primarily to get maximum benefit. Caution is
necessary while drawing conclusion from readmission data as many ICU readmissions are due to
poor post shifting care in the ward therefore linking ICU readmission to injudicious decision
making and quality of care in ICU would be illogical under such circumstances. 2 Target taken to
reduce such readmissions will make ICU team more defensive leading to prolonged and
unnecessary ICU stay. Higher risk of nosocomial infection and iatrogenic complications and
creating a strain on hospital resources will be the end result of such defensive approach. 4 LOS of
ICU is not very sensitive parameter unless it is linked with ultimate outcome. Short-term
outcomes like LOS should therefore be correlated to long term outcomes at least in the hospital
and preferably on a more long term basis such as survival adjusted for the quality of life ( quality-
adjusted life years).11
Cost effectivity and revenue generation: Resources are not unlimited. Higher expenditure in
intensive care units is a global concern. One day in an ICU costs $2,000 to $3,000, which is six
fold higher than those for non-ICU care. 5,12 This is more important if patient, generally
entertained in a given unit belonged to poor socio economic status, not covered by medical
insurance and also not supported financially by state for free medical care. This kind of situation
is more often a rule than exception in India. Considering this background, ICU expenditure/
patient/day is an important parameter. Attempts should be made to minimize it by taking local
factors into account while practicing evidence based medicine and international protocols. Cost
conscious units can maintain the same quality or offer a better quality with lesser and judicious
utilization of resources. There is no proportionate relationship between the cost and quality. USA,
despite being the most expensive medical care system, is not the leading nation in quality of care.
Cost effectivity is expected to be the natural fallout of efficient care. The benefit so accrued can
either be shared with the patients/ relatives by maintaining same quality at reduced charges or
enhancing offered service level without reduction in charges.
Economic viability of the unit is judged by the income generated after deduction of all expenses.
Higher management always measures the success in terms of revenue loss or gain. Analysis of the
expenses to identify expenditure on vital few and trivial many should be done. Measures should
be directed at vital few items to get maximum return. While doing this exercise, judicious cost
control should be done. Prevention of wasteful expenditure can significantly reduce running cost
of the unit.
Resource Utilization: Because ICU care is expensive, resource utilization should be optimum.
Assessment of resource utilization should be reflected in selection of quality indicators.2 Optimum
utilization of beds is essential to make the unit economically viable. Number of patients managed,
percentage occupancy, average length of stay (LOS) and occupied bed days (LOS of each patient
added in a predefined duration) etc. help in quantifying resource utilization and justifying the need
of future expansion. Deserving patients denied ICU care due to paucity of bed or equipment,
percentage of patients remaining in ICU who could have been managed elsewhere and patients
getting ICU care where intensive care is expected to be futile should be taken into consideration
while assessing judicious utilization of resources. 13- 15 Adherence to written or published ICU
admission and discharge standards can be used to measure the quality of ICU bed utilization, but
such standards have not been subjected to the scientific validation and therefore are not endorsed
- 23 -
for this purpose. 2 Proprietary systems such as APACHE III can be used to match units data with
the predicted ICU length of stay, days spent receiving mechanical ventilation, and the likelihood of
receiving active intervention. This approach is limited by the fact that APACHE III has been
validated only for the length of stay . 16 Despite the limitations in addressing this issue, local
protocol should be developed based on the scientific background and local factors.
Equipment utilization is an equally important dimension of resource utilization to justify future
procurement. Downtime in hours, revenue loss due to equipment remaining down, expenditure on
overall maintenance of equipment and equipment wise revenue generation (return on investment or
ROI) indicate the efficiency of maintenance support and skilled utilization of equipment by the ICU
team. Check list of all equipment should be updated in the unit on daily basis to monitor equipment
utilization and downtime.
Errors and patient safety: Focus should be both on safety of patients and care providers. The
2005 Critical Care Safety Study, published in the August 2005 issue of Critical Care Medicine,
reported that adverse events in ICUs occur at a rate of 81 per 1,000 patient-days and that serious
errors occur at a rate of 150 per 1,000 patient-days, supporting the findings of an earlier study
indicating that nearly all ICU patients suffer potentially harmful events. According to another study
conducted in an Israeli ICU , errors were observed to occur in 1% of all the activities performed
each day and incidence was higher with physicians than nurses.5,12 Nearly half (45%) of the adverse
events were deemed preventable in the Critical Care Safety Study.17 Medical errors and hospital-
acquired complications often lead to disability, large costs and mortality. 27,000 to 98,000
preventable deaths/ year had been reported in USA due to medical errors which is a matter of great
concern. 18 – 22 Situation is not expected to be better in other countries. Common ICU errors are
treatment and procedure related. Medication errors result in more than 770,000 injuries and deaths
each year at a cost of up to $5.6 million per hospital, depending on size in USA. 23 Communication
failure while ordering prescription or carrying out medication orders and compliance to protocols
are often the important causes of errors. 24,25,26 More disturbing fact is the denial by physicians and
nurses that the error was committed by them. In one study, one third of ICU nurses and physicians
denied having ever made an error in the ICU, whereas at the same time they said that many errors
are neither acknowledged nor discussed.5,12
Errors could be due to various reasons. Shortage of man power, deficiency of trained manpower,
injudicious work pressure, inadequate infrastructural and equipment support, lack of protocol, and
personal issues are the few important causes of errors. These factors should be addressed before
blaming a person. Complacent attitude and lack of commitment could also be responsible for
certain errors though it is infrequently observed in a sensible unit.23,27 Majority of errors are not
caused by individual inadequacies but are a product of defects in the system of care. 4 Therefore,
before doing error surveillance, ambiguity of practice in offering various services should be
eliminated. Care providers must know what is expected from them. Guidelines, protocols, systems
and processes developed locally with reference to national/international guidelines and
recommendations should be in place. 23 Protocols should be in written form and adequate training
should be given to the people who are expected to follow the protocol. 28 Development of local
guidelines/processes etc. should be done in consultation with the stake holders to break the
resistance and to create a sense of ownership. This exercise should be done in piecemeal and
training should be imparted as the systems and processes are being developed and implemented.
Noncompliance to monitoring and record keeping should be done regularly to find out the
magnitude of problem and area of concern.29 Writing protocols is relatively easy but
implementation of the same and to conduct compliance monitoring are difficult to accomplish.
Non-adherence to established standards of care have been related to poor outcomes.4 Only 50 to
70% of Americans receive the care that is recommended for their condition 30 and 20 to 30%
receive inappropriate medical interventions. 18, 31-34 Parameters should also be selected to ensure that
- 24 -
care providers are not exposed to undue risk. Audit can also be done at prefixed intervals by
internal and external agencies to find the safety standard of the unit. Corrective measures can
be taken accordingly. In authors‘ view, error documentation and analysis is expected to pay rich
dividend in quality oriented and matured unit where acceptance of deficiency is not considered as a
failure rather viewed as an improvement opportunity. More practical approach for beginners would
be to select mortality, morbidity and resource utilization parameters. Introspection drive for error
documentation and analysis can be given priority when the unit is ripe enough to accept the
deficiency without being defensive about it.
People: Efficient, motivated and trained man power is the backbone of any critical care unit.
Training is must for maintaining and further up gradation of skill of the ICU personnel. Imparting
training based on identified need is essential for any sensible unit. Days or hours of training
should be monitored as a parameter. 29 Effectiveness of training in form of reduction of repetitive
errors, is however the end product of good training.
Although certification for critical care nurses is not mandatory but certification comforts patients
and employers that a nurse is qualified and had gone through rigorous training requirements to
achieve the additional credential.23 Same is true for the doctors involved in the unit. Efficiency of
work force should also be monitored based on the targets given to them in relation to certain key
result areas.
Satisfaction level of staff is very important. Higher turnover due to dissatisfaction causes wastage
of time and money on staff training. Quality of care goes down due to higher turnover.
Replacement of trained and motivated manpower is not good for the unit. Satisfaction level and
staff turnover should therefore be taken as performance parameter of the ICU. 2 Many survey
tools are available to assess this aspect.
Customer Focus: Care provided should be perceived and appreciated by the patients and
relatives. Concern and empathy should be exhibited by the natural action of the care provider.
ICU patients or their surrogates are often dissatisfied with the amount, nature, and clarity of
communications by care givers. These contacts, which are often delayed and too brief, lead to
confusion, conflict, and uncertainty about the goals of therapy. 2 Communication protocol and
complain capturing and handling system prevents confusion and conflict. Patients and their
relatives should be encouraged to give suggestions and to express their feelings. Number of
complains/suggestions lodged and addressed could be taken as parameters. Mere distribution of
feed back form, though is easier, often does not serve the purpose if educational background of
feed back givers do not match with the expectation of the surveillance team. Instead of routine
ritual of passive surveillance, effort should be made to explain and assist the relatives of patients
or patients before giving them feed back forms. They should also appreciate the need and
importance of surveillance otherwise they might ignore such request. They should also be
encouraged to give feed back without hesitation and fear. Such active surveillance is expected to
be a better alternative and helps in identifying actual difficulties and expectations of the target
population. Uninhibited feed back is possible if care providers are not part of such surveillance.
Trained third party involvement for conducting the survey and analysis is a better but a costlier
alternative. Care providers can help in designing the feed back format based on the past feed
backs and area needing more attention. Efficient customer feed back system also helps in
identifying expectations of the community. Quality indicators should be selected keeping these
concepts in mind. Frequency, method of surveillance and analysis should be predefined. ICU
management should do compliance monitoring and keep the necessary documents for review.
Corrective action taken should get reflected in the subsequent satisfaction survey; provided
methodology remains the same.
Variation in standard of care: Variation in care is mostly due to geographical location, type of
hospital, and physicians‘ preference. These variations can be tackled to a great extent by protocols
developed based on international guidelines and evidence based medical approach.
- 25 -
Resistance offered by individual clinician or group of clinicians could be the road blocks while
implementing the protocols and systems. Protocol based approach might be viewed or projected
as restriction in the authority and autonomy of individual clinician but keeping objective of
evidence based medicine in view such variability should be curbed. Supportive administration can
help in overcoming such resistance. While developing local protocols, individuals‘ or groups‘
opinion should be honored as much as possible. Once protocol is developed, compliance of these
is expected from them. Monitoring of compliance and need based action is the responsibility of
ICU management with the help of hospital authority.
Variation in care due to financial status, and insurance coverage could be difficult to address. In
one study, 200 to 400% variation was noted in the use of pulmonary artery catheter due to ICU
organization and staffing pattern, 38% due to racial variation and 33% was in relation to patients
insurance status. 34
Table : 1 Suggested measures of ICU performance
Indicators Parameters
1 Mortality ICU:Crude , Severity adjusted, Disease based

Hospital mortality
2 Morbidity Incidence Of:

Accidental extubation,Reintubation in planned
extubated patients, pneumothorax,
Unanticipated cardiac arrest, hypotension, renal failure
%Nosocomial infections (VAP , BSI,UTI)
%of patient with VRE, MRSA etc.
% of patients with GI bleed
Pressure sore, dental trauma, nerve & vascular injury.
ICU readmission within 24hours
3 Cost effectivity Patient/ICU day cost to the institution.
Actual expenditure on
Man power cost, capital equipment cost
Equipment maintenance, consumables,
Diagnostics, house keeping, electricity etc.
Overall expenditure in ICU Expense
(post ICU) in hospital Expense (post
hospital) after discharge Long term
survival and quality of life
Per survivor cost in ICU/ hospital / post discharge
4 Safety of patient Error reporting : incidence of different errors
complication rates related to care Number
of complications/ patient Incidence of
mishaps during transportation
% compliance to waste disposal
% compliance to hand hygiene protocol
Blood component therapy
Frequency of Noncompliance to protocol.
Antibiotic free stay ( days) in ICU
Antibiotic resistance & Drug resistant microbial
pattern
Broad spectrum antibiotic use/1000 patient days
Descalation in % of patients receiving antimicrobials
- 26 -
Indicators Parameters
5 Safety of ICU personnel Number of needle stick injuries
Number injured while working
6 Man power Per Person training (in hours or days) /Yr
Appraisal of targets given.
Staff satisfaction and turnover rate
7 Resource utilization ICU:
Infrastructure Number of patient managed, %bed occupancy,
Av. LOS, total occupied bed days,
% ICU patient ideally should be shifted but remaining in ICU
number of readmissions, fraction of patients
for whom ICU care is expected to be futile, number of X
rays done / 1000 patient days.
Average ventilatory days
Equipment Utilization in days or hours/ month

Downtime in days or hours/ month
ROI (Return on Investment) of individual equipment
8 Customer external % satisfaction level of patient/relatives
Number of negative and positive fee backs
Number of complains/ suggestions & number
addressed.
Internal Customer Satisfaction of others in the hospital with the care and
services supplied by the ICU.
9 Administrative Revenue generation
B ) Selection and action plan for implementation of indicators :

Selection: It is practically not possible to select all the parameters discussed above. Therefore,
2
while selecting the performance measures certain basic principles should be kept in mind.
1) Evaluate varieties of parameters that cover the dimensions of ICU performance.
2) Select performance measures that are primarily relevant or that have a proven relationship
with the primary objective of the unit.
While selecting parameters focus should be on the ultimate outcome of the patient. Therefore,
selection of mortality parameters is mandatory. High impact morbidity parameters should also
be taken into account to reduce mortality. Resource utilization and financial results are
essential from administration point of view. Similarly satisfaction level with the care and
communication is of paramount importance to judge the customers‘ perception. Critical care
team members generally need not test the validity, reliability, and responsiveness of every
quality indicators they choose, but they should ascertain that attributes of the indicators have
linkage with the objective of the unit. 35
Following this other parameters having bearing on the morbidity and mortality such as : error
reporting and analysis, safety, compliance monitoring, training etc. should be included based
on the specific requirement of the unit. Willingness and courage to accept criticism and desire
to enhance quality through self introspection are prerequisites for error reporting and analysis.
Mutual understanding between doctors, nurses, other staff and ICU directors is also important
for embarking on error reporting exercise. While doing error reporting it is imperative to
understand that despite potential relationship of errors/adverse events with morbidity,
mortality and cost 19 all events do not lead to clinically relevant consequences.11 Adverse drug
events (ADEs) should always be monitored 23 due to its direct linkage with morbidity.
Underreporting and surveillance problems make the data collecting system porous. It has been
- 27 -
claimed that incident reports, or chart reviews are inefficient, inaccurate, and debatable means
of data collection. 4 Similarly cultivation of safety consciousness is also essential before safety
practices are introduced and parameters are selected to monitor the safety standards. 24 Safety
self assessment and personal safety plan helps in paving the way for bringing a safety
consciousness in the unit.
Action plan:
1.Target setting and bench marking: Current level of performance and bench mark data help in
deciding the future targets. For example if reintubation rate is considered as the perceived
problem and needs attention then the gap between the current level of reintubation in the unit and
bench mark should be identified. Literature background of bench mark and method adopted for
collecting the data should also be noted for future reference. Reported reintubation rate in patients
receiving mechanical ventilation is 12.2% within 48 hrs of extubation based on the published data
of large international survey conducted by Esteban et al in 2002. 36 This target can be used as
benchmark, provided unit is planning to collect similar data for comparison. An overstretched but
realistic target should be selected with appropriate action plan to achieve the target. However,
such approach can not be used always because database is scarce and incomplete; therefore
comparing each parameter might not be possible. 37 Comparison with the unit‘s own data can be
done in such situations. More over influence of nonphysiologic parameters, such as
socioeconomic factors should not be ignored while linking the monitored parameter with the main
objective i.e mortality, morbidity outcomes. 2 Due to these reasons direct comparison with the
bench mark data from a different socio economic background might not be always logical.
Reducing the incidence might not be the desired goal always. For example reducing the
readmission and reintubation to zero level would be ideal but would be associated with
unnecessary stay and prolonged ventilation respectively. 4 Sometimes availability of appropriate
bench mark could also be difficult. If 41% reintubation rate in unplanned extubation in the above
mentioned survey is compared with observation of 12.2% reintubation in planned extubation,
then it becomes evident that deciding optimal time of extubation and acceptable rate of
reintubation is not an easy task. 38 Similarly it is not plausible that error levels will be zero, the
goal should be reduced error rate to an acceptable level or below what it was previously present
in the setup. Presence of error does not always prove that the overall performance is poor
therefore target setting and interpretation of result should be done with care. 2 The Joint
Commission on the Accreditation of Healthcare Organizations (JCAHO) has developed eight ICU
Core Measures. Ready made tools are also available that can assist in measuring individual unit‘s
performance. [ Available at : JCAHO Project Impact CCM, Inc.]
2.Data collection: Hospital Management System (HMS) should be robust enough to generate
data and analyze the same based on the fed information to minimize man power utilization and
errors. 4 Information collected by computerized system is superior to that collected by humans,
especially if the system is specifically programmed to acquire the desired information. ICU team
should remain involved if a tailor-made soft ware is being used. Specific need should be identified
and introduced by ICU professionals while the software is being developed.
Manual data collection is possible but computerized physician order entry (CPOE) system
automatically detects errors in unbiased manner and thus improves quality care by reducing costs
and errors. 2,23 In absence of this, data collection and incidence reporting by individuals is the
only viable alternative. Predefined criteria for data collection should be established with least
dependency on human judgement. It is always better if ICU personnel collect data rather than
relying on the health-care workers. 2 Ownership and accountability should be fixed for data
collection, monitoring and maintenance of score board.
3.Trend analysis: Score Card should be prepared to accommodate vital parameters based on the
monitored parameters. Score Board should depict overall performance of the ICU. This helps in
- 28 -
systematic collection of data, monitoring of important parameters at a glance and also conduct
trend analysis. While selecting the parameter, whenever possible correlate the desired parameter
(numerator) with another parameter (denominator) to make it more meaningful. For example
number of adverse events (numerator) can be expressed as the rate of events by dividing the
absolute number with a denominator like aggregate number of at-risk patients, patient-days etc. 2
Irrespective of the data type, care must be taken to collect a sample size that is large enough to
allow reliable statistical comparisons. 2 Suppose monthly tracking shows that a particular
parameter fluctuates between 0% and 6%, then while doing the trend analysis over a period of
time a difference in the parameter within the acceptable limit should not be considered as
deterioration in service. Thus, it is important not to over-interpret short-term changes in
performance measurements while evaluating the same. 2 Frequency of data analysis is therefore
important. Short term analysis can show wide variation in the parameters. Standardization and
accuracy of data collection is also important for subsequent analysis and comparison. For example
measuring the number of calendar days a patient spends in the ICU is likely to overestimate LOS.
Accuracy will be better if exact number of hours occupied or the number of days with midnight
bed occupancy is taken into account for LOS calculation. 39 Proper statistical analysis is also
important for avoiding misrepresentation of data. If the arithmetic mean is used to calculate LOS
in the ICU, it will often misrepresent the population because LOS data are skewed by atypical
stays of few patients. Reporting the median, mode, or geometric mean will more accurately reflect
the central tendency of the data .40 Standard deviation and range will also be informative while
interpreting LOS data and instituting improvement initiatives.
4. Continuous improvement Data collection alone by any means is an insufficient guarantor of

the delivery of quality medical care because it merely facilitates and does not ensure a predefined
care unless process modification and corrective actions are taken for continuous improvement.4
Analyzed data indicates the direction care provider should take to bring a positive change. PDSA
cycle (Plan, Do, Study, and Act) should always be followed to bring a qualitative change in the
performance. This cycle is repeated after achieving the desired goal and while setting new goals.
41
Common tools used while following the PDSA cycle are : brain storming, cause and effect
diagram, prioritization of ‗vital few‘ causes, corrective action, and monitoring of impact . Process
improvement is needed even for data collection to prevent it from becoming burdensome . 4
5.Team building: Contribution of ICU team and involvement of each member is vital for
qualitative and sustained change in the unit. It is also important to appreciate that a close working
group of dedicated healthcare providers can be as, if not more, important than the written
protocol. 4 ICUs offering a ―closed‖ model of care (in which ICU care and admission and
discharge decisions are made exclusively by intensivists or in consultation with intensivist), have
shown better outcome parameters and shortened LOS . 42 . An association of leaders of industry
from the Business Roundtable, the Leapfrog Group, has advocated for the widespread
implementation of the intensivist model of care in the ICU 43. Same recommendation
subsequently had been given by the National Quality Forum. 4
Conclusion: Quality indicators act as the yard stick to measure the level of care offered in a unit
over a period of time. Variation in care in the unit and among different units with similar case mix
can only be done if indicators are compared on regular basis. Quality of care in ICU depends on
the complex interaction between patient, machine and care providers. Process driven and protocol
based management should eliminate ambiguity and ensure better outcome. Such approach is not
possible unless care provided is quantified and gap between current level and desired level is
assessed followed by improvement initiatives taken to bridge the gap. Selection of indicators and
monitoring the same therefore should be considered as the most vital and challenging task to bring
continuous improvement in the performance level of the unit.
- 29 -
References :
1. Margaret M. Parker.A letter from the president. SCCM President, 2004 SCCM President,
2004
2. Allan Garland, critical care reviews Improving the ICU Part 1CHEST 2005; 127:2151–
2164
3. Joint Commission on Accreditation ofHealthcare Organizations has also identified hospital
mortality of ICU patients as the core measure Available at :
http://www.jcaho.org/pms/core_measures/icu_manual.htm.
4. Tracy R. McMillan, Robert C. Hyzy. Bringing quality improvement into the intensive
care unit. Crit Care Med 2007; 35[Suppl.]:S59–S65.
5. Norris C, Jacobs P, Rapoport J, et al. ICU and non-ICU cost per day. Can J Anaesth 1995;
42:192–196. ( cross reference)
6. Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet
2000; 355:1138–1142. ( cross reference)
7. Beck DH, McQuillan P, Smith GB. Waiting for the break of dawn? The effects of
discharge time, discharge TISS scores and discharge facility on hospital mortality after
intensive care. Intensive Care Med 2002; 28:1287–1293. ( cross reference)
8. Daly K, Beale R, Chang RWS. Reduction in mortality after inappropriate early discharge
from intensive care unit: logistic regression triage model. BMJ 2001; 322:1274–1276.
(cross reference)
9. Metnitz PG, Fieux F, Jordan B, et al: Critically ill patients readmitted to intensive care
units: Lessons to learn? Intensive Care Med 2003; 29:241–248. ( cross reference)
10. Rosenberg AL, Watts C: Patients readmitted to ICUs*: A systematic reviewof risk factors
and outcomes. Chest 2000; 118:492–502. ( cross reference)
11. Kerridge RK, Glasziou PP, Hillman KM. The use of ―quality-adjusted life years‖
(QALYs) to evaluate treatment in intensive care. Anaesth Intensive Care 1995; 23:322–
331. ( cross reference)
12. Luce JM, Rubenfeld GD. Can health care costs be reduced by limiting intensive care at the
end of life? Am J Respir Crit Care Med 2002; 165:750–754. . ( cross reference)
13. Atkinson S, Bihar B, Smithies M, et al. Identification of futility in intensive care. Lancet
1994; 344:1203–1206. ( cross reference)
14. Spielman B. Collective decisions about medical futility. J Law Med Ethics 1994; 22:152–
160. . ( cross reference)
15. Luce JM, Alpers A. End-of-life care: what do American courts say? Crit Care Med 2001;
29:N40–N44. ( cross reference)
16. Knaus WA, Wagner DP, Zimmerman JE, et al. Variations in mortality and length of stay
in intensive care units. Ann Intern Med 1993; 118:753–761. ( cross reference)
17. Critical Care Safety: Essentials for ICU PatientCare and Technology.available at
www.ecri.org/criticalcare
18. Starfield B. Is US health really the best in the world? JAMA 2000; 284:483–484
19. Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human. Washington, DC: National
Academies Press, 2000.
20. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in
hospitalized patients:results of the Harvard Medical Practice Study . N Engl J Med 1991;
324:370–376
21. Zhan C, Miller MR. Excess length of stay, charges and mortality attributable to medical
injuries during hospitalization. JAMA 2003; 290:1868–1874.
22. Haywood RA, Hofer TP. Estimating hospital deaths due to medical errors. JAMA 2001;
286:415–420
23. Tips to improve care in your ICU. Available at www,sccm.org/tips
24. Critical Care Safety: Essentials for ICU Patient Care and Technology.available at
www.ecri.org/criticalcare.
- 30 -
25. Chang, S. Y., Multz, A. S., Hall, J. B. (2005). Critical care organization.Critical Care
Clinics, 21(5), 43-53
26. Pronovost, P. J., Angus, D. C., Dorman, T., et al. (2003, November 6). Physician staffing
patterns and clinical outcomes in critically ill patients: A systematic review. JAMA
2003 ;288 (17), 2151-2162
27. sample safety attitudes questionnaire from the University of Texas‘s (Houston) Center of
Excellence for Patient Safety Research and Practice is available online (available at
http://www.uth.tmc.edu/schools/med/imed/patient_safety/survey&tools.htm)
28. Garland A: Improving the ICU: Part 2. Chest 2005; 127:2165–2179.(Cross reference)
29. Quality in Critical Care -Beyond ‗Comprehensive Critical Care‘Quality Critical Care –
recommended actions for Strategic Health Authorities (SHAs)
30. Centers for Disease Control and Prevention. National Center for Health Statistics. Deaths
by place of death, age, race, and sex: United States, 1999–2002. Available at: http://www.
cdc.gov/nchs/data/dvs/mortfinal2002_work309.pdf. Accessed February 21, 2002
31. Schuster MA, McGlynn EA, Brook RH. How good is the quality of health care in the
United States? Milbank Q 1998;76:517–563. ( Cross reference)
32. Chassin MR, Kosecott J, Park RE, et al. Does inappropriate use explain geographic
variations in the use of health care services? JAMA 1987; 258:2533–2537. ( Cross
reference)
33. McNeil BJ. Shattuck lecture: hidden barriers to improvement in the quality of care. N
Engl J Med 2001; 345:1612– 1620. ( Cross reference)
34. Rapoport J, Teres D, Steingrub J, et al. Patient characteristics and ICU organizational
factors that influence frequency of pulmonary artery catheterization. JAMA 2000;
283:2559– 2567. ( Cross reference)
35. J. Randall Curtis, Deborah J. Cook, Richard J. Wall, Derek C. Angus. Intensive care unit
quality improvement: A ―how-to‖ guide for the interdisciplinary team. Crit Care Med
2006; 34:211–218 (Review article)
36. Esteban A, Anzueto A, Frutos F, et al: Characteristics and outcomes in adult patients
receiving mechanical ventilation: An international survey. JAMA 2002; 287:345–355)
37. Antonio O. Gallesio, Daniel Ceraso,Fernando Palizas. Improving Quality in the Intensive
Care Unit Setting. Crit Care Clin 22 (2006) 547–571
38. Berenholtz SM, Dorman T, Ngo K, et al:Qualitative reviewof intensive care unit quality
indicators. J Crit Care 2002; 17:1–12.
39. Marik PE, Hedman L: What‘s in a day? Determining intensive care unit length of stay.
Crit Care Med 2000; 28:2090–2093. (Cross reference)
40. Weissman C: Analyzing intensive care unit length of stay data: problems and possible
solutions.Crit Care Med 1997; 25:1594–1600. (Cross reference)
41. Rosmin Esmail, Ann Kirby , Thelma Inkson, Paul Boiteau. Quality improvement in the
ICU. A Canadian perspective. Journal of Critical Care (2005) 20, 74–78.
42. Pronovost PJ, Angus DC, Dorman T, et al: Physician staffing patterns and clinical
outcomes in critically ill patients: A systematic review. JAMA 2002; 288:2151–2162.
(Cross reference)
43. The Leapfrog Group. Available at: http://www.leapfroggroup.org/about_us. Accessed
January 12, 2006.
- 31 -
Annexure 2:
Quality Indicators in Critical Care : Patient safety
S K Todi
Introduction
―To err is human‖, a seminal paper from Institute of medicine , USA in 1999 citing 44,000 to
98,000 deaths annually in USA due to medical errors which is roughly equivalent to a jumbo jet
full of passengers crashing every day, took the world by storm. This paper attracted huge media
attention and gave rise to a new ―safety‖ movement in medicine.
With increasing corporatization of health sector in India, there is a growing demand from the
consumers, regulatory authorities, and the government that health care providers adopt a culture
of ―safety‖ and hospital managers have taken this as the prime Quality initiative . ―primum non
norcere‖ – first, do no harm is being rediscovered and is the present day ―mantra‖ in health care
institutions all across the globe and to be competetitive internationally, we need to firmly put this
as the primary agenda of health care delivery in our country.
Epidemiology
Intensive care units have been the main focus of delivering safe health care, as the patient
population are at greatest risk of harm here, due to multiple interventions, polypharmacy, increase
workload, variability of staffing and patient related factors. Observers who attended ICU rounds
found that staff reported a serious adverse event in 17% of patients . Self-reports and direct
observations in a medical /surgical ICU found 1.7 error per patient per day, one third of these
were potentially harmful. With an average length of ICU stay of three days, it turns out that every
patient has a potential of serious error at least once during their icu stay.
Definition.
The term ―safety‖ is more diplomatic than ―error‖ as the latter implies direct fault of health care
provider. An error of ―omission‖ i.e. what we fail to do ( meeting standard of care ) is often
termed as ―quality‖ and error of ―commission ― i.e. what has already been done ( not meeting
standard) is termed ―safety‖ . Quality and Safety are two sides of the same coin and it is difficult
to know where quality ends and safety begins. Medical researchers have so far concentrated on
clinical management part of patient care and only lately has attention been given towards research
in implementation of therapy and safe patient care. In order to standardize and compare,
regulatory authorities have laid down definitions pertaining to safe patient care.
Patient safety: It is defined as the absence of the potential for, or occurrence of, health care–
associated injury to patients. It is created by avoiding medical errors as well as taking action to
prevent errors from causing injury.
Error: It is defined as mistakes made in the process of care that result in, or have the potential to
result in, harm to patients. Mistakes include the failure of a planned action to be completed as
intended or the use of a wrong plan to achieve an aim. These can be the result of an action that is
taken (error or commission) or an action that is not taken (error of omission).
Incident: unexpected or unanticipated events or circumstances not consistent with the routine
care of a particular patient, which could have, or did lead to, an unintended or unnecessary harm
to a person, or a complaint, loss, or damage.
Near miss: as an occurrence of an error that did not result in harm.

- 32 -
Adverse event: an injury resulting from a medical intervention.
Preventable adverse event: harm that could be avoided through reasonable planning or proper
execution of an action.
Measurement
As patient safety is a concept and an abstract term, converting it into numerical terms for research
and audit purposes is difficult. One also has to consider many dimensions of safe patient care. We
all try to practice safe patient care but when it comes to quantifying it certain basic principles need
to be followed.
Principles of management from industry are being increasingly incorporated in medicine and this
is most evident in regards to patient safety. Safe industries (e.g. aviation) reports defect rate in
terms of sigma or defects per 10,100 or 1,000 events. One sigma equates to a 69% defect rate and
six sigma equals three defects per million. Health care industries record is abysmal in this regard
which runs at one or two sigmas
Any quantification tool will be meaningful if it consists of a numerator (number of events
observed) and denominator (number at risk) so that a rate can be calculated. It is labour intensive
to keep a tab on rates of adverse event, and a more subjective approach may be appropriate some
time which acts to highlight problem areas to be specifically addressed in a more objective way .
Examples of such subjective approach will be peer review, morbidity and mortality conferences,
investigation of liability claims, and incident reports. In all of these, a single event is analysed
which is not linked to a denominator which limits the ability to estimate rates. Nonetheless, they
help to identify problem areas.
Incident report: It evaluates how a single patient is harmed but can also be utilized to look at
near misses i.e. incidents that did not but could have caused harm. The ICUSRS project pioneered
by Dr. Pronovost from Johns Hopkins is an example of such incident reporting system which is
web based.
To be successful an Incident reporting system should be voluntary , anonymous, and not linked
with any form of punitive measures . The ICUSRS system is open to participating hospitals and
personnel can entry incidents and near misses confidentially which is analysed centrally and
feedback is given . Over 1700 reports have been analysed in the system. In order to standardize
reporting system, hospitals are encouraged to report incidents in terms of patient variables,
exposure variables and outcome variables. A framework for evaluating such reports is also laid
down which analyses the incident reports under Patient factor, Provider factor , Team factor, Task
factor, Training and Education factor, ICU environment and Institutional environment.
Root Cause Analysis- This is a more focused enquiry on certain incidents which are deemed to
be important for patient safety. A sentinel event is identified and important preventive aspects of
this event is discussed by the ―safety‖ team and safeguards implemented.
Failure mode and effects analysis (FMEA) - Both the incident report and root cause analysis
are post hoc analysis which tries to improve patient safety after the incident has occurred . A
more proactive approach where a problem area is identified prospectively, and all possible
preventable aspects are discussed and remediable measures are taken . This approach takes away
the primary burden from an individual and focuses more on system failure. In an FMEA, an error-
prone process is identified and a multi-disciplinary team is formed to analyze the process from
multiple perspectives. The team systematically assesses failure modes and the urgency with which
each failure mode should be addressed. Where RCA can be thought of as an expanding circle of
inquiry that is focused on a sentinel event, FMEA is a linear process that examines a selected
process from start to finish. Conducting FMEA is highly time consuming and labor intensive, so
- 33 -
its use should be restricted to areas prone to serious adverse events .Regulatory authorities are
now making it mandatory in USA and UK for medical and nursing directors of ICUs to conduct
at least one FEMA annually.
Implementation
Implementing ―safety‖ culture in the ICU has to come from a strong leadership primarily from
ICU director , backed by a willing Management.
The first step in our country is to ensure that the health care providers are assured that no punitive
actions will be taken against them if an adverse event is identified or reported. In fact some
institution in India have started rewarding such bold steps of revealing errors to the authority.
The concept of ‗system failure‘ rather than ―individual failure‖ need to be enforced.
Secondly, a system of reporting adverse events have to be in place for audit or root cause analysis.
This system should be discreet and could be paper or computer based.
Thirdly, an audit of incident report, root cause analysis or FMEA should be performed
periodically by a multidisciplinary team consisting of ICU director, Nursing director, Quality
control personnel, and hospital administrator. Corrective measures should be identified and
feedback given to health care providers.
Finally, established practices for decreasing errors like Computerised Physician Order Entry
(CPOE) system, Patient identification tags, Check list for blood transfusion should be in place
and checked periodically for compliance.
There is a great need for research in this field in our country to identify areas of vulnerability , and
finding cost effective solutions to problems of patient safety.
References
1. The Critical Care Safety Study: The incidence and nature of adverse events and serious
medical errors in intensive care. Jeffrey M. Rothschild et al . Crit Care Med 2005; 33:1694
–1700
2. Failure mode and effects analysis application to critical care medicine. Beau Duwe et al .
Crit Care Clin 21 (2005) 21– 30
3. Defining and measuring patient safety. Peter J. Pronovost et al. Crit Care Clin 21 (2005) 1
– 19.
4. Monitoring Patient Safety. M. Berenholtz et al Crit Care Clin 23 (2007) 659–673.
5. The electronic medical record, safety, and critical care. William F. Bria II et al. Crit Care
Clin 21 (2005) 55– 79.
6. An irreplaceable safety culture Marta L. Render, MD et al Crit Care Clin 21 (2005) 31–
41.
7. Medication safety and transfusion errors in the ICU and beyond. Erfan Hussain, MD et al.
Crit Care Clin 21 (2005) 91– 110.
8 Safety in training and learning in the intensive care unit. John E. Heffner et al. Crit Care
Clin 21 (2005) 129– 148
- 34 -
Annexure 3
Quality indicators in Critical care : Personnel Development
Suresh Ramasubban
Historically the speciality of critical care started with cohorting of acutely ill patients into Separate
clinical areas. These discrete geographical areas were subsequently named Intensive care units.
With the advent of various new technologies, these specialized clinical areas became segregated
from other hospital wards and had personnel needs which were different from that of the other
hospital wards.
The delivery of care in the intensive care units require the presence of highly trained, skilled and
motivated personnel who can apply modern techniques and interventions in an appropriate fashion
to provide the highest quality of care.
Irrespective of the type of ICU‘s and their geographic locations, all ICUs have the responsibility to
provide services and personnel that ensure quality care to patients. With the Leapfrog initiative in
the US based on the Institute of Medicine‘s (IOM) report, commitment to high quality care is now
of paramount importance. Personnel Development is an integral part of this quality initiative. This
chapter will focus on ICU personnel development and quality initiatives focussed to personnel
development. This will be discussed under the following headings:
1) Definition of Staff in ICU

2) Training requirement
3) Staffing logistics
4) Quality measures
Staff in ICU:
Irrespective of the model of critical care delivery in an ICU, a multidisciplinary approach is

recommended by the SCCM. As an example Medication errors are reduced significantly in
hospital with intensivist staffing and multidisciplinary rounds. This involves the presence of
dedicated ICU personnel specifically the Intensivist, the ICU nurse, ICU pharmacist and
respiratory therapist.
An Intensivist is a physician who is trained in a primary speciality such as

Medicine/Anesthesia/Surgery/Chest Medicine) and has a certificate of special qualification in
critical care. He diagnoses, manages, monitors, intervenes, arbitrates and individualizes the care to
each patient at risk, in the midst of or recovering from critical illness. He/ She should be
immediately and physically available to patients in the ICU. The credentials should include both
cognitive and procedural skills.
ICU House staffs are either physicians in training or otherwise who are fully dedicated to the ICU
and have no other responsibility and are on site to provide all emergency care to the patient.
An ICU nurse should be a licensed nurse with preferably added certification in critical care.
Although certification is not mandatory but certification validates to patients and employers that a
nurse is qualified and has gone through rigorous training requirements to achieve the additional
credential.
- 35 -
ICU Pharmacist is defined as a practitioner who is a qualified pharmacist and has specialized
training or practice experience providing pharmaceutical care for the critically ill patient.
The presence of an ICU pharmacist as part of the ICU team improves quality of care in the ICU by
reducing medication error by as much as 66%.
Another important Personnel in the ICU is the Respiratory Therapist who provides cardio-
respiratory care to critically ill patients. The absence of trained therapist should lead to
establishment of training programs for Respiratory therapist
Training:
Training is must for maintaining and further up gradating of skills of the ICU personnel.
Imparting training based on the identified need is essential for any sensible unit.
In the absence of any certification, nurses working in the ICU should have periodic assessment of
competence by the nursing director with provision for feedback and need based education
curriculum. This competency assessment should be standardized according to nursing guidelines
of AACN.
House staff should have training in advanced airway management and ACLS Training.
FCCS/BASIC critical course training is recommended but not mandatory for ICU House staff.
Staffing Logistics:
ICU staffing pattern can be classified as low intensity (no intensivist or elective intensivist
consultation) or high-intensity (mandatory intensivist consultation or closed ICU (all care directed
by intensivist) groups. High-intensity staffing is associated with lower hospital mortality, lower
ICU mortality, reduced hospital LOS, and reduced ICU LOS.
The lack of adequate staffing of Nurses leads to delays in weaning patients, higher infection rates,
increased readmission rates, increased medication errors and increased length of stay. Excessive
Nursing workload as defined by ―hours per patient days‖ or ―nurse/patient ratios‖ is associated
with increased mortality in critically ill patients. Staffing pattern for nurses should take into
account patient load and case mix. The gold standard for staffing should be one nurse for each
critically ill patient.
Inadequate House staff leads to poor emergency care and poor continuity of care, adequate staffing
pattern should be taking into account patient load and acuity of care.
Quality Measures:
Quality measures in the ICU are predominantly medical outcomes related but since the ICU
provides service to relatives and friends, ICU personnel, the hospital and the society, other
parameters must also be used. These include economic outcomes, psychosocial and ethical
outcomes and Institutional outcomes.
Institutional outcomes like staff satisfaction and turnover rate are important measure of quality in
the ICU related to personnel. Higher rates of staff turnover leads to increased costs, increased
training time, decreased morale and increased stress on remaining staff, leading to decreased
quality of performance and worse patient outcomes.
- 36 -
Each ICU should measure and control regularly the efficiency of the use of nursing manpower
evaluating the work utilization ratio (WUR) by recommended scoring tools.
Measuring staff satisfaction is an important quality initiative. Staff retention rates should be
obtained from personnel records and data of job satisfaction should be obtained from
questionnaires or exit interviews.
Days or hours of training should be monitored to ensure quality of personnel development

Conclusions: A multidisciplinary approach with adequate ICU personnel and staffing pattern
combined with ongoing training and need based skill development and measurement of
institutional outcomes is necessary to provide Quality critical care.
Further Reading :
1. Critical care delivery in the intensive care unit: Defining clinical roles and the best practice
model.Crit Care Med 2001 Vol. 29, No. 10
2. Guidelines on critical care services and personnel: Recommendations based on a system of

categorization of three levels of care*Crit Care Med 2003 Nov;31(11):2677-2683
3. European Federation of Critical Care Nursing Associations, EfCCNa Position Statement on

workforce requirements within European Critical Care Nursing .2007
4. Tips to improve care in your ICU. Available at www,sccm.org/tips
5. Quality in Critical Care -Beyond ‗Comprehensive Critical Care‘Quality Critical Care –

recommended actions for Strategic Health Authorities (SHAs)
6. Pronovost, P. J., Angus, D. C., Dorman, T., et al. (2003, November 6). Physician staffing
patterns and clinical outcomes in critically ill patients: A systematic review. JAMA 2003 ;288
(17), 2151-2162
7. Garland A: Improving the ICU: Part 1 & 2. Chest 2005; 127
8. ISCCM Guidelines:Proposed Guidelines for ICU‘s in India
9. ISCCM Guidelines: critical care delivery in intensive care units in India

- 37 -
Annexure 4
Quality Indicators for ICU : Process Parameters
George John, N Ramakrishnan
The Critical Care Services in a modern hospital has a vital role to play in delivering prompt,
appropriate and adequate care to acutely ill patients. Acutely ill patients can present with a variety
of pathopysiological derangements which need rapid repeated interventions with constant
monitoring and further interventions based on the results of the monitoring process. These
interventions involve multiple components – all of which need to be seamlessly integrated to
optimize outcome. In a study in which engineers observed patient care in ICUs for twenty four
hours periods, it was found that the average ICU patient required 178 individual interactions per
day. These included a range of interventions from physical manoevers (such as positioning the
patient) to medication administration.
Quality and Safety are two facets of a system designed to deliver optimum care. The terms have
been separated as two components by defining Quality as referring to errors of omission and
Safety as errors of commission. Quality of care is an important issue because the cost of non-
quality in any enterprise is more expensive than investing in quality. Quality of Care is defined
as the degree of correspondence between goals set and goals achieved in relation to patient care
without excessive use of financial resources. Hence, Quality is the ratio of Standard Achieved /
Expected Standard. It is 1.0 if all standards are achieved.
Quality of care is a complex process that can be monitored on three levels:

1. Structure: This includes architectural design, staffing, nurse: patient ratio, bed
occupancy and all other components of structure related to quality.
2. Process refers to the current practice of care delivery – hand washing and
implementation of other guidelines belong to this domain
3. Outcome: Indicators of outcome such as nosocomial infection rates, mortality
stratified to severity of illness and other outcome measures are the most valuable
and readily recognised indicators of quality.
Quality In Processes:
1. Critical care services should employ best evidence practices, such as those
described in ‗care bundles‘.
2. Patients requiring critical care are entitled to the care given by dedicated, highly
skilled, multidisciplinary teams.
3. Critical illness has a great impact on the lives of patients and their families.
Decisions about care should be made in partnership between the critical care team,
the patient, and relatives.
4. Continuity of care and facilities are important throughout the patient‘s care period
but especially when stepping down to lower levels of care, to general wards or
home.
- 38 -
The 20 Fundamental Quality Indicators for Critical Care developed by the Spanish Society of
Intensive & Critical Care and Coronary Units (SEMICYUC) are:.
1. Compliance with hand hygiene protocols

2. Providing information to families of patients in the ICU
3. Appropriate sedation
4. Appropriate pain management
5. EGDT in sepsis
6. Early enteral nutrition
7. Prophylaxis for GI bleed in those undergoing invasive mechanical ventilation
8. Inappropriate transfusion of packed cells
9. Semirecumbent position for patients on invasive mechanical ventilation
10. Ventilator associated pneumonia
11. Prevention of thromboembolism
12. Early administration of acetyl salicylic acid in acute coronary syndrome
13. Early reperfusion therapy in STEMI
14. Monitoring ICP in severe traumatic brain injury with CT findings
15. Surgical intervention in traumatic brain injury with subdural and/or epidural haematoma
16. Protocols and implementation of with holding / withdrawing life support
17. Organ donation
18. Perceived Quality Survey at discharge from ICU
19. Presence of an intensivist in the ICU
20. Maintaining an Adverse Events Register
SAFETY: CRITICAL INCIDENTS:

Errors increase as a function of complexity. Medical error is rarely the result of the actions of a
single person. The cognitive process underlying decisions in a complex system such as critical
care are distributed not only across the minds of many clinicians but also across non living objects
such as handover notes and computers. Thus, flaws in distributed cognition leads to errors.
Critical incidents may be near misses or adverse events.
The phrase ‗error in evolution‘ denotes the progression of a series of small mistakes towards a
cumulative adverse event; erroneous decisions undergo a selection process based on their
anticipated consequences. The figure below illustrates the progression of error in critical care,
where clinicians conducting routine work hit a boundary and where they come close to making an
error. At this stage, the error can still be detected and corrected before the second boundary is
crossed, resulting in an adverse event.
Errors in any complex system progresses as follows:

- 39 -
Adverse Events are defined as those which have resulted in actual harm to the patient due to the
management of a disease process and not as a result of the underlying disease. A Near Miss is an
unplanned event that does not result in injury, illness, or damage; but has the potential to do so.
Only a fortuitous break in the chain of events prevents an injury, fatality or damage. Near misses
do not necessarily result in patient harm (but has the potential to do so). Analysing near misses
has the advantage of gaining insight into unsafe practices and to discover reasons why it did not
lead to an adverse event. Consider an iceberg where 90 percent is submerged under water. Fatal
adverse events are only the tip of the iceberg. Major adverse events comprise the visible portion
below the tip. The submerged section is divided into 2 layers. The minor adverse events are just
below the surface of water and the bottom layer is the near misses.
Heinrich proposed more than 60 years ago a 300-29-1 ratio between near-miss incidents, minor
injuries, and major injuries. Heinrich also estimated that 88 percent of all near misses and
workplace injuries resulted from unsafe acts. It's interesting that the 300-30 ratio of near misses to
injuries is referred to as a "law," when in fact it was only an estimate. More than 30 years later
that this "law" was actually tested empirically. Frank E. Bird, Jr. analyzed 1,753,498 "accidents"
reported by 297 companies. The result was a new ratio: For every 600 near misses, there were 30
property damage incidents, 10 minor injuries, and one major injury. It's likely the base number is
much larger than 600. A reduction of near misses (events at the bottom of the iceberg) should lead
to a reduction in the number of events at the exposed top of the iceberg.
Unlike other areas in medical care, adverse events can occur even when care is delivered
appropriately; as an example renal failure can occur even with appropriate dosing of
aminoglycosides. Crude event rates do not provide an adequate measure of adverse events as it
does not account for the unknown range of opportunities for harm.
- 40 -
Error Detection:
Clinicians make decisions in a highly complex environment by negotiations and compromises as
they trade off between competing goals. In order to characterize the systemic causes of error in
such environments, we need to identify the pressures (e.g. fatigue, workload, policy, and lack of
resources) that push people towards these boundaries, and then make efforts to counteract
pressures.
Error Resilience:
A realistic approach is to recognize that human error cannot be eradicated, but that the negative
consequences of an error can be controlled. Thus, an error resilient system should have the
following targets:
control the propagation of human error towards accident occurrence

reduce adverse events
error correction / recovery
Error correction forms an integral part of the cognitive system underlying critical care (and other
complex tasks). In keeping with contemporary human error research, approaches seeking to
eradicate error fail to recognize that error recovery is integral to any cognitive work. The critical
role of error recovery mechanisms in the maintenance of system safety is neglected by approaches
that focus exclusively on completed errors.
TOOLS TO DELIVER QUALITY MEDICAL CARE:
Evidence based medicine:

Measures to improve quality of healthcare delivery and patient safety must be based on evidence.
However, unlike the rest of medical care, there has been a push to prioritizing action over
evidence in this field. It is essential to ensure that measures to improve patient safety and improve
quality of care does in fact, do so. Rigorous evaluation of such measures does not necessarily
mean that randomized trials are always needed. Robust evidence can be obtained by alternative
strategies such as before-and-after studies with concurrent control groups and time series designs
with measurable outcomes. Such an approach will ensure that the solutions implemented will not
squander resources or blind us to the adverse effects of interventions.
Protocols, checklists, bundles & guidelines:

Delivery of healthcare is a science in three domains - the first is to understand disease biology/
dynamics; the second is to find effective interventions; the third is to find strategies to deliver the
most appropriate intervention effectively by incorporating relevant research findings into daily
practice. The inability to translate top quality research into medical practice is a major problem in
healthcare. Published best practice guidelines do not by themselves reliably improve patient care.
Continuing educational programs, use of quality indicators and feedbacks are important elements
of the strategy to deliver the best evidence based care to the bedside. Checklists have been found
to be effective in implementing evidence based management bundles. They help in two ways :
with memory recall and with making explicit the minimum expected steps in complex processes.
An average ICU patient requires multiple individual interventions per day and checklists help in
establishing higher standards of baseline performance. Even the simple strategy of having doctors/
nurses make their own checklists for what they thought should be done each day improves
consistency and quality of care.
- 41 -
Clinical Management Bundles:

There are more opportunities for clinicians to modify their care in an effort to improve patient
outcome as more high-level evidence in critical care medicine becomes increasingly available.
Recent examples of some of the evidence that should have triggered reevaluation of clinicians'
approaches to patients include the use of steroids in septic shock, early goal-oriented resuscitation
in sepsis, hypothermia for out of hospital cardiac arrests, tight blood glucose control, use of
spontaneous breathing trials, and lung-protective ventilation. In these scenarios, it is tempting to
locally implement the exact protocol used in the study. As with any change initiative, this
implementation process can be complex in order to improve the delivery of scientifically proven
therapies, the concept of ―bundles‖ is useful.
A "bundle" is a group of interventions related to a disease process that, when executed together,
result in better outcomes than when implemented individually. The science behind the bundle is
so well established that it should be considered standard of care. Bundle elements should be
dichotomous and compliance should be measurable as yes/no answers. Bundles avoid the
piecemeal application of proven therapies in favor of an ―all or none‖ approach. This strategy
provides a simple but rigorous check list and documentation. It facilitates easy performance
monitoring.
Basic Bundle for all ICU patients: A checklist:
REMEMBER: FAST HUG

Feed
Analgesia
Sedation
Throboprophylaxis
Head of bed elevation
Ulcer prophylaxis
Glucose Control
Sepsis Resuscitation Bundle:

Serum lactate to be measured
Blood cultures obtained prior to antibiotic administration
From the time of presentation, broad-spectrum antibiotics administered within 3 hours for
Emergency Department admissions and 1 hour for non-ED ICU admissions
In the event of hypotension and/or lactate > 4 mmol/L (36 mg/dl):
Deliver an initial minimum of 20ml / kg of crystalloid (or colloid equivalent).
Use vasopressors for hypotension not responding to initial fluid resuscitation to maintain
mean arterial pressure (MAP) > 65 mm Hg
In the event of persistent hypotension despite fluid resuscitation (septic shock) and/or lactate > 4
mmol/L (36 mg/dl):
Achieve central venous pressure of 8mm Hg
Achieve central venous oxygen saturation of > 70%
- 42 -
Sepsis Management Bundle:

1. Low dose steroid administered for septic shock in accordance with a standardized ICU policy
2. Dotrecogin alfa (activated) administered in accordance with a standardized ICU policy
3. Glucose control maintained > lower limit of normal, but < 150 mg/dl (8.3 mmol/L)
4. Inspiratory plateau pressure maintained < 30 cm H2O for mechanically ventilated patients
The ‗Antibiotic Care Bundle‘:

1. Clinical criteria for initiation of antimicrobial therapy
2. Actively get specimens for microbiology
3. Initial empiric antibiotic choice based on local policy
4. Remove infected source: foreign body, drain collections
5. Modify when microbiology results are available
6. Daily review of antibiotic choice and continuation.
7. Regular expert input
Ventilator Care Bundle:

General:
DVT prophylaxis: Unfractionated heparin 5000 units every eight hourly or twice daily
GI stress ulcer prophylaxis: H2 blocker as prophylaxis
Eye & Skin Care
Skin prep:
2% w/v chlorhexidine is better than 10% w/v povidone; chlorhexidine
povidone and chlorhexodine sequential cleaning is even better as skin
preparation for central line insertion.
Chlorhexidine % v/v is equivalent to only 1/5 of w/v solution. Chlorhexidine 2.5
% v/v is equivalent to only to a 0.5% w/v solution – inadequate for skin
preparation, but adequate for hand hygiene
Maintain internal environment:

Hb > 7g%;
Electrolytes
Glycemic control
Support of failing organ systems as appropriate: inotropes, dialysis
Infection control
Hand Hygiene:
Use 60 – 90% alcohol or 0.5-1.0% chlorhexidine (w/v)
Airway - orotracheal
Oral Hygiene – chlorhexidine 2% or povidone 10% at least thrice a day
Ventilator Circuits – change if visibly contaminated
Suction - no difference between closed and open
Body Position – 30o – 45o Head of Bed up (not just the head of patent as a sedated
patient will slip down)
Oxygenation & Ventilation settings:

Lowest FiO2 and adequate PEEP- to keep PaO2 55 – 80mm Hg
Mode: Non Invasive if possible
Volume Control mode:
- Tidal Volume 6ml / kg
- High rate if CO2 high – upto 35 / minute; permissive
- 43 -
hypercapnoea
- E ratio 1:1 to 1:3
- If pH < 7.30 – use HCO3 infusion
Measures to decrease CO2 production (sedation, decrease temperature)
Intermittent interruption of sedation if there is 1:1 nursing care
Bundle for prevention of Ventilator Associated Pneumonia is known as WHAP:
Early Weaning Hand

Hygiene Aspiration
Precautions
Prevention of contamination
Caution regarding bundles!
First, it cannot be emphasized adequately that the time-consuming process of protocol

implementation could negatively impact the acquisition and maintenance of high-level clinical
skills. In other words, the protocol can become a priority and patient care can become uncoupled
from skillful clinical decision making. Cinicians should be always aware that when implementing
an evidence-based approach,the importance of being good clinicians should always be kept in
mind.
Second, the development of bundles is also potentially vulnerable to manipulation for
inappropriate ends. Seeing in these bundles a potentially powerful vehicle for promoting their
products, some pharmaceutical and medical-device companies have begun to invest in influencing
the adoption of guidelines that serve their own financial goals. There is thus a question of whether
these bundles are ―evidence based‖ or ―evidence biased‖. The relationship between scientific
societies and industry is complex and fraught with problems. Theoretically, each group exists to
improve patient care and outcome. In practice, the primary objective of any industry is to sell its
products and make a profit while the scientific society exists to represent its members, to
impartially judge available evidence and provide advice and support to its members in the best
interest of patient care. The process of developing guidelines should not be perceived as a
marketing vehicle for any particular industry.
Further Reading :
1. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky Y, Sprung CL, Pizov R, Cotel S. A look
into the nature and causes of human error in the intensive care unit. Qual. Saf Health Care
2003; 12: 143 – 147
2. Leape LL & Berwick DM. Five years after To Err Is Human What have we learned.
JAMA 2005; 293: 2384 – 2390
3. Garland A. Improving the ICU: Part 1. Chest 2005; 127: 2151 – 2164
4. Garland A. Improving the ICU: Part 2. Chest 2005; 127: 2165 – 2179
5. http://www.semicyuc.org/calidad/quality_indicators_SEMICYUC2006.pdf
6. Gawande A. The Checklist. The New Yorker, Dec 10, 2007
(http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande)
7. Auerbach AD et al. The tension between needing to improve care and knowing how to do
it. N Engl J Med 2007; 357: 608 – 613
8. Scales DC & Laupacis A. Health technology assessment in critical care. Intensive Care
Med. 2007; 33: 2183 – 2191
- 44 -
9. Ranganathan P et al. Cost of ICU care in India – Prohibitive or Justified? Critical Care
Update 2007; 20-27
10. Dastur FD. Quality and safety in Indian Hospitals. Journal of Assoc. Phys. India 2008; 56:
85 – 87
11. Najjar-Pellet Jet al. Quality assessment in intensive care units: proposal for a scoring
system in terms of structure and process. Intensive Care Med 2008; 34: 278 – 285
12. Weinert CR. The science of implementation: changing the practice of critical care. Current
Opinion in Crit Care 2008; 14: 460 – 465
13. Patel V, Cohen T. New perspectives on error in critical care. Current Opinion in Crit Care.
2008; 14: 456 – 459
14. MacLaren R et al. Clinical and economic outcomes of involving pharmacists in the direct
care of critically ill patients with infections. Crit Care Med 2008; 36: 3184-3189
15. Gallesio AO. Improving quality and safety in the ICU: a challenge for the next years.
Current Opinion in Critical Care. 2008; 14: 700–707
16. Valentin A. Reducing the number of adverse events in intensive care units. Controversies
in Intensive Care Medicine 2008 (ESICM publication) 337 – 342
- 45 -
Annexure 5
Quality Indicators in Critical Care – Outcome Parameters
George John, N Ramakrishnan
The cost of non-quality in any enterprise is more expensive than investing in quality.
The difference is magnified in settings such as the Intensive Care Unit where the baseline costs
are among the highest in the health care domain.
In order to choose outcome parameters in any enterprise, the mission goals must be clearly
defined. In the critical care setting, the goals are as follows:
1. To preserve meaningful life. In this context ―meaningful life‖ refers to a quality of life
valued by the patient.
2. To provide specialised care to patients in order to sustain, protect and rehabilitate them
during their treatment for a critical illness or injury. ―Specialised care‖ in this context
implies care in an environment where it is possible to provide real time monitoring of vital
parameters along with the ability to intervene rapidly when necessary.
3. To provide compassionate palliative care to those who are dying from irreversible diseases
in order to alleviate suffering during their final hours.
4. To ensure the viability and sustainability (economic and human resources) of the unit in
order to deliver the above modes of care professionally as a team.
Sentinel Events are measurable events which indicate the achievement (or non achievement)
of a goal. The Sentinel Events in the corresponding domains would be:
1. PRESERVATION OF LIFE:
The marker of a negative outcome in this domain would be mortality. The mortality can be
measured as:
• Crude: Crude mortality rates cannot be used to measure quality of ICU care because
they do not adjust for differences in diagnosis and severity of disease.
• Standardized Mortality Ratio: Disease based / Severity Score adjusted: The
Standardized Mortality Ratio (SMR) is defined as the ratio of the observed mortality
rate to the expected mortality rate. This permits performance-based comparisons of
ICUs by adjusting for disease category and severity of physiological derangement. The
reference values for the expected mortality rates are obtained by documenting
mortality rates of patients from a large number of ICUs in a specific population. These
are then stratified based on disease categories and within multiple outcome score
bands of standard ICU scoring systems. If the SMR for an ICU is <1, then the
outcomes for that unit are interpreted to be better than the overall outcomes of the
reference set used to develop the scoring system. Alternatively, an SMR of >1 signifies
that the observed mortality rate is higher than the expected mortality rate, suggesting
that the quality of care needs to be improved.
- 46 -
2. SPECIALISED CARE DURING CRITICAL ILLNESS:
The markers for this domain would be:
• Morbidity
• Post discharge events
a. Morbidity: Morbidity could be due to 3 broad reasons: chance, faults in the system
or human error. System faults and human errors are appropriate targets for quality
improvement. Faults in the system include overutilization, underutilization and
misutilisation of resources.
Measures of morbidity during ICU stay are:

Resource utilization & availability General Complications:
New admissions Rates for:

Patient Days Airway Tube block (endotracheal, tracheostomy)
Ventilator Days Reintubation
Device Days (airway, CVC, NG tube, urinary) Unplanned extubation
Nurse:Patient ratio Pneumothorax
Doctor:Patient ratio Unexpected Cardiac Arrest
Non availability of ICU bed (denied request) Hypoglycemia
Non availability
Infection Relatedof Complications:
Ventilator (denied request) Hyperkalemia
Medication / Transfusion Related:
Length of Stay GI bleed
Unplanned
Hand Readmission
hygiene complianceRate Pressure Sores
Medication Errors
Equipment downtime
Nosocomial Infection Rate Deep Vein Thrombosis
Prescription of a wrong medication
CRBSI Eye problems
Inadequate prescription – wrong dose, time
Acute Kidney
VAPb. Post Discharge: at varying periods (po stschedule
ICU or Injury
hospital discharge)
Wound• / Survival
Soft tissue
rate Critical Illness Neuropathy
Wrong administration – dilution solution,
• Quality of Life
Urinary strength, infusion rate
Others – Para nasal sinus, Eye Adverse Drug Reaction
MDR3.Infections: ESBL, MRSA
PALLIATIVE CARE: Blood / Component Transfusion Reaction
Fungal Infections
Antibiotic De-escalation
The sentinel rate are:
events to track
• Futility: number of patients being admitted for futile care to the ICU; there is, as yet, no
universally accepted definition of futility.
• Number of counselling sessions for family members
• Family satisfaction
3. VIABILITY & SUSTAINABILITY OF THE ICU AS A HEALING UNIT:

It is obvious that intensive care is based on team work and the markers of quality should
not be restricted to a reductionist view of intensive care. The following are important:
a. Economic Issues:
This is important in our Indian setting where the public funding for the tertiary
level of care is inadequate, the level of health insurance cover is low and health
care bills drive families into debt.
- 47 -
It has to be looked at from the

Health providers viewpoint - capital / running expenses versus income
Patients‘/ Families‘ viewpoint - cost per person who has not survived; debt
the family / person has incurred per person alive / expired. This is not an
issue covered in Western literature and we need to have our own data.
b. Education & Safety issues:
i. Patient safety: error detection, reporting & error resilience;
ii. Staff safety: needle stick injuries; HBsAg immunization rate in ICU
personnel; HIV prophylaxis given; staff burnout
iii. Education & Training: Personnel trained – medical, nursing, technical;
continuing medical, nursing and technical education
ERRORS IN MEDICAL PRACTICE:

It is very important to have a pragmatic perspective of error in the ICU. Errors increase as a
function of complexity. In a study in which engineers observed patient care in ICUs for twenty
four hour periods, the average ICU patient required 178 individual interactions per day. These
included a range of interventions from physical maneuvers (positioning the patient,
physiotherapy) to medication administration.
Error Detection:
Clinicians in the ICU make decisions in a highly complex environment by negotiations and
compromises as they trade off between competing goals. In order to characterize the systemic
causes of error in such environments, we need to identify the pressures (e.g. fatigue, workload,
policy and / or lack of resources) that push people towards these boundaries and then make efforts
to counteract these pressures.
The phrase „error in evolution‟ denotes the progression of a series of small mistakes towards a
cumulative adverse event. Erroneous decisions undergo a selection process based on their
anticipated consequences. The figure below illustrates the progression of error in critical care,
where personnel (clinicians, nurses, technicians and others) conducting routine work hit a
boundary and where they come close to making an error (near miss). ―Near Miss‖ is a breach of
the first boundary and is a violation of the bounds of safe practice. At this stage, the error can still
be detected and corrected before the second boundary is crossed. This is a window of opportunity
to detect and prevent a potentially adverse event. If only adverse events are reported, the ―near
misses‖ will continue to remain undetected. Since ―near misses‖ are an integral component of the
chain of events leading to an adverse event, detection, reporting and reducing these should be an
integral component of any strategy to reduce errors in any system.
If undetected / uncorrected, it can proceed to the next stage - an adverse event which occurs when
the second boundary is crossed.
- 48 -
The conventional framework of individual accountability is ill suited to address the problem of
medical error because it fails to address the complexity of the system within which medical errors
occur. Within the traditional culture of medicine, the approach has been to blame a single
individual for any error. In reality, medical error is rarely the result of the actions of a single
person. The data and analysis (thought processes) underlying critical care decision making do not
exist in the mind of just a single individual. In actuality, they are spread or distributed not only
across the minds of many clinicians but also across non living objects (physical objects such as
notes and computer equipment). It is essential to internalize the perspective that faulty action is a
product of flawed thinking across the system - this is the concept of “distributed cognition”. The
perspective that distributed cognition is responsible for, any error shifts the focus of analysis from
the study of individuals in controlled settings to the study of groups of individuals in their real-
world context. Using this framework, a collective workflow can be reconstructed from events of
critical importance that are spatially or temporally correlated. This mode of analysis focuses on
the identification of vulnerabilities and flaws in the system (as opposed to the action of a single
individual). In contrast, retrospective analysis of individual error is vulnerable to the bias of 20/20
hindsight: actions leading to the error may be viewed as incorrect although they may have been
the best alternative with the information available at that point in time.
The cognitive demands imposed by multitasking, interruptions and handovers during change of
shift can be sources of error. Gaps in information flow occur during handovers. Error production
and error detection rate are studied as a function of task demand. Three levels of demand are
considered; very demanding, busy and low workload. While it might seem intuitive that more
errors would occur at a high workload, the actual results of research show an apparent paradox:
the greatest number of errors occurred at a low workload, with the least number of errors at a
high workload. However, at high workload, error detection was reduced, leading to a much
higher rate of adverse events. The rate of error detection improves with practice.
Error Resilience:
A realistic approach is to recognize that error cannot be completely eliminated, but that the
negative consequences of an error can be controlled. Thus, an error resilient system should have
the following targets:
• control the propagation of error towards occurrence of adverse events

• reduce adverse events
• have a strategy for error correction / recovery
Error correction and recovery should form an integral part of the cognitive system underlying
quality in critical care. The critical role of error resilience in the maintenance of safety in any
system is neglected by approaches that focus exclusively on completed errors.
Research findings challenge the common perception that experts are somehow infallible. They are
consistent with error research in other domains which show a constant rate of error regardless of
expertise (with the exception of absolute beginners who make significantly more errors at the
beginning of their learning curve). Clinicians at all levels of expertise make errors; however,
experts make errors from which it is easier to recover.
The cost of non-quality in any enterprise is more expensive than investing in quality.
- 49 -
Further Reading :
1. Donchin Y, Gopher D, Olin M, Badihi Y, Biesky Y, Sprung CL, Pizov R, Cotel S. A look
into the nature and causes of human error in the intensive care unit. Qual. Saf Health Care
2003; 12: 143 – 147
2. Leape LL & Berwick DM. Five years after To Err Is Human What have we learned.
JAMA 2005; 293: 2384 – 2390
3. Weinert CR. The science of implementation: changing the practice of critical care. Current
Opinion in Crit Care 2008; 14: 460 – 465
4. Patel V, Cohen T. New perspectives on error in critical care. Current Opinion in Crit Care.
2008; 14: 456 – 459
5. MacLaren R et al. Clinical and economic outcomes of involving pharmacists in the direct
care of critically ill patients with infections. Crit Care Med 2008; 36: 3184-3189
6. Gallesio AO. Improving quality and safety in the ICU: a challenge for the next years.
Current Opinion in Critical Care. 2008; 14: 700–707
- 50 -
Annexure 6
Quality indicators : Infection Control
D P Samaddar
Value addition in health-care is directly proportional to quality and inversely proportional to cost.
Goal therefore should be to obtain the highest quality health care at an affordable price. Hospital
acquired infection or health care related infection (HAI) creates an imbalance between quality and
cost by increasing mortality, morbidity, length of stay, psychological stress and disproportionately
higher financial drain. This imbalance can be bridged by improvement in the process and system
as quality of health care is progressively being linked to process and system and not to
individuals. Compliance to processes and its qualitative impact on the delivered health care can be
assessed by selecting and monitoring appropriate quality indicators1.
1.Magnitude of problems :
Healthcare-associated infections (HAIs) account for an estimated 1.7 million infections, 99,000
deaths, and $4.5 billion in excess healthcare costs annually in USA.2 . In England, the cost
incurred due to HAI is estimated to be 3.6 million pounds per year per health unit. 3
Bloodstream infection (BSI) alone causes an estimated 26,250 deaths per year. It is ranked as the
eighth leading cause of death in the United States.4 Attributable death due to ventilator-associated
pneumonia (VAP) is 15 to 30 percent with overall mortality of 42 percents 3 HAI also causes
increased length of stay , non availability of beds due to unacceptable bed occupancy. Reported
average prolonged stay for urinary infection is 3.8 days, 7.4 days for surgical-site infection, 5.9
days for pneumonia, and 7 to 24 days for primary bloodstream infection . 3
Emergence and spread of antimicrobial-resistant organisms is a major concern. HAI also is an
important issue because 30 to 50 percent reduction in HAI is possible by running an efficient
infection control programme. 3
2.Objective : Reduction in the incidence of nosocomial infection is the main objective but it is a
broad based and less specific outcome parameter. Pursuing this parameter in isolation could be a
futile exercise unless it is linked to the influencing variables such as: patient sub groups, device,
intervention, process and protocols. It is also important to understand that improvement in
incidence of nosocomial infection does not necessarily mean improvement in quality unless it is
linked to other parameters such as : mortality outcome, length of stay, antibiotic consumption,
cost implications etc. Mere reduction in the incidence of HAI rate without desired impact on the
parameters mentioned earlier might not indicate qualitative improvement because such reduction
is possible from change in the case mix. 5
3.Factors influencing infection rate:

3.1.Sub groups: Overall infection loses its importance unless it is linked to patient sub groups
such as ; age , pre-morbid conditions, immuno competence level. Therefore infection rate could
be different in a neonatal, paediatric, trauma, medical, surgical, burn and mixed intensive care
units. Infection rate will also be different in institution with predominance of a particular sub
group of patients. Incidence in the institutions or units primarily managing cancer patients will be
different than unit managing non cancer patients. Similarly result of a closed unit could be
different as compared to an open unit.
- 51 -
3.2.Device and intervention related: Ventilator associated pneumonia, urinary catheter and
invasive catheter or line related infection are device related parameters. Percentage of patients
being maintained on different devices will influence the infection rate.
3.3.Processes and protocols : Compliance to protocols , processes, guidelines, work instructions
are also important determinants of infection rate. Process and protocol could be linked to
antibiotic usage, investigations done , implementations of different treatment bundles, nursing
care (line care, tracheostomy care etc.), and hand hygiene. 6 Uniformity of practice through
continuous training should be ensured then compliance monitoring should be done.
3.4.Infrastructure and support service: Design of intensive care unit, quality of water, laundry
management, food handling, waste disposal, sterilization and other reprocessing and maintenance
procedures, as well as microbiology support influence infection rate.
3.5.Organizational, human resource and system support : Infection rate is also related to the
organizational and human resource. Comparison of infection rate is possible if support level is
similar in participating institution. Service provider related (nurse vs patient , doctor vs patient
ratio) parameter should therefore be taken into consideration.
3.6 Surveillance System: Surveillance system available in the unit also makes a difference.
Reliability of data is an important consideration, particularly if adequate staffing has not been
ensured. Generating and stratifying voluminous data is labour intensive. Variability in reporting is
possible in absence of electronic surveillance.7,8
4. Prioritization of parameter: Despite the availability of multiple parameters, it is practically
not possible or logical to monitor all the possible parameter on long term basis. Prioritization of
parameter therefore is essential to select parameters with maximum out put potential. Selection of
limited few parameters, while the unit is getting quality oriented, is also an alternative and easier
approach. As the unit matures, need based addition and deletion can be done for the optional
parameters but mandatory parameters should always be monitored. For example if use of
vancomycin is very limited in a particular unit then monitoring vancomycin resistant enteroccoci
(VRE) is not logical on routine basis and can be taken as an optional parameter whereas line
related infection could be a mandatory parameter. Certain key indicators should also be common
and mandatory for inter institution, national or international comparison, accreditation and public
reporting.
For prioritization, importance of parameters can be judged on a matrix where the Y axis
represents determinants of importance and on X axis, each determinant is given a score. Based on
the overall score, prioritization can be done to select parameters. Example of such matrix is given
below.
Quality indicators matrix

Determinants VAP BSI UTI SSI
Ease of data collection
Ease of definition
Frequency of events
Impact on mortality,
morbidity, LOS
Financial implications
Ease of stratification
Total score
Score 1 to 5 (where 1= least important , 5= most important)
VAP = ventilator associated pneumonia, BSI = Blood stream infection , UTI = Urinary tract
infection, SSI = surgical site infection
- 52 -
5. Defining parameter and bench marking:

Whenever possible, parameter (numerator) should be linked to a denominator to make it more
meaningful. Parameters used as denominator are: number of patients, bed occupancy days,
number ventilated etc. 9
Although international bench marks can be used for comparison of data, influence of geographical
variation, nutritional and economical status etc. should be considered before comparing the result.
It is therefore advisable to have national bench marks.
6. Common quality indicators related to infection:
6.1. Device related Infection : Ventilator associated pneumonia(VAP), Central line associated
blood stream infection (BSI), indwelling catheter related urinary tract infection (UTI) etc. are
commonly monitored parameters.
Although VAP is being monitored very frequently wide variation in incidence is possible based
on the diagnostic criteria used. Due to wide variation in surveillance definition, it is difficult to
acquire, interpret and compare intra and inter institutional data. 10 Clinical and radiological
diagnostic criteria are simplest. Quantitative and non quantitative culture of bronchial aspirate,
quantitative culture of broncho-alveolar lavage (BAL)fluid and specimen collected by protected
bronchial brush (PBS) are the other options.BAL and PBS are technically more challenging.
Despite claims and counterclaims , superiority of a particular technique could not be proved.
Similar clinical outcomes and similar overall use of antibiotics had been recently claimed when
nonquantitative culture of the bronchial aspirate and quantitative culture of BAL were compared
for identification and subsequent management of VAP by the Canadian Critical Care Trials
Group.11 In order to bypass this controversy some authors advocate monitoring of risk factors
which leads to VAP. This kind of monitoring is known as process oriented monitoring. 12 For
example compliance monitoring to VAP prevention bundle can be taken as process quality
parameter. 13
Urinary tract infections are the second most common nosocomial infections in ICUs in Europe
and the first in the United States. 14 Risk factors for bacteriuria should be taken into consideration
such as : duration of catheterization, length of stay in the ICU, and female gender and drainage
system. 2.96 cases of UTI per 100 admissions and 6.11per 1,000 device-days had been reported in
medical ICU and 4.23 and 8.14 respectively had been reported in surgical ICU. 15
Hospital-acquired bloodstream infection (BSI) alone has been estimated to be responsible for
26,250 deaths per year and ranks as the eighth leading cause of death in the United States. 3.55
cases of BSI per 100 admissions and 7.33per 1,000 device-days had been reported in medical
ICU. Incidence varies depending upon the subset of patients managed in the ICU. In surgical ICU,
4.89 and 9.40 incidence of BSI per 100 patients and per 1000days had been reported
respectively.15
6.2. Infection from specific Organism: Infection due to C. difficile and methicillin-resistant
Staphylococcus aureus extended spectrum beta lactamase producers (ESBL), Vancomycin
resistant enerococci etc. could also be quality indicators . Infection caused by C. difficile and
methicillin-resistant Staphylococcus aureus are being focused in US hospitals.16
6.3. Antimicrobial use and resistance pattern: Both antimicrobial use and drug resistance can
be taken as quality indicators. For antimicrobial consumption ―Defined Daily Dose (DDD)‖ can
be monitored. DDD of antimicrobial agent is calculated by dividing the total grams of the
antimicrobial agent used in a hospital area by the number of grams in an average daily dose of the
agent given to an adult patient.17
- 53 -
DDD of specific agent used

DDD per 1000 patient days = x 1000
Total no. of patient days
Similarly resistance rate can be calculated as :

Number of resistant isolates
= x 100
Number of isolates tested
7. Cost effectiveness of Infection control programme: Resources are not unlimited therefore
above mentioned parameters should be linked to the expenditure incurred for implementation of
infection control programme. More than 30% reduction in infection rate had been claimed in the
hospitals being monitored by National Nosocomial Infections Surveillance (NNIS) system which
justifies expenditure on infection control .18
8. Summary: Nosocomial infection is a major concern due to multidimensional adverse influence

it casts on the outcome, revenue, bed availability and patient satisfaction. Parameters should be
selected considering the influence HAI has on patient and hospital management. Reduction in the
incidence of infection should not be the only target, how this reduction is influencing long-term
patient and hospital management should also be evaluated. Initially very common parameters
should be selected. Subsequently based on the support and resource availability and need of the
institution, focus can be shifted to other parameters.
References:
1. Institute of Medicine (IOM). 2001. Crossing the Quality Chasm. Crossing the Quality
Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy
Press.
2. Centers for Disease Control and Prevention. Estimates of healthcareassociated infections.
Available at: http://www.cdc.gov/ncidod/dhqp/ hai.html. Accessed October 15, 2007.
3. Lindsay E. Nicolle. Nosocomial Infection. Available at
http://www.answers.com/topic/nosocomial-infection.
4. Wenzel RP, Edmond MB. The impact of hospital-acquired bloodstream infections. Emerg
Infect Dis 2001; 7:174-177.
5. The quality indicator study group.An approach to the evaluation of quality indicators of
the outcome of care in hospitalized patients; with a focus on nosocomial infection
indicators. Infect Control hosp Epidemiol 1995;16:308 -316.
6. Available at : http://quality.mainehealth.org/SiteQualityPage.aspx? groupingID=2&
LocationID=4
7. Julie Louise Gerberding. Julie Louise Gerberding. Health-Care Quality Promotion through
Infection Prevention: Beyond 2000.Emerg Infect Dis 7(2), 2001. © 2001 Centers for
Disease Control and Prevention (CDC).Available at http://www.medscape.com/
viewarticle/414423_3.
8. Nyamogoba H, Obala AA. Nosocomial infections in developing countries: cost effective
control and prevention. East Afr Med J. 2002 ;79(8):435-41.
9. The quality indicator study group.An approach to the evaluation of quality indicators of
the outcome of care in hospitalized patients; with a focus on nosocomial infection
indicators. Infect Control hosp Epidemiol 1995;16:308 -316.
10. Michael Klompas , Richard Platt . Ventilator-Associated Pneumonia—The Wrong
Quality Measure for Benchmarking. Ann Intern Med. 2007;147:803-805.
- 54 -
11. Daren Heyland, Deborah Cook, Peter Dodek, John Muscedere et al. A Randomized Trial of
Diagnostic Techniques for Ventilator-Associated Pneumonia.The Canadian Critical Care
Trials Group.NEJM 2006;355:2619 – 2630.
12. Uçkay I, Ahmed QA, Sax H, Pittet D.Ventilator-Associated Pneumonia as a Quality
Indicator for Patient Safety? Clin Infect Dis 2008 Jan 16.PubMed ID 18199039.
(Abstract.)
13. Didier Pittet. Comment and Response: "Ventilator-Associated Pneumonia - The Wrong Quality
Measure for Benchmarking ..Annals of Internal Medicine .30 January 2008. (Letter to
editor)
14. Marc Leone, Franck Garnier, Myriam Dubuc, Marie Christine Bimar et al. Prevention of
Nosocomial Urinary Tract Infection in ICU Patients. Chest. 2001;120:220-22.
15. David J. Weber, Emily E. Sickbert-Bennett , Vickie Brown, William A. Rutala.
Comparison of Hospitalwide Surveillance and Targeted Intensive Care Unit Surveillance of
Healthcare-Associated Infections. Infect Control Hosp Epidemiol 2007; 28:1361-1366.
16. Miriam E .Tucker Protocols focus on infection prevention in hospitals Available.at
www.journals.uchicago.edu/toc/iche/2008/29/s1
17. NNIS) System Report, data summary from January 1992 through June 2003, issued
August 2003. Am J Infect Control 2003;31:481-98.
18. Julie Louise Gerberding. Health-Care Quality Promotion through Infection Prevention: Beyond
2000. Available at http://www.cdc.gov/ncidod/eid/vol7no2/gerberding.htm.
- 55 -

Quality Indicators For ICU: Indian Society of Critical Care Medicine 2009

Uploaded by

Copyright:

Available Formats

Quality Indicators For ICU: Indian Society of Critical Care Medicine 2009

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Quality Indicators For ICU: Indian Society of Critical Care Medicine 2009

Uploaded by

Copyright:

Available Formats

Quality indicators for ICU

Indian Society of Critical Care Medicine

notwithstanding the variations in deployment of processes, resources, drugs, consumables and

relatives and intensivists.

arms of any improvement process, may it be in industry or in service scenario. While

particular individual or a section of the people connected with the unit.

before it is finally accepted.

Dr B Ray : General Manager ( Medical Services ) Tata Main Hospital, Jamshedpur

Dr S K Todi: Head of Medicine & Critical Care , AMRI , Kolkata

N Ramakrishnan : Director , Critical Care Services,Senior Consultant in Critical Care &

Dr S Ramasubban: Director Critical Care , Apollo, Kolkata

Index Page no.

1. Back ground ( Introduction ) : 1

2. Gathering the evidence: 1

6. Definition of Indicators 2-15

8. Limitations and concerns 16

9. Future course 16-17

11. List of symbols 17-18

13. References (additional) 18-19

Quality indicators in Critical Care : An overview 21-30

Patient safety 31-33

Quality indicators in Critical care : Personnel Development 34-36

Quality Process 37-44

Quality Indicators in Critical Care – Outcome Parameters 45-49

Q indicators : Infection Control 50-54

Indicator Standardized mortality rate ( SMR) or risk adjusted

6.2 Morbidity Parameters :

Indicator Iatrogenic Pneumothorax

2.Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz

6.2.2 Incidence of Acute Renal Failure in noncoronary ICU :

Indicator Incidence of severe Acute Renal Failure in noncoronary ICU

Denominator : Patient managed in ICU in a given time frame.

10% patients develop ARF ( including Severe ARF) 4

References 1. Uchino, S, Kellum, JA, Bellomo, R, et al Acute renal failure

2. Ramesh Venkataraman and John A. Kellum..Prevention of

3. Chertow GM, Burdick E, Honour M, Bonventre JW, Bates

4. Maria Cruz Martin Delgado, Lluis Cabre Pericas, Javier Ruiz

6.2.3. Decubitus ( Pressure) ulcer :

Indicator Decubitus ( Pressure) ulcer

2. Pressure care for pressure ulcer and ain therapy. National

3. AHRQ national average .Sharphealth care ,2007 Malcolm

6.3 Operational Or Process Parameters :

Indicator Length of Stay (LOS)

4.36 days in general ICU;

2.43 days in vascular ICU

2. Peter J. Pronovost ,Accelerating Change Today (A.C.T.)for

6.3.2 Compliance to protocol

6.3.3 ICU readmission rate

Indicator ICU readmission rate

6.4 Error and patient Safety

6.4.1 Patients’ fall rate

Norton Hospital USA, 2008 Norton Healthcare statistics per

Without injury With injury

ICU 2.10 0.22

Medical surgical 2.23 0.74

Medical 2.62 0.70

Surgical 2.02 0.37

References 1 Barnett, K. (2002) Reducing patient falls in an acute general

6.4.2 Medication error