Quality Indicators for Critical Care

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Quality Indicators for Critical Care

• Jane Harper
• Royal Liverpool University Hospital
• ICS Standards, Safety and Quality Committee

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The menu

• What is quality?
• Why have we just discovered it?
• What is the national agenda?
• What about critical care?
• What should we do next?

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Quality

• Degree or standard of excellence
• (Collins)

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Quality is a term so general and ambiguous as to
be almost completely meaningless. Use it as often
as you can!"

• Russell Ackoff,
• Professor of Management, U Penn

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Patients

• Make me better effectiveness
• Dont hurt me safety
• (prevent MRSA), make me feel safe
• Be kind to me patient experience
• Give me pain relief
• care about me

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The menu

• What is quality?
• Why have we just discovered it?
• What is the national agenda?
• What about critical care?
• What should we do next?

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Per capita healthcare expenditure, 1996
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Per capita healthcare expenditure 1970-2005
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NHS Reforms 1997-2006

• More money, more staff, more beds
• More local responsibility
• GPs pay partially dependent on quality measures
• how do you maintain standards?
• National regulation
• NICE, CHI, NSFs
• Targets no more 4 hour waits in Emergency
• Payment by results
• Reform fatigue

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Numbers of ICU Beds
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Patients on waiting lists
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Dr Foster data HSMR
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Life expectancy/ GPs per local authority
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Choosing quality measures

• In God we trust
• All others must bring data
• Robert Hayden

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The menu

• What is quality?
• Why have we just discovered it?
• What is the national agenda?
• What about critical care?
• What should we do next?

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• Google Darzi 249,000 results (0.35 s)
• Darzi, qualilty 87,200

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NHS Next Stage Review
Professor the Lord Darzi KBE Parliamentary
Under-Secretary of State
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Quality at the heart of the NHS

• Getting the basics right first time, every time
• Improvements in safety, enforced by the new Care
  Quality Commission to tackle, for example,
  healthcare acquired infection
• Independent clinical standards and priority
  setting
• NICE expanded to set and approve independent
  quality standards
• A new National Quality Board will give
  transparent advice to Ministers regarding top
  clinical priorities
• Quality of care measured from the frontline up
• Every organisation will be required by law to
  publish Quality Accounts just as they publish
  financial accounts
• All staff will have access to NHS Evidence
  service
• Web based portal on what high quality care looks
  like, and how to deliver it

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In the post-Darzi NHS QIPPCommissioning
imperatives

• Quality safety, personal experience and
  effectiveness
• Innovation
• Productivity Lean methods, PDSA cycles,
  touch-time
• Prevention prevent admissions
• Pathways PROMs
• Less concern with structure/process, more
  outcomes
• disinvesting misuse, underuse, overuse

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Quality Agenda post-DarziLead National Quality
Board

• Quality Standards (approx 20) NICE
• Quality Metrics (200) Information centre
• Quality Accounts Trusts
• CQIN PCTs
• Quality Observatories SHA
• Clinical Excellence awards ACCEA
• Quality Outcomes Framework NICE

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Work of the NQB

• System alignment
• Mid-Staffs review, clinical prioritisation
• Tools and techniques
• NICE quality standards, QIs, QAs
• Leadership
• MRSA new goals to replace 50 reduction target
• CEA

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NICE quality standards

• Quality standard specific, concise statement
• Evidence-based
• Markers of quality care
• 6-10 statements/ quality standard
• CVA, specialist neonatal care, VTE prevention,
  dementia
• The new targets, NSFs

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Key Quality Indicators
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Quality Metrics

• National
• Quality indicators
• National Audits
• Regional network
• Local
• Clinical performance indicators
• PROMs
• NICE audit
• Complaints
• Dr Foster

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The problem

• Engagement
• Data
• Validation

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Choosing quality measures

• How effective is the measure is it important?
• How costly is it to implement is it achievable?
• What perverse consequences are produced?
• Will we want to do it?
• Is this the new NSF/ target?

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The Specialist Societies and QIs
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ICS SSQ QIs Aim

• Relevant - evidence available
• Important
• Measureable standard definitions
• Collectible by all units
• Based on good practice, professional opinion
• Distinguished from standards
• Define up to 20 that are relevant for use in UK
  intensive care units
• Use to
• Benchmark units
• Assess quality improvement programmes
• Research

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The Process

• Literature review
• Expert opinion
• Disseminated to membership
• Ranked on modified Likert scale
• Health warning self-selected sample

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Quality indicators

• Relevant
• Important
• Measureable
• Collectible
• Based on evidence-based practice
• Structure, process, outcome

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Examples

• Computerised Physician Order Entry
• CVA thrombolysis
• 24/7 intensivist availablity
• Nurse patient ratio
• Catheter-related blood stream infection
• Ventilator-associated pneumonia

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Health warning

• Self-selected individuals responded
• Of the expert group, 44 responded
• Of the entire membership, 73 responses
• Some members were sceptical
• Analysis simple

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Structure

• Computer-assisted physician order entry
• Consultant cover 24/7 by intensivist
• Patientnurse ratio
• Quality-improvement programme in place

• Patient/family satisfaction
• Weaning protocols
• Outreach
• Rehabilitation
• MDT ward round
• Pharmacists
• Donation
• SAQ
• Handover

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Process

• Ongoing care bundle audits
• Proportion of discharges between 2201 and 0659
• Readmissions within 48 hours of discharge
• Formal evaluation of delirium
• End-of-life care pathway in place

• Daily goals
• Early enteral feeding
• Hand hygiene audit
• Sepsis bundle
• Morbidity/ mortality meetings

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Outcome

• Standardised mortality ratio
• Proportion of patients receiving mechanical
  ventilation
• Number of non-clinical transfers
• Incidence of unit-acquired MRSA bacteraemias
• Incidence of all unit-acquired bacteraemias
• Unit-acquired MRSA or Cdiff
• Measurement of patient-family satisfaction in
  place
• Days of 100 occupancy
• Number of organ donors as a of those eligible
  to donate

• CR-BSI
• Incidence of VAP
• Early enteral nutrition
• CVA thrombolysis
• ACS Rx
• End of life care pathway
• Falls
• Reintubation rate

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Mean/ median highest scores

• 24/7 intensivist (8.9, 10) n63
• Nurse/ patient ratio (8.6, 9) n66
• Audit of hand hygiene (8.4, 9) n43
• Non-clinical transfers (8.3, 9) n67
• CR-BSI (7.9, 9)

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Mean, median lowest scores

• CVA thrombolysis (5.1, 5) n60
• CPOE (5.19, 5) n63
• MV (5.4, 6) n64
• Reintubation rate (5.5, 5) n24
• Organ donation (5.9, 6) n66

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Wide range (example CPOE)
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Organ Donation
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VAP
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Top 20

• Intensivist 24/7
• Nursepatient ratio
• Hand hygiene compliance
• Non-clinical transfers
• Morbidity/mortality review
• Unit-acquired bacteraemias
• Unit-acquired MRSA
• CR-BSI
• Readmission within 48h
• Discharges 2201-0659

• Unit acquired Cdiff or MRSA
• End of Life care
• SMR
• Isolation
• Early enteral nutrition
• Days of 100 occupancy
• Daily goals
• Structured handover
• Multidisciplinary ward rounds

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Conclusions

• Quality means different things to different
  people
• We accept QIs which are
• Not always evidence-based
• Wide range of views amongst professionals
• Family/ patient involvement
• How do you use these data to improve care?