Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: January 27^th 2014

Accepted: March 19^th 2014

Quality care in an intensive therapy unit at private hospital

Mauricio Tejeda-Miranda,^a,b Francisco Javier Anthon-Mendez,^a,b Juan Gerardo Esponda-Prado,^a,b Mario Enrique Rendón-Macías^a,c

^aFacultad Mexicana de Medicina, División de Postgrado, Universidad La Salle.

^bUnidad de Terapia Intensiva, Hospital Ángeles del Pedregal

^cUnidad de investigación en Epidemiología Clínica, Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social.

Distrito Federal, México

Communication with: Mauricio Tejeda-Miranda

Telephone: (55) 2858 1993

Email: coordinación_vitae2@hotmail.com

Background: The aim of this article is to evaluate the quality of care in intensive care, with international quality indices.

Methods: It was a descriptive study in an intensive care private care in Mexico. 2012 indicators are analyzed in a total of 446 hospital patients. The quality indicators were in line with international recommendations. The severity was determined by the scale SAPS III.

Results: Indicator of ventilation associated pneumonia was below the recommended standard (11.7 vs. 12 per thousand), bacteremia related central venous catheter in accepted ranges (5.7 vs. 4 per thousand). The ulcer prophylaxis, prevention of pulmonary embolism and prevention of falls in high compliance proportions (> 90, > 95 % and 0 falls). The rates of unplanned extubation and re-intubation below indicators (< 1 per thousand days intubation and < 12 %). While indicators varied by classification of severity of the condition, the goals were met. Mortality was lower than that estimated by gravity.

Conclusion: In this therapy the implementation of internationally recommended actions has helped maintain an adequate quality of care. The effort has impacted not only the patients with acute conditions of admission, but also patients with high mortality or Hazard.

Keywords: Quality of health care; Indicators of health services; Hospital mortality; Intensive care

---

The overall objective of intensive therapy is to provide adequate care for the recovery of any critical patient, avoiding the presence of complications inherent in such management. Therefore, at the international level a number of preventive recommendations for the most frequently observed complications have been suggested. Such complications mainly involve prevention of: nosocomial infections, gastrointestinal bleeding, lung damage, and others.^1-3

In addition, to assess the impact of the implementation of these preventive actions indicators are designed to track and evaluate the achievements obtained.¹ These indicators are instruments to measure the real impact on the reduction of morbidity and mortality associated with attention.^1,2 On the other hand, compliance can determine whether intensive therapy can be certified on the quality of provision of services, for which it is necessary to ensure the availability of human, material, technological and financial resources for optimal care. Moreover, the evaluation of these indicators should be continued, due to advances in knowledge and technologies emerging every day.

In a previous evaluation of our intensive care unit, although we found adequate compliance with quality indicators, we still had unacceptable rates of infection associated with ventilation and incomplete compliance in tromboembolia prevention actions.⁴ Therefore, in the last year, surveillance actions and compliance support were created. In this paper, we report on the conditions of quality in our next evaluation from March 2012 to January 2013.

Methods

A prospective surveillance was conducted from March 2012 to January 2013. Data from all patients, regardless of gender and age 18 and over, who were admitted to the intensive care unit of the Angeles del Pedregal Hospital were included. The data were stored in a BASUTI system, designed expressly to save the information on: demographics, diagnostic state at admission, complications, procedures, gravity of specific conditions, organ failure and death probability estimate (SAPS III). Patients were classified into 3 risk conditions: (A) failure of one or more major organ systems, (B) the risk of failure of one or more major organs and (C) postoperative and special care.

The quality was evaluated by the following indicators:

• Ventilator-associated pneumonia. Defined as the presence within 48 hours of onset of ventilation of any of the following: purulent sputum or purulent drainage through endotracheal tube, clinical signs of lower airway infection and / or chest radiograph consistent with pneumonia. The indicator was estimated number of episodes per total thousand days of ventilation-assisted patients.¹
• Bacteremia related to central venous catheter. The presence of chills or fever after catheter use in patients with central venous catheter, presence of fever without source of infection identified, evidence of infection at the site of entry of the catheter, positive culture from catheter tip in body identified by blood or disappearance of signs and symptoms upon catheter removal. The indicator is "events per thousand days of catheter stay".^1,2
• Prophylaxis of gastrointestinal bleeding. Defined as the percentage of patients who were given a proton-pump inhibitor or an H1.1 antagonist during their stay.
• Prophylaxis of thromboembolic disease. Defined as the percentage of patients who were given low molecular weight heparin, unfractionated heparin, complete anticoagulation, or pneumatic compression measures.¹
• Unscheduled extubation. Defined as that not intended or not desired by the health personnel, or that done by action of the patient himself. The indicator takes into account the number of events per thousand total days of ventilation. To avoid confusion, the approximate number of days on mechanical ventilation was taken as the number of days of intubation in service.¹
• Reintubation. Defined as the need to re-intubate a patient within 48 hours of a scheduled extubation. The indication is the percentage of events per 100 patients extubated.¹
• Accidental falls. This was considered as any episode where the patient falls from their bed, this was determined by the number of falls per 1,000 days of patient stay.¹
• For mortality, the expected mortality based on severity (SAPS III) was contrasted with the observed mortality. Average and percentile distribution of risk is obtained according to the clinical condition group (A, B or C) and was compared with the mean and confidence intervals found. Mortality was determined as the number of deaths among all patients admitted to therapy for each group.

To compare the indicators by condition upon admission, estimates of each indicator and confidence intervals were obtained. Epidat 3 statistical package was used and to tests were performed using the chi square test. A statistically significant difference with a P value <0.05 was considered.

Results

In this period, 446 patients were admitted to our ICU, Table I shows the demographic characteristics and condition upon admission. Most were patients with diseases whose conditions were due to failure of one or more systems.

Quality indices for the period are shown in Table II. Pneumonias associated with ventilation were found in the point estimate below standard. For bacteremia associated with central venous catheter, the estimate was slightly up. In both cases, the confidence interval still shows variability by sample size.

Compliance with preventive measures for gastrointestinal bleeding and thromboembolism were met. Rates of unscheduled extubation and reintubation were below the standard international indicator.

As for fall prevention, which should be zero, we had one case in a patient with neurological agitation.

When analyzing compliance with regard to condition upon admission, as seen in Table III, ventilation-associated pneumonia was greater in patients with condition C, although there was great variability in the estimate based on sample size. For the other indicators, the condition group B had the highest rate of catheter-related bacteremia and patient fall.

With respect to mortality (Figure 1), in all groups mortality was observed below that expected according to SAPS III severity score.

The lowest mortality was observed for the group in clinical condition C.

Discussion

This study was conducted to continue the evaluation of our services to critically ill patients. The success of an improvement program depends heavily on the ongoing review of the effects obtained by changes to protocol.

In reviewing the types of patients seen in this period, we found no differences with respect to our previous report,⁴ to which the comparison is made. However, the calculated risk of mortality (SAPS III) in this new group was a little lower than before for patients with clinical conditions A and B (43% versus 35% today and 19% from the current 9% , respectively), although it is greater for the condition C (on 10% from the current 18%). In this new analysis period, our indicators showed improvement with respect to the implementation of strategies for prophylaxis in reducing complications such as pneumonia associated with ventilation and prevention of thromboembolic disease.

Significantly, the indicators evaluated here are directed to results in the process of care for patients hospitalized in an intensive care unit. These do comprehensively reflect the performance, but they are not the only ones.^1-3,5 It is still necessary to assess other indicators such as the rate of readmission to the ICU, which reflects the conditions at discharge and risks of the non-resolution of base pathologies. This also fails to evaluate discharged cases for continued palliative care because of the non-recovery of patients, and, lastly, transfers to other centers. These conditions may change the mortality indicators of a care unit. In this respect, our frequency of transfers is low and analysis of the other two conditions is still needed.

On the other hand, the indicators analyzed here were established by our unit for monitoring and measuring quality. That is, we only consider the minimum necessary to capture and analyze it, without overwhelming the medical work. We know of the existence of many other related to the structure and process in providing services,^6,7 which in our case are captured and analyzed by other administrative services.

The most important thing in the process of analyzing these indicators is continuous review and discussion by the personnel involved in the improvements.⁸ This allows us to generate appropriate actions for correction. Community outreach work like this, allows the comparison of results and reveals the scope obtained through the implementation of quality indicators in the care of critically ill patients.

For now we can conclude that the implementation and ongoing monitoring of quality indicators in our intensive care unit has allowed the reduction of some complications associated with mortality. Still we need a deeper analysis of other quality indicators as to the conditions upon discharge in surviving patients.

References

1. Pyle K, Wavra T. Quality indicators for critical care. AACN Adv Crit Care 2007;18(3):229-43.
2. Martin MC, Cabre LI, Blanch L, Blanco J, Castillo F, et al. Indicadores de calidad en el enfermo crítico. Med Intensiva 2008;32 (1):23-32.
3. Flaaten H. The present use of quality indicators in the intensive care unit. Acta Anaesthesiol Scand 2012; 56:1078-83.
4. Elguera-Echeverría PA, Esponda-Prado JG, Cerón-Díaz UW, García-Gómez MN. Calidd de la atención en el cuidado del paciente crítico en una unidad de terapia intensiva mexicana del sector privado. Rev Asoc Mex Med Crit y Ter Int 2012;26(4):209-14.
5. Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Xhichw JD, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2012; 38: 598-605.
6. Braun JP, Mende H, Baue H, Bloos F, Geldner G, et al. Quality indicators in intensive care medicine: why? Use or burden for the intensivist Germ Med Sci 2010;8: ISSN 1612-3174.
7. De Vos ML. Van der Veer SN, Graafmans WC, de Keizer NF, Jager KJ, et al. Process evaluation of a tailored multifaced feedback program to improve the quality of intensive care by using quality indicators. BMJ Quality & Safety 2013; 22(3): 233-41.
8. Martin MC, Cabré LI, Ruíz J, Blanch LI, Blanco J, Castillo F, Galdós P, Roca J, Saura RM. Indicadores de calidad en el enfermo crítico. Med Intensiva, 2008; 32(1):23-32.

Enlaces refback

• No hay ningún enlace refback.