How to cite this article: Tejeda-Miranda M, Anthon-Mendez FJ, Esponda-Prado JG, Rendón-Macías ME. Quality care in an intensive therapy unit at private hospital. Rev Med Inst Mex Seguro Soc. 2015 Jul-Aug;53(4):400-4.
Received: January 27th 2014
Accepted: March 19th 2014
Mauricio Tejeda-Miranda,a,b Francisco Javier Anthon-Mendez,a,b Juan Gerardo Esponda-Prado,a,b Mario Enrique Rendón-Macíasa,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
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.
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:
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.
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.
|Table I Characteristics of patients admitted to intensive care unit|
|Variable||N = 446|
|Age in years; median (1SD)||61 (17)|
|Sex||Male||243 54.4 %)|
|Female||203 (45.5 %)|
|Condition at admission||A||209 (46.9 %)|
|B||122 (27.4 %)|
|C||115 (25.8 %)|
|Reason for admission||Medical||286 (64.1 %)|
|Surgical||160 (35.9 %)|
|Distribution||Coronary||118 (26.5 %)|
|Surgical||23 (5.2 %)|
|Non-surgical||305 (68.4 %)|
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.
|Table II Results of quality of care indicators in patients treated in a private intensive care unit|
|Pneumonia associated with mechanical ventilation||11.7 (6-20.1)||12 x 103 DIMV|
|Bacteremia related to central venous catheter||5.7 (2.9-9.9)||4 x 103 DCVC|
|Ulcer prophylaxis||95.4 % (91.7-99.1)||95 %|
|Pulmonary tromboembolia prevention||94.7 % (90.8-98.6)||90 %|
|Unscheduled extubation||4.5 (1.5-10.5)||15 x 10
|Reintubation||2 % (0.6-3.4)||12 %|
|Accidental falls||0.9 (0.1 - 3.4)||0 x 103 DIH|
|CI = confidence interval 95 %, DIMV = days of intermittent mechanical ventilation, DCVC = days with central venous catheter, DIH = days in hospital|
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.
|Table III Indicators of quality of care based on the clinical condition at admission to intensive care unit|
|Quality Indicator||Clinical condition A||Clinical condition B||Clinical condition C||p
|Pneumonia associated with mechanical ventilation ep/103 DMV||10 (4-18.4)||19(2.4-70)||50 (1-278)||ns|
|Bacteremia related to central venous catheter ep/103 DCVC||9 (4.1-17.1)||29.4 (6-86)||0||ns|
|Ulcer prophylaxis||94.6 % (89.5-98.7)||96 % (79.6-99.8)||100 %||ns|
|Pulmonary tromboembolia prevention||
93.3 % (88.4-98.2)
|96 % (79.6-99.8)||100 %||ns|
|4 % (1.1-10.3)||9.8 % (2-54.6)||0||ns|
|Reintubation||2 % (0.6-3.4)||2.5 % (0.5-7)||0||0.04|
|DMV= days of mechanical ventilation, DCVC = days with central venous catheter in place. Rate or percent ( 95 % confidence interval), chi squared test; ns = not statistically significant|
With respect to mortality (Figure 1), in all groups mortality was observed below that expected according to SAPS III severity score.
Figure 1 Distribution of estimated mortality by SAPS II and that found by clinical condition at admission. Death estimated by SAPS III is in blue; Median and interquartile range 1-3 in the box, that observed is in black (Table represents the confidence interval 95% of observed death), standardized mortality ratio for condition. A = 0.57, condition. B = 0.54 and C = 0.09 condition.
The lowest mortality was observed for the group in clinical condition C.
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.
Conflict of interest statement: The authors have completed and submitted the form translated into Spanish for the declaration of potential conflicts of interest of the International Committee of Medical Journal Editors, and none were reported in relation to this article.