Automatic quality improvement reports in the intensive care unit: One step closer toward meaningful use

Table 1 Critical Care Independent Multidisciplinary Program defined metrics

Metric		Description	Variables needed
M1	Hospital length of stay for ICU graduates - unadjusted	Hospital length of stay is based on all patients discharged from the hospital during the specified time-frame. A patient may have multiple admissions to the ICU	Hospital Admission Hospital Discharge ICU admission ICU discharge
M2	ICU length of stay - unadjusted	ICU length of stay is based on all patients discharged from the ICU during the specified time-frame	ICU admission ICU discharge
M3	ICU length of stay - adjusted	Adjusted ICU length of stay is based on all patients discharged from the ICU during the specified time-frame. Expected ICU length of stay is the APACHE IV predicted ICU length of stay. Adjusted length of stay is observed ICU length of stay divided by expected ICU length of stay	ICU admission ICU discharge APACHE IV bundle (demographic, vitals, labs, Glasgow coma score, health conditions, time stamps and geolocations, procedures and diagnosis)
M4	ICU readmission rate	Readmission summary is based on all patients admitted to the ICU during the specified time-frame. An admission is counted as a readmission if it is not the patient’s first admission to the ICU during that hospital stay. Readmissions to the same ICU and readmissions within 24 h are summarized	ICU admission ICU discharge Admission source (location)
M5	ICU admissions	Admission summary is based on all patients admitted to the ICU during the specified time-frame	ICU admission ICU discharge
M6	ICU admission source and admission service	Admission source summary is based on all patients admitted to the ICU during the specified time-frame	ICU admission ICU discharge Admission source (location)
M7	Duration of mechanical ventilation	Ventilation summary is based on all patients discharged from the ICU during the specified time- frame. Use of invasive and non-invasive ventilation is summarized as well as the median duration. Numbers for invasive and non-invasive ventilation will not sum to the numbers for ventilation because patients may have both types	ICU admission ICU discharge Duration invasive or non-invasive ventilation for each day of ICU stay
M8	ICU mortality rate - unadjusted	Mortality rate summary is based on all patients discharged from the ICU during the specified time frame. Multiple discharges per patient are allowed	ICU admission ICU discharge Patient status
M9	ICU mortality rate - adjusted	Mortality summary is based on all patients discharged from the ICU during the specified time-frame. Multiple discharges per patient are allowed. Expected ICU mortality is based on each patient’s APACHE IV predicted probability of hospital death. Standard mortality ratio is calculated by dividing observed ICU mortality by expected APACHE IV hospital mortality	ICU admission ICU discharge Patient status APACHE III/IV bundle (demographic, vitals, labs, Glasgow coma score, health conditions, time stamps and geolocations, procedures and diagnosis)
M10	ICU admissions for low-risk monitoring	Low-risk monitoring summary is based on all patients admitted to the ICU during the specified time-frame. Low risk monitoring calculation based on the TISS-28 score[27]. Patients with score 0-13 are considered low-risk monitoring	ICU admission ICU discharge TISS-28 score bundle (vitals, labs, orders, procedures)
M11	ICU census - hourly utilization	Unit utilization summarizes the average hourly unit utilization for each specified time-frame on the hourly ending census	ICU admission ICU discharge Number of bed per unit

ICU: Intensive care unit.

Table 2 Clinical characteristics of baseline cohort

Number	Characteristic1	Overall (n = 93)
1	Age (yr)	73 (62, 83)
2	Male sex	53 (57%)
3	APACHE III score	60 (46.5, 72)
4	SOFA score	3 (2, 5)
5	ICU type
	Medical	51 (56%)
	Surgical	29 (30%)
	Mixed	13 (14%)
	Ventilator use
6	Invasive	18 (19.4%)
7	Non-invasive	22 (23.7%)
8	ICU length of stay (d)	1.1 (0.9, 2.1)
9	ICU mortality	1 (1%)
10	Hospital length of stay (d)	5.4 (3.6, 11.1)
11	Hospital mortality	10 (10.7%)

¹Values are n (%) for categorical variables and median (IQR) for continuous variables. ICU: Intensive care unit.

Table 3 Agreement of admission, discharge, and transfer information

Component	Agreement
Admit/discharge times1
ICU admission	99%
ICU discharge	89%
Hospital admission	100%
Hospital discharge	100%
Pre-ICU location	100%
Admission ICU	100%
ICU discharge location	100%

¹Agreement was considered to be within ± 1 h. ICU: Intensive care unit.

Table 4 Analysis of sensitivity and specificity

Variables and their usage for metrics	Sensitivity	Specificity	True positive	False positive	True negative	False negative
MV use (from M7)	100%	94.40%	75	1	17	0
NIV use (from M7)	100%	95.50%	71	1	21	0
ICU mortality (M8, M9)	100%	100%	0	0	93	0
In-hospital mortality	100%	100%	10	0	83	0

M7, M8, M9 are quality metrics 7, 8 and 9 respectively. ICU: Intensive care unit.