Key messages
-
To the best of our knowledge, the present study has the largest sample among investigations of quality control in ICUs in the world. The present study reflected the national policy on ICU quality control and the impact factor in China.
-
The present study reflected the development of the ICU in China. Interestingly, we found that the human resources, that is, the number of doctors and nurses, might not have kept pace with the expansion of the ICUs in China over the past 3 years. An imbalanced relationship between ICU expansion and human resources was found in this study. The health administration department should pay attention to ICU overextension, which might negatively affect quality.
-
The national QI program was validated in the present study; the program resulted in significant improvements in the VAP incidence rate, microbiology detection rate before antibiotic use, DVT prophylaxis rate, and the 3-h and 6-h SSC bundle compliance rates.
Introduction
Methods
Intervention
Study population and setting
Study measurements
Indicators | Definition and meaning |
---|---|
Proportion of ICU patients to total inpatients (%) | Definition: (patients admitted to the ICU)/(patients admitted to hospital during the same period) Meaning: reflects the proportion and hospital course of ICU patients among all hospitalized patients |
Proportion of ICU patient bed occupancy to total inpatient bed occupancy (%) | Definition: (days of ICU bed occupancy by patients)/(days of hospital bed occupancy by patients during the same period) Meaning: reflects the proportion and hospital course of ICU patients among all hospitalized patients |
Proportion of ICU patients with APACHE II score ≥ 15 (%) (within 24 h after being admitted to ICU) | Definition: (no. of patients with APACHE II score ≥ 15 during the first 24 h in the ICU)/(patients admitted to the ICU during the same period) Meaning: reflects the severity of illness of patients admitted to ICU. |
3-h SSC bundle compliance rate (%) | Definition: (no. of septic shock patients who received the 3-h SSC bundle treatment)/(no. of septic shock patients admitted to the ICU during the same period) Meaning: reflects the clinical standardization and medical care capacity for septic shock |
6-h SSC bundle compliance rate (%) | Definition: (no. of septic shock patients who received the 6-h SSC bundle treatment)/(no. of septic shock patients admitted to the ICU during the same period) Meaning: reflects the clinical standardization and medical care capacity for septic shock. |
Microbiology detection rate before antibiotic use (%) | Definition: (no. of patients with microbiology detection before antibiotics)/(no. of patients who received antibiotics during the same period) Meaning: reflects the normative use of antibiotics in ICU. |
DVT prophylaxis rate (%) | Definition: (no. of patients who received DVT prophylaxis treatment)/(no. of patients admitted to the ICU during the same period). The optimal mode of DVT prophylaxis includes pharmacological prophylaxis (heparin or LMWH), mechanical prophylaxis (intermittent pneumatic leg compression or elastic stockings), and inferior vena cava filter. Meaning: assesses the DVT prophylaxis for ICU patients. |
Unplanned endotracheal extubation rate (%) | Definition: (no. of patients with unplanned endotracheal extubation)/(no. of patients with endotracheal extubation during the same period) Meaning: reflects the integral management and treatment level of ICU. |
Reintubation rate within 48 h (%) | Definition: (no. of patients reintubated within 48 h after endotracheal extubation)/(no. of patients with endotracheal extubation during the same period) Meaning: reflects the judgment of proper extubation indication in ICU. |
Rate of unplanned transfer to ICU (%) | Definition: (no. of patients with unplanned transfer to the ICU from other wards)/(no. of patients transferred to the ICU from other wards during the same period) Meaning: reflects the quality of medical care in medical institutions. |
ICU readmission rate within 48 h (%) | Definition: (no. of patients readmitted to the ICU within 48 h after discharge from the ICU)/(no. of patients discharged from the ICU during the same period) Meaning: reflects the judgment of proper discharge indication in the ICU. |
VAP incidence rate (%) per 1000 ventilator days | Definition: (no. of patients with VAP)/(no. of patients with mechanical ventilation during the same period) Meaning: reflects the capability of infection control, invasive mechanical ventilation, and disease management in the ICU. |
CRBSI incidence rate (%) per 1000 catheter days | Definition: (no. of patients with CRBSI)/(no. of patients with a central venous catheter during the same period) Meaning: reflects the capability of infection control, intravascular catheter indwelling, and disease management in the ICU. |
CAUTI incidence rate (%) per 1000 catheter days | Definition: (no. of patients with CAUTI)/(no. of patients with a urinary catheter during the same period) Meaning: reflects the capability of infection control, urinary catheter indwelling, and disease management in the ICU |
ICU mortality rate (%)* | Definition: (no. of patients who died in the ICU)/(no. of patients admitted to the ICU during the same period) |
Statistical analysis
Results
Characteristics of the total study group
Hospital and ICU organizational characteristics
Parameters | 2016 | 2017 | 2018 | Trend P value |
---|---|---|---|---|
Total no. of admitted patients | 26,282,732 | 27,321,537 | 27,857,285 | |
Median (25th–75th) | 31,973(20367–51,045) | 34,864(21881–57,119) | 37,252(23034–59,531) | 0.0013 |
Total no. of admitted patients in ICU | 471,432 | 526,663 | 589,629 | |
Median(25th–75th) | 519(297–851) | 562(334–927) | 610(351–1055) | 0.0002 |
Total no. of hospital beds | 612,441 | 680,429 | 691,511 | |
Median(25th–75th) | 600(941–1446) | 997(605–1500) | 993(650–1552) | 0.0580 |
Total no. of ICU beds | 10,668 | 11,355 | 13661* | |
Median(25th–75th) | 12(9–20) | 13(10–20) | 15(10–24) | 0.0002 |
ICU: hospital bed percentage(%) | 1.5(1.1–2) | 1.5(1.1–2) | 1.6(1.2–2.1)*† | 0.0018 |
Doctor-to-nurse ratio in ICU | 0.31 (0.26, 0.38) | 0.31 (0.25, 0.38) | 0.30 (0.25, 0.38) | 0.1949 |
Doctor-to-bed ratio in ICU | 0.64 (0.50, 0.83) | 0.60 (0.50, 0.80) | 0.60 (0.45, 0.75)* | 0.0005 |
Nurse-to-bed ratio in ICU | 2.00(1.64, 2.50) | 2.06 (1.63, 2.50) | 2.00 (1.50, 2.40)* | 0.0113 |
Effects of the QI program on ICU performance
Indicators | 2016 | 2017 | 2018 | Trend P value |
---|---|---|---|---|
Proportion of ICU in total inpatients(%) | 1.60(1.13, 2.44) | 1.63(1.13, 2.45) | 1.63(1.12, 2.42) | 0.7562 |
Proportion of ICU in total inpatient bed occupancy(%) | 1.18 (0.82, 1.74) | 1.22(0.84, 1.88) | 1.23 (0.87, 1.79) | 0.1315 |
Proportion of APACHE II score ≥ 15 in all ICU patients(%) | 61.02(38.22,79.22) | 61.89(40.52,79.69) | 59.38(36.86,76.52)) | 0.3361 |
3 h SSC bundles compliance rate(%) | 83.18 (61.29, 100) | 86.71 (65.96, 100) | 89.22 (70.00, 100) † | 0.0102 |
6 h SSC bundles compliance rate(%) | 64.93(33.55,93.06) | 74.00(39.62,96.91) | 76.19 (46.88,96.67) † | 0.0031 |
Microbiology detection before antibiotics(%) | 83.91(49.75,97.87) | 84.14(60.46,97.24) | 90.00 (69.62, 100) *† | < 0.0001 |
DVT prophylaxis rate(%) | 74.19(33.47,96.16) | 71.70(38.05,96.28) | 83.27 (47.36,97.77) *† | 0.0093 |
Unplanned endotracheal extubation rate(%) | 1.10(0.14, 3.35) | 1.27(0.24, 3.23) | 1.29(0.34, 3.35) | 0.1075 |
Reintubation rate within 48 h(%) | 1.64(0.48, 4.44) | 1.60(0.55, 3.81) | 1.81(0.66, 3.79) | 0.4621 |
Rate of unplanned transfer to ICU(%) | 2.70(0.68, 8.46) | 2.47(0.70, 7.77) | 2.59(0.83, 7.73) | 0.7667 |
ICU re-admission rate within 48 h(%) | 0.97(0.40, 2.09) | 0.89(0.32, 2.01) | 1.10(0.46, 2.09) | 0.1904 |
VAP incidence rate(%)/1000 ventilator days | 11.06 (4.23, 22.70) | 10.20 (4.25, 23.94) | 8.05(3.13, 17.37) *† | 0.0002 |
CRBSI incidence rate(%)/1000 line days | 1.30(0, 3.40) | 1.39(0, 3.39) | 1.24(0, 3.13) | 0.6586 |
CAUTI incidence rate(%)/1000 line days | 2.12(0.53, 4.52) | 1.76(0.61, 4.41) | 1.84(0.70, 4.10) | 0.6703 |
ICU Mortality rate(%) | 8.49(4.42, 14.82) | 8.95(4.89, 15.70) | 9.05(5.12, 15.80) | 0.1075 |
Subgroup analysis of secondary and tertiary hospitals
Indicators | 2016 | 2017 | 2018 |
---|---|---|---|
Proportion of ICU in total inpatients(%) | |||
Second-level hospital | 1.73 (1.19, 2.55) | 1.78(1.25, 2.66) ¶ | 1.71(1.19, 2.49) |
Tertiary hospital | 1.55(1.10, 2.35) | 1.56(1.08, 2.29) | 1.58(1.09, 2.37) |
Proportion of ICU in total inpatient bed occupancy(%) | |||
Second-level hospital | 1.33 (0.96, 1.98) | 1.37(0.94, 1.93) | 1.28(0.92, 1.84) |
Tertiary hospital | 1.12(0.71, 1.53) | 1.16(0.79, 1.77) | 1.19(0.84, 1.74) |
Proportion of APACEH II score ≥ 15 in all ICU patients(%) | |||
Second-level hospital | 52.70 (29.94, 74.55) ¶ | 58.65 (35.75, 79.93) | 55.56 (29.85, 75.38) |
Tertiary hospital | 65.07 (42.86, 80.04) | 64.49 (46.53, 79.31) | 61.12 (41.93, 76.60) |
3 h SSC bundles compliance rate(%) | |||
Second-level hospital | 75.00 (57.14, 100) | 85.54 (57.74, 100) | 86.75 (55.09, 100) |
Tertiary hospital | 84.92 (62.50, 100) | 87.64 (67.46, 100) | 89.83(75.00, 100) * |
6 h SSC bundles compliance rate(%) | |||
Second-level hospital | 54.34 (27.27, 90.00) | 68.75 (34.15, 100) | 72.54 (33.19, 100) |
Tertiary hospital | 70.47 (39.87, 93.44) | 76.27 (41.86, 94.44) | 78.47 (54.55, 94.74) |
Microbiology detection before antibiotics(%) | |||
Second-level hospital | 73.76 (40.00, 95.90) ¶ | 72.12 (39.30, 96.34) ¶ | 87.40 (58.50, 99.93) *† |
Tertiary hospital | 87.44 (62.42, 98.43) | 88.49 (69.03, 97.48) | 90.48 (73.77, 100) * |
DVT prophylaxis rate(%) | |||
Second-level hospital | 63.33 (25.00, 96.18) ¶ | 67.12 (29.42, 95.92) | 80.74 (35.87, 97.44) |
Tertiary hospital | 76.95 (41.67, 96.07) | 74.16 (42.48, 96.30) | 84.43 (51.87, 98.26) |
Unplanned endotracheal extubation rate(%) | |||
Second-level hospital | 1.55 (0, 4.76) | 1.65(0, 4.17) | 2.07(0.45, 4.65) |
Tertiary hospital | 0.93(0.29, 2.42) | 1.06(0.24, 2.50) | 1.06(0.33, 2.78) |
Reintubation rate within 48 h(%) | |||
Second-level hospital | 1.92 (0, 5.77) | 1.62(0.19, 4.32) | 2.00(0.36, 4.44) |
Tertiary hospital | 1.57(0.65, 3.76) | 1.60(0.61, 3.27) | 1.72(0.74, 3.50) |
Rate of unplanned transfer to ICU(%) | |||
Second-level hospital | 2.24 (0.45, 6.74) | 2.40(0.66, 6.82) | 2.69(0.76, 8.83) |
Tertiary hospital | 2.99(0.76, 10.05) | 2.53(0.70, 8.76) | 2.54(0.84, 7.28) |
ICU readmission rate within 48 h(%) | |||
Second-level hospital | 1.01 (0, 2.42) | 0.85(0.22, 2.08) | 1.26(0.38, 2.27) |
Tertiary hospital | 0.97(0.50, 1.90) | 0.91(0.37, 1.98) | 1.02(0.48, 1.89) |
VAP incidence rate(%) | |||
Second-level hospital | 12.75 (3.68, 31.15) | 15.48 (2.79, 31.81) | 9.22(2.43, 22.73) |
Tertiary hospital | 10.30 (4.58, 19.67) | 9.04(4.59, 18.62) | 7.62(3.30, 15.07) *† |
CRBSI incidence rate(%) | |||
Second-level hospital | 0.47 (0, 2.47) | 0.76(0, 2.84) | 0.86(0, 3.17) |
Tertiary hospital | 1.82(0.52, 3.55) | 1.68(0.53, 3.49) | 1.40(0.49, 3.12) |
CAUTI incidence rate(%) | |||
Second-level hospital | 2.42 (0, 6.11) | 1.42(0.19, 5.10) | 1.97(0.62, 4.98) |
Tertiary hospital | 2.02(0.68, 4.00) | 1.79(0.79, 4.21) | 1.79(0.76, 3.71) |
ICU Mortality rate(%) | |||
Second-level hospital | 7.36(3.78,13.25) ¶ | 7.72(4.43,13.7) ¶ | 8.41(4.59,13.96) ¶ |
Tertiary hospital | 9.24(4.62,16.13) | 10.09(5.17,17.32) | 9.66(5.52,16.42) |
Subgroup analysis based on the provincial GDP per capita
Indicators | 2016 | 2017 | 2018 |
---|---|---|---|
Proportion of ICU in total in-patients (%) | |||
Low GDP province | 1.77 (1.25, 2.53) | 1.66(1.14, 2.59) | 1.72(1.15, 2.51) |
Middle GDP province | 1.54(1.15, 2.56) | 1.60(1.2, 2.68) | 1.57(1.16, 2.56) |
High GDP province | 1.56(1.06, 2.26) | 1.60(1.08, 2.21) | 1.55(1.09, 2.26) |
Proportion of ICU in total inpatient bed occupancy(%) | |||
Low GDP province | 1.12 (0.74, 1.58) | 1.16 (0.84, 1.76) | 1.15(0.77, 1.8) |
Middle GDP province | 1.08 (0.72, 1.65) | 1.13 (0.73, 1.65) | 1.19(0.87, 1.63) |
High GDP province | 1.27 (0.90, 1.87) | 1.35 (0.91, 1.97) § | 1.36(0.94, 1.85) |
Proportion of APACHE II score ≥ 15 in all ICU patients(%) | |||
Low GDP province | 66.00 (40.07, 81.89) | 62.81 (41.87, 80.25) | 61.79 (39.94, 76.6) |
Middle GDP province | 56.88 (34.12, 75.33) | 62.50 (42.31, 80.36) | 60.15 (35.01, 77.39) |
High GDP province | 57.34 (37.44, 79.47) | 60.31 (39.57, 75.17) | 57.74 (36.55, 74.96) |
3 h SSC bundles compliance rate(%) | |||
Low GDP province | 85.00 (61.22, 100) | 88.61 (66.67, 100) | 90.28 (70.42, 100) |
Middle GDP province | 77.78 (60.00, 94.12) | 82.43 (58.82, 100) | 84.03 (67.33, 100) |
High GDP province | 83.33 (62.41, 100) | 89.47 (66.67, 100) | 89.83 (71.76, 100) |
6 h SSC bundles compliance rate | |||
Low GDP province | 66.67 (33.33, 95.16) | 72.84 (41.86, 96.49) | 77.14 (50.00, 95.77) |
Middle GDP province | 65.15 (29.31, 87.18) | 67.86 (31.98, 90.12) | 71.01 (40.92, 93.05) |
High GDP province | 64.04 (38.10, 93.33) | 77.78 (43.90, 100) | 78.93 (50.00, 99.09) |
Microbiology detection rate before antibiotics(%) | |||
Low GDP province | 80.24 (46.69, 99.02) | 83.73 (60.81, 97.24) | 89.15 (70.02, 100) * |
Middle GDP province | 85.90 (46.96, 97.32) | 84.50 (64.51, 97.36) | 87.95 (69.17, 98.09) |
High GDP province | 85.71 (57.42, 98.33) | 82.78 (57.01, 97.09) | 91.34 (70.72, 100) *† |
DVT prophylaxis rate(%) | |||
Low GDP province | 74.22 (30.74, 95.39) | 65.40 (32.78, 94.99) | 82.47 (47.02, 96.09) |
Middle GDP province | 74.39 (32.48, 98.42) | 72.25 (33.00, 96.28) | 76.80 (40.89, 96.39) |
High GDP province | 72.93 (41.96, 95.58) | 75.46 (42.48, 97.68) | 85.77 (55.62, 99.66) |
Unplanned endotracheal extubation rate(%) | |||
Low GDP province | 1.20 (0.11, 3.37) | 1.32 (0.34, 3.33) | 1.19 (0.36, 3.19) |
Middle GDP province | 1.44 (0.29, 4.17) | 1.29 (0.22, 4.10) | 1.41 (0.41, 3.50) |
High GDP province | 0.96 (0.05, 3.00) | 1.23 (0.19, 2.78) | 1.34 (0.30, 3.79) * |
Reintubation rate within 48 h(%) | |||
Low GDP province | 1.49 (0.44, 4.00) | 1.59 (0.64, 3.91) | 1.61 (0.56, 3.62) |
Middle GDP province | 1.78 (0.43, 4.58) | 1.67 (0.56, 3.45) | 2.18 (0.73, 4.37) |
High GDP province | 1.63 (0.59, 4.44) | 1.56 (0.44, 3.97) | 1.87 (0.66, 3.67) § |
Rate of unplanned transfer to ICU(%) | |||
Low GDP province | 2.57 (0.50, 7.21) | 2.27 (0.68, 7.53) | 2.49 (0.87, 8.71) |
Middle GDP province | 3.30 (0.74, 14.21) | 2.89 (0.68, 10.16) | 2.21 (0.62, 7.78) |
High GDP province | 2.67 (0.76, 7.59) | 2.62 (0.70, 6.93) | 2.76 (0.93, 7.34) |
ICU readmission rate within 48 h(%) | |||
Low GDP province | 0.97 (0.38, 2.00) | 0.93 (0.34, 1.97) | 1.11 (0.48, 2.16) |
Middle GDP province | 1.13 (0.36, 2.49) | 0.84 (0.26, 2.00) | 1.34 (0.62, 2.38) † |
High GDP province | 0.93 (0.42, 2.08) | 0.89 (0.37, 2.09) | 1.00 (0.38, 1.72) |
VAP incidence rate(%) | |||
Low GDP province | 12.39 (4.86, 28.81) | 11.64 (4.28, 25.04) | 9.52 (3.27, 18.32) |
Middle GDP province | 9.93 (3.71, 22.87) | 9.13 (3.96, 20.91) | 7.83 (3.13, 15.15) |
High GDP province | 11.15 (4.13, 20.64) | 9.77 (4.32, 23.83) | 7.52 (3.02, 16.79) *† |
CRBSI incidence rate(%) | |||
Low GDP province | 1.39 (0, 3.76) | 1.21 (0, 3.01) | 1.19 (0, 3.29) |
Middle GDP province | 0.98 (0, 3.25) | 1.39 (0, 3.58) | 1.24 (0.11, 2.98) |
High GDP province | 1.46 (0, 3.16) | 1.60 (0, 3.62) | 1.34 (0, 3.19) |
CAUTI incidence rate(%) | |||
Low GDP province Middle GDP province | 1.97 (0.47, 4.31) 2.13 (0.89, 4.97) | 1.40 (0.55, 3.48) 2.02 (0.83, 4.94) | 1.45 (0.59, 4.05) 2.14 (0.92, 4.59) |
High GDP province | 2.17 (0.59, 4.42) | 1.93 (0.58, 4.55) | 1.92 (0.68, 3.78) |
ICU Mortality rate(%) | |||
Low GDP province | 8.16 (4.60, 13.50) | 8.39 (4.57, 16.05) | 8.54 (4.65, 14.31) |
Middle GDP province | 7.68 (4.39, 13.12) | 8.32 (4.91, 13.29) | 8.90 (5.27, 14.89) |
High GDP province | 9.83 (4.31, 17.06) | 10.15 (5.21, 15.81) | 10.15 (5.67, 17.15) |