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. 2019 Mar 22;23(1):95.
doi: 10.1186/s13054-019-2377-x.

Development of a quality indicator set to measure and improve quality of ICU care for patients with traumatic brain injury

Jilske A Huijben  1 , Eveline J A Wiegers  2 , Nicolette F de Keizer  3 , Andrew I R Maas  4 , David Menon  5 , Ari Ercole  5 , Giuseppe Citerio  6   7 , Fiona Lecky  8 , Lindsay Wilson  9 , Maryse C Cnossen  2 , Suzanne Polinder  2 , Ewout W Steyerberg  2   10 , Mathieu van der Jagt  11 , Hester F Lingsma  2 ; Delphi panel
Collaborators, Affiliations

Development of a quality indicator set to measure and improve quality of ICU care for patients with traumatic brain injury

Jilske A Huijben et al. Crit Care. .

Abstract

Background: We aimed to develop a set of quality indicators for patients with traumatic brain injury (TBI) in intensive care units (ICUs) across Europe and to explore barriers and facilitators for implementation of these quality indicators.

Methods: A preliminary list of 66 quality indicators was developed, based on current guidelines, existing practice variation, and clinical expertise in TBI management at the ICU. Eight TBI experts of the Advisory Committee preselected the quality indicators during a first Delphi round. A larger Europe-wide expert panel was recruited for the next two Delphi rounds. Quality indicator definitions were evaluated on four criteria: validity (better performance on the indicator reflects better processes of care and leads to better patient outcome), feasibility (data are available or easy to obtain), discriminability (variability in clinical practice), and actionability (professionals can act based on the indicator). Experts scored indicators on a 5-point Likert scale delivered by an electronic survey tool.

Results: The expert panel consisted of 50 experts from 18 countries across Europe, mostly intensivists (N = 24, 48%) and neurosurgeons (N = 7, 14%). Experts agreed on a final set of 42 indicators to assess quality of ICU care: 17 structure indicators, 16 process indicators, and 9 outcome indicators. Experts are motivated to implement this finally proposed set (N = 49, 98%) and indicated routine measurement in registries (N = 41, 82%), benchmarking (N = 42, 84%), and quality improvement programs (N = 41, 82%) as future steps. Administrative burden was indicated as the most important barrier for implementation of the indicator set (N = 48, 98%).

Conclusions: This Delphi consensus study gives insight in which quality indicators have the potential to improve quality of TBI care at European ICUs. The proposed quality indicator set is recommended to be used across Europe for registry purposes to gain insight in current ICU practices and outcomes of patients with TBI. This indicator set may become an important tool to support benchmarking and quality improvement programs for patients with TBI in the future.

Keywords: Benchmarking; Intensive care unit; Quality indicators; Quality of care; Trauma registry; Traumatic brain injury.

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Conflict of interest statement

Ethics approval and consent to participate

Not applicable. No patients participated and Delphi panelist (experts) have given consent by completion of the agreement form in the questionnaire. Compliance with ethical standards was confirmed by the medical ethical committee of the Erasmus Medical Center Rotterdam (MEC-2018-1371).

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Overview of the Delphi process. Overview of the Delphi process: time frame, experts’ involvement, and indicator selection; *8 indicators were removed based on the sensitivity analyses. The left site of the figure shows the number of indicators that were removed after disagreement and consensus with no comments to improve definitions. In addition, the number of changed indicator definitions is shown. The right site of the figure shows the number of newly proposed indicators (that were rerated in the next Delphi round) and the number of indicators that were included in the final indicator set. After round 2, 17 indicators were included in the final set (and removed from the Delphi process), and after round 3, 25 indicators were included in the final set—a total of 42 indicators. The agreement was defined as a median score of 4 (agreement) or 5 (strong agreement) on all four criteria (validity, feasibility, discriminability, and actionability) to select indicators. The disagreement was defined as a median score below 4 on at least one of the four criteria. The consensus was defined as an interquartile range (IQR) ≤ 1 (strong consensus) on validity—since validity is considered the key characteristic for a useful indicator [19]—and IQR ≤ 2 (consensus) on the other criteria
Fig. 2
Fig. 2
Facilitators or barriers for implementation of the quality indicator set. Percentage of experts that indicated a certain facilitator or barrier for implementation of the quality indicator set. Other indicated facilitator was “create meaningful uniform indicators.” Other indicated barriers were “gaming” (N = 1, 2%) and “processes outside of ICU (e.g., rehabilitation) are hard to query.” *Participation in trauma quality improvement program
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