Effect of ICU Quality Control and Secondary Analysis: A 12-Year Multicenter Quality Improvement Project

Abstract

Background: China's aging population and increasing demand for critical care pose significant challenges to ICU quality improvement (QI). This study evaluates the impact of a 12-year multicenter QI initiative on ICU performance and patient outcomes in the context of resource constraints.

Methods: A pre-post intervention study was conducted across 75 ICUs in Beijing from January 2011 to December 2022. Key interventions included the establishment of QI teams, infection prevention protocols, pain and sedation management, nutritional support, and early mobilization strategies based on the PDCA cycle, as well as regular training and feedback. Primary outcomes included ICU mortality, standardized mortality ratio (SMR) (ratio of observed to expected deaths, adjusted for risk), and healthcare-associated infections (HAIs), such as VAP, CLABSI, and CAUTI rates. Secondary outcomes included unplanned extubation rates, reintubation within 48 hours, and ICU readmission rates within 48 hours.

Results: Analysis of 425,534 patient records from 5396 reports revealed significant improvements. The proportion of ICU admissions among total inpatients increased from 4.1% in 2011 to 7.3% in 2022 (P < 0.001), and the proportion of patients with APACHE II scores ≥15 rose from 52.0% to 67.5% (P < 0.001). Compliance with 3-hour and 6-hour sepsis bundles increased (P < 0.001), and microbiological testing before antibiotic administration also improved (P < 0.001). Outcome indicators showed significant reductions in CRBSI and CAUTI rates (P < 0.001), ICU mortality (P < 0.001), and SMR (P < 0.001). VAP rates decreased from 6.29 to below 5.0 per 1000 ventilator days. ICU readmission rates and unplanned transfers slightly increased but remained low (P > 0.05).

Conclusion: The study highlights the importance of addressing structural, process, and outcome indicators for effective ICU management. Continued monitoring and targeted interventions for high-risk ICUs are essential to sustaining quality improvements.

Keywords: data analysis; intensive care unit; mortality rate; patient prognosis; quality improvement.

Figure 1

The QI indicator’s varieties across 12 years. (A). SMR, ICU Mortality Rate, and Expected Mortality Rate: The Standardized Mortality Ratio (SMR) (red line) shows a decline over time, while ICU mortality rate (blue) and expected mortality rate (pink) remain relatively stable with minor fluctuations. (B). Microbiology Detection Before Antibiotics, DVT Prophylaxis, and APACHE II Scores: There is an upward trend in the proportion of microbiology detection before antibiotics (green), DVT prophylaxis (blue), and patients with APACHE II scores ≥ 15 (purple), reflecting improved clinical practices and increasing patient acuity in the ICU. (C). Nosocomial Infection Rates: The rates of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSI), and catheter-associated urinary tract infections (CAUTI) show a consistent decline, signaling improvements in infection control practices in the ICU. (D). ICU Bed Occupancy and Transfers: The proportion of ICU patients relative to total inpatient beds (blue) peaked and then stabilized, while unplanned transfers to the ICU (green) fluctuated over time. This suggests evolving ICU admission and transfer protocols. (E). Unplanned Endotracheal Extubation, Reintubation, and Readmission Rates: Unplanned endotracheal extubation (pink) fluctuates significantly, while reintubation rates within 48 hours (green) and ICU readmission rates within 48 hours (blue) show minor changes, indicating areas for improvement in airway management. (F). Compliance with 3-hour and 6-hour SSC Bundles: Compliance with both 3-hour (blue) and 6-hour (pink) SSC bundles improved over time, demonstrating effective implementation of quality improvement protocols aimed at reducing sepsis-related complications.

Figure 2

The focus of quality control in ICUs differs based on different characteristics and geographical regions.

Figure 3

Continued.

Figure 3

Trends in ICU quality control indicators over the past twelve years. (A). Readmission rate to ICU within 48 hours (24 hours). (B). ICU bed occupancy relative to total inpatient beds. (C). Proportion of ICU patients relative to total inpatients. (D). Unplanned transfers to ICU. (E). 3-hour SSC bundle. (F). 6-hour SSC bundle. (G). Ventilator-associated pneumonia (VAP) incidence per 1000 line days. (H). Pressure sores incidence per 1000 line days. (I). Catheter-associated urinary tract infections (CAUTI) per 1000 line days. (J). Catheter-related bloodstream infections (CRBSI) per 1000 line days. (K). Unplanned endotracheal extubation. (L). Reintubation rate within 48 hours. (M). Microbiology detection before antibiotics. (N).Proportion of DVT prophylaxis .(O).Proportion of ICU patients with APACHE II scores ≥ 15.(P). Expected mortality rate. (Q). ICU mortality rate. (R). Standardized Mortality Ratio (SMR).