1. Quality Management in the ICU Mazen Kherallah, MD, FCCP Chairman, Critical Care Department King Faisal Specialist Hospital & Research Center

2. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

3. Administration Quality Clinical service Ancillary service Others Individual Functions

4. Administration Quality Clinical service Ancillary service Others Interaction: Links

5. Quality Clinical service Ancillary service Others Order Administration

6. Facility Quality Clinical service Ancillary service Others Group Function

7. Quality Indicators Length of stay Unscheduled return to OR Readmission rate to ICU Reintubation rate Medication errors Blood utilization rates Infectious complication rate Inappropriate empiric antimicrobial coverage Iatrogenic pneumothorax rate

8. Quality Management

9. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

12. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

13. Length of Stay

14. LOS Benchmark

18. Sepsis LOS Benchmark

25. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

26. Bars show percents noyes Re-admission to ICU 0% 25% 50% 75% Percent n=235 94% n=16 6% Patients Re-admitted to ICU

27. Patients Re-admitted to ICU Benchmark

28. Patients Re-admitted to ICU

35. Mortality of Re-admitted Patients

36. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

37. Device-Associated Infectious Rates

38. Device-Associated Infection Rates Medical/Surgical ICU Benchmarked with NNIS 1995-2001 Denominator: Device-Days

39. NIC, Trend

40. VAP

41. CR-BSI

42. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

43. DDD’s

44. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

45. Inappropriate Empiric Antibiotic Coverage 8.2%

46. Causes of Inappropriateness MDR pseudomonas(1) ESBL E. Coli (1) Sensitive pseudomonas(1) Aeromonas (1) Stenotrophomonas (1) Yeast (1)

47. Quality Management Issues APACHE II Length of Stay Patients re-admitted to ICU Nosocomial infections in ICU Antibiotic utilization Inappropriateness of empiric antibiotic coverage Mortality review

48. ICU Mortality Rates 0-5 6-10 11-15 16-20 21-25 26-30 31-35 >35 SMR: Standardized Mortality Ratio: < 1

49. Hospital Mortality of ICU patients

50. Hospital Mortality Rates 0-5 6-10 11-15 16-20 21-25 26-30 31-35 >35 SMR: Standardized Mortality Ratio: < 1 SMR >1

51. Mortality of Patients Receiving Prolonged Mechanical ventilation (>2 days) Armando J et al. Chest2002;121:549-558 ICU Mortality Hospital Mortality 2-Month Mortality

52. Mortality as per Diagnosis

53. Mortality as per Referring Service

54. Age Distribution 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

55. Age Distribution and Referring Service 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Medicine Surgery Cardiothoracic Oncology Neuroscience Years

56. Distribution of APACHE II/Terminal Illness on Arrival to ICU 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 Advanced malignancy ESLD Brain death Severe brain injury End-stage lung disease APACHE II score

57. Quality Issues 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 Potentially preventable Possibly preventable No quality issues Poor respiratory care, early ICU discharge Failure to recognize life threatening disease Delayed diagnosis Years Questionable procedure indication

58. It should be there when you need it!