Quality Metrics and Outcomes Among Critically Ill Patients in China: Results of the National Clinical Quality Control Indicators for Critical Care Medicine Survey 2015–2019
In recent years, medical quality and patient safety have emerged as major goals for healthcare professionals and hospital managers. The intensive care unit (ICU) is a hospital unit with substantial levels of risk for morbidity and mortality. ICU patients face intrinsic risks related to their underlying diseases or pathophysiologic derangements, as well as extrinsic risks related to the care process itself. ICU patients experience an average of 1.75 medication errors each day, with nearly 20% of these errors being life-threatening and 40% requiring treatment. Therefore, it is crucial to improve the quality of care provided to ICU patients, especially in the context of the COVID-19 pandemic.
To address the need for improved care quality in China, the Quality Improvement of Critical Care (QICC) program, led by the China National Critical Care Quality Control Center (China-NCCQC), was initiated in 2015. This program conducted an annual survey of ICU medical quality from 2015 to 2019, analyzing adherence to quality metrics and outcomes among critically ill patients. This study presents the results of this national survey, providing a comprehensive overview of the quality of care in China’s ICUs over the past five years.
The survey was conducted at the ICU level and included a 15-indicator online questionnaire. The indicators were classified into three categories: structural indicators, procedural indicators, and outcome indicators. Structural indicators included the proportion of ICU patients relative to the total number of inpatients, the proportion of ICU bed occupancy relative to the total inpatient bed occupancy, and the proportion of patients with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores ≥15. Procedural indicators included compliance with the 3-hour and 6-hour Surviving Sepsis Campaign (SSC) bundles, microbiology detection rates before antibiotic administration, deep vein thrombosis (DVT) prophylaxis, unplanned endotracheal extubations, reintubations within 48 hours, unplanned transfers to the ICU, and ICU readmissions within 48 hours. Outcome indicators included the incidences of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), catheter-associated urinary tract infections (CAUTIs), and in-hospital mortality.
The survey results revealed significant heterogeneity in the quality of care across different regions and hospital grades in China. The proportion of ICU patients relative to the total number of inpatients ranged from 1.83% to 2.22%, while the proportion of ICU bed occupancy relative to the total inpatient bed occupancy ranged from 0.87% to 3.13%. The proportion of patients with APACHE II scores ≥15 ranged from 46.33% to 51.43%. These structural indicators varied greatly across provinces and regions, with the highest rates of ICU admissions and bed occupancy observed in Midwest and South China, while the proportion of patients with APACHE II scores ≥15 was highest in South China.
Procedural indicators also showed significant variation across regions. The compliance rates for the 3-hour and 6-hour SSC bundles were 74.37% and 76.60%, respectively, in 2015, with the 3-hour bundle compliance rate increasing to 80.65% by 2019. The microbiology detection rate before antibiotic administration improved from 62.93% in 2015 to 82.56% in 2018. The proportion of ICU patients receiving DVT prophylaxis ranged from 54.92% to 60.49%, with some provinces such as Chongqing and Shandong showing rates over 80%, while others like Shanghai and Hainan had rates below 30%.
Outcome indicators revealed that the incidence of VAP ranged from 12.77 to 14.54 cases per 1000 ventilator days, with the highest rates observed in Qinghai Province. The incidence of CRBSI ranged from 2.07 to 3.66 cases per 1000 catheter days, with the highest rates in Central China. The incidence of CAUTI ranged from 2.70 to 4.41 cases per 1000 catheter days, with the highest rates in Yunnan and Gansu. In-hospital mortality rates varied significantly across provinces, with the highest rate of 18.39% in Ningxia and the lowest rate of 5.37% in Gansu. Overall, the national ICU mortality rate declined from 10.19% in 2015 to approximately 8% in 2019.
Multivariate analysis identified several factors associated with ICU mortality and nosocomial infections. Unplanned transfers to the ICU and higher APACHE II scores were significantly associated with increased odds of ICU mortality (OR=3.863 and OR=4.539, respectively). Treatment in certain regions (North and Central China) and higher 3-hour SSC bundle compliance rates were associated with reduced mortality (OR=0.567, OR=0.598, and OR=0.618, respectively). Tertiary hospitals were associated with decreased odds of VAP and CAUTI but increased odds of CRBSI (OR=0.869, 0.827, and 1.154, respectively). The proportion of ICU bed occupancy relative to the total inpatient bed occupancy was associated with higher incidences of VAP and CAUTI (OR=31.236 and OR=23.670, respectively).
The study highlights the importance of early identification of critically ill patients and timely implementation of targeted treatments to improve outcomes. The 3-hour SSC bundle compliance rate, in particular, was associated with improved survival and cost savings. The survey also revealed gaps in the management of nosocomial infections, with higher incidences of VAP and CRBSI in certain regions compared to developed countries. These findings underscore the need for continued efforts to improve the quality of care in China’s ICUs, particularly in the areas of infection control and resource allocation.
In conclusion, the quality of medical care in China’s ICUs is heterogeneous, with significant geographic disparities and variations across hospital grades. The identification of critically ill patients and the implementation of appropriate and timely treatment interventions are crucial for enhancing the overall level of critical care in China. Since 2015, the China-NCCQC has been committed to improving the quality management of ICUs based on these survey results. Some positive outcomes have been achieved, and the critical care quality control system played a major role in addressing the COVID-19 pandemic. However, there is still considerable room for improvement in China’s ICU construction, particularly in terms of technology, talent, and resource allocation. Future efforts will focus on improving the quality of critical care programs throughout the entire country, using these data to enhance the medical quality levels of ICUs in China.
doi.org/10.1097/CM9.0000000000001933
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