3.16 Unplanned Intensive Care Unit Admission

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Description of Indicator

Relationship to Quality Medical care should be effective, efficient and safe
Type of Indicator Hospital outcome, Hospital level
Proposed Data Source Trauma Registry, Administrative Data
Definition Number of patients with a primary injury diagnosis admitted to ICU from the ward per 100 patients*
Numerator All patients age 18 years and older with a primary injury diagnosis admitted to ICU from the ward‡†
Denominator All patients age 18 years and older with a primary injury diagnosis admitted to a hospital ward†
Benchmark Not specified at presentβ
Risk Adjustment Age, sex, pre-existing conditions and a validated ISS [e.g. abbreviated ISS (AIS) or International Classification of Diseases–based ISS (ICISS)]

* How to calculate Risk-Adjusted Unplanned ICU Admission:
Risk-adjusted Unplanned ICU Admission = [Observed Unplanned ICU Admission Rate/Risk-adjusted Unplanned ICU Admission Rate (X100)] x Overall Unplanned ICU Admission Rate in the standard population.
Note: Standard population refers to a population of institutions under evaluation (e.g. institutions contributing data to a national trauma registry or centrally collected administrative data bank).
Alternatively Risk-adjusted Unplanned ICU Admission can be calculated directly from parameter estimates from a multivariable risk adjusted model examining data from individual institutions or from multiple institutions.
‡ A small number of injured patients may have “planned” admissions from the ward to the ICU. However, this number is likely to be small compared to the number of patients with transfers from the ward to the ICU that are “unplanned”. To make the indicator easy to implement, a small amount of misclassification will likely need to be tolerated.
† Excludes patients admitted to ICU from the ED, operating room or post-operative care unit.
ß Mean unplanned ICU admission across all centers excluding the center under evaluation is one possible benchmark that can be considered.

The indicator is intended to monitor unplanned admissions to the ICU.

Panel Review
Panelists noted that distinguishing unplanned versus planned ICU admissions is challenging and that
either the definition could be operationalized to facilitate measurement (approach selected by panel) or that medical record level data may be needed. It was noted that the indicator may help identify opportunities or interventions to improve patient safety.

Trauma Center Review
The trauma centers similarly highlighted the challenges of distinguishing unplanned versus planned ICU admission as well the potential value of also capturing the reason for transfers from ward to the ICU.

Review of Literature & Evidence
Face Validity: No studies identified.
Construct Validity: One study demonstrated that implementation of a trauma quality improvement program that included the quality indicator was associated with reduced hospital mortality44.
Reliability: No studies identified.
Risk Adjustment: No studies identified.
Utilization: Unplanned ICU admission is used as a quality indicator by a moderate number of trauma centers: USA 9% (17/200), Canada 23% (8/35), Australasia 33% (4/12).
There is limited literature exploring unplanned admissions to the ICU for trauma patients.

This indicator consists of an amalgamation of two separate measures evaluated by the Quality Indicators in Trauma Care Consensus Panel; Unplanned Return to ICU and Unplanned ICU Admission /Readmission, previously proposed by Chadbunchachai et al.44.



44. Chadbunchachai W, Saranrittichai S, Sriwiwat S, Chumsri J, Kulleab S, Jaikwang P. Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000. J Med Assoc Thai. 2003;86(1):1-7.