Quality in intensive care units: proposal of an assessment instrument.

BACKGROUND: There is an increasing need for standardized instruments for quality assessment that are able to reflect the actual conditions of the intensive care practices, especially in low and middle-income countries. The aim of this article is to describe the preparation of an instrument for quality assessment of adult intensive care services adapted to the actual conditions of intensive care in a middle-income country and comprising indicators validated in the literature. METHODS: The study consisted of five steps: (1) a literature survey; (2) a discussion with specialists by consensus method; (3) a pilot field test; (4) a description of indicators; and (5) an elaboration of the final version of the instrument. Each generated indicator was attributed a score ("out of standard" = 0; "below standard" = 1; "standard" = 2) that allowed calculation of the total score for each service assessed. RESULTS: A total of 62 indicators were constructed, distributed as follows: 38 structure indicators (physical structure: 4; human resources: 14; continued education and training: 2; protocols and routines: 12; material resources: 6); 17 process indicators (safety: 7; work: 10); and seven outcome indicators. The maximum possible total score was 124. CONCLUSIONS: Possible future applications of the instrument for the assessment of intensive care units that was constructed in the present study include benchmarking, multicenter studies, self-assessment of intensive care units, and evaluation of changes resulting from interventions.

Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study.

INTRODUCTION: Sedation overuse is frequent and possibly associated with poor outcomes in the intensive care unit (ICU) patients. However, the association of early oversedation with clinical outcomes has not been thoroughly evaluated. The aim of this study was to assess the association of early sedation strategies with outcomes of critically ill adult patients under mechanical ventilation (MV). METHODS: A secondary analysis of a multicenter prospective cohort conducted in 45 Brazilian ICUs, including adult patients requiring ventilatory support and sedation in the first 48 hours of ICU admissions, was performed. Sedation depth was evaluated after 48 hours of MV. Multivariate analysis was used to identify variables associated with hospital mortality. RESULTS: A total of 322 patients were evaluated. Overall, ICU and hospital mortality rates were 30.4% and 38.8%, respectively. Deep sedation was observed in 113 patients (35.1%). Longer duration of ventilatory support was observed (7 (4 to 10) versus 5 (3 to 9) days, P = 0.041) and more tracheostomies were performed in the deep sedation group (38.9% versus 22%, P = 0.001) despite similar PaO2/FiO2 ratios and acute respiratory distress syndrome (ARDS) severity. In a multivariate analysis, age (Odds Ratio (OR) 1.02; 95% confidence interval (CI) 1.00 to 1.03), Charlson Comorbidity Index >2 (OR 2.06; 95% CI, 1.44 to 2.94), Simplified Acute Physiology Score 3 (SAPS 3) score (OR 1.02; CI 95%, 1.00 to 1.04), severe ARDS (OR 1.44; CI 95%, 1.09 to 1.91) and deep sedation (OR 2.36; CI 95%, 1.31 to 4.25) were independently associated with increased hospital mortality. CONCLUSIONS: Early deep sedation is associated with adverse outcomes and constitutes an independent predictor of hospital mortality in mechanically ventilated patients.