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  • Measure Summary
  • NQMC:008552
  • Mar 2011

Continuing medical education, teaching, and research: does the hospital have duly updated basic protocols?

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in July 2015.

Primary Measure Domain

Clinical Quality Measures: Structure

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess whether the hospital has duly updated basic protocols.

Rationale

The aim of intensive care medicine is to provide critical patients with the healthcare that they need, ensuring the quality and safety of care. Intensive care medicine is one of the principal components of modern healthcare systems. There is an increasing demand for this resource, which involves high costs.

The quality of care has gradually come to be the central focus of healthcare, and in recent years patient safety has come to represent one of the key aspects of quality. In the case of intensive care medicine, this interest in quality is even more evident, not only because of its social and economic impact, but also because some of the dimensions involved in the quality of care of critical patients take on greater importance: critical patients are more vulnerable, access to critical care is more limited so efforts to distribute resources equitably are more important, scant scientific evidence is available, and the efficiency is limited.

Good clinical practice is favored by the standardization of processes in agreement with current scientific evidence by means of periodically updated protocols. Protocols should adjust guidelines to the diagnostic and therapeutic possibilities of our working environments. Protocols should aim to homogenize the care provided in each center and serve as tool to facilitate and streamline decision making.

Evidence for Rationale

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Primary Health Components

Continuing medical education (CME); teaching; research; updated basic protocols

Denominator Description

This measure applies to hospitals (one hospital at a time).

Numerator Description

Existence of duly updated basic protocols (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Clinical Administrators/Managers

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Does not apply to this measure

Target Population Age

Does not apply to this measure

Target Population Gender

Does not apply to this measure

IOM Care Need

Not within an IOM Care Need

IOM Domain

Not within an IOM Domain

Case Finding Period

Unspecified

Denominator Sampling Frame

Health care or public health organization

Denominator (Index) Event or Characteristic

Does not apply to this measure

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
This measure applies to hospitals (one hospital at a time).

Exclusions
Unspecified

Exclusions/Exceptions

Does not apply to this measure

Numerator Inclusions/Exclusions

Inclusions
Existence of duly updated basic protocols

Note:

  • Protocol: At the very least, should include assessment, diagnosis, treatment, and healthcare circuits used.
  • Basic protocols: Every intensive care unit (ICU) should have protocols for:
    • Criteria for admission to and discharge from the ICU
    • Acute coronary syndrome (ACS)
    • Management of severe arrhythmias and heart block
    • Traumatic brain injury
    • Sedation and pain management
    • Invasive and noninvasive mechanical ventilation and weaning
    • Severe sepsis and treatment of infections in general
    • Limiting life support
    • Appropriate end-of-life care
    • Use of restraints
    • Enteral and parenteral nutrition
    • Renal replacement techniques
    • Brain death
    • Acute respiratory distress syndrome (ARDS)
    • Life support
    • Prophylaxis against upper-gastrointestinal bleeding
    • Prophylaxis against deep vein thrombosis
    • Acute intoxications
    • Intrahospital transport
  • Updating: Referring to the period of time established for their revision. In general a period of 3 to 5 years is recommended.
  • The standard should be considered met only when all 19 protocols listed above are available and up to date.

Exclusions
Protocols for disease whose treatment is not among the services provided by the critical care department should be excluded from the list of basic protocols.

Numerator Search Strategy

Fixed time period or point in time

Data Source

Organizational policies and procedures

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Dichotomous

Interpretation of Score

Desired value is presence of a characteristic

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Prescriptive standard

Prescriptive Standard

Standard: Yes or 100%

Evidence for Prescriptive Standard

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Original Title

Existence of basic protocols.

Measure Collection Name

Quality Indicators in Critically Ill Patients

Measure Set Name

Continuing Medical Education, Teaching, and Research

Submitter

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Developer

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Funding Source(s)

Boehringer Laboratories

Composition of the Group that Developed the Measure

Scientific Coordination:

  • Maria Cruz Martín Delgado
  • Jesús Blanco Varela
  • Lluís Cabré Pericas
  • Pedro Galdos Anuncibay
  • Federico Gordo Vidal

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2011 Mar

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

2016 Jul

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in July 2015.

Source(s)

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Measure Availability

Source available in English External Web Site Policy and Spanish External Web Site Policy from the Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC) Web site.

For more information, contact SEMICYUC at Paseo de la Reina Cristina, 36, 4o D, Madrid, Spain; Phone: +34-91-502-12-13; Fax: +34-91-502-12-14; Web site: www.semicyuc.org External Web Site Policy; E-mail: secretaria@semicyuc.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on April 3, 2014. The information was verified by the measure developer on April 25, 2014.

The information was reaffirmed by the measure developer on July 2, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The Quality Indicators in Critically Ill Patients update 2011 can be used by any private or public body only for the purposes of research, clinical management, teaching and education, and will not be used for any other purpose. In all cases, full credit to the Spanish Society of Intensive Care Medicine (SEMICYUC) will be granted. The commercial use of the Quality Indicators in Critically Ill Patients update 2011 is explicitly forbidden.

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