Unit Mortality

Percent ICU deaths per calendar month

Indicators
Indicator:	Unit Mortality
Created/Raw:	Created
Program:	Critical Care
Start Date:
End Date:
Reports:	Critical Care Program Quality Indicator Report, Directors Quarterly and Annual Report (Critical Care), Directors Quarterly and Annual Report (Medicine)

• Cargo

• SMW:

• Categories

• Default form:

QI domain

• Safe
• Effective

Significance

Mortality is heavily influenced by case mix and severity of illness. Any differences in mortality between units or over time should be examined for differences in patient population first. Other Factors affecting mortality include structural and process-related aspects of care.

Sampling Plan / Procedure

Inclusion Criteria

100% of all patients physically present in an ICU bed awaiting transfer out of the ICU and having a date value on the Transfer Ready DtTm field

• For the Critical Care Report, the Directors and QIT agreed to separate the transfer to IICU from the rest of the locations (to home, to ward, to outside hospital ward, rehab, PCH and those who died but have transfer ready date_time) - start date Jan to March 2018 Qtr report.

Frequency

• Once the transfer ready date has been written and the allowable 2.0 hours has elapsed, compute Transfer Delay (Critical Care) or the total time it takes for ICU patient to leave the unit.
  • If no time is indicated with the transfer ready date_tm field a proxy time of 10:00 am for day shift and midnight for night shift will be used for calculation purposes.
• To be completed at time of discharge from ICU, compute the total days spent in ICU (refer as LOS)
• To be calculated and reported on a monthly, quarterly or yearly basis based on either ICU Admission Dates or ICU Discharge Dates.
• For the Director reports, the discharge dates are used as the time of reference.

Definition and Derivation

Avoidable days is defined as the total time from date/time of transfer ready to date/time transfer out of ICU (in hours) less 2.0 hours (and divided by 24 to give yield total avoidable days)

• Refer to the definition of Transfer Ready DtTm and Transfer Delay (Critical Care)

Numerator

Num = Total Transfer Delay (Critical Care) in a given period

Denominator

Denom =Total Patient Days on the same period as the numerator

Formula

Avoidable Days (%) = Num / Denom * 100

Example

• Time Reference: Discharge Dates from Jan 1, 2017 to March 31, 2017
• Total Avoidable Days of all patients with transfer ready date-time= 254.5
• Total LOS of all ICU discharges = 1175.3
• Avoidable Days (%) = 254.5 / 1175.3 * 100= 21.7%

Data Sources

• Per patient Transfer Delay (Critical Care)
  • Before Oct 1, 2020 : derived from Transfer Ready DtTm field and Dispo DtTm field.
  • Starting Oct 1, 2020: derived from the first transfer ready date and time in the Transfer Ready DtTm tmp entry and Dispo DtTm field .
• Per patient LOS is derived from Accept DtTm field or Arrive DtTm field and Dispo DtTm field

SAS Program

X:\Julie\SAS_CFE\CFE_macros\logphiunit.sas

Data Integrity Checks

• Query check long transfer delay

Data use

• Outcomes Improvement Team Quarterly ICU Report

Report Users

• Critical Care Directors and Site Managers
• Critical Care Quality Improvement Team (QIT)

Change Log

July 1, 2018 - Definition changed "Avoidable days is defined as the total time from date/time of transfer ready to date/time transfer out of ICU (in hours) less 2.0 hours (and divided by 24 to give yield total avoidable days)" from 4 hrs as per instruction by p:Jodi Walker Tweed.

Related articles

Related articles:

Dispo field ‎ (← links) User:JMojica ‎ (← links)