Effects of a national quality improvement program on ICUs in China: a controlled pre-post cohort study in 586 hospitals

The prevalence and risk factors of work-related musculoskeletal disorders among nurses in China: A systematic review and meta-analysis

BACKGROUND

Work-related musculoskeletal disorders significantly impact the job performance and quality of life of nursing personnel in China, necessitating an understanding of their prevalence and risk factors to enhance occupational health and improve medical safety.

OBJECTIVE

To systematically evaluate the prevalence and risk factors of work-related musculoskeletal disorders among clinical nurses in China.

DESIGN

Systematic literature review and meta-analysis.

METHODS

A computerized search was conducted on databases, including the China Knowledge Resource Integrated Database, Wanfang Database, China Biomedical Literature Database, Weipu Database, Embase, PubMed, Web of Science, the Cochrane Library, and CINAHL, covering studies from inception to February 28, 2024, addressing the risk factors for work-related musculoskeletal disorders among clinical nursing professionals in China. The meta-analysis was performed using Review Manager 5.4 and Stata 14 software.

RESULTS

The analysis included 23 articles, involving a total of 21,042 cases, and revealed a prevalence rate of 79 % (95 % CI: 73 %-84 %) for work-related musculoskeletal disorders among clinical nursing staff in China. Subgroup analysis revealed that the prevalence of work-related musculoskeletal disorders was highest among those with length of service >15 years, at 87 %; the 31-40 age group had a higher prevalence than other age groups, at 85 %; female nurses exhibited a prevalence rate of 80 %, surpassing male nurses at 77 %, while surgical nurses had a higher prevalence rate (83 %) than those in other departments. The most affected body parts were the neck (58 %), waist (57 %), shoulders (49 %), and back (35 %). Identified risk factors for work-related musculoskeletal disorders among clinical nurses in China included age >35 years (OR = 1.69, 95 % CI: 1.16-2.45), length of service ≥10 years (OR = 3.30, 95 % CI: 1.84-5.92), marital status (married) (OR = 2.19, 95 % CI: 1.91-2.50), heavy workload (OR = 2.46, 95 % CI: 1.25-4.83), weekly work hours >40 h (OR = 1.50, 95 % CI: 1.34-1.67), daily work hours >8 h (OR = 1.71, 95 % CI: 1.32-2.21), strong sense of work fatigue (OR = 1.47, 95 % CI: 1.22-1.76), and high night shift frequency (OR = 1.81, 95 % CI: 1.62-2.02). Regular physical exercise was found to be a protective factor (OR = 0.68, 95 % CI: 0.56-0.82).

CONCLUSION

The overall prevalence of work-related musculoskeletal disorders among clinical nursing staff in China was 79 %. Age >35 years, length of service ≥10 years, marital status (married), heavy workload, weekly work hours >40 h, daily work hours >8 h, strong sense of work fatigue, and night shift frequency were identified as risk factors. Nursing administrators and staff can take proactive measures against the aforementioned factors to reduce the risk of illness and ensure the safety of medical care.

REGISTRATION

PROSPERO: CRD42023479433.

Association between ICU quality and in-hospital mortality of V-V ECMO-supported patients-the ECMO quality improvement action (EQIA) study: a national cohort study in China from 2017 to 2019

This cohort study was performed to explore the influence of intensive care unit (ICU) quality on in-hospital mortality of veno-venous (V-V) extracorporeal membrane oxygenation (ECMO)-supported patients in China. The study involved all V-V ECMO-supported patients in 318 of 1700 tertiary hospitals from 2017 to 2019, using data from the National Clinical Improvement System and China National Critical Care Quality Control Center. ICU quality was assessed by quality control indicators and capacity parameters. Among the 2563 V-V ECMO-supported patients in 318 hospitals, a significant correlation was found between ECMO-related complications and prognosis. The reintubation rate within 48 hours after extubation and the total ICU mortality rate were independent risk factors for higher in-hospital mortality of V-V ECMO-supported patients (cutoff: 1.5% and 7.0%; 95% confidence interval: 1.05-1.48 and 1.04-1.45; odds ratios: 1.25 and 1.23; P = 0.012 and P = 0.015, respectively). Meanwhile, the V-V ECMO center volume was a protective factor (cutoff of ≥ 50 cases within the 3-year study period; 95% confidence interval: 0.57-0.83, odds ratio: 0.69, P = 0.0001). The subgroup analysis of 864 patients in 11 high-volume centers further strengthened these findings. Thus, ICU quality may play an important role in improving the prognosis of V-V ECMO-supported patients.

Chinese critical care certified course in intensive care unit: a nationwide-based analysis

BACKGROUND

A training program for intensive care unit (ICU) physicians entitled "Chinese Critical Care Certified Course" (5 C) started in China in 2009, intending to improve the quality of intensive care provision. This study aimed to explore the associations between the 5 C certification of physicians and the quality of intensive care provision in China.

METHODS

This nationwide analysis collected data regarding 5 C-certified physicians between 2009 and 2019. Fifteen ICU quality control indicators (three structural, four procedural, and eight outcome-based) were collected from the Chinese National Report on the Services, Quality, and Safety in Medical Care System. Provinces were stratified into three groups based on the cumulative number of 5 C certified physicians per million population.

RESULTS

A total of 20,985 (80.41%) physicians from 3,425 public hospitals in 30 Chinese provinces were 5 C certified. The deep vein thrombosis (DVT) prophylaxis rate in the high 5 C physician-number provinces was significantly higher than in the intermediate 5 C physician-number provinces (67.6% vs. 55.1%, p = 0.043), while ventilator-associated pneumonia (VAP) rate in the low 5 C physician-number provinces was significantly higher than in the high 5 C physician-number provinces (14.9% vs. 8.9%, p = 0.031).

CONCLUSIONS

The higher number of 5 C-certified physicians per million population seemed to be associated with higher DVT prophylaxis rates and lower VAP rates in China, suggesting that the 5 C program might have a beneficial impact on the quality of intensive care provision.

Evaluation of ICUs and weight of quality control indicators: an exploratory study based on Chinese ICU quality data from 2015 to 2020

This study aimed to explore key quality control factors that affected the prognosis of intensive care unit (ICU) patients in Chinese mainland over six years (2015-2020). The data for this study were from 31 provincial and municipal hospitals (3425 hospital ICUs) and included 2 110 685 ICU patients, for a total of 27 607 376 ICU hospitalization days. We found that 15 initially established quality control indicators were good predictors of patient prognosis, including percentage of ICU patients out of all inpatients (%), percentage of ICU bed occupancy of total inpatient bed occupancy (%), percentage of all ICU inpatients with an APACHE II score ⩾15 (%), three-hour (surviving sepsis campaign) SSC bundle compliance (%), six-hour SSC bundle compliance (%), rate of microbe detection before antibiotics (%), percentage of drug deep venous thrombosis (DVT) prophylaxis (%), percentage of unplanned endotracheal extubations (%), percentage of patients reintubated within 48 hours (%), unplanned transfers to the ICU (%), 48-h ICU readmission rate (%), ventilator associated pneumonia (VAP) (per 1000 ventilator days), catheter related blood stream infection (CRBSI) (per 1000 catheter days), catheter-associated urinary tract infections (CAUTI) (per 1000 catheter days), in-hospital mortality (%). When exploratory factor analysis was applied, the 15 indicators were divided into 6 core elements that varied in weight regarding quality evaluation: nosocomial infection management (21.35%), compliance with the Surviving Sepsis Campaign guidelines (17.97%), ICU resources (17.46%), airway management (15.53%), prevention of deep-vein thrombosis (14.07%), and severity of patient condition (13.61%). Based on the different weights of the core elements associated with the 15 indicators, we developed an integrated quality scoring system defined as F score=21.35%xnosocomial infection management + 17.97%xcompliance with SSC guidelines + 17.46%×ICU resources + 15.53%×airway management + 14.07%×DVT prevention + 13.61%×severity of patient condition. This evidence-based quality scoring system will help in assessing the key elements of quality management and establish a foundation for further optimization of the quality control indicator system.

Impact of Nosocomial Infection on in-Hospital Mortality Rate in Adult Patients Under Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery

Objective

There was no consensus on the impact of nosocomial infection on In-hospital mortality rate in patients receiving ECMO. This study aimed to investigate the impact of nosocomial infection (NI) on In-hospital mortality rate in adult patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac surgery.

Materials and Methods

This retrospective study included 503 adult patients who underwent VA-ECMO after cardiac surgery. The impact of time-dependent NIs on In-hospital mortality rate within 28 days of ECMO initiation was investigated using a Cox regression model. The cumulative incidence function for death was compared between patients with NIs and those without NIs using a competing risk model.

Results

Within 28 days after ECMO initiation, 206 (41.0%) patients developed NIs, and 220 (43.7%) patients died. The prevalence rates of NIs were 27.8% and 20.3% during and after ECMO therapy, respectively. The incidence rates of NIs during and after ECMO therapy were 49‰ and 25‰, respectively. Time-dependent NI was an independent risk factor for predicting death (hazard ratio = 1.05, 95% confidence interval = 1.00-1.11). The cumulative incidence of death in patients with NI was significantly higher than that in patients without NI at each time point within 28 days of ECMO initiation. (Z = 5.816, P = 0.0159).

Conclusion

NI was a common complication in adult patients who received VA-ECMO after cardiac surgery, and time-dependent NI was an independent risk factor for predicting mortality in these patients. Using a competing risk model, we confirmed that NIs increased the risk of In-hospital mortality rate in these patients.

Association between quality control and outcomes of septic shock caused by intestinal perforation in China: a cross-sectional study

Septic shock, largely caused by intestinal perforation, is a common critical disease in intensive care unit (ICU). For hospitals and health systems, a performance improvement program for sepsis was strong recommended in guidelines. Numerous studies have shown that improved quality control improves outcomes in patients with septic shock. Nevertheless, association between quality control and outcomes of septic shock caused by intestinal perforation are not fully revealed. Thus we designed this study to investigate effects of quality control on septic shock caused by intestinal perforation in China. This was a multicenter observational study. A total of 463 hospitals were enrolled in this survey, led by the China National Critical Care Quality Control Center (China-NCCQC) from January 1, 2018 to December 31, 2018. In this study, the indicators of quality control included the proportion of ICU patient bed occupancy to total inpatient bed occupancy, the proportion of ICU patients with APACHE II score ≥ 15, and the microbiology detection rate before antibiotic use. The outcome indicators included hospital stays, hospitalization costs, complications, and mortality. Generalized linear mixed models were used to analyse the association between quality control and septic shock caused by intestinal perforation. The proportion of ICU patient bed occupancy to total inpatient bed occupancy is positively correlated with hospital stays, incidence of complications (ARDS, AKI) and costs in septic shock caused by intestinal perforation (p < 0.05). The proportion of ICU patients with APACHE II score ≥ 15 was not associated with hospital stays and incidence of ARDS and AKI (p < 0.05). Increasing of the proportion of ICU patients with APACHE II score ≥ 15 decreased the costs of patients with septic shock caused by intestinal perforation (p < 0.05). The microbiology detection rate before antibiotic use was not associated with hospital stays, incidence of AKI and costs of patients with septic shock caused by intestinal perforation (p < 0.05). Surprisingly, the increase of microbiology detection rate before antibiotic use increased the incidence of ARDS in patients with septic shock caused by intestinal perforation (p < 0.05). The above three indicators of quality control were not associated with mortality of the patients with septic shock caused by intestinal perforation. On the one hand, the number of ICU patients admitted should be controlled to reduce the proportion of ICU patients out of total inpatient bed occupancy. On the other hand, intensive care unit admission of severe patients (patients with APACHE II score ≥ 15) should be encouraged to improve the proportion of patients with APACHE II score ≥ 15 in the ICU, so that ICU can focus more on the treatment of severe patients and promote the professionalization of severe patient management. It is not advisable to collect sputum specimens too frequently for patients without pneumonia.

The decision-making process of transferring patients home to die from an intensive care unit in mainland China: A qualitative study of family members' experiences

OBJECTIVES

To map the decision-making process of family members involved in transferring a critically ill patient home to die from an intensive care unit in mainland China and to explore the experiences of those family members.

DESIGN

A constructivist qualitative study.

SETTING

One hospitals intensive care unit in Southeast China.

METHODS

Thirteen adult family members (of ten patients) who participated in decision-making related to transferring a relative home to die from the intensive care unit were purposively selected. Data were collected via interviews and analysed applying thematic analysis.

FINDINGS

A two-stage decision-making process was identified. Family decision-making was mediated by factors including: accepting the impending death and hope that the patient would not die; time pressures in which decisions had to be made, and the challenges of meeting cultural expectations of a home death. Transfer home was a family-centred decision constrained by a gender-based hierarchy restricting the involvement of different family members.

CONCLUSION

The stages and key factors in the decision-making process of family members when involved in transferring a patient home to die from an intensive care unit in China are rooted and informed by cultural expectations and limits in the current healthcare system regarding end-of-life care options. Understanding the climate in which family members must make decisions will facilitate supportive interventions to be implemented by healthcare professionals. Further empirical research is needed to explore family members' needs when the patient has been transferred and dies at home in mainland China.

IMPLICATIONS FOR CLINICAL PRACTICE

Healthcare professionals need to understand the challenges family members face when deciding to transfer a relative home to die from an intensive care unit. For example time pressures can limit the choices of family members so that to provide them with timely, ongoing, realistic updates for a greater involvement of family members in generating end of life care plans could be beneficial.¹.

Effect of ICU quality control indicators on VAP incidence rate and mortality: a retrospective study of 1267 hospitals in China

PURPOSE

To investigate the effects of ICU quality control indicators on the VAP incidence rate and mortality in China throughout 2019.

METHODS

This was a retrospective study. A total of 1267 ICUs from 30 provinces in mainland China were included. Data were collected using the National Clinical Improvement System Data that report ICU information. Ten related quality control indicators were analyzed, including 5 structural factors (patient-to-bed ratio, physician-to-bed ratio, nurse-to-bed ratio, patient-to-physician ratio, and patient-to-nurse ratio), 3 process factors (unplanned endotracheal extubation rate, reintubation rate within 48 h, and microbiology detection rate before antibiotic use), and 2 outcome factors (VAP incidence rate and mortality). The information on the most common infectious pathogens and the most commonly used antibiotics in ICU was also collected. The Poisson regression model was used to identify the impact of factors on the incidence rate and mortality of VAP.

RESULTS

The incidence rate of VAP in these hospitals in 2019 was 5.03 (2.38, 10.25) per 1000 ventilator days, and the mortality of VAP was 11.11 (0.32, 26.00) %. The most common causative pathogen was Acinetobacter baumannii (in 39.98% of hospitals), followed by Klebsiella pneumoniae (38.26%), Pseudomonas aeruginosa, and Escherichia coli. In 26.90% of hospitals, third-generation cephalosporin was the most used antibiotic, followed by carbapenem (24.22%), penicillin and beta-lactamase inhibitor combination (20.09%), cephalosporin with beta-lactamase inhibitor (17.93%). All the structural factors were significantly associated with VAP incidence rate, but not with the mortality, although the trend was inconsistent. Process factors including unplanned endotracheal extubation rate, reintubation rate in 48 h, and microbiology detection rate before antibiotic use were associated with higher VAP mortality, while unplanned endotracheal extubation rate and reintubation rate in 48 h were associated with higher VAP mortality. Furthermore, K. pneumoniae as the most common pathogen was associated with higher VAP mortality, and carbapenems as the most used antibiotics were associated with lower VAP mortality.

CONCLUSION

This study highlights the association between the ICU quality control (QC) factors and VAP incidence rate and mortality. The process factors rather than the structural factors need to be further improved for the QC of VAP in the ICU.

Association of annual hospital septic shock case volume and hospital mortality

BACKGROUND

The burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China.

METHODS

In this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines.

RESULTS

We enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14-76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β - 0.86; 95% CI - 0.98, - 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed.

CONCLUSIONS

The findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume-outcome relationship.

Association between hospital and ICU structural factors and patient outcomes in China: a secondary analysis of the National Clinical Improvement System Data in 2019

Background

Hospital and ICU structural factors are key factors affecting the quality of care as well as ICU patient outcomes. However, the data from China are scarce. This study was designed to investigate how differences in patient outcomes are associated with differences in hospital and ICU structure variables in China throughout 2019.

Methods

This was a multicenter observational study. Data from a total of 2820 hospitals were collected using the National Clinical Improvement System Data that reports ICU information in China. Data collection consisted of a) information on the hospital and ICU structural factors, including the hospital type, number of beds, staffing, among others, and b) ICU patient outcomes, including the mortality rate as well as the incidence of ventilator-associated pneumonia (VAP), catheter-related bloodstream infections (CRBSIs), and catheter-associated urinary tract infections (CAUTIs). Generalized linear mixed models were used to analyse the association between hospital and ICU structural factors and patient outcomes.

Results

The median ICU patient mortality was 8.02% (3.78%, 14.35%), and the incidences of VAP, CRBSI, and CAUTI were 5.58 (1.55, 11.67) per 1000 ventilator days, 0.63 (0, 2.01) per 1000 catheter days, and 1.42 (0.37, 3.40) per 1000 catheter days, respectively. Mortality was significantly lower in public hospitals (β =  − 0.018 (− 0.031, − 0.005), p = 0.006), hospitals with an ICU-to-hospital bed percentage of more than 2% (β =  − 0.027 (− 0.034, -0.019), p < 0.001) and higher in hospitals with a bed-to-nurse ratio of more than 0.5:1 (β = 0.009 (0.001, 0.017), p = 0.027). The incidence of VAP was lower in public hospitals (β =  − 0.036 (− 0.054, − 0.018), p < 0.001). The incidence of CRBSIs was lower in public hospitals (β =  − 0.008 (− 0.014, − 0.002), p = 0.011) and higher in secondary hospitals (β = 0.005 (0.001, 0.009), p = 0.010), while the incidence of CAUTIs was higher in secondary hospitals (β = 0.010 (0.002, 0.018), p = 0.015).

Conclusion

This study highlights the association between specific ICU structural factors and patient outcomes. Modifying structural factors is a potential opportunity that could improve patient outcomes in ICUs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03892-7.

The story of critical care in Asia: a narrative review

Background

Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia.

Main body

Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty.

Conclusions

Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00574-4.

Analysis of structure indicators influencing 3-h and 6-h compliance with the surviving sepsis campaign guidelines in China: a systematic review

Background

Compliance with the surviving sepsis campaign (SSC) guidelines (C_ssc) is a key factor affecting the effects of sepsis treatment. We designed this study to investigate the relationships of the structure indicators of ICU on 3 and 6-h C_ssc in China.

Methods

A total of 1854 hospitals were enrolled in a survey, led by the China National Critical Care Quality Control Center (China-NCCQC) from January 1, 2018, through December 31, 2018. We investigated the 1854 hospitals’ 3 and 6-h C_ssc, including compliance with each specific measure of the 3-h and 6-h SSC bundles. We also investigated the actual level of the structure indicators of ICU, released by China-NCCQC in 2015.The outcomes were in adherence with the SSC guidelines (2016). Monitoring indicators included 3 and 6-h C_ssc.

Results

In the subgroup, the rate of broad-spectrum antibiotic therapy was the highest, and the rate of CVP and ScvO2 measurement was the lowest among the items of 3 and 6-h C_ssc. Structure indicators related to 3 and 6-h C_ssc include the predicted mortality rate and the standardized mortality ratio (SMR). The relationships between 3 and 6-h C_ssc and the proportion of ICU in total inpatient bed occupancy, the proportion of acute physiology and chronic health evaluation (APACHE) II score ≥ 15 in all ICU patients were uncertain. There was no relationship of 3 and 6-h C_ssc with the proportion of ICU patients among total inpatients.

Conclusions

Structure indicators influencing 3 and 6-h C_ssc in China are the predicted mortality rate and the standardized mortality rate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-021-00498-7.