Impact of modified quality control checklist on protocol adherence and outcomes in a post-surgical Intensive Care Unit

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.

Discovering metformin-induced vitamin B12 deficiency in patients with type 2 diabetes in primary care

BACKGROUND

Although metformin is the preferred initial pharmacological choice in type 2 diabetes, there is evidence that reveals a link between metformin use and vitamin B12 deficiency. The American Diabetes Association (ADA) has recently recommended periodic measurement of B12 levels for all patients on metformin.

LOCAL PROBLEM

Medical record data collected for the preintervention period showed that only 5% (n = 23) of patients diagnosed with diabetes and on metformin had B12 levels checked at an internal medicine primary care practice.

METHODS

This was a quasi-experimental project of preintervention and postintervention design using a checklist containing important measures of diabetes control. The project sample population consisted of data of adults with type 2 diabetes aged 18 years and older who were prescribed metformin in the previous year at the primary care practice.

INTERVENTIONS

The intervention focused on revising an existing diabetes measures checklist to include a prompt for an annual measurement of B12 levels.

RESULTS

There was significant improvement in monitoring vitamin B12 levels and discovery of low vitamin B12 levels. These data show that the number of B12 levels checked increased from 23 during the preintervention to 155 during the intervention (p ≤ 0.0000).

CONCLUSIONS

This project supports a conclusion that including a prompt to check B12 levels to an existing checklist increases B12 monitoring in this patient population. Results may encourage other providers to follow the ADA guidelines for monitoring vitamin B12 levels for patients taking metformin.