Peptic Ulcer Disease Prophylaxis Research Articles

Underutilization of Peptic Ulcer Disease Prophylaxis Among Elderly Users of Antiplatelets and Anticoagulants.

Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD in the elderly. An expert consensus document published jointly in 2008 by the American College of Gastroenterology (ACG), the American College of Cardiology Foundation (ACCF), and the American Heart Association (AHA) provided recommendations on prevention of PUD among users of antiplatelets and anticoagulants. This work aimed to evaluate physicians' compliance with these guidelines in a tertiary academic setting. We examined our medical record database for the 9month period extending from April 2018 until December 2018. Using this database, we identified elderly patients (> 64years old) who were chronic (> 3months) users of low dose aspirin (81mg once daily) and had an indication for PUD prophylaxis as per the ACG-ACCF-AHA guideline document. We performed a retrospective chart review of patients included in this study. Descriptive statistics were compared using χ2 and independent sample t tests. A total of 852 patients were included in this study. The mean age was 75years old, and 43% of patients were females. In addition to aspirin, patients were prescribed P2Y12 inhibitors (45.5%), direct oral anticoagulants (DOACs) (23%), warfarin (12%), steroids (9%) or enoxaparin (1%). Users of DOACs were most commonly prescribed apixaban (16%), followed by rivaroxaban (6%) and dabigatran (1%). Overall, only 40% of patients with an indication for PUD prophylaxis received a proton pump inhibitor. PUD prophylaxis may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and an aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

The Impact of Using Echinacea as a Complementary Modality on ICU Length of Stay and Mortality in Intubated and Ventillated Patient

Abstract Background: Ventilator Associated Pneumonia (VAP) is a common concern in Intensive Care Unit (ICU), where many risk factors have been reported to be associated with it. VAP can increase patient's length of stay in ICU and possibly causes high mortality rate. Application of several interventions have been found to reduce incidence of VAP, including head of bed elevation, deep vein thrombosis prophylaxis, peptic ulcer disease prophylaxis, daily sedation vacation, daily assessment for readiness for extubation, daily spontaneous breathing trial, and oral care with chlorohexadine. These interventions are called ventilator care bundle. Echinacea is a herb that has been utilized to strengthen the body's innate resistance. It contains multiple active compounds which gives it its medicinal qualities, it has been shown to reduce the severity of respiratory infections. Aim of Study: The aim of this study was to evaluate the effect of adding Echinacea to ventilator care bundle in intubated and ventilated ICU patient on length of stay in ICU and mortality. Material and Methods: This clinical trial included 80 patients who were intubated and mechanically ventilated within 48 hours of admission to ICU in Surgical Intensive Care Unit (SICU) in Kasr Aini Hospital during the period between December 2013 and December 2014. All patients were adults more than 18 years, who have no witnessed aspiration or pneumonia on admission. Intervention: Patients were divided into two equal groups of 40 patients each, one group received Echinacea in the form of Immulant capsules and the other didn't receive it. Both groups have ventilator care bundle applied. All patients were followed-up clinically, radiologically and by laboratory. Length of ICU stay, mortality and VAP associated mortality were calculated in both groups. Results: Both length of stay in ICU and mortality had no statistical significance in both groups, but VAP associated mortality had decreased significantly in the group that received Echinacea. Conclusion: Echinacea may be found to decrease VAP associated mortality.

Use of Ventilator Care Bundle to Prevent Ventilator-Associated Pneumonia: The Impact of Using Echinacea as a Complementary Modality

Abstract Background: Ventilator Associated Pneumonia (VAP) is one of the most common hospital acquired infections in Intensive Care Unit. It is a complication in many patients who receive mechanical ventilation. One of the recent approaches for prevention of VAP was the application of ventilator care bundle which includes; head of bed elevation, deep vein thrombosis prophylaxis, peptic ulcer disease prophylaxis, daily sedation vacation, daily assessment for readiness for extubation, daily spontaneous breathing trial, and oral care with chlorohexadine. Echinacea is a herb that has been utilized to strengthen the body's innate resistance. It contains multiple active compounds which gives it its medicinal qualities, it has been shown to reduce the severity of respiratory infections. This herb may be used in prophylaxis against VAP. Aim of Study: The objective of this study was to evaluate the effect of adding Echinacea to ventilator care bundle in intubated and ventilated ICU patient on prophylaxis against ventilator associated pneumonia. Material and Methods: This clinical trial included 80 patients who were intubated and mechanically ventilated within 48 hours of admission to ICU in Surgical Intensive Care Unit (SICU) in Kasr Aini Hospital during the period between December 2013 and December 2014. All patients were adults more than 18 years, who have no witnessed aspiration or pneumonia on admission. Intervention: Patients were divided into two equal groups of 40 patients each, one group received Echinacea in the form of Immulant capsules and the other didn't receive it. Both groups have ventilator care bundle applied. All patients were followed-up clinically, radiologically and by laboratory as-sessment. VAP was suggested according to Clinical Pulmonary Infection Score (CPIS). Results: Inflammatory indicators in the form of occurrence of fever and rising trend in the count of WBCs in the first five days were significantly less in the group that received Echinace. Gram negative organisms were the most prevalent in cases with VAP with no statistical difference between both groups in the type of organisms. VAP rate had no significant difference between the two groups. Conclusion: No apparent difference is found on adding Echinacea to ventilator care bundle on prevention of VAP, But Echinacea may be found to decrease severity of inflam-matory reactions reducing VAP complications.

1226 Under-Utilization of Proton Pump Inhibitors in the Prevention of NSAID-Related Peptic Ulcer Disease in the Elderly

INTRODUCTION: Peptic ulcer disease (PUD) develops in approximately 25% of chronic users of non-steroidal anti-inflammatory drugs (NSAIDs). The incidence of uncomplicated PUD has been declining over the past 3 decades unlike that of complicated PUD especially in the elderly. We aimed to evaluate physician compliance with the American College of Gastroenterology (ACG) guidelines on the prevention of NSAID-related PUD complications in a tertiary academic setting. METHODS: We examined the Saint Louis University Hospital medical record database for a 9-month period extending from April 2018 until December 2018. Using this database, we identified 2,064 adult elderly patients (>64 years old) who were chronic (>3 months) users of low dose aspirin (81 mg once daily). We performed a retrospective analysis of patients who were at least on aspirin and had an indication for PUD prophylaxis as per ACG guidelines. Data collected from patient charts included age, gender, relevant medications (including proton pump inhibitors (PPI), aspirin, P2Y12 inhibitors, direct oral anticoagulants (DOACs), warfarin, or oral steroids), and whether prophylaxis was provided as per the ACG guidelines. RESULTS: A total of 301 adult elderly patients who were at least on aspirin and had an indication for PUD prophylaxis were identified in this study. The mean age was 75 years old. Six percent of included patients had a history of peptic ulcer disease. In addition to aspirin, patients were using P2Y12 inhibitors (clopidogrel or ticagrelor, 50%), DOACs (24%), warfarin (11%), or steroids (9%). DOAC users were prescribed apixaban (16%), rivaroxaban (7%), or dabigatran (1%) (Table 1). All antiplatelets, anticoagulants, and steroids were prescribed by non-gastroenterologists. Only 35% of patients with an indication for PUD prophylaxis received a PPI. The prophylaxis rates were highest for patients with a history of peptic ulcer disease (62%) and were lowest for users of P2Y12 inhibitors (29%). There were no statistically significant age or gender related differences in the rates of compliance when independent sample t and chi square tests were performed (Table 1). CONCLUSION: Peptic ulcer disease prophylaxis with proton pump inhibitors may be underutilized in elderly patients. This finding, along with increasing rates of NSAID use and aging population, may help explain the increased incidence of complicated PUD in the elderly. Efforts are needed to raise physician awareness of PUD prophylaxis guidelines.

The impact of implementing multifaceted interventions on the prevention of ventilator-associated pneumonia

Ventilator-associated pneumonia (VAP) is a frequent hospital acquired infections among intensive care unit patients. The Institute for Healthcare Improvement has suggested a "care bundle" approach for the prevention of VAP. This report describes the effects of implementing this strategy on VAP rates. All mechanically ventilated patients admitted to the intensive care unit between 2008 and 2013 were prospectively followed for VAP development according to the National Healthcare Safety Network criteria. In 2011, a 7-element care bundle was implemented, including head-of-bed elevation 30°-45°, daily sedation vacation and assessment for extubation, peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, oral care with chlorhexidine, endotracheal intubation with in-line suction and subglottic suctioning, and maintenance of endotracheal tube cuff pressure at 20-30 mmHg. The bundle compliance and VAP rates were then followed. A total of 3665 patients received mechanical ventilation, and there were 9445 monitored observations for bundle compliance. The total bundle compliance before and after initiation of the VAP team was 90.7% and 94.2%, respectively (P < .001). The number of VAP episodes decreased from 144 during 2008-2010 to only 14 during 2011-2013 (P < .0001). The rate of VAP decreased from 8.6 per 1000 ventilator-days to 2.0 per 1000 ventilator-days (P < .0001) after implementation of the care bundle. This study suggests that systematic implementation of a multidisciplinary team approach can reduce the incidence of VAP. Further sustained improvement requires persistent vigilant inspections.

The impact of a ventilator bundle on preventing ventilator-associated pneumonia: A multicenter study

For prevention of ventilator-associated pneumonia (VAP), a bundle approach was applied to patients receiving mechanical ventilation in intensive care units. The incidence of VAP and the preventive efficacy of the VAP bundle were investigated. A quasi-experimental study was conducted in adult intensive care units of 6 university hospitals with similar VAP rates. We implemented the VAP bundle between March 2011 and June 2011, then compared the rate of VAP after implementation of the VAP bundle with the rate in the previous 8 months. Our ventilator bundle included head of bed elevation, peptic ulcer disease prophylaxis, deep venous thrombosis prophylaxis, and oral decontamination with chlorhexidine 0.12%. Continuous aspiration of subglottic secretions was an option. Implementation of the VAP bundle reduced the VAP rate from a mean of 4.08 cases per 1,000 ventilator-days to 1.16 cases per 1,000 ventilator-days. The incidence density ratio (rate) was 0.28 (95% confidence interval, 0.275-0.292). Implementing the appropriate VAP bundle significantly decreased the incidence of VAP in patients with mechanical ventilation.

H2RBs vs PPIs part 2: histamine-2 receptor blockers as a first-line agent for peptic ulcer disease prophylaxis

In the first part of this two-part series, the author reviewed several studies assessing the clinical scenarios in which histamine-2 receptor blockers (H2RBs) and proton pump inhibitors (PPIs) should be used. Although H2RBs and PPIs have been used extensively in the treatment of peptic ulcer disease (PUD), little is known about which should be the initial medication for PUD prophylaxis. PPIs tend to be stronger than H2RBs and are therefore more frequently prescribed in hospitals; however, their overuse can be detrimental to healthcare outcomes. Since H2RBs have evidenced themselves to be on par with PPIs, but with fewer side effects, in the second part of this two-part series, Ronnell Regidor explains why HR2Bs should be considered as the initial treatment for PUD prophylaxis.

Combination of ventilator care bundle and regular oral care with chlorhexidine was associated with reduction in ventilator associated pneumonia

BackgroundVentilator associated pneumonia (VAP) is an important source of morbidity and mortality in patients receiving mechanical ventilation. VAP is associated with prolongation of mechanical ventilation, ICU and hospital stay and increases in costs.MethodsQuality improvement project. Mechanically ventilated patients received oral care every 8 h with chlorhexidine 2%. A formal process was developed to evaluate compliance with the following ventilator bundle initiatives: head of the bed elevation to 30–45°, daily sedation vacation and assess the readiness to extubate, providing peptic ulcer disease prophylaxis and providing deep vein thrombosis prophylaxis (unless contraindicated).ResultsThe rate of VAP before starting the project, in the first 6 months of year 1431H, was 16.2 cases/1000 ventilator days. Six month after inception of the quality improvement project, the VAP rates decreased to 5.6 cases/1000 ventilator days at the end of 1431H, and at the end of 1432H, it was 5.5 cases/1000 ventilator days. This leads to significant reduction in mortality (adjusted according to APACHE II) from 23.4% to 19.1% (p value 0.024) and the length of stay in ICU from 9.7 to 6.5 days (p value 0.00002).ConclusionThe combination of regular oral hygiene with chlorhexidine 2% and rigorous implementation of ventilator care bundle was associated with significant reduction in VAP rate in mechanically ventilated patients. This has led to reduction in length of stay in ICU from 9.7 to 6.5 days and reduction in mortality from 23.4% to 19.1%.

Histamine-2 receptor blockers vs proton pump inhibitors part 1: a literature review

While the use of histamine-2 receptor blockers (H2RBs) and proton pump inhibitors (PPIs) have been useful for the prophylaxis of peptic ulcer disease (PUD), there has been little information regarding which medication should be used initially. In the hospital setting, PPIs are often prescribed for PUD prophylaxis, even when patients have no history of gastroesophageal reflux disease. While PPIs have been demonstrated to be stronger than H2RBs, their long-term use can be detrimental to health-care outcomes. Owing to this overuse of PPIs, the use of H2RBs should be re-examined. In the first part of this two-part series on H2RBs vs PPIs, Ronnell Regidor will review several studies that assess the clinical scenarios in which H2RBs and PPIs should be used. Ultimately, this article proposes that, for patients without any gastrointestinal medical history, H2RBs should be the initial medication for PUD prophylaxis.

Dedicated Multidisciplinary Ventilator Bundle Team and Compliance with Sedation Vacation

How compliance with a ventilator bundle is monitored varies from institution to institution. Some institutions rely on the primary intensive care unit team to review the bundle during their rounds; others rely on a separate team of health care personnel that may include representatives from disciplines such as nursing, respiratory therapy, and pharmacy. To compare rates of compliance with ventilator bundle components between a dedicated ventilator bundle rounding team and the primary intensive care unit rounding team in a 68-bed medical intensive care unit. A query of the medical intensive care unit's database was used to retrospectively determine rates of compliance with specific ventilator bundle components at a tertiary care hospital in an urban community for 1 year. Compared with the intensive care unit rounding team, the ventilator bundle rounding team had better compliance with sedation vacation (61.7% vs 54.0%, P < .001). Rates of compliance with spontaneous breathing trials and prophylaxis of peptic ulcer disease were similar in both study groups. A dedicated ventilator bundle rounding team improves compliance with sedation vacation, but not with spontaneous breathing trials and prophylaxis of peptic ulcer disease. In a large-volume tertiary center, a dedicated ventilator bundle rounding team may be more effective than the primary rounding team in achieving compliance with some bundle components.

Ventilator associated pneumonia:pathogens, diagnosis and prevention

The purpose of this article was to review the current knowledge base related to the risk factors,pathogens,diagnosis and to review and evaluate the strategies to reduce ventilator associated pneumonia (VAP),especially ventilator bundles for prevention of VAP which including elevation of the head of the bed,daily sedative interruption and daily assessment readiness of extubate,peptic ulcer disease prophylaxis,deep venous thrombosis prophylaxis,daily oral care with chlorhexidine.This article also reviewed the role of new type endotracheal tube in reducing incidence of VAP. Key words: Ventilator associated pneumonia; Pathogens; Diagnosis; Prevention

Bundles to prevent ventilator-associated pneumonia: how valuable are they?

To review the value of care bundles to prevent ventilator-associated pneumonia (VAP). The Ventilator Bundle contains four components, elevation of the head of the bed to 30-45 degrees, daily 'sedation vacation' and daily assessment of readiness to extubate, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis, aimed to improve outcome in mechanically ventilated patients, but not all are associated with VAP prevention. Daily spontaneous awakening and breathing trials are associated with early liberation from mechanical ventilation and VAP reduction. Although a small prospective, randomized clinical study documented that the semirecumbent position was associated with a significant reduction in VAP, more recent studies have documented that the semirecumbent position is difficult to maintain in mechanically ventilated patients and may not impact VAP reduction. Prophylaxis for peptic ulcer disease and deep venous thrombosis do not directly impact VAP reduction. Other methods to reduce VAP, such as oral care and hygiene, chlorhexidine in the posterior pharynx, and specialized endotracheal tubes (continuous aspiration of subglottic secretions, silver-coated), should be considered for inclusion in a revised Ventilator Bundle more specifically aimed at VAP prevention. The Ventilator Bundle is an effective method to reduce VAP rates in ICUs. The ventilator bundle should be modified and expanded to include specific processes of care that have been definitively demonstrated to be effective in VAP reduction or a specific VAP bundle created to focus on VAP prevention.

Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit

The ventilator bundle (VB) includes a group of clinical maneuvers (head-of-bed elevation, "sedation vacation," deep vein thrombosis prophylaxis, and peptic ulcer disease prophylaxis) to improve outcomes in patients undergoing mechanical ventilation. We modified the standard VB in our medical intensive care unit to include a group of respiratory therapist-driven protocols and, postimplementation, observed a statistically significant (P = .0006) reduction in ventilator-associated pneumonia (VAP), from a median of 14.1 cases/10(3) ventilator-days (interquartile range [IQR] = 12.1 to 20.6) to 0 cases/10(3) ventilator-days (IQR = 0 to 1.1).

Implementing a Ventilator Bundle in a Community Hospital

Mercy & Unity Hospitals of Minnesota implemented the ventilator bundle concept as part of an Institute for Healthcare Improvement (IHI) collaborative on improving care in the intensive care unit (ICU). The two hospitals, which function as a single hospital, have a total of 450 beds, and each has a 20-bed ICU. The IHI bundle was composed of (1) head-of-bed elevation, (2) a daily "sedation vacation" along with a readiness-to-wean assessment, (3) peptic ulcer disease prophylaxis, and (4) deep vein thrombosis prophylaxis. Additional interventions likely complementary to the ventilator bundle were a hand hygiene campaign and an oral care protocol. Overall compliance with the four bundle elements reached 100% by January 2004. At the end of the collaborative, Mercy's VAP rate decreased from 6.1 to 2.70 per 1000 ventilator days, and Unity's VAP rate decreased from 2.66 to 0 per 1000 ventilator days. The all-or-none nature of the bundle may have helped multidisciplinary staff members perceive the project as a systemic change versus a one-time intervention. Staff members needed to implement both structural changes, such as preprinted order sets for ventilator management and sedation, and cultural changes, such as increased collaboration with respiratory therapy. The decrease in VAP provides a promising example of the potential of intervention techniques and bundle implementation in a community hospital.

Evidence-based Clinical Improvement for Mechanically Ventilated Patients

Bundling or grouping together evidence-based interventions to improve care for the mechanically ventilated patient was piloted by a 10-bed medical-surgical critical care unit of a hospital. The bundled care interventions included: (a) keeping the head of bed elevated at 30 degrees, (b) instituting daily interruption of continuous sedative infusion, (c) assessing readiness to wean using a rapid-wean assessment guide, (d) initiating deep venous thrombosis prophylaxis, and (e) implementing peptic ulcer disease prophylaxis. The interventions were implemented using a plan-do-check-act quality-improvement methodology. Results indicated that the use of bundled interventions for mechanically ventilated patients could decrease average ventilator times and average length of stay with no concomitant increase in reintubations. Average mortality rates and the number of adverse events per 100 patient days also were reduced.

Using a Bundle Approach to Improve Ventilator Care Processes and Reduce Ventilator-Associated Pneumonia

A "bundle" of ventilator care processes (peptic ulcer disease prophylaxis, deep vein thrombosis prophylaxis, elevation of the head of the bed, and a sedation vacation), which may also reduce ventilator-associated pneumonia (VAP) rates, can serve as a focus for improvement strategies in intensive care units (ICUs). Between July 2002 and January 2004, teams of critical care clinicians from 61 health care organizations participated in a collaborative on improving care in the ICU. ICU team members posted data monthly on a Web-based extranet and submitted narrative descriptions describing the changes tested and the strategies implemented. For the 35 units that consistently collected data on ventilator bundle element adherence and VAP rates, an average 44.5% reduction of VAP was observed. The goal-oriented nature of the bundle appears to demand development of the teamwork necessary to improve reliability. The observations seem sufficiently robust to support implementing the ventilator bundles to provide a focus for additional change in ICUs.

Partnering for quality

This article discusses efforts being made by multiple stakeholders to improve quality and safety in intensive care units (ICUs). The Leapfrog Group (Washington, DC), a consortium of purchasers, is reaching for quality by implementing safety standards. One standard, staffing ICUs with intensivists, is associated with a 30% reduction in hospital mortality and a 40% reduction in ICU mortality. While Leapfrog is addressing quality improvements on a structural level, JCAHO is developing empiric measures for ICU quality, which are being beta tested, to complement Leapfrogs’ efforts. JCAHO used rigorously defined processes to develop and refine these measures. These measures include deep venous thrombosis prophylaxis, peptic ulcer disease prophylaxis, catheter-related blood stream infections, mortality and length of stay—APACHE III risk adjustment. Finally, ICU providers at Hopkins implemented an 8-step unit-based safety program. This comprehensive program is run at the unit level, works to improve safety culture, addresses staff safety concerns, partners hospital leaders with unit workers, helps staff implement improvement initiatives, uses rigorous data collection methods, and easily disseminated in other clinical areas. Providers can frame their efforts after 3 fundamental concepts from these initiatives: create a culture that supports quality and safety, standardize work processes by reducing complexity and using independent redundancy, and automate. The take home message is, when we come to work every day, we must be committed to quality and safety, and lead our teams to do the same.

Improving Care for the Ventilated Patient

Despite evidence that the use of specific interventions can decrease morbidity and mortality for patients receiving mechanical ventilation, a gap exists between best evidence and practice. A prospective cohort study was conducted in a surgical intensive care unit (ICU) that included all patients who were mechanically ventilated. The study was designed to ensure that for 90% of ventilator days, patients receive processes associated with improved outcomes, including semirecumbent positioning, daily interruption of sedative-drug infusions, peptic ulcer disease prophylaxis, and deep venous thrombosis prophylaxis. The improvement model included three interventions: (1) administering a questionnaire to identify barriers to compliance with the four care processes, (2) implementing an educational intervention, and (3) implementing a checklist to be completed daily during ICU rounds to ask providers whether patients were receiving these therapies. Overall, 80% of nurses did not know there was evidence to support at least one of the four therapies. During the study period (March 4-April 29, 2002), the percentage of ventilator days on which patients received all four care processes increased from 30% to 96% (p < .001). Evidence-based therapies for mechanically ventilated patients can reduce morbidity, mortality, and costs of care.

Developing and pilot testing quality indicators in the intensive care unit

Purpose: To develop and implement a set of valid and reliable yet practical measures of intensive care units (ICU) quality of care in a cohort of ICUs and to estimate, based on current performance, the potential opportunity to improve quality. Methods : We included 13 adult medical and surgical ICUs in urban community teaching and community hospitals. To monitor performance on previously identified quality measures, we developed 3 data collection tools: the Team Leader, Daily Rounding, and Infection Control forms. These tools were pilot tested, validated, and modified before implementation. We used published estimates of efficacy to estimate the clinical and economic effect of our current performance for each of the process measures: appropriate sedation, prevention of ventilator-associated pneumonia, appropriate peptic ulcer disease (PUD) prophylaxis, appropriate deep venous thrombosis (DVT) prophylaxis, and appropriate use of blood transfusions. Results: Performance varied widely among the 13 ICUs and within ICUs. The median percentage of days in which ventilated patients received therapies that ought to was 64% for appropriate sedation, 67% for elevating head of bed, 89% for PUD prophylaxis, and 87% for DVT prophylaxis. The median rate of appropriate transfusion was 33%. The failure to use these therapies may lead to excess morbidity, mortality, and ICU length of stay. Conclusion : To improve quality of care, we must measure our performance. This pilot study suggests that it is feasible to implement a broad set of ICU quality measures in a cohort of hospitals. By improving performance on these measures, we may realize reduced mortality, morbidity, and ICU length of stay.

Qualitative review of intensive care unit quality indicators

Purpose: The purpose of this study was to (1) conduct a systematic review of the literature to identify interventions that improve patient outcomes in the intensive care unit (ICU); (2) evaluate potential measures of quality based on the impact, feasibility, variability, and the strength of evidence to support each measure and to categorize these measures as outcome, process, access, or complication measures; and (3) select a list of candidate quality measures that can be broadly applied to improve ICU care. Methods: We identified and independently reviewed all studies in Medline (1965-2000) and The Cochrane Library (Issue 3, 2001) that met the following criteria: design: observational studies, experimental trials, or systematic reviews; population: critically ill adults; and intervention: process or structure measure that was associated with improved patient outcomes: morbidity, mortality, complications, errors, costs, length of stay (LOS), and patient reported outcomes. Studies were grouped into categories by the type of outcome that was improved by the intervention. Potential quality measures were evaluated for: impact on morbidity, mortality, and costs; feasibility of the measure; and variability in the measure. We evaluated the strength of evidence for each intervention used to improve outcomes and using the Delphi method, assigned an over-all recommendation for each quality measure. Results: A total of 3,014 citations were identified. Sixty-six studies that met selection criteria reported on a variety of interventions that were associated with improved patient outcomes. We identified 6 outcome measures: ICU mortality rate, ICU LOS greater than 7 days, average ICU LOS, average days on mechanical ventilation, suboptimal management of pain, and patient/family satisfaction; 6 process measures: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator-associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis, and appropriate deep venous thrombosis prophylaxis; 4 access measures: rate of delayed admissions, rate of delayed discharges, cancelled surgical cases, and emergency department by-pass hours; and 3 complication measures: rate of unplanned ICU readmission, rate of catheter-related blood stream infections, and rate of resistant infections. Conclusions: Further work is needed to create operational definitions and to pilot test the selected measures.The value of these measures will be determined by our ability to evaluate our current performance and implement interventions designed to improve the quality of ICU care. Copyright 2002, Elsevier Science (USA). All rights reserved.