Table 3: Quality indicators with highest grades of supporting evidence
Area of care; quality indicatorEvidence grade*Implementation results reported
Mechanical ventilation
Ventilator-associated pneumonia bundleModerate to high†Yes‡
    Elevation of head of bedLevel 1‡
Daily sedation vacation and assessment of readiness to extubateLevel 1‡
    Prevention of venous thromboembolismLevel 1‡
    Pressure ulcer disease prophylaxisLevel 1‡
    Daily oral care with chlorhexidineLevel 1‡
Pneumonia
    Blood cultures performed within 24 hr or before arrivalEvidence synthesis§No
    Antibiotics consistent with guidelinesEvidence synthesis§No
Invasive procedures
Ultrasound guidance for central venous catheter insertionHigh†No
Central line insertion bundleModerate to high†Yes‡¶
    Maximal barrier precautions1B¶; evidence synthesis§
    Chlorhexidine skin antisepsis1A¶
    Hand hygiene1B¶
    Optimal catheter type and site selection1A-1B¶
Central line care bundleYes‡¶
    Daily review of line necessity1A¶
    Aseptic lumen access1A¶
    Catheter site and tubing care1B¶
Patient-centred care
Documentation of goals of careModerate†No
Sepsis management
Sepsis management bundle
    Administer low-dose steroids by standard policy2C‡**No
    Maintain adequate glycemic control1B‡No
    Prevent excessive inspiratory plateau pressures1C‡**Yes**
Sepsis resuscitation bundle
    Serum lactate levels measured1B‡No
    Timing of blood cultures1C‡**No
    Treat hypotension and/or elevated lactate with fluids1B‡No
    Maintain adequate central venous oxygen saturation1C-2C‡No
    Antibiotics given by time goal1B‡**No
    Apply vasopressors for ongoing hypotension1C‡No
    Maintain adequate central venous pressure1C‡**Yes**
Patients with sepsis: second litre of crystalloid administered by time goal1C**No
Blood for culture drawn before antibiotics administered1C**No
Glycemic control policiesModerate to high†No
    After initial stabilization for patients with severe sepsis1B**No
    Validated protocol for insulin dosage adjustments2C**No
Prevention of adverse events
Appropriate transfusion practicesNot gradedYes‡
Pharmacist on roundsModerate to high†No
Medication reconciliation by a pharmacistModerate†Yes‡
Venous thromboembolism prophylaxisEvidence synthesis§Yes¶††
Preventing pressure ulcersModerate†; evidence synthesis§Yes‡
Simulation trainingModerate to high†No
Training on infusion pumpsLow†No
Infection control
Isolation of patients with resistant infectionsModerate†No
Hand hygiene improvementLow†Yes‡‡
Staffing
Establishment of rapid-response teamModerate†Yes‡¶
Staffing ratios: increasing nurse to patient ratio to prevent deathModerate†No

*See Table 4.

†Agency for Healthcare Research and Quality.

‡Institute for Healthcare Improvement.

§National Quality Measures Clearinghouse.

¶Canadian Patient Safety Institute.

**Society of Critical Care Medicine, European Society of Intensive Care Medicine.

††Australian and New Zealand Intensive Care Society.

‡‡Health Quality Ontario.