Assessing quality of critical care during an ongoing health emergency-a novel approach to evaluate quality of care at Lebanese public ICUs during COVID-19.

BACKGROUND: Quality of care has been systematically monitored in hospitals in high-income countries to ensure adequate care. However, in low- and middle-income countries, quality indicators are not readily measured. The primary aim of this study was to assess to what extent it was feasible to monitor the quality of intensive care in an ongoing health emergency, and the secondary aim was to assess a quality of care intervention (twinning project) focused on Intensive Care Unit (ICU) quality of care in public hospitals in Lebanon. METHODS: We conducted a retrospective cohort study nested within an intervention implemented by the World Health Organization (WHO) together with partners. To assess the quality of care throughout the project, a monitoring system framed in the Donabedian model and included structure, process, and outcome indicators was developed and implemented. Data collection consisted of a checklist performed by external healthcare workers (HCWs) as well as collection of data from all admitted patients performed by each unit. The association between the number of activities within the interventional project and ICU mortality was evaluated. RESULTS: A total of 1679 patients were admitted to five COVID-19 ICUs during the study period. The project was conducted fully across four out of five hospitals. In these hospitals, a significant reduction in ICU mortality was found (OR: 0.83, P < 0.05, CI: 0.72-0.96). CONCLUSION: We present a feasible way to assess quality of care in ICUs and how it can be used in assessing a quality improvement project during ongoing crises in resource-limited settings. By implementing a quality of care intervention in Lebanon's public hospitals, we have shown that such initiatives might contribute to improvement of ICU care. The observed association between increased numbers of project activities and reduced ICU mortality underscores the potential of quality assurance interventions to improve outcomes for critically ill patients in resource-limited settings. Future research is needed to expand this model to be applicable in similar settings.

Development of a quality assurance tool for intensive care units in Lebanon during the COVID-19 pandemic.

BACKGROUND: During the coronavirus disease (COVID-19) pandemic, low- and middle-income countries have rapidly scaled up intensive care unit (ICU) capacities. Doing this without monitoring the quality of care poses risks to patient safety and may negatively affect patient outcomes. While monitoring the quality of care is routine in high-income countries, it is not systematically implemented in most low- and middle-income countries. In this resource-scarce context, there is a paucity of feasibly implementable tools to monitor the quality of ICU care. Lebanon is an upper middle-income country that, during the autumn and winter of 2020-1, has had increasing demands for ICU beds for COVID-19. The World Health Organization has supported the Ministry of Public Health to increase ICU beds at public hospitals by 300%, but no readily available tool to monitor the quality of ICU care was available. OBJECTIVE: The objective with this study was to describe the process of rapidly developing and implementing a tool to monitor the quality of ICU care at public hospitals in Lebanon. METHODS: In the midst of the escalating pandemic, we applied a systematic approach to develop a realistically implementable quality assurance tool. We conducted a literature review, held expert meetings and did a pilot study to select among identified quality indicators for ICU care that were feasible to collect during a 1-hour ICU visit. In addition, a limited set of the identified indicators that were quantifiable were specifically selected for a scoring protocol to allow comparison over time as well as between ICUs. RESULTS: A total of 44 quality indicators, which, using different methods, could be collected by an external person, were selected for the quality of care tool. Out of these, 33 were included for scoring. When tested, the scores showed a large difference between hospitals with low versus high resources, indicating considerable variation in the quality of care. CONCLUSIONS: The proposed tool is a promising way to systematically assess and monitor the quality of care in ICUs in the absence of more advanced and resource-demanding systems. It is currently in use in Lebanon. The proposed tool may help identifying quality gaps to be targeted and can monitor progress. More studies to validate the tool are needed.