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Key process and outcome indicators on quality and safety of care for critically ill pediatric patients according to international standard organization protocols: a four-year follow-up study

  • Eleni Volakli1,*,
  • Asimina Violaki1
  • Menelaos Svirkos1
  • Peristera-Eleni Mantzafleri1
  • Elpis Chochliourou1
  • Serafeia Kalamitsou1
  • Athanasios Kasimis1
  • Eleni Karakeke1
  • Parthena Georgiadou1
  • Maria Katsafiloudi1
  • Vasiliki Avramidou1
  • Εvangelia Karaiskou1
  • Maria Sdougka1

1Pediatric Intensive Care Unit, Hippokration General Hospital, 54642 Thessaloniki, Greece

DOI: 10.22514/sv.2023.085 Vol.19,Issue 5,September 2023 pp.186-195

Submitted: 11 November 2022 Accepted: 12 January 2023

Published: 08 September 2023

(This article belongs to the Special Issue Pediatric Critical Care)

*Corresponding Author(s): Eleni Volakli E-mail:


The European Society of Intensive Care Medicine (ESICM) suggests nine quality and safety indicators of care for critically ill patients. The aim of the present study was to examine the Key Process and Outcome Indicators (KPOIs) chosen according to International Standard Organization (ISO) protocols in a Greek Pediatric Intensive Care Unit (PICU). Two structure, one process, and four outcome indicators were examined in a stepwise approach according to Observe-Plan-Do-Study-Act (OPDSA) cycles, in an observational four-year cohort study (2017–2020). Two structure indicators—that ICUs fulfil national requirements to provide intensive care and 24-h consultant availability were requirements for the creation of the PICU and considered standards of care. One process indicator—Standardized Handover Procedure was transformed from handwritten (2017–2018) into electronic form (2019–2020) and 100% compliance rates throughout the four years were recorded. 96, 85, 103 and 94 patients were admitted in 2017, 2018, 2019 and 2020 with median (IQR) Pediatric Risk of Mortality III-24 h scores of 10 (6.25–17), 10 (6–13), 8 (5–13) and 8 (6.75–12), respectively. Mortality rates were 24%, 11.8%, 17.5%, 16%, and Standardized Mortality Ratio (SMR) were 1.42, 0.92, 1.56 and 1.33, correspondingly. No early (<48 h after PICU discharge) readmissions were recorded for 2017 and 2018, only 1 in 2019 (0.8%) and none in 2020. Catheter Related Bloodstream Infection rates were 1.37:1000, 1.37:1000, 1.26:1000 and 1.39:1000 catheter days, respectively. Unplanned extubation rate was 10.30% in 2019 and 5.72% and 3.91:1000 ventilation days in 2020. In conclusion, ISO implementation of our unit was the trigger for internal PICU audit and external benchmarking. OPDSA cycles, following small steps at a time, in an iterate cycle of evolution, facilitated our actions. The majority of the KPOIs examined in our study was within international PICUs reference values.


Pediatric intensive care unit—PICU; Quality; Safety; Key process and outcome indicators—KPOIs; Pediatric risk of mortality—PRISM III; Standardized mortality ratio—SMR

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Eleni Volakli,Asimina Violaki,Menelaos Svirkos,Peristera-Eleni Mantzafleri,Elpis Chochliourou,Serafeia Kalamitsou,Athanasios Kasimis,Eleni Karakeke,Parthena Georgiadou,Maria Katsafiloudi,Vasiliki Avramidou,Εvangelia Karaiskou,Maria Sdougka. Key process and outcome indicators on quality and safety of care for critically ill pediatric patients according to international standard organization protocols: a four-year follow-up study. Signa Vitae. 2023. 19(5);186-195.


[1] International organization for standardization. 2022. Available at: International_Organization_for_Standardization&oldid= 1088219236 (Assessed: 17 May 2022).

[2] Neshovski R. Home. United nations sustainable development. 2022. Available at: 17 May 2022).

[3] Martin. Health. United nations sustainable development. 2022. Available at: 17 May 2022).

[4] ISO—sustainable development goals. Available at: https://www.iso. org/sdgs.html (Assessed: 17 May 2022).

[5] PDCA. In: Wikipedia. 2022. Available at: https://en.wikipedia. org/w/index.php?title=PDCA&oldid=1075817132 (Assessed: 17 May 2022).

[6] Shewhart’s learning and deming’s quality cycle—the foresight guide. Available at: (Assessed: 17 May 2022).

[7] Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety. 2014; 23: 290–298.

[8] Lynch-Jordan AM, Kashikar-Zuck S, Crosby LE, Lopez WL, Smolyansky BH, Parkins IS, et al. Applying quality improvement methods to implement a measurement system for chronic pain-related disability. Journal of Pediatric Psychology. 2010; 35: 32–41.

[9] Blumenthal JA, Ormsby JA, Mirchandani D, Petti CA, Carpenter J, Geller M, et al. Stewardship intervention to optimize central venous catheter utilization in critically ill children. Pediatric Quality & Safety. 2021; 6: e389.

[10] Rhodes A, Moreno RP, Azoulay E, Capuzzo M, Chiche JD, Eddleston J, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the task force on safety and quality of the European society of intensive care medicine (ESICM). Intensive Care Medicine. 2012; 38: 598–605.

[11] Moreno RP, Hochrieser H, Metnitz B, Bauer P, Metnitz PGH. Characterizing the risk profiles of intensive care units. Intensive Care Medicine. 2010; 36: 1207–1212.

[12] Marcin JP, Pollack MM. Review of the acuity scoring systems for the pediatric intensive care unit and their use in quality improvement. Journal of Intensive Care Medicine. 2007; 22: 131–140.

[13] Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric Risk of Mortality score. Critical Care Medicine. 1996; 24: 743–752.

[14] Volakli E, Sdougka M, Tamiolaki M, Tsonidis C, Reizoglou M, Giala M. Demographic profile and outcome analysis of pediatric intensive care patients. Hippokratia. 2011; 15: 316–322.

[15] Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care—associated infection and criteria for specific types of infections in the acute care setting. American Journal of Infection Control. 2008; 36: 309–332.

[16] Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the infectious diseases society of America. Clinical Infectious Diseases. 2009; 49: 1–45.

[17] Central line-associated bloodstream infection (CLABSI). 2022. Available at: (Assessed: 17 May 2022).

[18] O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections. Clinical Infectious Diseases. 2011; 52: 1087–1099.

[19] Guidelines for the prevention of intravascular catheter-related infections (2011). 2020. Available at: (Assessed: 17 May 2022).

[20] Hsu BS, Hill V, Frankel LR, Yeh TS, Simone S, Arca MJ, et al. Executive summary: criteria for critical care of infants and children: PICU admission, discharge, and triage practice statement and levels of care guidance. Pediatrics. 2019; 144: e20192433.

[21] Parihaar MS, Sankar J. Impact of ‘the Intensivist’ in the PICU. The Indian Journal of Pediatrics. 2020; 87: 251–252.

[22] Gupta P, Rettiganti M, Rice TB, Wetzel RC. Impact of 24/7 inhospital intensivist coverage on outcomes in pediatric intensive care. A multicenter study. American Journal of Respiratory and Critical Care Medicine. 2016; 194: 1506–1513.

[23] Pickering BW, Hurley K, Marsh B. Identification of patient information corruption in the intensive care unit: using a scoring tool to direct quality improvements in handover. Critical Care Medicine. 2009; 37: 2905–2912.

[24] Bell CM, Brener SS, Gunraj N, Huo C, Bierman AS, Scales DC, et al. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011; 306: 840–847.

[25] Ji J, Yang H, Yang L, Jiang Y, Tang P, Lu Q. Nursing perspectives on transitional care between pediatric intensive care units and general wards: a focus group study. J Nurs Manag. 2022; 30: 3430–3439.

[26] Alali H, Antar M, AlShehri A, AlHamouieh O, Al-Surimi K, Kazzaz Y. Improving physician handover documentation process for patient transfer from paediatric intensive care unit to general ward. BMJ Open Quality. 2020; 9: e001020.

[27] International classification of diseases, tenth revision (ICD-10). 2021. Available at: (Assessed: 08 October 2022).

[28] DiSantostefano J. International classification of diseases 10th revision (ICD-10). The Journal for Nurse Practitioners. 2009; 5: 56–57.

[29] Intensive Care Unit clinical outcomes. 2022. Available at: https: // (Assessed: 03 June 2022).

[30] Leteurtre S, Leclerc F, Wirth J, Noizet O, Magnenant E, Sadik A, et al. Can generic paediatric mortality scores calculated 4 hours after admission be used as inclusion criteria for clinical trials? Critical Care. 2004; 8: R185–193.

[31] Slater A, Shann F. The suitability of the pediatric index of mortality (PIM), PIM2, the pediatric risk of mortality (PRISM), and PRISM III for monitoring the quality of pediatric intensive care in Australia and New Zealand. Pediatric Critical Care Medicine. 2004; 5: 447–453.

[32] Volakli E, Svirkos M, Boubraki P, Stavrou V, Tziouvas K, Vasilipoulou M, et al. Epidemiology and outcome of pediatric critical illness in Greece. A six-point prevalence study. Abstract 372. 31st Annual Meeting of the European Society of Paediatric and Neonatal Intensive Care. 15–18 June 2021, Athens. Greece. Available at: (Assessed: 19 May 2022).

[33] Farias JA, Fernández A, Monteverde E, Flores JC, Baltodano A, Menchaca A, et al. Mechanical ventilation in pediatric intensive care units during the season for acute lower respiratory infection. Pediatric Critical Care Medicine. 2012; 13: 158–164.

[34] Balcells Ramírez J, López-Herce Cid J, Modesto Alapont V, Grupo de Respiratorio de la Sociedad Española de Cuidados Intensivos Pediátricos. Prevalence of mechanical ventilation in pediatric intensive care units in Spain. Anales de Pediatría. 2004; 61: 533–541. (In Spanish)

[35] Ruttimann UE, Patel KM, Pollack MM. Relevance of diagnostic diversity and patient volumes for quality and length of stay in pediatric intensive care units. Pediatric Critical Care Medicine. 2000; 1: 133–139.

[36] Tilford JM, Simpson PM, Green JW, Lensing S, Fiser DH. Volume-outcome relationships in pediatric intensive care units. Pediatrics. 2000; 106: 289–294.

[37] Edwards JD, Houtrow AJ, Vasilevskis EE, Rehm RS, Markovitz BP, Graham RJ, et al. Chronic conditions among children admitted to U.S. pediatric intensive care units. Critical Care Medicine. 2012; 40: 2196–2203.

[38] Pronovost PJ, Angus DC, Dorman T, Robinson KA, Dremsizov TT, Young TL. Physician staffing patterns and clinical outcomes in critically ill patients. JAMA. 2002; 288: 2151.

[39] West E, Barron DN, Harrison D, Rafferty AM, Rowan K, Sanderson C. Nurse staffing, medical staffing and mortality in intensive care: an observational study. International Journal of Nursing Studies. 2014; 51: 781–794.

[40] Kane RL, Shamliyan T, Mueller C, Duval S, Wilt TJ. Nurse staffing and quality of patient care. Evidence Report/Technology Assessment. 2007; 1–115.

[41] Aragon Penoyer D. Nurse staffing and patient outcomes in critical care: a concise review. Critical Care Medicine. 2010; 38: 1521–1528.

[42] Angus DC. Grappling with intensive care unit quality-does the readmission rate tell us anything? Critical Care Medicine. 1998; 26: 1779–1780.

[43] Rosenberg AL, Watts C. Patients readmitted to ICUs. Chest. 2000; 118: 492–502.

[44] Metnitz PGH, Fieux F, Jordan B, Lang T, Moreno R, Le Gall J. Critically ill patients readmitted to intensive care units—lessons to learn? Intensive Care Medicine. 2003; 29: 241–248.

[45] Kramer AA, Higgins TL, Zimmerman JE. Intensive care unit readmissions in U.S. hospitals. Critical Care Medicine. 2012; 40: 3–10.

[46] Edwards JD, Lucas AR, Stone PW, Boscardin WJ, Dudley RA. Frequency, risk factors, and outcomes of early unplanned readmissions to PICUs. Critical Care Medicine. 2013; 41: 2773–2783.

[47] Prutsky GJ, Padhya D, Ahmed AT, Almasri J, Farah WH, Prokop LJ, et al. Is unplanned PICU readmission a proper quality indicator? a systematic review and meta-analysis. Hospital Pediatrics. 2021; 11: 167–174.

[48] Kotsakis A, Stevens D, Frndova H, Neal R, Williamson G, Mohseni-Bod H, et al. Description of PICU unplanned readmission. Pediatric Critical Care Medicine. 2016; 17: 558–562.

[49] Czaja AS, Hosokawa PW, Henderson WG. Unscheduled readmissions to the PICU: epidemiology, risk factors, and variation among centers. Pediatric Critical Care Medicine. 2013; 14: 571–579.

[50] Ding M, Yang C, Li Y. Risk factors of readmission to pediatric intensive care unit within 1 year: a case-control study. Frontiers in Pediatrics. 2022; 10: 887885.

[51] Natale JE, Marcin JP. PICU readmissions: not just output but patient throughput. Pediatric Critical Care Medicine. 2016; 17: 573–574.

[52] Namachivayam P, Shann F, Shekerdemian L, Taylor A, van Sloten I, Delzoppo C, et al. Three decades of pediatric intensive care: who was admitted, what happened in intensive care, and what happened afterward. Pediatric Critical Care Medicine. 2010; 11: 549–555.

[53] Zingg W, Hopkins S, Gayet-Ageron A, Holmes A, Sharland M, Suetens C, et al. Health-care-associated infections in neonates, children, and adolescents: an analysis of paediatric data from the European centre for disease prevention and control point-prevalence survey. The Lancet Infectious Diseases. 2017; 17: 381–389.

[54] Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital. Critical Care Medicine. 2006; 34: 2084–2089.

[55] Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis. Infection. 2015; 43: 29–36.

[56] Olaechea PM, Palomar M, Álvarez-Lerma F, Otal JJ, Insausti J, López-Pueyo MJ, et al. Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients. Revista Espanola de Quimioterapia. 2013; 26: 21–29.

[57] Buetti N, Marschall J, Drees M, Fakih MG, Hadaway L, Maragakis LL, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 update. Infection Control & Hospital Epidemiology. 2022; 43: 553–569.

[58] Ista E, van der Hoven B, Kornelisse RF, van der Starre C, Vos MC, Boersma E, et al. Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases. 2016; 16: 724–734.

[59] Healthcare-associated infections acquired in intensive care units. 2019. Available at: (Assessed: 18 September 2022).

[60] Hsu HE, Mathew R, Wang R, Broadwell C, Horan K, Jin R, et al. Health care-associated infections among critically ill children in the us, 2013–2018. JAMA Pediatrics. 2020; 174: 1176.

[61] Rosenthal VD, Duszynska W, Ider BE, Gurskis V, Al-Ruzzieh MA, Myatra SN, et al. International nosocomial infection control consortium (INICC) report, data summary of 45 countries for 2013–2018, adult and pediatric units, device-associated module. American Journal of Infection Control. 2021; 49: 1267–1274.

[62] Miller MR, Niedner MF, Huskins WC, Colantuoni E, Yenokyan G, Moss M, et al. Reducing PICU central line-associated bloodstream infections: 3- year results. Pediatrics. 2011; 128: e1077–e1083.

[63] Patrick SW, Kawai AT, Kleinman K, Jin R, Vaz L, Gay C, et al. Health care-associated infections among critically ill children in the us, 2007–2012. Pediatrics. 2014; 134: 705–712.

[64] Venturini E, Montagnani C, Benni A, Becciani S, Biermann KP, De Masi S, et al. Central-line associated bloodstream infections in a tertiary care children’s university hospital: a prospective study. BMC Infectious Diseases. 2016; 16: 725.

[65] Ullman AJ, Marsh N, Mihala G, Cooke M, Rickard CM. Complications of central venous access devices: a systematic review. Pediatrics. 2015; 136: e1331–e1344.

[66] Torre FPFL, Baldanzi G, Troster EJ. Risk factors for vascular catheter-related bloodstream infections in pediatric intensive care units. Revista Brasileira de Terapia Intensiva. 2018; 30: 436–442.

[67] Dueñas L, Bran de Casares A, Rosenthal VD, Jesús Machuca L. Device-associated infections rates in pediatrics and neonatal intensive care units in El Salvador: findings of the INICC. The Journal of Infection in Developing Countries. 2011; 5: 445–451.

[68] Rasslan O, Seliem ZS, Ghazi IA, El Sabour MA, El Kholy AA, Sadeq FM, et al. Device-associated infection rates in adult and pediatric intensive care units of hospitals in Egypt. International Nosocomial Infection Control Consortium (INICC) findings. Journal of Infection and Public Health. 2012; 5: 394–402.

[69] Kouni S, Tsolia M, Roilides E, Dimitriou G, Tsiodras S, Skoutelis A, et al. Establishing nationally representative central line-associated bloodstream infection surveillance data for paediatric patients in Greece. Journal of Hospital Infection. 2019; 101: 53–59.

[70] Mougkou K, Gkentzi D, Kourlaba G, Kouni S, Kopsidas I, Nteli C, et al. Central line associated bloodstream infections in hospitalized children in Greece before and after implementation of a prevention bundle. International Journal of Infection Control. 2015; 11: 1–9.

[71] Lutwick L, Al-Maani AS, Mehtar S, Memish Z, Rosenthal VD, Dramowski A, et al. Managing and preventing vascular catheter infections: a position paper of the international society for infectious diseases. International Journal of Infectious Diseases. 2019; 84: 22–29.

[72] Bell T, O’Grady NP. Prevention of central line–associated bloodstream infections. Infectious Disease Clinics of North America. 2017; 31: 551–559.

[73] de Lassence A, Alberti C, Azoulay E, Le Miere E, Cheval C, Vincent F, et al. Impact of unplanned extubation and reintubation after weaning on nosocomial pneumonia risk in the intensive care unit. Anesthesiology. 2002; 97: 148–156.

[74] Peñuelas Ó, Frutos-Vivar F, Esteban A. Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation. Critical Care. 2011; 15: 128.

[75] de Groot RI, Dekkers OM, Herold IH, de Jonge E, Arbous MS. Risk factors and outcomes after unplanned extubations on the ICU: a case-control study. Critical Care. 2011; 15: R19.

[76] Rachman BR, Watson R, Woods N, Mink RB. Reducing unplanned extubations in a pediatric intensive care unit: a systematic approach. International Journal of Pediatrics. 2009; 2009: 1–5.

[77] da Silva PSL, Reis ME, Fonseca TSM, Fonseca MCM. Predicting reintubation after unplanned extubations in children: art or science?Journal of Intensive Care Medicine. 2018; 33: 467–474.

[78] Al-Abdwani R, Williams CB, Dunn C, Macartney J, Wollny K, Frndova H, et al. Incidence, outcomes and outcome prediction of unplanned extubation in critically ill children: an 11-year experience. Journal of Critical Care. 2018; 44: 368–375.

[79] Klugman D, Melton K, Maynord PO, Dawson A, Madhavan G, Montgomery VL, et al. Assessment of an unplanned extubation bundle to reduce unplanned extubations in critically ill neonates, infants, and children. JAMA Pediatrics. 2020; 174: e200268.

[80] Lucas da Silva PS, de Carvalho WB. Unplanned extubation in pediatric critically ill patients: a systematic review and best practice recommendations. Pediatric Critical Care Medicine. 2010; 11: 287–294.

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