Quality Indicators for Ebola Clinical Management

Development of quality indicators for clinical management in an ETU is currently underway. The final indicators will be selected through a several phase process involving Delphi methodology. The first table of indicators represents the items generated by a core group of clinical ETU experts who worked as World Health Organization consultants during the 2013-2016 West African Ebola outbreak. The next phases of the process will include circulating the indicators to a broader group of clinical ETU experts (from affected countries and from international organizations) in 2 to 3 cycles to ultimately arrive at a final set of agreed upon indicators. Updates on the process will be included in this link and the final process with indicators will be submitted for publication in peer-reviewed literature.

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Jump to section:   Screening  •  Triage (illness severity)/Assessment  •  Management  •  Supplies/Equipment  •  Staffing  •   Discharge  •  Special (Pregnancy)  •  Special (Pediatric)  •  Special (Nutrition)

IndicatorType of indicator
Screening
% of admitted patients with completed case report formProcess
% of new admissions who do not fit the current case definitionProcess
Mechanism in place for ongoing communication with family/next of kinStructure
% of days with communication between screening clinician and surveillance teamProcess
Number of days reporting new or zero casesProcess
Number of days reporting contacts of new casesProcess
Triage (illness severity)/ Assessment
Mechanism in place to identify patients based on their risk for developing EVD (e.g., probable vs suspect)Structure
Mechanism in place to identify patients based on their risk for transmitting EVD (e.g., wet vs dry)Structure
% of patients with severity classification recorded (e.g., ETAT/QC+)Process
Management
Monitoring
% of severely ill patients with the following initial vital signs recorded:Process
temperature
BP
HR
RR
O2 saturation
AVPU
Capillary refill
% of patients with ambulatory status recorded per shiftProcess
% of patients with micturition status recorded per shiftProcess
Fluids
Mechanism in place for recording volume of ORS consumed per shiftStructure
IV
% of patients no longer capable of drinking sufficient ORS who have an IV in placeProcess
Mechanism in place to ensure that IV is placed promptly for patients no longer capable of drinking sufficient ORS (i.e., 1 hour)Structure
Mechanism in place for recording volume of IV fluid administered per shiftStructure
% of patients assessed every shift regarding whether transition to IV is warrantedProcess
Safe and adequate IV insertion with regards to the following:
all equipment availableProcess
IV lines observed to be placed appropriately with regards to:Process
skin disinfectionProcess
safety catheter usedProcess
one-way valve usedProcess
sharps container presentProcess
Documentation of intravascular volume status
% of patients with ins/outs recorded per shiftProcess
% of patients with ORS intake recorded per shiftProcess
% of patients with IV placed with IV fluid intake recorded per shiftProcess
% of patients with an IV whose IV site has been assessed for functionality at least once per shiftProcess
% of patients with appropriate volumes of resuscitation to achieve hydration targetsProcess
% of patients receiving IV fluids monitored every shift with serial oxygen saturation and respiratory ratesProcess
Electrolytes
Mechanism for periodic assessment of electrolytes in severely ill patientsStructure
% of severely ill patients with periodic assessment of electrolytesProcess
Availability of IV and po K+, Mg+, HCO3-, glucoseStructure
Oxygen
Oxygen saturation monitors are functionalProcess
Oxygen delivery devices (cylinders or concentrators) are availableStruture
Antibiotics
% of severely ill patients (e.g., any emergency signs, inability to ambulate, shock) receiving appropriate broad spectrum antibiotics (e.g., ceftriaxone or similar)Process
Antimalarials (in settings with RDTs)
% of patients with RDT documentedProcess
% of patients with positive RDT result receiving anti-malarialsProcess
% of patients with no RDT result receiving anti-malarialsProcess
Symptomatic
Standard operating procedure present for management of delirious patients in the ETUStructure
Mechanism in place for administering sedatives to delirious/agitated patientsStructure
Mechanism in place for monitoring change in illness severity (emergency signs, shock, etc)Structure
% of patients who have been assessed for illness severity every shiftProcess
% of severely ill patients with monitoring and appropriate treatment administered per shift for the following signs/symptoms:Process
pain (e.g., headache, abdominal, myalgias)
nausea
diarrhea/vomiting
dyspepsia
hiccoughs
mental status (including anxiety, confusion, etc)
mechanism in place for palliation as part of end of life care (including ongoing communication to families)Structure
Medication list
% of drugs missing from WHO ETU essential medication listProcess
Mechanism in place to ensure rapid availability of urgently needed medicines in the red zone (e.g., diazepam, ondansetron, metoclopramide, electroytes, glucose, pain control)Structure
Diagnostics
Mechanism in place for daily notification of EVD test result (including PCR value) and other laboratory results to clinical teamStructure
% of EVD test results (including PCR Ct value) available to clinical team within 24 hours from testingProcess
% of other laboratory test results available to clinical team within 24 hours from testingProcess
Availability of diagnostics for performing rapid essential laboratory testing including:Structure
Na+
K+
HCO3-
Creatinine
Glucose
Hb
Lactate
Pregnancy test
HIV rapid test
Other
Mechanism for providing psychosocial support for in-patientsStructure
% of patients with hospital stays > 3d who have received psychosocial supportProcess
Supplies/Equipment
Monitoring
Availability of single use BP cuffsStructure
Availability of oxygen saturation probes for each wardStructure
Safe sharps
Availability of IV cannuale with one-way valve mechanism (to avoid retrograde flow)Structure
Standard operating procedure with strong recommendations against breaking glass vialsStructure
Availability of I/O access
availability of EZ-IO drill to introduce I/O access by trained staffStructure
Other
Patient identification system in placeStructure
Availability of white boards (for inside and outside red zone)Structure
Mechanism in place for communication from inside the ETU to outside the ETU and vice versa (e.g., walkie-talkie)Structure
Staffing
% of ETU staff who have been trained to work in ETU based on agreed upon competenciesProcess
Mechanism in place for internal clinical quality assessment to review clinical and safety competency of health workersStruture
Ratios for ETU clinicians to patients (by cadre category) per shift as compared to national requirementsProcess
Mechanism in place to provide ETU staff back up for clinical emergencies when necessaryStructure
Discharge
Availability of discharge package, including pre-discharge counseling (psychosocial and post-EVD sequelae), and medical follow-up planStructure
Availability of a formal referral process for EVD negative patients requiring ongoing medical careStructure
For suspect patients, % of EVD negative patients about whom the surveillance team has been informed for ongoing monitoring and surveillance as a contactProcess
Survival
% of confirmed patients discharged alive among all admitted confirmed patientsOutcome
% of suspected patients discharged alive among all admitted suspected patientsOutcome
Special (Pregnancy)
% of women of childbearing age with a pregnancy testProcess
If you are managing pregnant women
Availability of staff trained for essential child birth and newborn careStructure
Availability of materials necessary for safe labor and deliveryStruture
Availability of Doppler for assessing viability of fetusStructure
Availability of oxytocin (or misoprostol as second line) for prevention and management of postpartum hemorrhageStructure
Standard operating procedures for counseling and management of EVD+ pregnant women who survive to dischargeStructure
Special (Pediatric)
Availability of smaller bore pediatric-sized cannulaeStructure
Standard operating procedure for administering IV fluids safely to childrenStructure
% of children with weights recorded during fluid monitoringProcess
% of children with MUAC recordedProcess
Availability of precautions for pediatric care in the ETU (e.g., appropriate sized bed)Structure
Mechanism in place for appropriately managing children who are asymptomatic contacts of EVD positive casesStructure
Special (Nutrition)
Availability of appropriate nutrition plans and formulations for adults and children (as per national guidelines)Structure