FORTIS ESCORTS

SUBMITTED BY-DR. SURBHI SHARMA

CASE STUDY ON ICU Return within 48 Hours (Quality Indicator)

Definition

ICU Return within 48 hours is a quality indicator that measures the number of patients who
are readmitted to the Intensive Care Unit (ICU) within 48 hours of transfer or discharge from
the ICU. This indicator reflects the effectiveness of clinical decision-making, discharge
planning, and continuity of care. A higher rate may indicate premature ICU discharge,
inadequate monitoring, or clinical deterioration.

INTRODUCTION
Quality indicators are standardized, measurable elements of healthcare performance that
are used to assess, monitor, and improve the quality, safety, and effectiveness of patient
care. In modern healthcare organizations such as Fortis Healthcare, quality indicators play a
vital role in ensuring patient- centre care, clinical excellence, and operational efficiency.

Quality Indicators as per WHO

According to the World Health Organization (WHO), quality indicators are tools that help
healthcare systems measure the extent to which health services provided to patients
improve desired health outcomes. WHO emphasizes that quality healthcare should be safe,
effective, timely, efficient, equitable, and people-centred. Quality indicators support
continuous quality improvement by identifying gaps in care delivery, reducing medical
errors, preventing hospital-acquired infections, and enhancing patient satisfaction.

Quality Indicators as per NABH

The National Accreditation Board for Hospitals and Healthcare Providers (NABH) defines
quality indicators as objective measures used to evaluate the performance of hospitals in
key areas such as clinical care, patient safety, infection control, medication management,
and hospital operations. As per NABH 6th Edition Standards, hospitals are required to
monitor defined quality indicators regularly, analysis trends, and take corrective and
preventive actions to improve outcomes. NABH quality indicators promote evidence-based
practices, compliance with national standards, and a culture of continuous improvement.

Importance of Quality Indicators in Fortis Healthcare

In a tertiary care hospital like Fortis, quality indicators help management and clinical teams
track performance in areas such as hospital-acquired infections (HAIs), ICU returns,
medication errors, surgical site infections, and patient outcomes. Regular monitoring of
these indicators supports accreditation requirements, improves patient safety, enhances
clinical outcomes, and strengthens organizational governance.

Objectives of the Study

1. To study and understand the concept of quality indicators in healthcare as per NABH
standards.

2. To evaluate the effectiveness of quality indicators in improving patient safety, clinical

outcomes, and operational efficiency.

3. To identify gaps and areas of improvement in quality indicator performance.

4. To analyze trends and use findings for quality improvement and accreditation
compliance.

QUALITY INDICATORS (32)

A. Clinical Care Indicators

1. Hospital Mortality Rate

Definition:
This indicator measures the proportion of patients who die during their hospital stay.
It reflects overall quality of clinical care, severity of illness, and effectiveness of management.
High mortality may indicate gaps in clinical processes or resource availability.

2. ICU Mortality Rate

Definition:
Shows the percentage of patients who die in the ICU among total ICU discharges.
It helps assess the quality of critical care services and clinical response to severe cases.
Higher rates may treatment delays or inadequate ICU protocols.
3. Unplanned ICU Admission Rate

Definition:
Indicates patients unexpectedly shifted to ICU from wards or OT due to sudden deterioration.
It reflects early warning system effectiveness, monitoring quality, and clinical decision-making.
High values may show inadequate assessment or missed deterioration signs.

4. Unplanned Return to OT Rate

Definition:
Measures how many patients need re-operation within 24 hours due to complications or errors.
It evaluates surgical quality, OT procedures, and postoperative care. A rise may indicate improper
technique, infection, or equipment issues.

5. Average Length of Stay (ALOS)

Definition:
Shows the average number of days a patient stays in the hospital. It reflects efficiency of treatment,
discharge planning, and care coordination. Higher ALOS may indicate slow recovery, complications,
or process delays.

6. Readmission Rate (within 28 days)

Definition:
Measures how many patients return to the hospital within 28 days of discharge.
It reflects discharge quality, effectiveness of treatment, and continuity of care.
High readmission suggests inadequate follow-up or premature discharge.

7. Surgical Case Cancellation Rate

Definition:
Shows the proportion of scheduled surgeries cancel on the day of operation.
It monitors OT utilization, scheduling efficiency, and patient preparation. Frequent cancellations
indicate process issues or poor pre-operative assessment.

8. Post-operative Complication Rate

Definition:
Reflects the percentage of patients developing complications after surgery.
This measure surgical quality, infection control, and postoperative monitoring.
High rates signal clinical inefficiencies or risk-factor mismanagement.

9. Anesthesia related Complication Rate

Definition:
Tracks complications directly linked to anesthesia administration. It helps evaluate safety of
anesthesia practices, drug handling, and monitoring quality. High values suggest training issues,
assessment gaps, or equipment failures.
10. Blood Transfusion Reaction Rate

Definition:
Measures the percentage of patients experiencing adverse reactions after blood transfusion.
It reflects safety of blood administration, compatibility checks, and nursing vigilance.
High rates point to procedural non-compliance or testing errors.

B. Infection Control Indicators (8)

11. Hospital Acquired Infection (HAI) Rate

Definition:
This indicator measures infections that patients acquire after 48 hours of hospital stay, not present
at admission. It reflects the effectiveness of infection control practices, sanitation, hand hygiene, and
patient care process. A high HAI rate indicates gaps in surveillance, aseptic technique, or
environmental cleaning.

12. Catheter-Associated Urinary Tract Infection (CAUTI) Rate

Definition:
CAUTI rate shows infection caused due to indwelling urinary catheters. It helps evaluate catheter
care bundles, aseptic insertion, and timely removal practices. Increased rates indicate poor catheter
handling, prolonged use, or hygiene breaches.

13. Central Line–Associated Blood Stream Infection (CLABSI) Rate

Definition:
CLABSI occurs when patients develop bloodstream infections due to central venous catheters. It
measures quality of sterile technique during insertion and maintenance. High CLABSI rate indicates
lapses in catheter bundle compliance and aseptic care.
14. Ventilator-Associated Pneumonia (VAP) Rate

Definition:
VAP rate identifies pneumonia that develops in patients who are on mechanical ventilation for >48
hours. It reflects adherence to ventilator bundles, oral care, and equipment hygiene. High VAP rate
suggests inadequate ventilator care or sterile practices.

15. Surgical Site Infection (SSI) Rate

Definition:
SSI rate measures postoperative infections occurring at the surgical wound site.
It helps assess sterile technique, antibiotic prophylaxis, and OT sterilization quality.
High rates indicate gaps in sterilization, hand hygiene, or postoperative dressing care.

16. Needle Stick Injury (NSI) Rate

Definition:
NSI rate tracks accidental needle or sharps injuries among healthcare workers. It evaluates staff
training, safe sharps disposal, and compliance with safety protocols. High NSI rate signals risk in staff
safety practices and improper handling of sharps.

17. Hand Hygiene Compliance Rate

Definition:
This measure how often staff correctly perform hand hygiene out of all observed opportunities.
It directly reflects infection prevention behaviour and adherence to WHO's 5 moments. Low
compliance indicates need for training, audits, or behavioural reinforcement.
18. Biomedical Waste Segregation Compliance

Definition:
This indicator tracks how accurately staff segregate biomedical waste into correct color-coded bins.
It reflects compliance with BMW rules and prevents infection spread within the hospital.
Low compliance shows gaps in staff awareness and waste management processes.

C. Patient Safety & Quality Indicators (6)

19. Medication Error Rate

Definition:
Measures how often medication errors occur out of all prescriptions. It reflects safety in prescribing,
dispensing, and administration processes.

20. Patient Fall Rate

Definition:
Tracks the number of patient falls occurring in the hospital.
Falls indicate safety risks, poor monitoring, or environmental hazards.

21. Pressure Ulcer Rate

Definition:
Shows the incidence of pressure sores developing during hospital stay. It indicates quality of nursing
care, mobilization, and skin assessment.
22. Code Blue Response Time Compliance

Definition:
Measures how many code blue calls received a response within the recommended time (usually 3
minutes). It reflects emergency preparedness and staff efficiency.

23. Adverse Event Reporting Rate

Definition:
Shows how many adverse events are reported out of all admissions. It reflects the safety culture and
willingness to report incidents.

24. Near Miss Reporting Rate

Definition:
Measures near-miss incidents reported before causing harm. It indicates staff vigilance and a
proactive patient safety culture.

D. Operational / Administrative Indicators (4)

25. Bed Occupancy Rate

Definition:
Shows percentage of hospital beds occupied over a given period. It reflects hospital utilization and
operational efficiency.

26. Bed Turnover Rate

Definition:
Measures how many times a bed is used by different patients during a period.
Indicates patient flow and operational capacity.

27. Discharge Process Turnaround Time (TAT)

Definition:
Average time taken from doctor’s discharge order to the patient's actual exit from hospital.
Shows process efficiency and coordination among departments.

28. Admission Waiting Time (TAT)

Definition:
Measures the time a patient waits from arrival to bed allotment. Reflects the efficiency of
admissions, bed allocation, and workflow.

E. Support Service Indicators (4)

29. Laboratory Report TAT Compliance

Definition:
Shows the percentage of lab reports released within their defined turnaround time. It reflects
timeliness and efficiency of laboratory operations.

30. Radiology Reporting TAT Compliance

Definition:
Measures how many radiology reports are submitted within the defined time.
Indicates radiology department efficiency and workflow.

31. CSSD Sterilization Failure Rate

Definition:
Tracks failed sterilization loads from CSSD.
Reflects quality of sterilization, equipment functioning, and adherence to protocols.

32. Laundry/Housekeeping Audit Compliance

Definition:
Shows percentage of housekeeping/laundry areas found compliant during audits.
Indicates hygiene standards and maintenance quality.

Rationale of the Study

Quality indicators are essential tools for measuring healthcare performance and ensuring
patient safety. In a multi-specialty hospital like Fortis, continuous monitoring of quality
indicators helps in early identification of clinical and operational gaps. This study is
undertaken to understand how quality indicators contribute to quality improvement,
compliance with NABH accreditation standards, reduction of adverse events, and
enhancement of patient satisfaction. The findings of this study will support hospital
management in evidence-based decision-making and strengthening the quality culture
within the organization.

Data Collection Methods

Primary Data Collection

Primary data will be collected directly from Fortis Hospital through the following methods:

 Observation of clinical and operational processes, Direct monitoring of selected

indicators ICU returns

 Interaction with quality department staff, infection control team, and nursing staff.

 Audit reports related to NABH quality indicators

 Review monthly dashboards and icu return cases.

Secondary Data Collection

Secondary data will be collected from existing sources, including:

 NABH 6th Edition Standards and Quality Indicator guidelines

 Previous quality reports, accreditation and monthly icu return cases.

ICU RETURN CASES

Case 1: ICU Return within 48 Hours

Patient Movement Details

 Step-down from MICU 1: 02/11/2025 (MICU Bed No. 4502)

 Step-up to ICU (MICU 1): 03/11/2025

 ICU return within: 24 hours

Clinical Status at Step-down (02/11/2025)

 Vital Signs:

o Blood Pressure: 101/66 mmHg

 o Pulse: 106/min

o Respiratory Rate: 21/min

The patient was shifted out of MICU after being assessed as hemodynamically stable.

Clinical Deterioration and ICU Return (03/11/2025)

 Reason for ICU Return:

o 3–4 episodes of loose motions

o Clinical deterioration and altered sensorium

 Medications Administered:

o Injection Minocycline 200 mg

o Tablet Refagut 500 mg TDS

o Injection Zavi 2 g at 7:10 PM

 Vital Signs at ICU Shift:

o Blood Pressure: 178/55 mmHg

o Pulse: 105/min

 Laboratory Findings:

o HB: 7.9 g/dL

o INR: 4.5

o Serum Creatinine: 2.50 mg/dL

o TLC: 27,051 /mm³

 Clinical Condition:

o Dull, drowsy, irritable

o Altered sensorium

o ABG analysis done

o Patient developed hypernatremia and hypoglycemia

Subsequent ICU Course

  04/11/2025:

o Fluid therapy initiated as per Doctor advice

 05/11/2025:

o Blood transfusion given

 06/11/2025:

o CPR performed at 7:11 AM

o Negative consent obtained from attendant at 3:30 PM

 09/11/2025 to 12/11/2025:

o Poor prognosis

o Multiple blood transfusions required

o HB: 7.15 g/dL

o ABG values:

 PCO₂: 39.2 mmHg

 PO₂: 102 mmHg

 Lactate: 27

 SCO₃: 12.2

 13/11/2025 at 2:40 AM:

o CPR performed
o Patient declared dead
o Cause of death: Complications related to increased INR and multi-organ
dysfunction

Case 2 – Orthopaedics

 Date of Step-down: 11/11/2025

 Step-down From: SICU 3
 Step-down To: 4th Floor (Bed 4417)
 Date of Step-up: 11/11/2025 Vitals- BP-190/110, PULSE-121
 Step-up To: SICU 3
 Reason for Step-up:
Patient had sudden increase in blood pressure requiring close monitoring and
intensive care management.
CASE-3 Orthopaedics

 Date of Step-down: 13/11/2025

 Step-down From: SICU 3
 Step-down To: 4th Floor (10:00 AM)
 Date of Step-up: 13/11/2025
 Step-up To: SICU 3 (11:25 PM)
 VITALS 10.00PM-BP-111/70, P-86, SPO2-93
 VITALS 11.35PM-BP-90/60, SPO2-88, P-71

Patient developed hypotension (BP 90/60 mmHg), low SpO₂ (88%), vertigo, anxiety,
and required urgent ICU care.

Case 4 – Neurosurgery

 Date of Step-down: 19/11/2025

 Step-down From: SICU 3
 Step-down To: General Ward
 Date of Step-up: 21/11/2025
 Step-up To: CCU

Reason for Step-up:

Patient developed low SpO₂ (80), shortness of breath, and chest pain indicating
cardiopulmonary compromise.

Case 5 – Urology

 Date of Step-down: 21/11/2025

 Step-down From: SICU 3
 Step-down To: Ward (4334)
 Date of Step-up: 21/11/2025
 Step-up To: MICU 5

Reason for Step-up:

Patient developed hypotension (90/60) and low oxygen (78) saturation requiring
intensive monitoring and support.

Case 6 – Neurosurgery

 Date of Step-down: 20/11/2025

 Step-down From: SICU 4 (VITALS STABLE)
 Step-down To: NSW (VITALS STABLE)
 Date of Step-up: 21/11/2025 (VITALS STABLE)
 Step-up To: SICU 4 (VITALS STABLE)

Reason for Step-up:

Patient developed altered sensorium indicating neurological deterioration. (EYES
OPEN, DULL AND DROWSY, SLUUREED SPEECH).
 Baseline Measurement (Weekly – 6 Scoring Method)

To monitor the ICU Return within 48 Hours indicator, a baseline measurement system
was implemented using a 6-point scoring scale on a weekly basis.

6-Point Scoring Criteria

Score Interpretation
0 No ICU return within 48 hours
1 ICU return due to unavoidable clinical deterioration
2 ICU return due to disease progression
3 ICU return due to delayed recognition of deterioration
4 ICU return due to inadequate monitoring post step-down
5 ICU return due to premature ICU discharge
6 ICU return due to system or communication failure

Root Cause Analysis (RCA) – Fishbone Method

Problem Statement:
Increased number of ICU returns within 48 hours after step-down.

Fishbone Categories and Causes

1. Patient Factors

 High disease severity

 Multiple comorbidities
 Poor physiological reserve

2. Clinical Factors

 Inadequate stabilization before step-down

 Unrecognized early warning signs
 Electrolyte imbalance
 Coagulopathy (raised INR)

3. Process Factors

 Absence of standardized ICU discharge checklist

 Infrequent post step-down monitoring
 Delay in escalation of care

4. Manpower Factors

 Inadequate nurse-to-patient ratio

 Lack of training in early deterioration signs
 Communication gaps during handover
 5. Equipment / Monitoring

 Limited continuous monitoring in wards

 Delay in ABG, lab investigations

6. Management / Policy

 Pressure for ICU bed availability

 Lack of step-down unit protocols

5-Why Analysis

Problem: Patient returned to ICU within 24 hours.

1. Why did the patient return to ICU?

→ Because the patient developed hypotension and altered sensorium.
2. Why was deterioration not detected earlier?
→ Because ward monitoring was not frequent enough.
3. Why was monitoring inadequate?
→ Because no structured post-ICU observation protocol was followed.
4. Why was there no structured protocol?
→ Because ICU discharge criteria were not standardized.
5. Why were criteria not standardized?
→ Because hospital-wide step-down guidelines were not implemented.

Root Cause Identified:

Lack of standardized ICU step-down and post-transfer monitoring protocol.
Case Review Summary (All 6 Cases)

A detailed review of all six ICU return cases revealed that most step-ups occurred due
to hemodynamic instability, respiratory distress, altered sensorium, electrolyte
imbalance, and disease progression. In several cases, early warning signs were present
but not escalated in time. Documentation gaps, communication issues during
handover, and absence of a structured post-ICU monitoring protocol were identified as
key contributors.

Corrective and Preventive Action (CAPA)

Quality Indicator: ICU Return within 48 Hours

Corrective Actions (Immediate Actions Taken)

Identified Issue Corrective Action

Premature ICU step-down ICU step-down decisions reviewed by senior
consultant before transfer
Delayed detection of Immediate re-assessment and urgent ICU
deterioration step-up initiated
Inadequate ward monitoring Increased frequency of vital signs monitoring
post step-down
Communication gaps during Verbal and written handover reinforced
handover between ICU and ward teams
Abnormal lab values (INR, Immediate correction initiated and repeat
electrolytes) investigations ordered
Lack of escalation Rapid Response Team (RRT) informed for
early intervention

Preventive Actions (System Improvement Measures)

Root Cause (Fishbone) Preventive Action

Patient Factors High-risk patients flagged; step-down only after
stability for minimum 24 hours
Clinical Factors Standardized ICU discharge criteria checklist
implemented
Process Issues Post-ICU observation protocol developed (first 24–
48 hours)
Manpower Issues Training sessions for nurses on early warning signs
and escalation
Equipment/ Continuous pulse oximetry for high-risk step-down
 Monitoring patients
Management/Policy Dedicated step-down beds planned to avoid ICU bed
pressure
Documentation gaps Mandatory ICU handover format introduced
Delayed escalation Early Warning Score (EWS) system implemented in
wards

Monitoring & Effectiveness Check

Parameter Method Frequency

ICU return rate Quality dashboard Monthly
review
Compliance to discharge Audit Weekly
checklist
Nurse training effectiveness Skill assessment REGUALR
High-risk patient outcomes Case review Monthly

Fortis System vs Observed Practice (Table)

Aspect Fortis Policy Observed Practice

ICU discharge criteria Standardized Partially followed
Post-ICU monitoring Defined Not uniform
Early warning signs Documented Delayed recognition
Handover process Structured Documentation gaps
Escalation protocol Available Delayed escalation
ICU return analysis Mandatory Reactive in some cases

Overall Suggestions (Quality Improvement)

1. Strengthen ICU Step-Down Criteria

 Mandatory senior consultant sign-off

 Risk stratification before step-down

2. Post-ICU Monitoring Protocol

 Hourly vitals for first 6 hours

 2-hourly monitoring for next 24 hours
 Continuous SpO₂ for high-risk patients

3. Early Warning Score (EWS)

 Mandatory EWS charting in wards

 Clear escalation triggers

4. Improve Handover Communication

  Standard ICU-to-ward handover checklist
 Verbal + written handover

5. Dedicated Step-Down Units

 For high-risk post-ICU patients

 Reduce ICU bed pressure

6. Staff Training & Sensitization

 Regular nursing training on deterioration signs

 Simulation-based escalation drills

7. Continuous Monitoring & Audit

 Monthly ICU return trend analysis

 Case-based learning sessions

ICU Return Policy / Document

(Fortis Escorts Hospital, Jaipur – as per NABH aligned practices)

At Fortis Escorts Jaipur, ICU return within 48 hours is monitored as a mandatory

NABH quality indicator. The hospital follows standardized policies and
documentation to ensure patient safety during ICU step-down and early detection of
deterioration.

1. ICU Step-Down & Transfer Policy

Purpose:
To ensure safe transfer of patients from ICU to ward and reduce unplanned ICU
returns.

Key Points:

 Patient must be hemodynamically stable

 No active vasopressors or unstable respiratory support
 Consultant approval mandatory
 Risk assessment before step-down
 Handover to ward nursing and treating team

Document Used:

 ICU Step-Down / Transfer Checklist

 Consultant progress notes
 Nursing handover sheet

2. ICU Return Monitoring Policy

 Purpose:
To track, analyse and reduce ICU returns within 48 hours.

Key Points:

 All ICU returns within 48 hours are documented

 Case review done by ICU & Quality team
 Root Cause Analysis conducted
 CAPA implemented if required
 Data reported in monthly quality dashboard

Document Used:

 ICU Return Register

 ICU Return Case Review Form
 NABH Quality Indicator Dashboard

3. Post-ICU Monitoring Policy

Purpose:
To ensure close observation of high-risk patients after ICU discharge.

Key Points:

 Vitals monitored more frequently for first 24–48 hours

 Early Warning Signs chart used
 Escalation protocol defined
 Rapid Response Team activated if needed

Document Used:

 Post-ICU Observation Chart

 Early Warning Score (EWS) Sheet

4. Rapid Response / Escalation Policy

Purpose:
To ensure timely escalation of deteriorating patients.

Key Points:

 Nursing staff empowered to escalate

 Consultant informed immediately
 ICU team support available
 Timely step-up to ICU if required

Document Used:

 Escalation Protocol Flowchart

 Rapid Response Team Log
 Early Warning Signs (EWS) (Used to Prevent ICU Return)

Early warning signs help in early identification of patient deterioration in wards.

Vital Sign–Based Early Warning Signs

Parameter Warning Value

Blood Pressure SBP < 90 or > 180 mmHg
Pulse Rate < 50 or > 120 /min
Respiratory Rate < 10 or > 30 /min
SpO₂ < 90% on room air
Temperature < 35°C or > 38.5°C
Urine Output < 0.5 ml/kg/hr
Blood Sugar < 70 or > 300 mg/dl

Clinical Early Warning Signs

 Altered sensorium (drowsy, confused, irritable)

 Sudden shortness of breath
 Chest pain
 Persistent vomiting or loose motions
 Sudden hypotension or hypertension
 Reduced urine output
 Signs of bleeding (raised INR)
 Severe pain or restlessness

Action on Early Warning Signs

1. Inform treating doctor immediately

2. Increase frequency of monitoring
3. Initiate corrective treatment
4. Activate Rapid Response Team
5. Shift patient to ICU if condition worsens

THANK YOU