KPI name

Definition

Exclusion

Formula

KPI name

Definition

Exclusion

Formula

KPI name

Definition

Exclusion

Formula

KPI name

Definition
Definition

Exclusion
Formula
Percentage of patients readmitted to the ICU within 48 hours of discharge
Readmission to the intensive care unit (ICU) results in increased consumption of medical resource
quality of care.
Grouping: Length of stay in the previous ICU admission, Diagnosis, Cause of readmission, ICU typ
duration of invasive ventilatory support (ventilator time), and time between extubation and disch
Benchmark: < 4%
Care setting for data source: Adult, Pediatric, Neonatal ICUs
Deceased patient, Discharged Against Medical Advice (DAMA)
Total Number of patient readmitted to ICU within 48 hours*100
DIVIDED BY Total number of discharges from ICU

Unplanned Extubations rate

Unplanned extubation rate used as a marker of quality of weaning care in intensive care units and
consequences, which could result in cardiopulmonary arrest and death. Rates of adverse events
as ranging from 5% to 28%.
Grouping: Diagnosis, ICU type (Adult, Pediatric or Neonatal), duration of invasive ventilatory support (ve
Benchmark: < 2%
Care setting for data source: Adult, Pediatric, Neonatal ICUs
Planned extubation
Total Number of unplanned extubations*100
DIVIDED BY Total number of Ventilator days

Re-Intubation rate within 48 hours of extubation

Reintubation rates helps determine whether decisions regarding liberating patients from mechan
the safety and effectiveness of existing ventilator weaning/management, sedation, and restraint
aggressive approach can be utilized to extubate patients safely.
Grouping: Diagnosis, ICU type (Adult, Pediatric or Neonatal), duration of previous invasive ventilatory su
Extubation type (planned or unplanned).
Benchmark: < 5%
Care setting for data source: Adult, Pediatric, Neonatal ICUs
Re-intubation > 48 hours.
Total Number of patients re-intubated within 48 hours*100
DIVIDED BY Total number of extubations (planned and unplanned)

Standardized mortality rate (SMR)

Mortality rate related to prior prediction is a sensitive indicator for comparison. Risk of death var
state, age, and comorbid conditions. Mortality rate can be obtained from predictive models such
Calculation: Estimated or expected mortality rate for all ICU patients will be calculated within 24
version 4)
Grouping: Diagnosis, ICU type (Adult, Pediatric or Neonatal), APACHE score.
Benchmark: < 1
Care setting for data source: Adult, Pediatric, Neonatal ICUs
Patients transferred out from ICU
Death rate (No. of actual death in ICU / Total no. of discharge including death) DIVIDED BY Average of expected
Name of Lead Data Collector TIJI ABRAHAM
Phone Number 554809928
Email Address tjoseph@moh.gov.sa
Data for the month of DECEMBER
Year 2018
Hospital MCH
Directorate Jeddah
City JEDDAH
Speciality AICU
 Columns with an aterisk sign (*) are necessary to calculate KPI - ‫ر‬

Registration

Was the patient

Date and Time of Date and Time of previous
Patient ID Mandatory admitted to ICU in Cause of readmission Age
current admission admission?
the last 48 hrs? *

1725119 /327/1440;1950H No 15 - 30 Year

1725119 3/28/1440;2300H Yes 27/3/1440;1950H Other 15 - 30 Year
1725186 3/29/1440;0920H No 15 - 30 Year
1551620 4/3/1440;1615H No 31 - 60 Year
1648589 4/5/1440;2240H No 15 - 30 Year
1725454 4/6/1440;0115H No 15 - 30 Year
1586046 4/6/1140;1030H No 31 - 60 Year
1723838 4/9/1440;1300H No 15 - 30 Year
1719263 4/10/1440;2100H No 31 - 60 Year
1725721 4/12/1440;1330H No 15 - 30 Year
1526249 4/13/1440;0210H No 31 - 60 Year
1526249 4/13/1440;0210 No 31 - 60 Year
1718143 4/14/1440;2015H No 31 - 60 Year
1725861 4/16/1440;0935 No 31 - 60 Year
1722864 4/16/1440;1340 No 31 - 60 Year
1554442 19/4/1440;0420h No 31 - 60 Year
1726056 19/4/1440;0505h No 15 - 30 Year
1721137 19/4/1440;1330h No 15 - 30 Year
1725750 19/4/1440;1640h No 15 - 30 Year
1726056 19/4/1440;1930H Yes 19/4/1440;0505H Other 15 - 30 Year
1580581 24/4/1440;1230H No 15 - 30 Year
1725510 24/4/1440 No 15 - 30 Year
necessary to calculate KPI - ‫ب المؤشر‬
‫ببح سا‬
‫ببع لمة النجمة ) * ( ضرورية ل‬
‫العمدة ب‬

Date & Time of intubation Date & Time of extubation

Need respiratory support? (invasive Date Date

Gender Diagnosis * or non-invasive) * (MM/DD/YYYY) Time (0:00 AM) (MM/DD/YYYY)

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other Yes 4/6/1440 1430H 4/7/1440

Female Neurology related disease No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Renal related disease No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No

Female Other No
 Click here for
APACHE SCORE

Date & Time of extubation

enter if adult
patient

Type of Was the patient re-intubated APACHE Predicted

Time (0:00 AM) Cause of re-intubation?
Extubation * within 48 hrs?* mortality rate*

0400H Unplanned No
 ck here for
ACHE SCORE
Columns with an aterisk sign

enter if female and pregnant

Is the patient pregnant? Or Gestational age Gravida Parity Galsgow comma scale
postpartum < 42 days*

Yes 2nd Trimester 2 1 15

Yes 2nd Trimester 3 15
Yes 2nd Trimester 4 15
Yes Postpartum 10 3 15
Yes Postpartum 2 0 15
Yes 2nd Trimester 3 2 15
Yes 3rd Trimester 3 3 15
Yes Postpartum 1 15
Yes Postpartum 4 15
Yes 3rd Trimester 1 15
Yes Postpartum 6 15
Yes 3rd Trimester 1 15
Yes Postpartum 3 15
Yes Postpartum 1 15
Yes Postpartum 1 1 15
Yes Postpartum 11 6 15
Yes 3rd Trimester 1 0 15
Yes Postpartum 1 15
Yes 3rd Trimester 1 0 15
Yes Postpartum 1 15
Yes Postpartum 3 2 15
Yes Postpartum 3 2 15
lumns with an aterisk sign (*) are necessary to calculate KPI - ‫ب المؤشر‬
‫ببح سا‬
‫ببع لمة النجمة ) * ( ضرورية ل‬
‫العمدة ب‬

KPI 1 KPI 2
Date and Time of discharge from ICU

Discharge Status* Percentage of patients

readmitted to the ICU within Unplanned extubation rate
Date (MM/DD/YYYY) Time (0:00 AM) 48 hrs of discharge

3/28/1440 1240H Discharge Alive 10.00% 0.00%

4/1/1440 1715H Discharge Alive
4/6/1440 1020H Discharge Alive
4/5/1440 1200H Discharge Alive
4/6/1440 1320H Discharge Alive
4/10/1440 1030H Discharge Alive
4/8/1440 1830H Discharge Alive
4/11/1440 1315H Discharge Alive
4/12/1440 1310H Discharge Alive
4/14/1440 1910H Discharge Alive
4/15/1440 1800H Discharge Alive
4/13/1440 1030H Discharge Alive
4/17/1440 12:00 AM Discharge Alive
4/18/1440 1410h Discharge Alive
4/19/1440 1100h Discharge Alive
4/20/1440 1045h Discharge Alive
4/19/1440 12:00 AM Discharge Alive
4/21/1440 1100h Discharge Alive
4/20/1440 1380h Discharge Alive
4/21/1440 12:00 AM Discharge Alive
‫ببع لمة الن‬
‫العمدة ب‬

KPI 3 KPI 4 Maternity KPI 1

Percentage of women who require

Re-intubation rate within Standardized mortality ratio ICU admission for more than 24 hrs
48 hrs (SMR) while pregnant or within 42 days
postpartum

0.00% 0.00% 0.00%

 Columns with an aterisk sign (*) are necessary to calculate KPI - ‫ب المؤشر‬
‫ببح سا‬
‫لمة النجمة ) * ( ضرورية ل‬

Estimated expected
mortality rate *

Please enter the total 0

number of ventilator days *
KPI - ‫ب المؤشر‬
‫ببح سا‬
‫ببع لمة النجمة ) * ( ضرورية ل‬
‫العمدة ب‬

Please enter the total number

of discharges from ICU 20
(excluding transfer to another
hospital) *

Please enter the total number 0

of live and still births *
 KPIs' Ratio
12.00%

10.00%
10.00%
8.00%

6.00%

4.00%

2.00%
0.00% 0.00% 0.00% 0.00%
0.00%