What metrics can be used to address the capacity to “anticipate”, “respond” and “incorporate new practices that lead to improvement (learn)”? Albeit imperfect, some potential indicators can be proposed.
First, the capacity to adapt to increased case-volume, defined by the total number of cases, occupation rates, transfers, and off-hours discharges. In addition, the increased number of patients presenting high severity (organ failures or severity of illness or decompensated co-morbid conditions) and use of resources (i.e., increased requirement of advanced support). Overall, ICU and in-hospital mortality, ICU LOS, and the rate of ICU-acquired complications should be defined as core measures of resiliency. Others could be added, such as risk-adjusted mortality rates, delayed/denied access to ICU, and process of care measures, such as adherence to evidence-based protocols. A comparative approach could improve the evaluation by measuring the variation of risk-adjusted mortality and LOS. A proposed framework to evaluate the resiliency of an ICU is provided in Fig. 1.
As resilience is not static, using an indicator such as the Variable life-adjusted display (VLAD) could overcome these limitations by reflecting the adaptation and responses using a risk-adjusted metric. The VLAD is often employed to measure healthcare quality and patient outcomes. This tool predicts the likelihood of a patient outcome, and subsequently plots the difference between the predicted and observed outcomes being represented graphically in a sequential (dynamic) way.
In Fig. 1, we describe an average VLAD showing that the ICU outcomes of non-COVID-19 critically ill-patients vary differently when the surge of COVID-19 patients occurs in two distinct resilience scenarios (Fig. 1B, C). We can observe an ICU, where the mortality of non-COVID-19 patients does not change substantially during the surge (Fig. 1B), demonstrating its resilience. In contrast, a low resilience ICU would present a considerable variation (increase) in mortality as the number of COVID-19 patients increases (Fig. 1C). Such evaluation would trigger actions based on the 4S structure and the implementation of evidence-based care practices.
We believe that a resiliency analysis adds a component of preparedness to the usual ICU performance evaluation and outcomes metrics to be used during the crisis and in regular times. In addition, it provides a dynamic perspective through VLAD or variation analysis.