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Int J Travel Med Glob Health. 2015;3(3):123-126

International Journal of Travel Medicine and Global Health DOI: 10.20286/ijtmgh-0303125

Original Article Open Access

The Quality Assessment of Performance in Intensive Care Units

According to APACHE II Score
Manaf Abdi1, Shahram Tofighi2,*, Sharareh Niakan-Kalhori3, Abbas Ebadi4, Roohollah Zaboli1, Mohammad Hossein
Basirat5, Esmaeil Feyzi1
1 Department of Health Services Management, School of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
2 HealthManagement Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
3 Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
4 Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
5 Baqiyatallah Hospital, Tehran, Iran

*Corresponding Author: Shahram Tofighi, Assistant Professor, Health Management Research Center, Baqiyatallah University of Medical
Sciences, Tehran, Iran. Email: [email protected]
Abstract
Introduction: Improving the health level of patients is one of the most important purposes in intensive care units. In order to promote these units
we need to measure their quality. To do so, some standards are needed in this area. The aim of this article was to study the mortality rate of the
patients admitted to intensive care units with different APACHE scores.
Methods: This descriptive and retrospective study was conducted in Tehran, Iran. The sampling was census and all the patients who had been
admitted to the intensive care unit in a hospital in Tehran in 2013 were studied in this study. The overall admitted patients were 350 that only 318
patients had completed the records and were involved in the study. Data was analyzed by using SPSS15.
Results: Mortality and viability in these two groups were 122 and 196, respectively. Seven out of 68 with scores <15 and 9 out of 49 patients with
scores between 19-16 died. Thirty three out of 103 patients who had scores between 30-20 died too and only 70 patients survived. In comparison
with the standard scoring system, the mortality rate in our study was <19 which was lower than standard, but with scores >20, the mortality rate
was 25% which was higher than standard values.
Conclusion: According to the obtained results, we can conclude that the quality of care in intensive care units is desirable. It can be said that
according to the APACHE system the quality of healthcare is desirable in the Intensive Care Units. As a conclusion, in order to promote quality,
more serious care is needed in patients with greater scores.
Keywords: Patients, Quality of Health Care, Intensive Care Unit, Mortality, APACHE
Article History: Received: 4 Feb. 2015; Accepted: 4 May. 2015; Online Published: 24 Aug. 2015
Cite this article as: Abdi M, Tofighi S, Niakan-Kalhori S, Ebadi A, Zaboli R, Basirat MH, et al. The quality assessment of performance in intensive care units according
to APACHE II score. Int J Travel Med Glob Health. 2015;3(3):123-6.

Introduction Other than monitoring and treating critically ill patients,

The intensive care unit is a specific location where the intensive care units’ doctors are also responsible for both
medical staff and equipment are used for the treatment and predicting the patients’ outcomes and identifying and
management of critically ill patients. A reasonable goal in distinguishing them. This is because hospitalizing is not
this unit is to save the lives of patients with reversible necessarily useful for all patients. Actually in some patients
situations. Since many factors play an important role in it will just lead to a more comfortable death [1]. Using the
patient recovery, therefore the right selection of patients severity-of-disease, the classification system can be a
admitted to these units can have beneficial effects on guidance for physicians to evaluate the patients’ outcome
treatment processes [1]. Nowadays, therapists can treat many and to estimate the chance of recovery. The determination
diseases by using new and advanced technologies and of prognosis systems can also help estimate the
methods which leads to the longer survival of patients. psychological instability in patients’ admitted in hospitals.
The need to assess quality of services provided in intensive The severity of illness scoring and predicting the mortality
units and comparing these services with standard ones rate can also be done in besides to the evaluation. Thereby
and using data to improve the care outcomes of patient led to the chance of the survival of patients will be assessed more
a criterion as Acute Physiology , Age and Chronic Health accurately by physicians and leads to longer survival of
Evaluation Acute that its acronym is APACHE (Acute patients [3].
Physiology and Chronic Health Evaluation). Humans have APACHE II is a severity-of-disease classification system
always been interested in the quality of services and (Knaus et al, 1985) that includes 12 physiological
production. The importance of quality in industries was measurements. This system is still used to predict the
considered in the 1940-1950s and was proposed in nursing admitted patients' treatment process in hospitals especially in
sciences in the 1980s. The Joint Commission Accreditation intensive care units due to its easy collecting of information
Healthcare Organization believes that quality is: "An through routine checkups and reducibility [4]. In fact,
acceptable level of health services provided to individuals because of the differences among patients in the same ward,
and populations that increase the possibility of desired health having a specific estimation system for every patient in every
outcomes and are consistent with the professional knowledge unit is necessary. In addition to prioritizing patients to
of the day". Every year, more than 2 million deaths occur in receive appropriate care facilities, the physicians can have a
Intensive Care Units of USA hospitals which can be reduced more accurate judgment to predict mortality rates, occupying
by more than 30% [2]. the hospital beds and patients' treatment process. This system
can also be a criterion for measuring the standard rate of physiological dimension were 0 and 59, respectively [6].
intensive care units and can be compared with global The score of the second section was obtained through
standards [1]. patients' age group. For the patients older than 44 years old,
According to the standards table, if the APACHE II score the minimum and maximum scores were 0 and 6,
is 0-15, 16-19, 20-30 and above 30, the possibility of respectively. The third part was related to the evaluation of
mortality will be 15, 10, 35 and 75, respectively [5]. chronic disease and chronic renal failure in one or multiple
This study aimed to investigate the diagnosis possibility in organs of patients which included heart, lungs, kidneys, liver
patients admitted to intensive care units in Tehran and was and immune system. The APACHE score was obtained from
conducted by using APACHE II. During different studies, the total scores of these three parts (minimum score is 0 and
assessment and scoring by APACHE has been conducted in maximum is 71). The mortality score predicts on the basis of
some of the medical and educational centers in Iran. In this percent. It is important to collect the data in the first 24 h of
study we decided to estimate the mortality rate in patients hospitalization which was considered in this study. Mortality
admitted to intensive care units by using the severity of was considered as deaths which occurred during the patient's
illness scoring systems. stay in hospital. The observed mortality rate was compared
with the predicted mortality rate.
Methods To avoid biased interpretations:
This study is a descriptive and retrospectively study. The 1. Apache point was calculated in the first 24hrs of
records of all the patients which had been admitted to this hospitalization.
hospital's intensive care unit in 2013 were used. Patients who 2. Patients who had been hospitalized more than 24hrs
were 18, those who had CPR (Cardiopulmonary and received controlling and therapeutic
Resuscitation), those who were admitted to the intensive care intervention were excluded from this study.
unit for less than 24 hours and also brain dead patients were 3. Patients who had been hospitalized due to brain
excluded from this study. Data was collected by using the death, were excluded from this study.
checklists in accordance with the APACHE II. APACHE II The results were analyzed in SPSS version 15 and t-test
checklist has 2 sections: the first section includes the and chi-square test were calculated. According to APACHE
personal identification and general and demographic scores, the percent of mortality in each group was also
questions such as age, gender, consciousness level, need for calculated. The reason for choosing this test was the fact that
mechanical ventilation and length of stay in the intensive this study was done on two independent groups (improved
care unit, and the second section includes clinical and para- and died patients) and that the normality of samples were
clinical data. Additionally, as the emphasis of this study was ascertained by Kolmogrov Smirnov test.
on ward management, our focus was on the performance
during hospitalization. Results
Clinical and para-clinical parts are also divided into three Among the 350 patients, 318 cases were included in this
sections. 11 items and the Glasgow Coma Scale are used to study. them, 50.6 % were male and 49.4 % were
measure physiological variables. Minimum and maximum female. It was also recorded that 50.3 % of the patients were
scores of each question in the physiological dimension were admitted for 5 days and 49.7% of them had stayed in the
0 and 4, respectively. These 11 items included: hospital for more than 5 days. The distribution of age was:
Temperature, Mean arterial pressure, Heart rate, Respiratory 4% from hospitalized patients in 10-19 year olds, 13% in 20-
rate per 1 minute, Sodium and Potassium amount, Creatinine 34 year olds, 15% in 35-54 year olds and 68% in those over
pH, PaO2 serum, Hematocrit, White blood cell count and pH 55 years old. It can also be mentioned that 38% of the studied
arterial. The minimum and maximum scores in the patients died and 62% of them finally survived.

Table 1. Results of patients on the basis of APACHE II

APACHE II Score Percentage of Mortality Percentage of Standard Death Hospital Condition
1 0-15 9 10 Up to standard
2 16-19 14 15 Up to standard
3 20-30 43 35 Lower than standard
4 31 ≤ 85 75 Up to standard

Table 2. Comparison of mortality based on APACHE II

APACHE II Score N (%) N (%) Total P Value
0-15 61 (32.8) 7 (5.3) 68 (21.4) 0.57
16-19 40 (21.5) 9 (6.8) 49 (15.4) 0.77
20-30 70 (37.7) 33 (25) 103 (32.3) 0.001
31 ≤ 15 (8) 83 (62.8) 98 (30.9) 0.001
Total 186 (58.5) 132 (41.5) 318 (100) 0.001

As shown in the table above, mortality rates for 0-15 and to 5 days and 36% were hospitalized more than 5 days.
16-19 scores are higher than standards and for the scores 20- Among the dead group, 76% were hospitalized for up to 6
30 and 31< are less than standard rates. In order to achieve a days and 24% were hospitalized more than 5 days. No
satisfactory level of quality, the hospital needs to provide significant differences were found in the duration of
more suitable healthcare services to end up with higher hospitalization in between the two groups (P=0.345). The
Apache points. number of dead and survival men were more than women,
The frequency of distribution related to the duration of but the sex differences were not significant (P=0.526). There
hospitalization between the dead and survival groups showed was no significant relationship between the diagnosis at
that among the survival group, 64% were hospitalized for up admission and mortality rate (P=0.787).
 The relation between the duration of hospitalization, life the patients that have had surgery has been confirmed by
status, type of trauma, APACHE score and gender was some studies [17].
statically significant (p=0.001, p=0.023, p=0.00, p=0.044). Many factors affect the accuracy of prediction of mortality
The mortality rate in patients with an APACHE score of 0- rates. These factors include limitations of APACHE II that
15 was 9% while this score is 13% in standard rates. This are due to a lot of components both in measuring and the
amount for 16-19 was 14 percent which was lower than individual differences (ethnicity, cultural, economic and
standard. For 20-30 and above 30 was 43 and 85 percent social) of patients studied in this article in compared to
which was higher than standard rates (the standard rate is patients evaluated for validation of the tool [18]. The other
35% and 75%, respectively). factors may be related to criteria that are for admitting
patients in intensive care units. The number of beds in
Discussion hospitals will also effect results [6]. According to the limited
Predicting the mortality rate in trauma patients with the beds in intensive care units in our country, using this scoring
APACHE scoring system has been a successful performance can be helpful for patients whom have higher scores. This is
for many years [7]. The mortality rate in this study was because patients are prioritized and those who are in higher
22.7%, while this amount was 27.9% in Schein et al.’s study. risk can have better outcomes by getting admitted to
Also, Kulkarni reported 11 and 16 percent, respectively [8, intensive care units.
9]. In a study conducted by Dossett et al. on patients that had There are many indicators to classify the severity of
been admitted to intensive care units, it was mentioned that diseases. This is while in many hospitals and training centers,
the mortality rate was 14 percent [10]. Due to low hospital patients admitted to intensive care units are still evaluated by
standards, this amount is justifiable. On the other hand, in using traditional methods such as GCS [6]. As shown in this
this study patients were studied that had higher risk of death. study, there is significant differences between GCS scores in
In comparison to the standard table, our table showed that survival groups and dead groups. This result indicates that
the mortality rate in patients with the scores < 15 was 9% GCS can be used for the admission of patients because this
which is close to the standard score (10%). Mohammadi et criterion can be measured simply and can be checked in early
al. reported that the mortality rate in this group is zero [11]. hours of hospitalization. Dossett et al. also showed the same
Also, in a study which was conducted by Rahimzade et al. relation [10]. This study indicated that there is no significant
on the Rasool Akram Hospital showed that this amount is 8 relation between age, gender, length of stay and the diagnosis
percent [2]. at admission and mortality of patients admitted to intensive
The mortality rate in the scores between 16 and 19 was 14 care units. This result has been confirmed in many other
percent that was lower than standard rates (15%). The studies [19, 20].
mortality rate in the scores of 30 and above 30 were also 43
and 85 % respectively which were higher than standard (35 Conclusion
and 75 percent). The results showed that the mortality rate in intensive care
This study showed that the mortality rate for the scores 15< units in patients with the scores 16< is lower than the
are lower than standard rates. The studies that have been standard rate. These results can be a guidance for predicting
conducted in Iran show the opposite results in some cases. the mortality rate in this unit in terms of the APACHE score
By increasing the APACHE score, the mortality rate also and can be effective in the decision making processes of
increases. This study showed that the APACHE score in both practitioners. This big difference with standard scores can
the survived and dead groups have no significant differences. be due to the differences between treatments and cares in
However, the mortality rate in the different APACHE scores Iran's medical centers and other countries. The main reasons
should be revised in our country and predictions should be can be: lack of skilled manpower in emergency cases, lack
based on the results of researches conducted in this area. of experience and not enough care in managing and nursing
Foreign studies showed that the APACHE scores is useful in critically ill patients and lack of appropriate equipment and
predicting the mortality rate, but this prediction is not the physical space. According to the results, care and treatment
same for all patients [12, 13]. Increasing the differences interventions in the hospital should be revised by using a
among the dead group in our study and other studies may be prospective study and a larger sample size. Also, the level of
due to the hospital standards such as medical equipment in quality should reach standard levels in order to reduce
intensive care units, adjustment of manpower, shift work and differences.
differences in policies in different hospitals [13]. According to the limited number of beds in Iranian
This study showed that this system is useful for patients hospitals, regular use of this scoring in intensive care units
whom were admitted to intensive care units. In other studies will be helpful in determining the priority of patients whom
that compared the APACHE II with APACHE III, TISS and have more need for care (have a higher APACHE score).
SAPS, found that the APACHE II has a much higher Patients who obtain lower scores and have a lower risk can
predictive power and is good for analyzing the quality in be placed in the next priority in the allocation of intensive
intensive care units [14]. The studies showed that the care unit beds. Thus, patients who needed intensive care and
APACHE II alone is not useful for predicting the mortality had a higher scoring could indicate better outcomes after
rate, the severity of disease classification and length of stay, treatment in intensive care units.
but it will be helpful in managing and providing the treatment Suggestion
methods, comparative effectiveness of treatments, making 1. Structural standards such as human force, physical
decisions for changing treatment and comparing the environment, equipment and so on must be observed by
performances and quality of services provided. Nevertheless, all work shifts.
the use of APACHE II in other sections is not yet known [15, 2. A model of quality improvement standards and ranking
16]. The usefulness of this scoring system in classifying the must be implemented in the ward.
patients admitted to intensive care units or better managing 3. Safety indices must he determined and monitored in the
 ward. 4. Matic I, Titlic M, Dikanovic M, Jurjevic M, Jukic I, Tonkic A. Effects
of APACHE II score on mechanical ventilation; prediction and
4. Triage and assessment of the patients must be
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emergency operations for perforated ulcers. Am J Surg.
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9. Kulkarni SV, Naik AS, Subramanian N, Jr. APACHE-II scoring
1. Incomplete file: to avoid biased interpretation, the system in perforative peritonitis. Am J Surg. 2007;194(4):549-52.
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2. Lack of pre-clinical information registration system: to validity of APACHE II in the trauma ICU: improved risk
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11. Mohammadi H, Haghighi M. The Assessment of mortality in ICU
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Acknowledgments R. Use of the APACHE II scoring system to determine mortality of
The authors would like to thank the responsible minister of gynecologic oncology patients in the intensive care unit. Obstet
Gynecol. 1995;85(1):53-6.
medical records for offering extremely useful information 14. Gupta R, Arora VK. Performance evaluation of APACHE II score for
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Authors’ Contributions
Outcome prediction for critically ill cirrhotic patients: a comparison
All authors were involved in the study design and result of APACHE II and Child-Pugh scoring systems. J Intensive Care
interpretation. All authors confirmed the final draft before Med. 2004;19(2):105-10.
submission. 16. Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Campos RA,
et al. SAPS 3--From evaluation of the patient to evaluation of the
intensive care unit. Part 2: Development of a prognostic model for
Financial Disclosure hospital mortality at ICU admission. Intensive Care Med.
The authors declared no financial disclosure. 2005;31(10):1345-55.
17. Neishaburi M, Raies Dana N, Ghorbani R, Sadeghi T. Examining the
nursing care quality from the viewpoints of nurses and patients of
Funding/Support therapeutic‐educational centers of the city of Semnan. Koomesh.
Not declared 2010;12(2):134-43.
18. Ratanarat R, Thanakittiwirun M, Vilaichone W, Thongyoo S,
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