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Jöbges S, Dutzmann J, Barndt I, Burchardi H, Duttge G, Grautoff S, Gretenkort P, Hartog C, Knochel K, Nauck F, Neitzke G, Meier S, Michalsen A, Rogge A, Salomon F, Seidlein AH, Schumacher R, Riegel R, Stopfkuchen H, Janssens U. Ethisch begründet entscheiden in der Intensivmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:52-57. [PMID: 38190826 DOI: 10.1055/a-2211-9608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
The process recommendations of the Ethics Section of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) for ethically based decision-making in intensive care medicine are intended to create the framework for a structured procedure for seriously ill patients in intensive care. The processes require appropriate structures, e.g., for effective communication within the treatment team, with patients and relatives, legal representatives, as well as the availability of palliative medical expertise, ethical advisory committees and integrated psychosocial and spiritual care services. If the necessary competences and structures are not available in a facility, they can be consulted externally or by telemedicine if necessary. The present recommendations are based on an expert consensus and are not the result of a systematic review or a meta-analysis.
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Waydhas C, Deffner T, Gaschler R, Häske D, Hamsen U, Herbstreit F, Hierundar A, Kumpf O, Rohe G, Spiekermann A, Vonderhagen S, Waeschle RM, Riessen R. Sedation, sleep-promotion, and non-verbal and verbal communication techniques in critically ill intubated or tracheostomized patients: results of a survey. BMC Anesthesiol 2022; 22:384. [PMID: 36503427 PMCID: PMC9743767 DOI: 10.1186/s12871-022-01887-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 10/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of this survey was to describe, on a patient basis, the current practice of sedation, pharmacologic and non-pharmacologic measures to promote sleep and facilitation of communication in critically ill patients oro-tracheally intubated or tracheostomized. METHODS Cross-sectional online-survey evaluating sedation, sleep management and communication in oro-tracheally intubated (IP) or tracheostomized (TP) patients in intensive care units on a single point. RESULTS Eighty-one intensive care units including 447 patients (IP: n = 320, TP: n = 127) participated. A score of ≤ -2 on the Richmond Agitation Sedation Scale (RASS) was prevalent in 58.2% (IP 70.7% vs. TP 26.8%). RASS -1/0 was present in 32.2% (IP 25.9% vs. TP 55.1%) of subjects. Propofol and alpha-2-agonist were the predominant sedatives used while benzodiazepines were applied in only 12.1% of patients. For sleep management, ear plugs and sleeping masks were rarely used (< 7%). In half of the participating intensive care units a technique for phonation was used in the tracheostomized patients. CONCLUSIONS The overall rate of moderate and deep sedation appears high, particularly in oro-tracheally intubated patients. There is no uniform sleep management and ear plugs and sleeping masks are only rarely applied. The application of phonation techniques in tracheostomized patients during assisted breathing is low. More efforts should be directed towards improved guideline implementation. The enhancement of sleep promotion and communication techniques in non-verbal critically ill patients may be a focus of future guideline development.
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Affiliation(s)
- Christian Waydhas
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany ,Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Teresa Deffner
- grid.275559.90000 0000 8517 6224Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum Jena, Bachstrasse 18, 07743 Jena, Germany
| | - Robert Gaschler
- Fakultät Für Psychologie, Lehrgebiet Allgemeine Psychologie: Lernen, Motivation, Emotion, FernUniversität in Hagen, Universitätsstrasse 33, 58084 Hagen, Germany
| | - David Häske
- grid.411544.10000 0001 0196 8249Center for Public Health and Health Services Research, University Hospital Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Uwe Hamsen
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Frank Herbstreit
- Klinik Für Anästhesiologie Und Intensivmedizin, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Anke Hierundar
- grid.413108.f0000 0000 9737 0454Klinik Für Anästhesiologie Und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Kumpf
- grid.7468.d0000 0001 2248 7639Klinik Für Anästhesiologie Mit Schwerpunkt Operative Intensivmedizin, Campus Charité Mitte Und Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117 Berlin, Germany
| | - Georg Rohe
- grid.5560.60000 0001 1009 3608University Clinic for Anaesthesiology / Intensive Care Medicine / Emergency Medicine / Pain Medicine, Klinikum Oldenburg, Medical Campus of the University Oldenburg), Rahel Straus - Str. 10, 26133 Oldenburg, Germany
| | - Aileen Spiekermann
- grid.5570.70000 0004 0490 981XRuhr-Universität-Bochum, Universitätsstrasse 150, 44801 Bochum, Germany ,grid.412471.50000 0004 0551 2937Klinik Und Poliklinik Für Chirurgie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum, Bürkle-de-La-Camp-Platz 1, 44789 Bochum, Germany
| | - Sonja Vonderhagen
- Present Address: Klinik Für Unfallchirurgie, Universitätsklinikum, Universitätsmedizin Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Reiner M. Waeschle
- grid.411984.10000 0001 0482 5331Klinik Für Anästhesiologie, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37099 Göttingen, Germany
| | - Reimer Riessen
- grid.411544.10000 0001 0196 8249Department Für Innere Medizin, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076 Tübingen, Germany
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Zuber A, Kumpf O, Spies C, Höft M, Deffland M, Ahlborn R, Kruppa J, Jochem R, Balzer F. Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study. BMJ Open 2022; 12:e045327. [PMID: 34992097 PMCID: PMC8739420 DOI: 10.1136/bmjopen-2020-045327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To measure and assess the economic impact of adherence to a single quality indicator (QI) regarding weaning from invasive ventilation. DESIGN Retrospective observational single-centre study, based on electronic medical and administrative records. SETTING Intensive care unit (ICU) of a German university hospital, reference centre for acute respiratory distress syndrome. PARTICIPANTS Records of 3063 consecutive mechanically ventilated patients admitted to the ICU between 2012 and 2017 were extracted, of whom 583 were eligible adults for further analysis. Patients' weaning protocols were evaluated for daily adherence to quality standards until ICU discharge. Patients with <65% compliance were assigned to the low adherence group (LAG), patients with ≥65% to the high adherence group (HAG). PRIMARY AND SECONDARY OUTCOME MEASURES Economic healthcare costs, clinical outcomes and patients' characteristics. RESULTS The LAG consisted of 378 patients with a median negative economic results of -€3969, HAG of 205 (-€1030), respectively (p<0.001). Median duration of ventilation was 476 (248; 769) hours in the LAG and 389 (247; 608) hours in the HAG (p<0.001). Length of stay (LOS) in the LAG on ICU was 21 (12; 35) days and 16 (11; 25) days in the HAG (p<0.001). LOS in the hospital was 36 (22; 61) days in the LAG, and within the HAG, respectively, 26 (18; 48) days (p=0.001). CONCLUSIONS High adherence to this single QI is associated with better clinical outcome and improved economic returns. Therefore, the results support the adherence to QI. However, the examined QI does not influence economic outcome as the decisive factor.
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Affiliation(s)
- Alexander Zuber
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Oliver Kumpf
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Moritz Höft
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Deffland
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Robert Ahlborn
- IT Department, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen Kruppa
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Roland Jochem
- Departments of Machine Tools and Factory Management, TU Berlin, Berlin, Germany
| | - Felix Balzer
- Institute of Medical Informatics, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
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John S, Riessen R, Karagiannidis C, Janssens U, Busch HJ, Kochanek M, Michels G, Hermes C, Buerke M, Kluge S, Baumgärtel M, Braune S, Erbguth F, Fuhrmann V, Lebiedz P, Mayer K, Müller-Werdan U, Oppert M, Sayk F, Sedding D, Willam C, Werdan K. [Core curriculum Medical intensive care medicine of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN)]. Med Klin Intensivmed Notfmed 2021; 116:1-45. [PMID: 33427907 PMCID: PMC7799161 DOI: 10.1007/s00063-020-00765-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 11/25/2022]
Abstract
Medical intensive care medicine treats patients with severe, potentially life-threatening diseases covering the complete spectrum of internal medicine. The qualification in medical intensive care medicine requires a broad spectrum of knowledge and skills in medical intensive care medicine, but also in the general field of internal medicine. Both sides of the coin must be taken into account, the treatment with life-sustaining strategies of the acute illness of the patient and also the treatment of patient's underlying chronic diseases. The indispensable foundation of medical intensive care medicine as described in this curriculum includes basic knowledge and skills (level of competence I-III) as well as of behavior and attitudes. This curriculum is primarily dedicated to the internist in advanced training in medical intensive care medicine. However, this curriculum also intends to reach trainers in intensive care medicine and also the German physician chambers with their examiners, showing them which knowledge, skills as well as behavior and attitudes should be taught to trainees according to the education criteria of the German Society of Medical Intensive Care and Emergency Medicine (DGIIN).
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Affiliation(s)
- S John
- Klinikum Nürnberg-Süd, Medizinische Klinik 8, Abteilung für Internistische Intensivmedizin, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - R Riessen
- Dept. für Innere Medizin, Internistische Intensivstation, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - C Karagiannidis
- ARDS und ECMO Zentrum Köln-Merheim, Professur für extrakorporale Lungenersatzverfahren der Universität Witten-Herdecke, Abteilung Pneumologie, Intensiv- und Beatmungsmedizin, Kliniken der Stadt Köln gGmbH, Köln, Deutschland
| | - U Janssens
- Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, Deutschland
| | - H-J Busch
- Universitäts-Notfallzentrum Freiburg, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - M Kochanek
- Klinik I für Innere Medizin (Hämatologie und Onkologie), Schwerpunkt Internistische Intensivmedizin, Universitätsklinikum Köln, Köln, Deutschland
| | - G Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Hospital gGmbH, Akademisches Lehrkrankenhaus der RWTH Aachen, Eschweiler, Deutschland
| | | | - M Buerke
- Medizinische Klinik II, St. Marien-Krankenhaus Siegen, Siegen, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - M Baumgärtel
- Klinikum Nürnberg-Nord, Intensivstation 10/II, Klinik für Innere Medizin 3, Schwerpunkt Pneumologie, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - S Braune
- IV. Med. Klinik - Internistische Intensivmedizin und Notaufnahme, Franziskus-Hospital Münster, Münster, Deutschland
| | - F Erbguth
- Klinikum Nürnberg, Universitätsklinik für Neurologie, Paracelsus Medizinische Privatuniversität, Nürnberg, Deutschland
| | - V Fuhrmann
- Klinik für Innere Medizin I, Evangelisches Klinikum Niederrhein, Duisburg, Deutschland
| | - P Lebiedz
- Klinik für Innere Medizin und Internistische Intensivmedizin, Ev. Krankenhaus Oldenburg, Steinweg 13-17, Oldenburg, Deutschland
| | - K Mayer
- Medizinische Klinik 4, Pneumologie und Schlafmedizin, ViDia Kliniken, Karlsruhe, Deutschland
| | - U Müller-Werdan
- Klinik für Geriatrie und Altersmedizin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Evangelisches Geriatriezentrum Berlin (EGZB), Berlin, Deutschland
| | - M Oppert
- Klinik für Notfall- und Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - F Sayk
- Campus Lübeck, Medizinische Klinik I, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland
| | - D Sedding
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland
| | - C Willam
- Universitätsklinikum Erlangen, Medizinische Klinik 4, Nephrologie und Hypertensiologie, Friedrich-Alexander-Universität Erlangen, Erlangen, Deutschland
| | - K Werdan
- Universitätsklinikum Halle (Saale), Klinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle (Saale), Deutschland.
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Kumpf O, Nothacker M, Dubb R, Kaltwasser A, Brinkmann A, Greim CA, Wildenauer R. [Quality Assurance in Intensive Care Medicine: Peer Reviews and Quality Indicators]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:12-27. [PMID: 33412600 DOI: 10.1055/a-1130-4950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Goal-oriented quality management in health care is an essential tool to provide good medical practice and treatment. It aims at a patient-centred case management with high transparency of structural and clinical process aspects, as well as patient outcome. An objective and comprehensive description of clinical care includes the use of quality indicators. However, the appliance of those indicators falls short, when the evaluation of quality is not followed by recommendations for improvement.As a highly specified area in health care provided in hospitals, intensive care medicine is characterized by complex interprofessional and multidisciplinary approaches. In addition, critical care units are an expensive resource. In order to provide an economic and yet high quality patient care, treatments should be evidence-based, and cost-drivers must be analysed for their effectiveness on patient-outcome.Various methods of quality assurance allow for a formative evaluation of intensive care units by peer reviews, including the use of quality indicators. This article focuses on peer review systems currently applied in German hospitals, and particularly describes quality indicators that have been established by DIVI (German Interdisciplinary Society of Intensive Care and Emergency Medicine). It also addresses the need for a professional dialogue between equal partners. This has to accompany each peer review that aims at an improvement in quality of critical patient care.
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Kumpf O, Nothacker M, Braun J, Muhl E. The future development of intensive care quality indicators - a methods paper. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc09. [PMID: 33214791 PMCID: PMC7656810 DOI: 10.3205/000285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 04/29/2020] [Indexed: 11/30/2022]
Abstract
Introduction: Medical quality indicators (QI) are important tools in the evaluation of medical quality. Their development is subject to specific methodological requirements, which include practical applicability. This is especially true for intensive care medicine with its complex processes and their interactions. This methods paper presents the status quo and shows necessary methodological developments for intensive care QI. For this purpose, a cooperation with the Association of the Scientific Medical Societies' Institute for Medical Knowledge Management (AWMF-IMWi) was established. Methodology: Review of published German manuals for QI development from guidelines and narrative review of quality indicators with a focus on evidence and consensus-based guideline recommendations. Future methodological adaptations of indicator development for improved operationalization, measurability and pilot testing are presented, and a development process is proposed. Results: The development of intensive care quality indicators in Germany is based on an established process. In the future, additional evaluation criteria (QUALIFY criteria) will be applied to assess the evidence base. In addition, a continuous exchange between the national steering committee of the DIVI responsible for QI development and guideline development groups involved in intensive care medicine is planned. Conclusion: Intensive care quality indicators will have to meet improved methodological requirements in the future by means of an improved development process. Future QI development is intended to improve the structure of the development process, with a focus on scientific evidence and a link to guideline projects. This is intended to achieve the goal of a broad application of QI and to further evaluate its relevance for patient outcome and performance of institutions.
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Affiliation(s)
- Oliver Kumpf
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management c/o Philipps-Universität, Marburg, Germany
| | - Jan Braun
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Martin-Luther-Krankenhaus, Berlin, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
| | - Elke Muhl
- Groß Grönau, Germany.,National Steering Committee Peer Review, German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), Berlin, Germany
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