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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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DeMellow J, Kim TY. Technology-enabled performance monitoring in intensive care: An integrative literature review. Intensive Crit Care Nurs 2018; 48:42-51. [PMID: 30054118 DOI: 10.1016/j.iccn.2018.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 05/20/2018] [Accepted: 07/07/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Implementation of evidence-based bundles in intensive care units is integral to improving quality of care and patient outcomes. However, it increases the burden of data collection and analysis required for performance monitoring and feedback of an inter-disciplinary care team. Health information technology including electronic health records and data analytic tools could automate this process and provide real-time feedback to the team. AIM This integrative literature review aimed to examine the extent to which technology-enabled performance monitoring and feedback contributed to improving quality of care and patient outcomes when implementing evidence-based bundles. METHODS A literature search of scientific databases was conducted using PubMed, Embase, Scopus, CINHAL and Ovid Medline. RESULTS Of nine studies included in this review, all reported improved compliance of the team with evidence-based bundles, ranging from 3% to 60% post implementation of technology-enabled performance monitoring and feedback. Significant reductions (p < .05) in hospital acquired infections were also reported in five studies. CONCLUSIONS Overall, the addition of documentation fields to electronic health records was essential in providing real-time feedback to teams and improving their compliance with evidence-based bundles. Further research is needed to assess the effectiveness of technology-enabled performance monitoring and feedback in improving patient outcomes on a larger scale, especially in resource-limited settings such as community hospitals.
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Affiliation(s)
- Jacqueline DeMellow
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48th Street, Suite 2600, Sacramento, CA 95817, United States.
| | - Tae Youn Kim
- University of California, Davis, Betty Irene Moore School of Nursing, 2450 48th Street, Suite 2600, Sacramento, CA 95817, United States
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Duclos G, Zieleskiewicz L, Antonini F, Mokart D, Paone V, Po MH, Vigne C, Hammad E, Potié F, Martin C, Medam S, Leone M. Implementation of an electronic checklist in the ICU: Association with improved outcomes. Anaesth Crit Care Pain Med 2017; 37:25-33. [PMID: 28705759 DOI: 10.1016/j.accpm.2017.04.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Revised: 03/27/2017] [Accepted: 04/01/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To assess the impact of an electronic checklist during the morning rounds on ventilator-associated pneumonia (VAP) in the intensive care unit (ICU). PATIENTS AND METHODS We conducted a retrospective, before/after study in a single ICU of a university hospital. A systematic electronic checklist focusing on guidelines adherence was introduced in January 2012. From January 2008 to June 2014, we screened patients with ICU stay durations of at least 48hours. Propensity score-matched analysis with conditional logistic regression was used to compare the rate of VAP and number of days free of invasive devices before and after implementation of the electronic checklist. RESULTS We analysed 1711 patients (before group, n=761; after group, n=950). The rates of VAP were 21% and 11% in the before and after groups, respectively (p<0.001). In propensity-score matched analysis (n=742 in each group), VAP occurred in 151 patients (21%) during the before period compared with 72 patients (10%) during the after period (odds ratio [OR]=0.38; 95% confidence interval [CI]=0.27-0.53). The after group showed increases in ICU-free days (OR=1.05; 95% CI=1.04-1.07) and mechanical ventilation-free days (OR=1.03; 95% CI=1.01-1.04). CONCLUSION In this matched before/after study, implementation of an electronic checklist was associated with positive effects on patient outcomes, especially on VAP. Further prospective studies are needed to confirm these observations.
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Affiliation(s)
- Gary Duclos
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Laurent Zieleskiewicz
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - François Antonini
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Djamel Mokart
- Service d'anesthésie et de réanimation, institut Paoli-Calmettes, 13015 Marseille, France
| | - Véronique Paone
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Marie Hélène Po
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Coralie Vigne
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Emmanuelle Hammad
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Frédéric Potié
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Claude Martin
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Sophie Medam
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France
| | - Marc Leone
- Service d'anesthésie et de réanimation, Aix-Marseille université, hôpital nord, Assistance publique-Hôpitaux de Marseille, 13015 Marseille, France.
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Adherence to All Steps of a Pain Management Protocol in Intensive Care Patients after Cardiac Surgery Is Hard to Achieve. Pain Res Manag 2017; 2017:7187232. [PMID: 28298879 PMCID: PMC5337384 DOI: 10.1155/2017/7187232] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 01/23/2017] [Indexed: 11/17/2022]
Abstract
Purpose. To investigate adherence to our pain protocol considering analgesics administration, number and timing of pain assessments, and adjustment of analgesics upon unacceptably high (NRS ≥ 4) and low (NRS ≤ 1) pain scores. Material and Methods. The pain protocol for patients in the intensive care unit (ICU) after cardiac surgery consisted of automated prescriptions for paracetamol and morphine, automated reminders for pain assessments, a flowchart to guide interventions upon high and low pain scores, and reassessments after unacceptable pain. Results. Paracetamol and morphine were prescribed in all 124 patients. Morphine infusion was stopped earlier than protocolized in 40 patients (32%). During the median stay of 47 hours [IQR 26 to 74 hours], 702/706 (99%) scheduled pain assessments and 218 extra pain scores were recorded. Unacceptably high pain scores accounted for 96/920 (10%) and low pain scores for 546/920 (59%) of all assessments. Upon unacceptable pain additional morphine was administered in 65% (62/96) and reassessment took place in 15% (14/96). Morphine was not tapered in 273 of 303 (90%) eligible cases of low pain scores. Conclusions. Adherence to automated prescribed analgesics and pain assessments was good. Adherence to nonscheduled, flowchart-guided interventions was poor. Improving adherence may refine pain management and reduce side effects.
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A Pediatric Sedation Protocol for Mechanically Ventilated Patients Requires Sustenance Beyond Implementation. Pediatr Crit Care Med 2016; 17:721-6. [PMID: 27355825 DOI: 10.1097/pcc.0000000000000846] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To reevaluate the effect of a nursing-driven sedation protocol for mechanically ventilated patients on analgesic and sedative medication dosing durations. We hypothesized that lack of continued quality improvement efforts results in increased sedation exposure, as well as mechanical ventilation days, and ICU length of stay. DESIGN Quasi-experimental, uncontrolled before-after study. SETTING Forty-five-bed tertiary care, medical-surgical-cardiac PICU in a metropolitan university-affiliated children's hospital. PATIENTS Children requiring mechanical ventilation longer than 48 hours not meeting exclusion criteria. INTERVENTIONS During both the intervention and postintervention periods, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol with a targeted comfort score. MEASUREMENT AND MAIN RESULTS The intervention cohort includes patients admitted during a 12-month period following initial protocol implementation in 2008-2009 (n = 166). The postintervention cohort includes patients meeting identical inclusion and exclusion criteria admitted during a 12-month period in 2012-2013 (n = 93). Median duration of total sedation days (IV plus enteral) was 5 days for the intervention period and 10 days for the postintervention period (p < 0.0001). The postintervention cohort received longer duration of mechanical ventilation (6 vs 5 d; p = 0.0026) and ICU length of stay (10 vs 8.5 d; p = 0.0543). After adjusting for illness severity and cardiac and surgical status, Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the postintervention group were 58% more likely to be receiving sedation (hazard ratio, 1.58; p < 0.001) and 34% more likely to remain in the ICU (hazard ratio, 1.34; p = 0.019). CONCLUSIONS Sedation quality improvement measures related to the use of opiate infusions, total days of sedation exposure, PICU length of stay, and mechanical ventilation days all deteriorated following initial successful implementation of a PICU sedation protocol. Implementation of a protocol alone may not lead to sustained quality improvement without routine monitoring and ongoing education to ensure effectiveness.
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Walsh TS, Kydonaki K, Antonelli J, Stephen J, Lee RJ, Everingham K, Hanley J, Uutelo K, Peltola P, Weir CJ. Rationale, design and methodology of a trial evaluating three strategies designed to improve sedation quality in intensive care units (DESIST study). BMJ Open 2016; 6:e010148. [PMID: 26944693 PMCID: PMC4785300 DOI: 10.1136/bmjopen-2015-010148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To describe the rationale, design and methodology for a trial of three novel interventions developed to improve sedation-analgesia quality in adult intensive care units (ICUs). PARTICIPANTS AND SETTING 8 clusters, each a Scottish ICU. All mechanically ventilated sedated patients were potentially eligible for inclusion in data analysis. DESIGN Cluster randomised design in 8 ICUs, with ICUs randomised after 45 weeks baseline data collection to implement one of four intervention combinations: a web-based educational programme (2 ICUs); education plus regular sedation quality feedback using process control charts (2 ICUs); education plus a novel sedation monitoring technology (2 ICUs); or all three interventions. ICUs measured sedation-analgesia quality, relevant drug use and clinical outcomes, during a 45-week preintervention and 45-week postintervention period separated by an 8-week implementation period. The intended sample size was >100 patients per site per study period. MAIN OUTCOME MEASURES The primary outcome was the proportion of 12 h care periods with optimum sedation-analgesia, defined as the absence of agitation, unnecessary deep sedation, poor relaxation and poor ventilator synchronisation. Secondary outcomes were proportions of care periods with each of these four components of optimum sedation and rates of sedation-related adverse events. Sedative and analgesic drug use, and ICU and hospital outcomes were also measured. ANALYTIC APPROACH Multilevel generalised linear regression mixed models will explore the effects of each intervention taking clustering into account, and adjusting for age, gender and APACHE II score. Sedation-analgesia quality outcomes will be explored at ICU level and individual patient level. A process evaluation using mixed methods including quantitative description of intervention implementation, focus groups and direct observation will provide explanatory information regarding any effects observed. CONCLUSIONS The DESIST study uses a novel design to provide system-level evaluation of three contrasting complex interventions on sedation-analgesia quality. Recruitment is complete and analysis ongoing. TRIAL REGISTRATION NUMBER NCT01634451.
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Affiliation(s)
- Timothy S Walsh
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Kalliopi Kydonaki
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Jean Antonelli
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Robert J Lee
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Kirsty Everingham
- Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Janet Hanley
- Edinburgh Health Services Research Unit, Edinburgh, UK
| | | | | | - Christopher J Weir
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
- Edinburgh Health Services Research Unit, Edinburgh, UK
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Collinsworth AW, Priest EL, Campbell CR, Vasilevskis EE, Masica AL. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med 2016; 31:127-41. [PMID: 25348864 PMCID: PMC4411205 DOI: 10.1177/0885066614553925] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/16/2014] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The objective of this review is to examine the effectiveness, implementation, and costs of multifaceted care approaches, including care bundles, for the prevention and mitigation of delirium in patients hospitalized in intensive care units (ICUs). DATA SOURCES A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted utilizing PubMed, EMBASE, and CINAHL. Searches were limited to studies published in English from January 1, 1988, to March 31, 2014. Randomized controlled trials and comparative studies of multifaceted care approaches with the reduction of delirium in ICU patients as an outcome and evaluations of the implementation or cost-effectiveness of these interventions were included. DATA EXTRACTION Data on study methods including design, cohort size, interventions, and outcomes were abstracted, reviewed, and summarized. Given the variability in study design, populations, and interventions, a qualitative review of findings was conducted. DATA SYNTHESIS In all, 14 studies met our inclusion criteria: 6 examined outcomes, 5 examined implementation, 2 examined outcomes and implementation, and 1 examined cost-effectiveness. The majority of studies indicated that multifaceted care approaches were associated with improved patient outcomes including reduced incidence and duration of delirium. Additionally, improvements in functional status and reductions in coma and ventilator days, hospital length of stay, and/or mortality rates were observed. Implementation strategies included structured quality improvement approaches with ongoing audit and feedback, multidisciplinary care teams, intensive training, electronic reporting systems, and local support teams. The cost-effectiveness analysis indicated an average reduction of $1000 in hospital costs for patients treated with a multifaceted care approach. CONCLUSION Although multifaceted care approaches may reduce delirium and improve patient outcomes, greater improvements may be achieved by deploying a comprehensive bundle of care practices including awakening and breathing trials, delirium monitoring and treatment, and early mobility. Further research to address this knowledge gap is essential to providing best care for ICU patients.
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Affiliation(s)
| | - Elisa L Priest
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX, USA
| | - Claudia R Campbell
- School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Eduard E Vasilevskis
- Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University, Nashville, TN, USA VA Tennessee Valley Healthcare System-Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN, USA
| | - Andrew L Masica
- Center for Clinical Effectiveness, Baylor Scott & White Health, Dallas, TX, USA
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8
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Brinkmann A, Braun JP, Riessen R, Dubb R, Kaltwasser A, Bingold TM. [Quality assurance concepts in intensive care medicine]. Med Klin Intensivmed Notfmed 2015; 110:575-80, 582-3. [PMID: 26497132 DOI: 10.1007/s00063-015-0095-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/19/2015] [Indexed: 11/25/2022]
Abstract
Intensive care medicine (ICM) is characterized by a high degree of complexity and requires intense communication and collaboration on interdisciplinary and multiprofessional levels. In order to achieve good quality of care in this environment and to prevent errors, a proactive quality and error management as well as a structured quality assurance system are essential. Since the early 1990s, German intensive care societies have developed concepts for quality management and assurance in ICM. In 2006, intensive care networks were founded in different states to support the implementation of evidence-based knowledge into clinical routine and to improve medical outcome, efficacy, and efficiency in ICM. Current instruments and concepts of quality assurance in German ICM include core intensive care data from the data registry DIVI REVERSI, quality indicators, peer review in intensive care, IQM peer review, and various certification processes. The first version of German ICM quality indicators was published in 2010 by an interdisciplinary and interprofessional expert commission. Key figures, indicators, and national benchmarks are intended to describe the quality of structures, processes, and outcomes in intensive care. Many of the quality assurance tools have proved to be useful in clinical practice, but nationwide implementation still can be improved.
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Affiliation(s)
- A Brinkmann
- Klinik für Anästhesiologie, operative Intensivmedizin und spezielle Schmerztherapie, Klinikum Heidenheim, gGmbH, Schlosshaustraße 100, 89522, Heidenheim, Deutschland.
| | - J P Braun
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Hildesheim, Hildesheim, Deutschland
| | - R Riessen
- Internistische Intensivstation, Department für Innere Medizin, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - R Dubb
- Akademie der Kreiskliniken Reutlingen, Kreiskliniken Reutlingen GmbH, Reutlingen, Deutschland
| | - A Kaltwasser
- Akademie der Kreiskliniken Reutlingen, Kreiskliniken Reutlingen GmbH, Reutlingen, Deutschland
| | - T M Bingold
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt/Main, Deutschland
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Murphy DJ, Ogbu OC, Coopersmith CM. ICU director data: using data to assess value, inform local change, and relate to the external world. Chest 2015; 147:1168-1178. [PMID: 25846533 DOI: 10.1378/chest.14-1567] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Improving value within critical care remains a priority because it represents a significant portion of health-care spending, faces high rates of adverse events, and inconsistently delivers evidence-based practices. ICU directors are increasingly required to understand all aspects of the value provided by their units to inform local improvement efforts and relate effectively to external parties. A clear understanding of the overall process of measuring quality and value as well as the strengths, limitations, and potential application of individual metrics is critical to supporting this charge. In this review, we provide a conceptual framework for understanding value metrics, describe an approach to developing a value measurement program, and summarize common metrics to characterize ICU value. We first summarize how ICU value can be represented as a function of outcomes and costs. We expand this equation and relate it to both the classic structure-process-outcome framework for quality assessment and the Institute of Medicine's six aims of health care. We then describe how ICU leaders can develop their own value measurement process by identifying target areas, selecting appropriate measures, acquiring the necessary data, analyzing the data, and disseminating the findings. Within this measurement process, we summarize common metrics that can be used to characterize ICU value. As health care, in general, and critical care, in particular, changes and data become more available, it is increasingly important for ICU leaders to understand how to effectively acquire, evaluate, and apply data to improve the value of care provided to patients.
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Affiliation(s)
- David J Murphy
- Emory Critical Care Center, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Atlanta, GA; Department of Surgery, Atlanta, GA.
| | - Ogbonna C Ogbu
- Emory Critical Care Center, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Atlanta, GA; Department of Surgery, Atlanta, GA
| | - Craig M Coopersmith
- Emory Critical Care Center, Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Atlanta, GA; Emory University School of Medicine, Atlanta, GA
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Balzer F, Weiß B, Kumpf O, Treskatsch S, Spies C, Wernecke KD, Krannich A, Kastrup M. Early deep sedation is associated with decreased in-hospital and two-year follow-up survival. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:197. [PMID: 25928417 PMCID: PMC4435917 DOI: 10.1186/s13054-015-0929-2] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 04/15/2015] [Indexed: 12/11/2022]
Abstract
Introduction There is increasing evidence that deep sedation is detrimental to critically ill patients. The aim of this study was to examine effects of deep sedation during the early period after ICU admission on short- and long-term survival. Methods In this observational, matched-pair analysis, patients receiving mechanical ventilation that were admitted to ICUs of a tertiary university hospital in six consecutive years were grouped as either lightly or deeply sedated within the first 48 hours after ICU admission. The Richmond Agitation-Sedation Score (RASS) was used to assess sedation depth (light sedation: −2 to 0; deep: −3 or below). Multivariate Cox regression was conducted to investigate the impact of early deep sedation within the first 48 hours of admission on in-hospital and two-year follow-up survival. Results In total, 1,884 patients met inclusion criteria out of which 27.2% (n = 513) were deeply sedated. Deeply sedated patients had longer ventilation times, increased length of stay and higher rates of mortality. Early deep sedation was associated with a hazard ratio of 1.661 (95% CI: 1.074 to 2.567; P = 0.022) for in-hospital survival and 1.866 (95% CI: 1.351 to 2.576; P <0.001) for two-year follow-up survival. Conclusions Early deep sedation during the first 48 hours of intensive care treatment was associated with decreased in-hospital and two-year follow-up survival. Since early deep sedation is a modifiable risk factor, this data shows an urgent need for prospective clinical trials focusing on light sedation in the early phase of ICU treatment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0929-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Felix Balzer
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Björn Weiß
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Oliver Kumpf
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Klaus-Dieter Wernecke
- Charité - Universitätsmedizin Berlin and SOSTANA GmbH, Wildensteiner Straße 27, Berlin, 10318, Germany.
| | - Alexander Krannich
- Coordination Centre for Clinical Trials, Department of Biostatistics, Charité -Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
| | - Marc Kastrup
- Department of Anaesthesiology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
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11
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Trogrlić Z, van der Jagt M, Bakker J, Balas MC, Ely EW, van der Voort PHJ, Ista E. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:157. [PMID: 25888230 PMCID: PMC4428250 DOI: 10.1186/s13054-015-0886-9] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 03/16/2015] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. METHOD We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described. RESULTS We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality. CONCLUSION Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes.
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Affiliation(s)
- Zoran Trogrlić
- Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands.
| | - Jan Bakker
- Department of Intensive Care, Erasmus MC, University Medical Center, P.O. Box 2040, Rotterdam, CA, 3000, the Netherlands.
| | - Michele C Balas
- College of Nursing, Center of Excellence in Critical and Complex Care, The Ohio State University, Ballantrae Place Dublin Ohio 43016, Columbus, Ohio, 6756, USA.
| | - E Wesley Ely
- Department of Medicine, Division of Pulmonary and Critical Care, Health Services Research Center, Vanderbilt University Medical Center, Nashville, TN, 37232, USA. .,Veteran's Affairs Tennessee Valley Geriatric Research Education Clinical Center (GRECC), 1215 21st Avenue South MCE Suite 6100, Nashville, TN, 37232, USA.
| | - Peter H J van der Voort
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, P.O. Box 95500, Amsterdam, 1090 HM, The Netherlands.
| | - Erwin Ista
- Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, University Medical Center, P.O. Box 2060, Rotterdam, 3000 CB, The Netherlands.
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Management strategies to effect change in intensive care units: lessons from the world of business. Part II. Quality-improvement strategies. Ann Am Thorac Soc 2014; 11:444-53. [PMID: 24601668 DOI: 10.1513/annalsats.201311-392as] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The success of quality-improvement projects relies heavily on both project design and the metrics chosen to assess change. In Part II of this three-part American Thoracic Society Seminars series, we begin by describing methods for determining which data to collect, tools for data presentation, and strategies for data dissemination. As Avedis Donabedian detailed a half century ago, defining metrics in healthcare can be challenging; algorithmic determination of the best type of metric (outcome, process, or structure) can help intensive care unit (ICU) managers begin this process. Choosing appropriate graphical data displays (e.g., run charts) can prompt discussions about and promote quality improvement. Similarly, dashboards/scorecards are useful in presenting performance improvement data either publicly or privately in a visually appealing manner. To have compelling data to show, ICU managers must plan quality-improvement projects well. The second portion of this review details four quality-improvement tools-checklists, Six Sigma methodology, lean thinking, and Kaizen. Checklists have become commonplace in many ICUs to improve care quality; thinking about how to maximize their effectiveness is now of prime importance. Six Sigma methodology, lean thinking, and Kaizen are techniques that use multidisciplinary teams to organize thinking about process improvement, formalize change strategies, actualize initiatives, and measure progress. None originated within healthcare, but each has been used in the hospital environment with success. To conclude this part of the series, we demonstrate how to use these tools through an example of improving the timely administration of antibiotics to patients with sepsis.
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Duyndam A, Houmes RJ, van Dijk M, Tibboel D, Ista E. How to achieve adherence to a ventilation algorithm for critically ill children? Nurs Crit Care 2014; 20:299-307. [PMID: 25271101 DOI: 10.1111/nicc.12104] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 03/16/2014] [Accepted: 04/27/2014] [Indexed: 01/09/2023]
Abstract
AIMS AND OBJECTIVES To evaluate to what extent physicians on a paediatric intensive care unit (PICU) adhered to a newly implemented ventilation algorithm. BACKGROUND PICUs worldwide use different ventilators with a wide variety of ventilation modes. We developed an algorithm, as part of a larger protocol, for choice of ventilation mode at time of admission. DESIGN This study was performed in a level III PICU of a university children's hospital and had an uncontrolled, pre-post test design with a period before implementation (T0) and two periods after implementation (T1 and T2). METHODS An invasive ventilation algorithm targeted at two patient groups was implemented in October 2008. The algorithm distinguished between lung disease, in which pressure control was considered as the preferred mode, and no lung disease, in which pressure-regulated volume control was preferred. Nurses and physicians were instructed in the use of the algorithm before implementation. RESULTS During three test periods, a total of 507 children with a median age of 5 months [interquartile range (IQR) 0-50] on conventional invasive mechanical ventilation were included. In patients with lung disease, pre-implementation adherence rate was 79% (67/85). At T1 it was 71% (51/72); at T2 84% (46/55). The slight improvement from T1 to T2 was statistically not significant (p = 0·092). In patients with no lung disease, the adherence rate rose statistically significantly from 66% at T0 (62/93) to 78% (79/101) at T1, and 84% at T2 (85/101) (p = 0·015). CONCLUSION Implementation of a new ventilation algorithm increased physicians' adherence to this ventilation algorithm and the effect was sustained over time. This was achieved by education, reminders and organizational changes such as admission of postcardiac surgery patients with protocolized nursing care including preset ventilator settings. RELEVANCE TO CLINICAL PRACTICE Interdisciplinary collaboration, effective communication, leadership support and organizational aspects may be effective strategies to improve adherence to protocols.
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Affiliation(s)
- Anita Duyndam
- Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Monique van Dijk
- Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Dick Tibboel
- Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Erwin Ista
- Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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