Andreas ValentinAllgemeine u. Internistische Intensivstation 12A
II. Med. Abt., KA Rudolfstiftung, Wien
[email protected]
Qualitt aus der Sicht desIntensivmediziners facts and fiction
STER RE ICH ISC HES ZEN TRU M FRD OK UMEN TA TION U ND QU ALIT TS-SIC HERU NG IN DE R INTE NSIVMED IZIN
AS
DI
http://www.go2pdf.com
http://www.go2pdf.com
Paradigm of Quality
Good-Bad
+
-t
good
bad
Q+
-t
QGood-Better
http://www.go2pdf.com
What is Quality ?
the degree to which health servicesincrease the likelihood of desired healthoutcomes and are consistent with currentprofessional knowledge
Institute of Medicine, 1990
ResultsQuality = Objectives
Quality Indicators
http://www.go2pdf.com
Eingrenzung und Funktion vonQualittsindikatoren
Qualitt ist ber Ziele definiert eine Frage der Perspektive
Qualittsindikatoren geben Zielbereiche vor ermglichen Monitoring legen einen Anspruch fest
http://www.go2pdf.com
TRAUM UND WIRKLICHKEIT
Wien Knstlerhaus 1985
http://www.go2pdf.com
Quality Indicator Domains
Structurewhat you need vs what is provided
Processwhat you should do vs. what you do
Outcomewhat you expect vs. what you find
http://www.go2pdf.com
Raumstruktur IntensivstationNormalflchenbedarf fr ICU Betten
Empfehlungen der European Society of Intensive Care Medicine
Patienten Einzelzimmer pro Bett 25m2
Patienten Mehrbettzimmer pro Bett 20m2
Lager pro Bett 10m2
Nebenrume pro Bett 33m2 Bros Dienstzimmer Labor Technik Besprechung Angehrige Sozialraum, Kche
Pro Bett63-68m2
http://www.go2pdf.com
Quality interactions in nosocomialinfection
Structure Room design Fixed installations Medical equipment Air conditioning Staffing Training level funding
Process Handwashing Isolation/infection
precaution Infection reporting Room cleaning,
desinfection Antibiotic use Communication
http://www.go2pdf.com
Availability of an alcohol solution can improve hand disinfectioncompliance in an intensive care unit
Maury E, AJRCCM 2000
Alcohol solutioneasily available
4 months later: 51.3 %
42.4 (621) 60.9 (905)
http://www.go2pdf.com
A. Valentin 10/2004
Schema Intensivaufenthalt
Aufnahme Behandlung Entlassung
Struktur + + +Prozess + ++ +Ergebnis + + ++
WerWann
Wo
WasWann
Wie lange
WerWannWohin
Phase
Merkmale
http://www.go2pdf.com
http://www.go2pdf.com
Confidential inquiry into quality of care beforeadmission to intensive care
McQuillan, BMJ 1999
100 Patienten retrospektive Beurteilung durch 2 Reviewer
Suboptimale Behandlungvor ICU-Aufnahme: 56%
Versptete ICU-Aufnahme: 39%
ICU Aufnahmebei optimaler Versorgung vermeidbar: 4 - 41%
Morbiditt / Mortalittdurch suboptimale Behandlung beeinflusst: 32%
http://www.go2pdf.com
Hospital volume and the outcomes of mechanical ventilation.Kahn JM, NEJM 2006
Hospital mortalitypts/yr reduction
87-150151-275 14%276-400 28%401-617 34%
ICU mortalitypts/yr reduction
87-150151-275 25%276-400 33%401-617 37%
http://www.go2pdf.com
http://www.go2pdf.com
Personal:Gibt es Dosiseffekte ?
http://www.go2pdf.com
The effect of prompt physician visitson intensive care unit mortality and cost
Risk of hospital death
Each 1 hour delay 1.6% increased
Engoren M, Crit Care Med 2005
http://www.go2pdf.com
Pronovost, P. J. et al. JAMA 2002;288:2151-2162
High-intensity vs low-intensity ICU physician staffingis associated with reduced hospital and ICU mortality
Hospital mortality0.71 (0.62-0.82)
ICU mortality0.61 (0.50-0.75)
http://www.go2pdf.com
Treggiari MM, AJRCCM 2007
Pts with ALI: Open versus closed ICU model
Regression models of effect of closed ICU on hospital mortality
10%
8.9 1.26.9 1.0
Closed ICU
12ml/kg
0.070.05
5.51.25.11.0
Intensivist coverage, mean h/dWeekdaysWeekends
pOpen ICU
http://www.go2pdf.com
A. Valentin 10/2004
Errors detected and recoveredduring 10-h of ICU practice
Patel VL, Curr Opin Crit Care 2008
http://www.go2pdf.com
Effect of Reducing Interns Work Hours on SeriousMedical Errors in Intensive Care Units
CP Landrigan et al, NEJM 2004
Traditional Intervention
Average hours/week 77-81 60-63Consecutive hours up to 34 16
Patient days 1294 909Errors/1000 pt days 136 100
- 26%
http://www.go2pdf.com
OR for at least one error in parenteral drug administration in ICU. Univiariate logistic regression
http://www.go2pdf.com
Einfluss des Personalaufwandes (Pflegepersonal) aufden Outcome von Intensivpatienten
Tarnow-Mordi WO, Lancet 2000
Hhere Arbeitsbelastung ist mit erhhter KHMortalitt assoziiert (OR 3.1; 95% CI 1.9-5.0)
http://www.go2pdf.com
A. Valentin 10/2004
Schema Intensivaufenthalt
Aufnahme Behandlung Entlassung
Struktur + + +Prozess + ++ +Ergebnis + + ++
WasWann
Wie lange
Phase
Merkmale
http://www.go2pdf.com
Possible ICU quality indicators (1)
Process DVT prophylaxis Stress ulcer prophylaxis VAP prevention strategies CVC bloodstream infection prevention
strategies Protocol driven ventilator weaning Treatment in severe sepsis
Adapted from Curtis JR, Crit Care Med 2006
http://www.go2pdf.com
Possible ICU quality indicators (2)
Process Low tidal volume in ALI/ARDS NIV for hypercarbic respiratory failure Early enteral feeding Appropriate transfusion threshold Delayed transfer out of ICU Palliative care
Adapted from Curtis JR, Crit Care Med 2006
http://www.go2pdf.com
Interventions to reduce mortality among ICU pts
% of ptsnot receiving
therapy___________________________________________________________________________________________________________________________________________
High intensity ICU physician staffing 63-90 Steroids in sepsis 15-85 Tight glucose control 70-80 Low tidal volume in ARDS 50-90
Pronovost PJ, J Crit Care 2004Process of care
http://www.go2pdf.com
Effect of standardized orders and provider educationon head-of-bed positioning in mechanically ventilatedpatients Helman DL et al, Crit Care Med 2003
Head of bed positioning
pts with =&30
Baseline 26%Endpoint 88%
http://www.go2pdf.com
Rates of Catheter-Related Bloodstream Infection from Baseline (before Implementation of theStudy Intervention) to 18 Months of Follow-up
Pronovost P et al. N Engl J Med 2006;355:2725-2732
Hand washing Full barrier precautions
during insertion Desinfection Avoiding the femoral site Removing unnecesary
catheters
http://www.go2pdf.com
Anwesenheit einesIntensivmediziners
Frhe enterale Ernhrung Milde, Therapeutische
Hypothermie nach Reanimation Registrierung von kritischen
Ereignissen Verzgerte Entlassung von der
IBS Beatmungsassoziierte
Pneumonie Durchschnittliche Dauer der
mechanischen Beatmung Durchschnittliche Lnge des
Aufenthaltes an der IBS Infektionsrate Zentralvenser
Katheter Mortalitt beim schweren
Schdel Hirntrauma Reintubationsrate Standardisierte Mortalittsrate Ungeplante Wiederaufnahmen
http://www.go2pdf.com
Association withrisk reduction of
Routine check at shift change -32% Critical incident reporting -31%
Parenteral drug administration errorsParenteral drug administration errors
Valentin A, BMJ 2009
http://www.go2pdf.com
Intensive Care is a time-dependentprocess
Golden hour Early treatment Rapid Response Continuity 24h/7d
http://www.go2pdf.com
Duration of hypotension before initiation of effective antimicrobial therapy is thecritical determinant of survival in human septic shock
Kumar A, Crit Care Med 2006
2.154 pts Septic shock Effective
antimicrobialtherapyonlyafter the onset ofrecurrent orpersistenthypotension
Only 50% of septic shock patients received effective antimicrobial therapywithin 6 hrs of documented hypotension
http://www.go2pdf.com
24h/7d coverage by intensivists ensuresconsistency of care
SMR* 0.82 SMR* 0.89
Arabi Y, Crit Care Med 2006
*C
alcu
late
dby
MP
MII 2
4
http://www.go2pdf.com
Electronic charting allowsassessment of ICU response time
Blood glucose Insulin dose change Response time
http://www.go2pdf.com
A. Valentin 10/2004
Schema Intensivaufenthalt
Aufnahme Behandlung Entlassung
Struktur + + +Prozess + ++ +Ergebnis + + ++
WerWannWohin
Phase
Merkmale
http://www.go2pdf.com
Khanduja K. Crit Care Med 2009
http://www.go2pdf.com
Post-ICU Mortality as %of Hospital Mortality
35UKRowan, 199333EURICUS IIMoreno, 200130AustriaValentin, ASDI, 200327UKGoldhill, 199825UKSmith, 1999
24.6SAPS 3SAPS 3, 200524PortugalMoreno, 199722USARubins, 198815BrasilBastos, 1966
Post-ICU Mortality(%)
CountryAuthor
http://www.go2pdf.com
Relative Post-ICU Mortalitt(% aller Todesflle) STER RE ICH ISC HES ZEN TRU M FR
D OK UMEN TA TION U ND QU ALIT TS-SIC HERUNG IN DE RINTE NSIVMED IZ
