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Qualität aus der Sicht des Intensivmediziners – facts · PDF fileQualität aus der Sicht des Intensivmediziners – facts and fiction ÖSTERRE ICHISCHES ZENTRUM FÜR DOKUMENTATION

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  • 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

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  • Paradigm of Quality

    Good-Bad

    +

    -t

    good

    bad

    Q+

    -t

    QGood-Better

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  • 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

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  • Eingrenzung und Funktion vonQualittsindikatoren

    Qualitt ist ber Ziele definiert eine Frage der Perspektive

    Qualittsindikatoren geben Zielbereiche vor ermglichen Monitoring legen einen Anspruch fest

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  • TRAUM UND WIRKLICHKEIT

    Wien Knstlerhaus 1985

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  • 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

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  • 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

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  • 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

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  • 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%

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  • 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%

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  • 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

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  • 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

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  • A. Valentin 10/2004

    Errors detected and recoveredduring 10-h of ICU practice

    Patel VL, Curr Opin Crit Care 2008

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  • 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%

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  • 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

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  • 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

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  • 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

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  • 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%

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  • 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

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  • 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

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  • 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

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  • 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

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  • 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