Ethisch begründet entscheiden in der Intensivmedizin.

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.

The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis.

BACKGROUND: To evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO2R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV). METHODS: Retrospective ancillary cost analysis of data extracted from a recently published multicentre case-control-study (n = 42) on the use of arterio-venous ECCO2R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO2R system. RESULTS: In the group treated with ECCO2R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO2R group (19.610 vs. 46.552 €, p = 0.01). CONCLUSIONS: Additional costs for the use of arterio-venous ECCO2R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.

[Overtreatment in intensive care medicine-recognition, designation, and avoidance : Position paper of the Ethics Section of the DIVI and the Ethics section of the DGIIN]. / Überversorgung in der Intensivmedizin: erkennen, benennen, vermeiden : Positionspapier der Sektion Ethik der DIVI und der Sektion Ethik der DGIIN.

Despite social laws, overtreatment, undertreatment, and incorrect treatment are all present in the German health care system. Overtreatment denotes diagnostic and therapeutic measures that are not appropriate because they do not improve the patients' length or quality of life, cause more harm than benefit, and/or are not consented to by the patient. Overtreatment can result in considerable burden for patients, their families, the treating teams, and society. This position paper describes causes of overtreatment in intensive care medicine and makes specific recommendations to identify and prevent it. Recognition and avoidance of overtreatment in intensive care medicine requires measures on the micro-, meso- and macrolevels, especially the following: (1) frequent (re-)evaluation of the therapeutic goal within the treating team while taking the patient's will into consideration, while simultaneously attending to the patients and their families; (2) fostering a patient-centered corporate culture in the hospital, giving priority to high-quality patient care; (3) minimizing improper incentives in health care financing, supported by reform of the reimbursement system that is still based on diagnose-related groups; (4) strengthening of interprofessional co-operation via education and training; and (5) initiating and advancing a societal discourse on overtreatment.

[Discussion paper for a hospital financing reform in Germany from the perspective of intensive care medicine]. / Diskussionspapier für eine Reform der Krankenhausfinanzierung in Deutschland aus der Perspektive der Intensivmedizin.

In Germany, there are currently many voices calling for a reform of hospital planning and reimbursement to correct some aberrations of the last decades and to enable the system to cope with future challenges. Some recent political decisions to change the structures of emergency medical services as well as the introduction of mandatory nurse-to-patient ratios and the exclusion of the cost for nursing from the case-based hospital reimbursement represent first steps of a reform, which also affects intensive care and emergency medicine. In this discussion paper a group of intensivists, emergency physicians, medical controllers, and representatives of nurses suggest more far-reaching changes, which can be summarized in 5 points: (1) General hospitals with intensive care units (ICU) and emergency departments (ED) which are part of the emergency medical system should be considered as an element of public service and be planned accordingly. (2) The planning of the intensive care infrastructure should be based on the three levels of emergency medical services to identify hospitals that are system relevant and to define appropriate criteria for structure and quality measures. (3) Hospital reimbursement should consist of a base amount (covering costs for hospital staff, infrastructure plus investments) and case-based fees (covering material costs). (4) To determine the requirements for nurses, physicians, and other medical staff, adequate tools for ICU and ED should be applied. (5) For these purposes as well as for quality management and optimal medical care, hospitals should be provided with a substantially improved IT-infrastructure.

Real-time assessment of hepatic function is related to clinical outcome in critically ill patients after polytrauma.

OBJECTIVES: The aim was to investigate the outcome MODS/MOF in critically ill patients with regard to early hepatic dysfunction. METHODS: Thirty adult polytrauma patients admitted to the ICU, with ISS >or=16 were prospectively investigated. Real-time liver function was assessed using the MEGX test and arterial ketone body ratio (AKBR) 12-24 h after admittance to ICU, and on days 3, 5, 8, 12. RESULTS: Six patients (19%) died between days 4 and 29. Non-survivors were older (64.2 vs. 31.5 years), had a significantly higher ISS (40.5 vs. 30; p=0.002) and MODS score (9.5 vs. 5; p=0.001) on admittance to the ICU than survivors. On day 3 MEGX values (31 vs. 71.3 microg/L; p=0.001) and the AKBRs (0.6 vs. 1.3; p=0.001) were significantly lower in non-survivors than in survivors whereas IL-6 levels were significantly higher in the former group (519 vs. 61 microg/L; p=0.05). CONCLUSIONS: The MEGX test and AKBR are sensitive early indicators of hepatic dysfunction in severely injured polytrauma patients at risk for developing MODS/MOF.

Bench-to-bedside review: leadership and conflict management in the intensive care unit.

In the management of critical care units, leadership and conflict management are vital areas for the successful performance of the unit. In this article a practical approach to define competencies for leadership and principles and practices of conflict management are offered. This article is, by lack of relevant intensive care unit (ICU) literature, not evidence based, but it is the result of personal experience and a study of literature on leadership as well on conflicts and negotiations in non-medical areas. From this, information was selected that was recognisable to the authors and, thus, also seems to be useful knowledge for medical doctors in the ICU environment.

A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units.

INTRODUCTION: Intensive care unit (ICU) costs account for up to 20% of a hospital's costs. We aimed to analyse the individual patient-related cost of intensive care at various hospital levels and for different groups of disease. METHODS: Data from 51 ICUs all over Germany (15 primary care hospitals and 14 general care hospitals, 10 maximal care hospitals and 12 focused care hospitals) were collected in an observational, cross-sectional, one-day point prevalence study by two external study physicians (January-October 2003). All ICU patients (length of stay > 24 hours) treated on the study day were included. The reason for admission, severity of illness, surgical/diagnostic procedures, resource consumption, ICU/hospital length of stay, outcome and ICU staffing structure were documented. RESULTS: Altogether 453 patients were included. ICU (hospital) mortality was 12.1% (15.7%). The reason for admission and the severity of illness differed between the hospital levels of care, with a higher amount of unscheduled surgical procedures and patients needing mechanical ventilation in maximal care hospital and focused care hospital facilities. The mean total costs per day were euro 791 +/- 305 (primary care hospitals, euro 685 +/- 234; general care hospitals, euro 672 +/- 199; focused care hospitals, euro 816 +/- 363; maximal care hospitals, euro 923 +/- 306), with the highest cost in septic patients (euro 1,090 +/- 422). Differences were associated with staffing, the amount of prescribed drugs/blood products and diagnostic procedures. CONCLUSION: The reason for admission, the severity of illness and the occurrence of severe sepsis are directly related to the level of ICU cost. A high fraction of costs result from staffing (up to 62%). Specialized and maximum care hospitals treat a higher proportion of the more severely ill and most expensive patients.

A pilot-controlled study of a polymyxin B-immobilized hemoperfusion cartridge in patients with severe sepsis secondary to intra-abdominal infection.

Endotoxin is an important pathogenic trigger for sepsis. The polymyxin B-immobilized endotoxin removal hemoperfusion cartridge, Toraymyxin (hereafter PMX), has been shown to remove endotoxin in preclinical and open-label clinical studies. In a multicenter, open-label, pilot, randomized, controlled study conducted in the intensive care unit in six academic medical centers in Europe, 36 postsurgical patients with severe sepsis or septic shock secondary to intra-abdominal infection were randomized to PMX treatment of 2 h (n = 17) or standard therapy (n = 19). PMX was well tolerated and showed no significant side effects. There were no statistically significant differences in the change in endotoxin levels from baseline to 6 to 8 h after treatment or to 24 h after treatment between the two groups. There was also no significant difference in the change in interleukin (IL)-6 levels from baseline to 6 to 8 h after treatment or to 24 h after treatment between the two groups. Patients treated with PMX demonstrated significant increases in cardiac index (CI; P = 0.012 and 0.032 at days 1 and 2, respectively), left ventricular stroke work index (LVSWI, P = 0.015 at day 2), and oxygen delivery index (DO2I, P = 0.007 at day 2) compared with the controls. The need for continuous renal replacement therapy (CRRT) after study entry was reduced in the PMX group (P = 0.043). There was no significant difference between the groups in organ dysfunction as assessed by the Sequential Organ Failure Assessment (SOFA) scores from day 0 (baseline) to day 6. Treatment using the PMX cartridge is safe and may improve cardiac and renal dysfunction due to sepsis or septic shock. Further studies are needed to prove this effectiveness.

Cost-effectiveness of immunoglobulin M-enriched immunoglobulin (Pentaglobin) in the treatment of severe sepsis and septic shock.

PURPOSE: To measure the cost-effectiveness of a specific polyclonal intravenous immune globulin preparation (Pentaglobin) in adult patients treated for severe sepsis and septic shock. MATERIALS AND METHODS: Effectiveness data from a meta-analysis of 9 randomized trials (N=435) were used to populate a decision model to estimate the cost-effectiveness of Pentaglobin and its comparator standard therapy from the hospital perspective in Germany. PRIMARY OUTCOME: all-cause morality; secondary outcome: intensive care unit (ICU) length of stay. Benefit was expressed as lives saved (LS). Published cost data were applied to assess differences in ICU treatment costs. Cost-effectiveness was calculated as incremental cost per LS. RESULTS: Pentaglobin reduced the risk of mortality (P<.001) but had no effect on ICU length of stay. A baseline risk of mortality of 0.4434 (risk ratio=0.5652; absolute risk reduction=0.1928; number-needed-to-treat=5.19) increased ICU treatment costs with Pentaglobin by 2,037 (22,711 vs 24,747) with a cost per LS of 10,565. Sensitivity analyses on baseline mortality risk (95% confidence interval 0.3293-0.5162) and risk ratio (95% confidence interval 0.4306-0.7420) yielded a cost per LS range of 5,715 to 28,443 with a 56.3% probability of cost-effectiveness of 12,000 or less. CONCLUSIONS: Pentaglobin is a promising adjuvant therapy both clinically and economically for treatment of adults with severe sepsis and septic shock.

Regional ventilation by electrical impedance tomography: a comparison with ventilation scintigraphy in pigs.

STUDY OBJECTIVE: The validation of electrical impedance tomography (EIT) for measuring regional ventilation distribution by comparing it with single photon emission CT (SPECT) scanning. DESIGN: Randomized, prospective animal study. SETTINGS: Animal laboratories and nuclear medicine laboratories at a university hospital. PARTICIPANTS: Twelve anesthetized and mechanically ventilated pigs. INTERVENTIONS: Lung injury was induced by central venous injection of oleic acid. Then pigs were randomized to pressure-controlled mechanical ventilation, airway pressure-release ventilation, or spontaneous breathing. MEASUREMENTS AND RESULTS: Ventilation distribution was assessed by EIT using cross-sectional electrotomographic measurements of the thorax, and simultaneously by single SPECT scanning with the inhalation of (99m)Tc-labeled carbon particles. For both methods, the evaluation of ventilation distribution was performed in the same transverse slice that was approximately 4 cm in thickness. The transverse slice then was divided into 20 coronal segments (going from the sternum to the spine). We compared the percentage of ventilation in each segment, normalized to the entire ventilation in the observed slice. Our data showed an excellent linear correlation between the ventilation distribution measured by SPECT scanning and EIT according to the following equation: y = 0.82x + 0.7 (R(2) = 0.92; range, 0.86 to 0.97). CONCLUSION: Based on these data, EIT seems to allow, at least in comparable states of lung injury, real-time monitoring of regional ventilation distribution at the bedside.

European Society of Intensive Care Medicine statement: intensive care medicine in Europe--structure, organisation and training guidelines of the Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) of the European Union of Medical Specialists (UEMS).

This article describes the structures and institutions in the European Union by which professional training and qualification in medical specialities will be harmonised. All main medical specialities are represented in the European Union of Medical Specialists (UEMS) by speciality sections. For intensive care medicine, as a multidisciplinary speciality, a new structure of a Multidisciplinary Joint Committee of Intensive Care Medicine (MJCICM) within the UEMS was established in 1999. In this MJCICM the European Society of Intensive Care Medicine and the European Society of Paediatric and Neonatal Intensive Care are represented by delegates without voting capacity in a Standing Advisory Board. Statements and recommendations which the MJCICM has worked out until now are presented: Definitions of intensive care medicine, structural conditions for education and training, continuing medical education, criteria for accreditation of intensive care medicine training centres, common core curriculum for optional specialist training in intensive care medicine, as well as an intensive care units accreditation visiting programme and standards for medical treatment and nursing care.

A new concept for DRG-based reimbursement of services in German intensive care units: results of a pilot study.

OBJECTIVE: To evaluate LOS in developing a concept of borderline ICU LOS for a realistic reimbursement of intensive care. DESIGN: Retrospective analysis of LOS and cost data extracted from patients' electronic records. SETTING: Surgical ICU of the University Hospital Göttingen, Germany. PATIENTS AND PARTICIPANTS: All adult ICU admissions with LOS >24 h over a 24-month period (1 January 2000 to 31 December 2001; n=1631.) INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Cluster analysis partitioned the ICU population into three homogeneous groups based on ICU LOS and total direct costs: cluster 1 (n=1405; mean LOS=2.8; mean cost= Euro 2399); cluster 2 (n=190; mean LOS=13.4; mean cost=Euro 12,754); cluster 3 (n=36; mean LOS=34.9; mean cost= Euro 34,173). Cost distribution between cluster 1 and clusters 2 and 3 combined was 48 vs 52%. Upper 95 percentile LOS of 6.7 allowed cluster 1 to be replaced by an LOS profile population of < or = 7 days population (n=1355; 96% population and 91% total ICU cost overlap with cluster 1) representing 83% of total ICU population and 44% of total ICU costs. Stratification of >7 day population into LOS less than or >20 days (n=220; n=56) were further differentiated by mortality (11 vs 23%) and sepsis incidence (33 vs 79%). CONCLUSIONS: It may be feasible to formulate a LOS-based reimbursement scheme for ICU services in Germany based on the selection of (appropriate) patients' ICU LOS profiles.

Direct costs of severe sepsis in three German intensive care units based on retrospective electronic patient record analysis of resource use.

OBJECTIVE: To determine the direct costs of severe sepsis patients in German intensive care units (ICUs). DESIGN: Retrospective electronic data analysis. SETTING: Three adult intensive care units (surgical/medical) in three university hospitals in Germany. PATIENTS: 385 patients identified by standard definitions as suffering from severe sepsis. MEASUREMENTS AND RESULTS: A bottom-up approach was used to determine the direct ICU cost on actual resource use (medication, laboratory tests, microbiological analysis, disposables, and clinical procedures) for patients with severe sepsis. To determine the total direct costs, center-specific personnel and basic bed ("hotel") costs were added to total resources consumed. Average hospital mortality of severely septic patients was 42.6%. Mean ICU length of stay (LOS) was 16.6 days. Survivors stayed on average 4 days longer than nonsurvivors. The mean direct ICU costs of care were 23,297+/-18,631 euros per patient and 1,318 euros per day. In comparison, average daily charges being paid for an ICU patient by the health care system in Germany are 851 euros (based on official statistics). Nonsurvivors were more expensive than survivors in total direct costs (25,446 vs. 21,984 euros) and in per day direct cost (1,649 vs. 1,162 euros). Medication makes up the largest part of the direct costs, followed by expenses for personnel. CONCLUSIONS. Patients with severe sepsis have a high ICU mortality rate and long ICU LOS and are substantially expensive to treat. Nonsurviving septic patients are more costly than survivors despite shorter ICU LOS. This is due to higher medication costs indicating increased efforts to keep patients alive.

Influence of different release times on spontaneous breathing pattern during airway pressure release ventilation.

OBJECTIVE: Airway pressure release ventilation (APRV) is a ventilatory mode with a time cycled change between an upper (P(high)) and lower (P(low)) airway pressure level. APRV is unique because it allows unrestricted spontaneous breathing throughout the ventilatory cycle. We studied the influence of different release times (time of P(low)) on breathing pattern and gas exchange in patients during partial mechanical ventilation. SETTING: Mixed intensive care unit in a university hospital. PATIENTS: Twenty-eight patients were included in the study. Nine patients suffering from acute lung injury (ALI), 7 patients with a history of chronic obstructive pulmonary disease (COPD) and 12 patients with nearly normal lung function, ventilated for non-respiratory reasons (postoperatively), were studied prior to extubation. INTERVENTIONS: At constant pressure levels and a pre-set airway pressure release rate of 12/min, P(low) was diminished and P(high) was prolonged in four steps of 0.5 s. Each respiratory setting was studied for 20 min after a steady state period had been achieved. MEASUREMENTS AND MAIN RESULTS: We measured gas exchange and respiratory mechanics. The different time intervals of P(high) and P(low) had only minor effects on the actual spontaneous inspiration and expiration times, but the proportion of spontaneous breathing on total ventilation increased when the duration of P(low) was decreased. Gas exchange was almost unaffected by the interventions despite a significant increase in mean airway pressure. However, when P(low) was set to only 0.5 s an increase in PaCO(2) occurred in patients with COPD and ALI, probably due to a decrease in mechanical ventilatory support. CONCLUSIONS: Airway pressure release ventilation is an open system which allows patients to maintain the "time control" over the respiratory cycle independent of the chosen duration for P(high) and P(low).

Epidemiology of sepsis and infection in ICU patients from an international multicentre cohort study.

OBJECTIVES: To examine the incidence of infections and to describe them and their outcome in intensive care unit (ICU) patients. DESIGN AND SETTING: International prospective cohort study in which all patients admitted to the 28 participating units in eight countries between May 1997 and May 1998 were followed until hospital discharge. PATIENTS: A total of 14,364 patients were admitted to the ICUs, 6011 of whom stayed less than 24 h and 8353 more than 24 h. RESULTS: Overall 3034 infectious episodes were recorded at ICU admission (crude incidence: 21.1%). In ICU patients hospitalised longer than 24 h there were 1581 infectious episodes (crude incidence: 18.9%) including 713 (45%) in patients already infected at ICU admission. These rates varied between ICUs. Respiratory, digestive, urinary tracts, and primary bloodstream infections represented about 80% of all sites. Hospital-acquired and ICU-acquired infections were documented more frequently microbiologically than community-acquired infections (71% and 86%, respectively vs. 55%). About 28% of infections were associated with sepsis, 24% with severe sepsis and 30% with septic shock, and 18% were not classified. Crude hospital mortality rates ranged from 16.9% in non-infected patients to 53.6% in patients with hospital-acquired infections at the time of ICU admission and acquiring infection during the ICU stay. CONCLUSIONS: The crude incidence of ICU infections remains high, although the rate varies between ICUs and patient subsets, illustrating the added burden of nosocomial infections in the use of ICU resources.

Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy.

Severe sepsis remains both an important clinical challenge and an economic burden in intensive care. An estimated 750,000 cases occur each year in the US alone (300 cases per 100,000 population). Lower numbers are estimated for most European countries (e.g. Germany and Austria: 54-116 cases per year per 100,000). Sepsis patients are generally treated in intensive care units (ICUs) where close supervision and intensive care treatment by a competent team with adequate equipment can be provided. Staffing costs represent from 40% to >60% of the total ICU budget. Because of the high proportion of fixed costs in ICU treatment, the total cost of ICU care is mainly dependent on the length of ICU stay (ICU-LOS). The average total cost per ICU day is estimated at approximately 1200 Euro for countries with a highly developed healthcare system (based on various studies conducted between 1989 and 2001 and converted at 2003 currency rates). Patients with infections and severe sepsis require a prolonged ICU-LOS, resulting in higher costs of treatment compared with other ICU patients. US cost-of-illness studies focusing on direct costs per sepsis patient have yielded estimates of 34,000 Euro, whereas European studies have given lower cost estimates, ranging from 23,000 Euro to 29,000 Euro. Direct costs, however, make up only about 20-30% of the cost of illness of severe sepsis. Indirect costs associated with severe sepsis account for 70-80% of costs and arise mainly from productivity losses due to mortality. Because of increasing healthcare cost pressures worldwide, economic issues have become important for the introduction of new innovations. This is evident when introducing new biotechnology products, such as drotrecogin-alpha (activated protein C), into specific therapy for severe sepsis. Data so far suggest that when drotrecogin-alpha treatment is targeted to those patients most likely to achieve the greatest benefit, the drug is cost effective by the standards of other well accepted life-saving interventions.

Cost-effectiveness of drotrecogin alfa (activated) for the treatment of severe sepsis in Germany.

Drotrecogin alfa (activated) (Xigris; Eli Lilly and Company, Indianapolis, IN) significantly reduced mortality in severe sepsis in the PROWESS trial. We evaluate the cost-effectiveness of drotrecogin alfa (activated) as an adjunct to standard therapy from the German healthcare payer's perspective with respect to patients with 1) severe sepsis and 2) severe sepsis and multiple organ failure the approved European indication. Hospital resource use based on PROWESS was valued using German unit costs. German life-tables and long-term survival assumptions determined life-years gained. European and German healthcare resource use data are examined in the sensitivity analysis. We assumed a unit price of euro;237.50 for drotrecogin alfa (activated). Per patient treated, drotrecogin alfa (activated) increased costs by euro;7,500, and hospital costs by euro;900 for all patients (euro;7,400 and euro;1,500 respectively for the approved indication) and survival by 0.59 life years (0.87 life years respectively for the approved indication). Thus drotrecogin alfa (activated) cost euro;14,100 (euro;17,700 discounting life years at 3%) per life year gained for all patients (euro;10,200 and euro;12,900, respectively, for the approved indication). Testing the unit cost of drotrecogin alfa (activated), pattern of resource use, and survival benefit, demonstrated that cost-effectiveness lies well within the range of other life saving interventions in Germany representing good economic value.