Quality indicators in intensive care medicine for Germany - fourth edition 2022.

The measurement of quality indicators supports quality improvement initiatives. The German Interdisciplinary Society of Intensive Care Medicine (DIVI) has published quality indicators for intensive care medicine for the fourth time now. After a scheduled evaluation after three years, changes in several indicators were made. Other indicators were not changed or only minimally. The focus remained strongly on relevant treatment processes like management of analgesia and sedation, mechanical ventilation and weaning, and infections in the ICU. Another focus was communication inside the ICU. The number of 10 indicators remained the same. The development method was more structured and transparency was increased by adding new features like evidence levels or author contribution and potential conflicts of interest. These quality indicators should be used in the peer review in intensive care, a method endorsed by the DIVI. Other forms of measurement and evaluation are also reasonable, for example in quality management. This fourth edition of the quality indicators will be updated in the future to reflect the recently published recommendations on the structure of intensive care units by the DIVI.

[Evaluation of the "TeleCOVID Hesse" project after 1 year in operation]. / Evaluation des Projekts "TeleCOVID Hessen" nach einjährigem Betrieb.

BACKGROUND: The SARS-CoV­2 pandemic posed unexpected challenges for hospitals worldwide and in addition to the supply emergency, simultaneously caused a high pressure to innovate. Due to the high number of cases of COVID-19 patients requiring intensive care, structured networking of hospitals gained particular importance. The tele-ICU communication platform TeleCOVID was developed to improve the quality of intensive care both by enabling teleconsultations and by supporting patient transfers. OBJECTIVE: The present study aimed to survey user experiences with TeleCOVID. The study investigated the extent to which the app is used, the user experiences of the participating hospitals, and the resulting implications for the further development of the telemedicine application. MATERIAL AND METHODS: A user survey was conducted in May 2022 using an online questionnaire. The survey contained both closed and open questions with a free text field. It was sent via the Hessian Ministry of Social Affairs and Integration (HMSI). All 135 hospitals in Hesse were contacted by e­mail and invited to participate in the study. The results of the closed questions were analyzed using descriptive statistics, and the results of the open questions were clustered and thematically summarized using qualitative content analysis. RESULTS: The study showed that TeleCOVID was used primarily for transfer requests, followed by the need for a treatment consultation without a transfer request. Most often, ECMO treatment or treatment in a hospital of a higher care level was required. The content analysis showed that users particularly rated the possibility of a data protection-compliant and structured transfer of patient data as advantageous. It is also worth mentioning that in almost 25% of the cases a transfer of patients could be prevented by TeleCOVID. Disadvantages frequently mentioned by respondents were the lack of connection to the electronic hospital information system, the increased time required for the registration process, and the poor primary accessibility of contact persons. CONCLUSION: In a further development of the application the connection to the electronic hospital information system should be considered particularly urgent. In addition, the time expenditure should be reduced by a simplified login process. Due to interface barriers, an alternative data infrastructure would also be conceivable to create interoperability. The introduction of a web client could also increase usability. The main beneficiaries of hospital networking are physicians and patients in a context associated with a high workload and specific medical issues. Continuation and expansion of the app to intensive care medicine and beyond are therefore recommended. In further studies on the project, personal interviews with decision makers could be useful to conduct a more targeted needs analysis.

[Quality Assurance in Intensive Care Medicine: Peer Reviews and Quality Indicators]. / Qualitätssicherung in der Intensivmedizin: Peer Reviews und Qualitätsindikatoren.

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.

Voluntary peer review as innovative tool for quality improvement in the intensive care unit--a retrospective descriptive cohort study in German intensive care units.

INTRODUCTION: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports. METHODS: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs - representing over 300 patient beds - had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. RESULTS: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interesting Conclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

The relationship between carotid blood-flow velocity and the left ventricular area during acute regional ischemia.

OBJECTIVE: Myocardial contractility can be described by the relationship between blood-flow velocity in the carotid artery and the left ventricular cross-sectional area. The authors investigated whether critical myocardial ischemia influences the derived contractility index, E'(es). DESIGN: A prospective animal study. SETTING: A university research laboratory. PARTICIPANTS: Eleven Göttinger minipigs. INTERVENTIONS: Within the closed-chest model, the authors placed a U-shaped 8-MHz miniature Doppler probe around the left internal carotid artery and inserted a combined pressure-conductance catheter into the left ventricular cavity via the right internal carotid artery. A balloon occlusion catheter was placed into the inferior caval vein from a femoral vein and acquired transthoracic-view echocardiographic images. An active coronary perfusion catheter was positioned in the proximal left circumflex coronary (LCx) artery. The LCx bed was perfused with blood from the contralateral femoral artery by using a high-precision-output roller pump. MEASUREMENTS AND MAIN RESULTS: Stage analysis during normal perfusion revealed evidence for the following function: E'(es) = 0.066 + 0.121 E(es) (R = 0.96, R(2) = 0.92, and p < 0.0001), which agrees with previously determined equations. Under ischemic conditions, the relationship changed to E'(es) = 0.048 + 0.196.E(es) (R = 0.83, R(2) = 0.69, and p < 0.0001). The limits of precision to detect changes in contractility by E'(es) increased from 16% to 45%; the bias did not notably deviate from zero. The indexes of mechanical dyssynchrony (mechanical dyssynchrony and internal flow fraction) derived from conductance catheter measurements increased significantly. CONCLUSION: The ability of E'(es) to indicate contractility during acute reduced coronary blood flow is limited.

Association of increased myocardial contractility and elevated end-diastolic wall tension with short-term myocardial ischemia: a pressure-volume analysis.

OBJECTIVE: Critical myocardial oxygen imbalance as indicated by elevated interstitial lactate levels may occur in cases of rapidly elevated end-diastolic myocardial wall tension during elevated myocardial contractility in the intact myocardium. Simultaneous administration of beta-adrenergic receptor agonist and antagonist reliably allows for investigating the myocardial response. DESIGN: Experimental using an in vivo animal model. SETTING: Research institution. PARTICIPANTS: Animal model. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Fifteen minipigs were investigated in an open-chest model. After a midline sternotomy, a thin dialysis tube was implanted into the LV midmyocardium. Extracellular lactate in perfusate was analyzed every 5 minutes. End-systolic time-varying elastance and end-diastolic wall tension were measured. After a stable period, dobutamine (10 microg/kg/min) was administered to 8 animals. After 20 minutes, esmolol (0.5-mg/kg bolus, repetitively) was added until heart rate decreased to <100 beats/min. For 20 minutes, esmolol was infused at a rate of 3 mg/kg/h, and then dobutamine alone was continued for 10 minutes. With dobutamine, the lactate level did not change, but wall tension decreased and contractility increased. Simultaneous esmolol initially (in the first 10 minutes) increased lactate, whereas LV end-diastolic wall tension and contractility both increased; but after 10 minutes, lactate and contractility decreased significantly. Lactate again increased within 10 minutes after stopping esmolol. A group of 7 animals received esmolol for 20 minutes and showed no changes in lactate; myocardial wall tension increased and contractility decreased. CONCLUSION: Results suggest that oxygen demand/supply is balanced until both end-diastolic wall tension and myocardial contractility are elevated to critical levels.

Determination of preload-recruitable stroke work and elastance by the relationship of arterial blood flow velocity to left ventricular area.

OBJECTIVE: The authors investigated the feasibility of an online sampling and display of LV flow-area loops for the determination of LV elastance and preload-recruitable stroke work (PRSW). Automated LV area measurements by echocardiography may be combined with flow velocity measurements in the internal carotid artery to construct LV flow-area loops as estimates of the systolic pressure-volume relationship. SETTING: University hospital. DESIGN: Open chest model. PARTICIPANTS: Eight anesthetized minipigs. INTERVENTIONS: Inferior vena cava occlusion was performed to simultaneously obtain parameters of the LV flow-area relationship and the LV pressure-area relationship. MEASUREMENTS AND MAIN RESULTS: Parameters were obtained at baseline and during sequential administration of dobutamine (5 microg/kg/min) and halothane (0.8 vol%). Linear regression analysis and analysis of variance were performed to investigate an underlying linear relationship between the corresponding variables. Highly linear elastance and PRSW curves were derived from the flow-area and pressure-area loops (n = 24, R >/= 0.85). Changes of the curve slopes indicated inotropic changes as well as model independent dP/dt(max). Elastance from the pressure-area relationship was expressed by elastance from the flow-area relationship by the term y = 0.52 + 0.04. x (R(2) = 0.84; p < 0.0001). Linear regression of PRSW as derived from the flow-area relationship with PRSW as derived from the pressure-area relationship was expressed by y = 0.43 + 0.02. x (R(2) = 0.77; p < 0.0001). CONCLUSION: Indices of the LV pressure-area relationship can be derived from real-time loops constructed from arterial flow velocity and LV area.

Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients?

OBJECTIVE: To determine the value of the bispectral index (BIS) in assessing the depth of sedation in sedated and mechanically ventilated ICU patients, compared with clinical sedation scores. DESIGN AND SETTING: Prospective convenience sample in a 12-bed anesthesiological-surgical ICU of a university hospital. PATIENTS: 19 consecutive patients without any central neurological diseases requiring mechanical ventilation for more than 24 h. MEASUREMENTS: BIS version 3.12 and clinical depth of sedation assessed by the modified Observers's Assessment of Alertness/Sedation Scale, modified Glasgow Coma Scale, modified Ramsay Scale, Cook Scale, and Sedation-Agitation Scale were measured twice daily while patients were intubated and once daily after extubation until discharged from ICU. RESULTS: there was a moderate correlation between BIS and each sedation score in 11 patients (58%, "BIS patients") and no correlation in 8 patients (42%, "non-BIS patients"). We found no parameters distinguishing between these two groups. On average eight measurements were necessary to establish a statistical correlation. In the BIS patients the slopes of the linear regression curves showed significant differences for all BIS score combinations with increasing scattering at deeper sedation levels. CONCLUSIONS: BIS is correlated only in some ICU patients with the clinical assessment of their sedation level as based on various scores. At deeper sedation levels the interindividual differences increase. There were no criteria found to distinguish patients with and without correlation. This suggests that the BIS is not suitable for monitoring the sedation in a heterogeneous group of surgical ICU patients.