Does adherence to a quality indicator regarding early weaning from invasive ventilation improve economic outcome? A single-centre retrospective study.

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.

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study.

BACKGROUND: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT02265263, Registered 15 October 2014.

Critical care guidelines on pain, agitation and delirium management: Which one to use? A systematic literature search and quality appraisal with AGREE II.

BACKGROUND: Clinical practice guidelines (CPGs) facilitate the provision of standardized, high-quality intensive care medicine. For the management of pain, agitation and delirium, several coexisting CPGs have been published. This study aims at the appraisal of CPGs on pain, agitation and delirium management in the intensive care unit to (a) identify high quality guidelines appropriate for clinical use and (b) identify potential areas for future improvement. METHODS: We performed a systematic literature search of Medline, three guideline registers and two grey-literature databases. The scope covered guidelines from 2007 to 2020 available in English or German. Identified CPGs were appraised by three independent reviewers using the appraisal of Guidelines Research and Evaluation (AGREE II) instrument. RESULTS: Eight CPGs were included in the final analysis. Three of the included guidelines exceeded the quality threshold of 60% in all six domains. The highest median [IQR] scores were achieved in the domain "Scope and Purpose" (84.3% [78.7-88.9]), whereas "Applicability" (45.8% [19.4-79.9]) received the lowest median score. CONCLUSION: Three of the eight reviewed guidelines exceeded the quality threshold in all domains, while the overall guideline quality was also very high. Focusing on guideline applicability and identifying strategies to facilitate implementation can improve future CPGs.