The German quality indicators in intensive care medicine 2013--second edition.

Quality indicators are key elements of quality management. The quality indicators for intensive care medicine of the German Interdisciplinary Society of Intensive Care Medicine (DIVI) from the year 2010 were recently evaluated when their validity time expired after two years. Overall one indicator was replaced and further three were in part changed. The former indicator I "elevation of head of bed" was replaced by the indicator "Daily multi-professional ward rounds with the documentation of daily therapy goals" and added to the indicator IV "Weaning and other measures to prevent ventilator associated pneumonias (short: Weaning/VAP Bundle)" (VAP = ventilator-associated pneumonia) which aims at the reduction of VAP incidence. The indicator VIII "Documentation of structured relative-/next-of-kin communication" was refined. The indicator X "Direction of the ICU by a specially trained certified intensivist with no other clinical duties in a department" was also updated according to recent study results. These updated quality indicators are part of the Peer Review in intensive care medicine. The next update of the quality indicators is due in 2016.

Introduction

Planned for a validity period of two years in 2010, the first version of the German quality indicators in intensive care medicine has been published [1]. This was the first time that quality indicators for surgical and medical ICUs have been developed. The acceptance of these indicators was broad. Congresses and meetings showed great interest to introduce these indicators and spread their implementation. The results of an increasing number of peer reviews in intensive care medicine are showing a high degree of implementation of these indicators in different ICUs. These indicators therefore fulfil the requirements stated in the RUMBA-rule:

Relevant for a problem

Understandable

Measurable, with good validity and reliability

Behaviourable

Achievable and feasible

The quality indicators in intensive care medicine changed the day-to-day routine care in ICUs in Germany. Limiting the number of indicators to ten for easier and better handling may have contributed to their implementation. Furthermore especially core processes of routine care in intensive care medicine are represented like ventilator therapy, antiinfective therapy as well as analgesia, sedation and management of delirium, nutrition, hygiene, controlled hypothermia and management of relatives. Staffing of the ICU is used as a structural indicator.

The pretension of these quality indicators in intensive care medicine is to introduce a high level of performance quality. Without measurement of quality there is no chance of detecting change. In a French study a score system for implementation of quality dimensions was developed and consecutively used in a network of ICUs. They showed that the median degree of translation of quality dimensions reached around 60% where the best units reached up to 80% [2].

When assuming that every intensive care physician has the intention to organize intensive care medicine in the best interest of his patients then all measures to optimize care have to be highly welcome. This aim has to be in the centre of interest when developing quality indicators.

International comparison of quality indicators in intensive care medicine

A Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM) published a list of indicators for improvement of quality and safety in intensive care medicine [3]. A five round Delphi-process with an agreement rate of at least 90% yielded the following indicators:

Structural indicators

The intensive care unit fulfils national requirements to provide intensive care

24-h availability of a consultant level intensivist

Adverse event reporting-system

Process indicators

Presence of routine multi-disciplinary clinical ward rounds

Standardized hand-over procedure for patients discharge

Outcome-indicators

Reporting and analysis of standardised mortality ratio (SMR)

ICU re-admission rate within 48 h of ICU discharge

Rate of central venous catheter-related blood stream infection

Rate of unplanned endotracheal extubations

These European quality- and safety indicators describe common problems or events. However, for example SMR is included in the Core data set (Kerndatensatz) of the German Interdisziplinary Society of Intensive Care Medicine (DIVI) and registration of catheter-associated blood stream infections is achieved by Krankenhaus-Infektions-Surveillance-System (KISS) (http://www.nrz-hygiene.de/surveillance/kiss/). Prerequisite for taking part in those surveillance systems is the technical ability of data transfer which – due to the lack of uniform technical standards – is problematic in many hospitals. Furthermore, it can be problematic to measure the rate of unplanned extubations because of the increasing use of non-invasive ventilatory support and the newly developed guidelines for sedation. If avoidance of unplanned extubation is a goal then in turn deeper sedation might be the consequence with other unfavourable outcomes instead.

We do not intend to diminish the relevance of these indicators with our critique. They give an important impulse for the further development of the German intensive care quality indicators. Additionally redundant indicators had to be avoided and hence more outcome related indicators are covered by different systems.

The first version of German quality indicators for intensive care medicine 2010 has been criticised to be biased towards process indicators. This comparison of seven other European countries with ICU quality indicators showed more presence of outcome indicators like the standardized mortality ratio (SMR), rate of re-intubation, patient satisfaction, rate of readmission to the ICU, duration of ventilation or bed occupancy rate [4]. Different national health care systems set different framework requirements for intensive care medicine. A part of the European outcome indicators are covered by alternative quality monitoring systems. For example the intensive care core data set (DIVI-REVERSI) covers SMR or 48-hour readmission rate. Adverse event indicators like “rate of pressure ulcers” are main indicators of the BQS in German hospitals. Incidence of nosocomial infection like catheter-related bloodstream infections or ventilator-associated pneumonias are present in the Hospital Infections Surveillance System (Krankenhaus Infektions Surveillance System, KISS).

The German quality indicators in intensive care medicine should be seen in the context of other measures and systems of quality improvement but overall they are only one part of quality improvement in intensive care. However redundancies with other measures and systems should be avoided. It is an explicit strength of these indicators that their implementation is rather unproblematic and not depending on large scale structural changes except the willingness to change daily routine in intensive care. These indicators may help with a self-assessment by the participating acting groups as well as by external assessment through peer review [5], [6]. It is the main intention of these quality indicators to represent core processes in intensive care medicine to change the quality of intensive care medicine according to the most recent evidence based principles to bring good practice to the patients’ bedside [1].

Development of the second edition of quality indicators for the ICU

Scientific evidence changes over time and therefore it is necessary to check the validity of science based quality indicators for improving outcomes of patient care. The National Steering Committee for peer review in intensive care medicine has been assigned by the DIVI to revise these indicators over a two-year cycle. One main goal was to keep the number of indicators at ten to avoid impracticability. In May of 2012 the revision process of the quality indicators in intensive care medicine started. Firstly, the medical societies involved in intensive care medicine, which are organized in the DIVI, were asked via their scientific working groups to revise the quality indicators. In November 2012 the proposals of the scientific committees were assembled. In December all proposals were discussed and a renewed version of the indicators was presented to the medical societies by means of the Delphi-method. In April 2013 no more proposals for change were recorded and the Executive Committee of the DIVI formally approved the quality indicators for intensive care medicine for publication.

The newly developed QI

An explanatory comment accompanies each indicator as it has been done in the first version of the German quality indicators for intensive care medicine. In Attachment 1 all indicators are presented in their final consented version.

QI I – Daily multi-professional ward rounds with the documentation of daily therapy goals

Determining daily goals in the multiprofessional ICU team, consisting at least of nurses and physicians of a ward, has been first published in 2003 by Pronovost et al [7]. Since then, several other authors have published about this topic. The original “daily goal form” of the Johns Hopkins Hospital in Baltimore, MD, USA is now widely used and has been modified to be included into clinical routine in different regions and countries all over the world. The agreement over daily goals in a patient has been shown to improve communication in the caring team, increases transparency of treatment goals and improves patient safety with a positive effect on outcome.

Establishing this new QI in German ICUs will have substantial impact on daily routine. The routine documentation, either paper based or electronically, needs to be adapted. This will lead to greater transparency and achievement of daily goals will be measured more easily. Such a change in daily routine needs the attentiveness of all professions involved in critical care medicine. The authors recommend the initiation of projects to achieve this change. The suppliers of commercially available documentation systems are asked to offer solutions for process implementation of daily goals sheets.

QI II – Monitoring sedation, analgesia, delirium

The QI II has not been changed. No new evidence regarding this topic has been published. The S3-Guideline is still in effect [8]. Preliminary unpublished data from peer reviews show potential for improvement in this field in intensive care medicine.

QI III – Lung protective ventilation

As fort he QI II the evidence situation for this QI is also unchanged. However, the implementation in clinical routine is still unsatisfactory. The discrepancy between theoretical knowledge and actual bedside use has been repeatedly published [9].

QI IV – Weaning and other measures to prevent ventilator associated pneumonias

The most extensive modification of the indicators took part in the QI IV. Both, the former QI I (Elevation of upper body) as well as the former QI IV (Weaning) aimed at the reduction of the incidence of ventilator associated pneumonias (VAP). VAP is of utmost importance in intensive care medicine. Avoidance of VAP has become a central quality indicator in the USA. Even financial compensation for this complication has been questioned recently to increase pressure to introduce quality improvement measures.

The positive effect of weaning on VAP incidence is mainly based on the time factor involved. The faster weaning from mechanical ventilation can be achieved the lower is the probability of VAP. However weaning is a complex process strongly linked to sedation concepts. Guideline based analgo-sedation is a prerequisite for successful weaning which in consequence is only achieved by a concerted standardized effort. This is one main component in the avoidance of atrophy of respiratory muscles which is a central pathophysiological factor for weaning failure.

The positive effect of elevation of the upper body on the reduction of VAP incidence has recently been questioned. No further study evidence was added and measuring daily compliance is difficult for two reasons:

Elevation of the upper body more than 30° is only rarely achieved

The necessary duration of elevation is unclear or if it even might interfere with other therapeutic or prophylactic measures (pressure ulcers etc.)

This lack of practicability has been seen in many peer reviews. The positive effect of the elevation of the upper body is based in the physical reduction in gastrointestinal reflux/regurgitation resulting in the avoidance of aspiration. The opposite, lowering the upper body, might also help achieving this particular goal. Minimizing aspiration can be achieved by many other measures, which were recently published. When used as a bundle they proved to be effective in reducing the incidence of VAP. With the view concentrated on outcome, some measures were effective and included in a VAP bundle (Body positioning protocol, hand disinfection before and after manipulating the airways, Oral hygiene and decontamination (with either antiseptic or antiinfective solutions, avoidance of micro aspiration by measuring cuff pressure, subglottic suctioning etc.). Upper body elevation is then considered one element of the bundle which mainly should emphasize avoidance of solely flatness. The other measures mentioned in the QI are examples which have been shown to be relevant for patient outcome.

We intended to bring order into the complexity of measures for the incidence of VAP reduction. The authors tried to achieve this by introducing this indicator based on two measurable parts.

Weaning, measured from the patient file

VAP-bundle, measured from the patient file and nursing documentation.

QI V – Early and adequate initiation of antibiotic therapy

This indicator was not changed. The evidence relating to this indicator has basically been the same over the last years. The experience from peer review in intensive care medicine has shown that implementation of sepsis bundles is still a challenge. The recognition of SIRS and signs of infection and consecutively the timely application of antiinfectives are demanding for the organization of an intensive care unit.

Overall the application of antibiotic stewardship programmes in this context is recommended [10]. The use of data regarding resistance of microbes is of high importance for adequate treatment It is strongly recommended to take part in national surveillance programmes. This has not yet been broadly established [11].

QI VI – Therapeutic hypothermia after cardiac arrest

This indicator has not been changed. The European guidelines have additionally been changed with regard to therapeutic hypothermia [12]. There appears to be a broader consciousness regarding the necessity of neuro-protection following cardiac arrest probably through campaigns featuring this issue. However, the authors think that the evaluation of this indicator might need other tools since patients following cardiac arrest and successful resuscitation are not a large patient group and measures like a peer review on a certain day might not adequately reflect implementation.

QI VII – Early enteral nutrition

This indicator has not been changed. In recent years numerous publications regarding nutrition in intensive care patients have been released. Especially evidence regarding parenteral nutrition has changed. Early enteral nutrition is still the main goal to achieve in intensive care patients. Overall nutrition via the natural route is preferred but also the adequate composition of nutrients and the adequate amount of caloric supply.

QI VIII – Documentation of structured relative-/next-of-kin communication

This indicator has been modified. The results of recent peer reviews showed that documentation of communication with relatives has not been implemented in a satisfactory manner. The main critique was the lack of definitions of goals for a patient. Especially there was a lack of documented topics addressed in these communications. Furthermore the goals defined in the best interest of the patient’s will were not routinely defined or sufficiently documented. Therefore it seemed necessary to modify this indicator. Additionally documentation forms/templates should be modified to address these obvious needs.

QI IX – Hand disinfectant consumption

This indicator has not been changed. In daily care, use of hand disinfectants is still insufficient. Therefore, it seemed necessary to focus on this indicator. The peer reviews showed that there is still some inconsistency in the use of this indicator. It is not solely the amount of disinfectant to be counted it is the relation to the amount of staff members of a unit that matters. This is the only reasonable measure for an adequate use of hand disinfectants in an ICU.

QI X – Direction of the ICU by a specialist dedicated intensivist with no other clinical duties in a department. Presence of a specialist ICU-physician during daytime and presence of experienced intensive care physicians and nurses over the course of 24 hours a day

This indicator has been modified according to new strong evidence published recently. Adequate care of ICU patients can only be achieved by the 24/7 presence of a qualified and experienced team of nurses and physicians. Especially in the daytime, when important decisions of all disciplines involved in the care of an individual patient have to be made and all decision-makers are present, the availability of a dedicated intensivist has been proven to improve outcome [13]. This intensivist doesn't need to be the head of a unit but most importantly has to be free of other clinical duties outside of the ICU. The head of the ICU should be the head of a distinct department or a leading consultant of a department. This is in accord to the actual demands articulated by the German Interdisciplinary Association for Intensive Care Medicine (Deutsche interdisziplinäre Vereinigung für Intensivmedizin, DIVI) This indicator also notes that the nurse-to-patient ratio in all mechanically ventilated patients (including non-invasive ventilation) has at least to be one nurse per two patients.

Notes

Authorship

Jan-Peter Braun and Oliver Kumpf contributed equally to this article.

Competing interests

The authors declare that they have no competing interests.