The effect on adherence rates of standard operating procedures through implementation of a technical feedbacksystems on intensive care units

Einleitung: Zur Optimierung der Behandlungsqualität werden Leitlinien als Entscheidungshilfen zur Qualitätssicherung und Reduzierung der Behandlungsvariabilität verwendet. Um das Wissen aus den Leitlinien in die tägliche Praxis zu integrieren, werden auf der im Rahmen dieser Arbeit untersuchten Intensivstation (ITS) dafür unter anderem „Standard Operating Procedures“ (SOP) verwendet. Diese sind in schriftlicher Form gebündelte klinikinterne Empfehlungen in Anlehnung an die Leitlinien. Ziel dieser Arbeit ist die Untersuchung, ob durch die Einführung eines technischen visuellen Feedbacksystems die Einhaltung der SOP für antimikrobielle Therapie in der Sepsis, Ernährung, Blutzuckerkontrolle und Nierenfunktion im klinischen Alltag einer ITS verändert wird. Sekundär wird der Zusammenhang der SOP-Einhaltung mit dem Outcome (u.a. der ITS-Behandlungsdauer, Beatmungstherapiedauer und intensivstationäre Mortalität) der Patienten untersucht. Methodik: Anhand 187 Patienten wurde retrospektiv in zwei Zeiträumen für je 3 Monate auf einer interdisziplinären universitären ITS, vor und nach Einführung des Feedbacksystems, die Einhaltung der klinikinternen SOP für die antimikrobielle Therapie, für die Ernährungs-Therapie, für die Blutzuckerkontrolle und für die Nierenfunktion untersucht. Es wurden alle Patienten eingeschlossen, deren vollständige Behandlungsdauer innerhalb dieser Zeiträume war und mindestens 24 Stunden betrug sowie älter als 16 Jahre waren. Ausgeschlossen wurden Organspender oder wenn eine Therapiebeschränkung bestand z.B. ein Reanimationsverbot. Für die Berechnung der tatsächlichen Mortalität wurden die ausgeschlossenen Patienten mitbetrachtet. Ergebnis: Eine Veränderung der SOP- Adhärenz konnte nicht nachgewiesen werden. Sekundär konnte gezeigt werden, dass eine schwach negative Korrelation der Behandlungsdauer (Korrelationskoeffizient=-0,301, p<0,001) und der Beatmungsdauer (Korrelationskoeffizient=-0,236, p=0,001) mit der prozentualen SOP-Einhaltung der antimikrobielle Therapie bestand. Die Patienten, bei denen die Ernährungs- SOP am ersten und vierten Behandlungstag eingehalten wurden, hatten kürzere Behandlungs- und Beatmungstherapiedauern (p<0,05) auf der Intensivstation. Es bestand eine schwach positive Korrelation zwischen Behandlungs- sowie Beatmungsdauer und der Anzahl der Tage mit Glukosewerte <80 mg/dl (Blutzucker SOP-Nicht-Einhaltung). Patienten mit einer RIFLE (Risk, Injury, Failure, Loss- of-kidney-function, End-stage kidney disease)-Klassifizierung von "Failure" oder schlechter wurden im Vergleich zu den Patienten mit einer besseren Einstufung signifikant länger im Median auf der Intensivstation behandelt (51 h vs 127 h, p=0,003). Die Beatmungsdauer war nicht signifikant länger (26 h vs 39 h, p>0,05). Die beobachtete Mortalität lag bei 13% (erwartete 26%-35%). Schlussfolgerung: Eine SOP-Adhärenz für antimikrobielle Therapien, Ernährung, Blutzuckerkontrolle und Nierenfunktion sollte angestrebt werden um die Behandlungs- und Beatmungsdauern auf der Intensivstation möglichst gering zu halten. In zukünftigen Untersuchungen zur Implementierungssteigerung durch ein technisches Feedbacksystem sollte dessen Inanspruchnahme miterhoben werden.Introduction: For the optimisation of treatment-quality and reduction of treatment-variability are guidelines of utmost importance. On the examined intensive-care-unit (ICU) were „Standard Operating Procedures“ (SOP) used to implement guidelines into daily praxis. These are detailed, written instructions adapted to local conditions in compliance to the guidelines. The aim of this study was to examine whether the daily adherence to standard operating procedures (SOP) for antimicrobial therapy in sepsis, feeding, bloodsugar-treatment and renal function could be improved by implementing a visual technical feedback software in a mixed intensive care unit. Secondary investigations were done about SOP-adherence and patient outcome (length of ICU stay [LOS], length of Ventilation [LOV], mortality etc). Method: The study retrospectively evaluated SOP adherence rates of 187 patients treated in a mixed ICU over a 6-month period (3 months before and 3 months after implementation of the feedback system). The inclusion criteria were met if the patient’s age was >16 years and the complete LOS was within the examined periods and at least 24 hours. Exclusion criteria were met if the patient was an organ donor or had a restricted therapy of any kind e.g. “do-not- rescucitate” (DNR). For the calculation of “actual mortality rates” were the DNR patients included. Results: Adherence rates for the SOP did not differ between the periods. A weak negative correlation was observed between LOS (r=-0,301, p<0,001) and LOV (r=-0,236, p=0,001) with procentual adherence of antimicrobial therapy. Patients with feeding SOP adherence for the first and/or fourth day of treatment had shorter LOS and LOV(p<0,05).A weak positive correlation was found between LOV and LOS with the number of days with hypoglycaemia (<80 mg/dl) (lack of adherence to bloodsugar-treatment SOP). Patients with a RIFLE (Risk, Injury, Failure, Loss of kidney function, End- stage kidney disease) Score>=2 had a longer LOS compared to those with a Scorevalue<2 (51 h vs 127 h p=0,003). LOV did not differ (26 h vs 39 h, p>0,05).The observed „actual ICU mortality“ was 13% (expected 26%-35%). “Take- home-points”: The SOP-Adherence for antibiotic treatment, feeding, bloodsugar- control and renal function is important and should be striven for to minimise VOS and LOS. Future implementation-investigations should survey the utilisation of the technical feedbacksystem

International registry on the use of the CytoSorb® adsorber in ICU patients : Study protocol and preliminary results

INTRODUCTION: The aim of this clinical registry is to record the use of CytoSorb(R) adsorber device in critically ill patients under real-life conditions. METHODS: The registry records all relevant information in the course of product use, e. g., diagnosis, comorbidities, course of the condition, treatment, concomitant medication, clinical laboratory parameters, and outcome (ClinicalTrials.gov Identifier: NCT02312024). Primary endpoint is in-hospital mortality as compared to the mortality predicted by the APACHE II and SAPS II score, respectively. RESULTS: As of January 30, 2017, 130 centers from 22 countries were participating. Data available from the start of the registry on May 18, 2015 to November 24, 2016 (122 centers; 22 countries) were analyzed, of whom 20 centers from four countries provided data for a total of 198 patients (mean age 60.3 +/- 15.1 years, 135 men [68.2%]). In all, 192 (97.0%) had 1 to 5 Cytosorb(R) adsorber applications. Sepsis was the most common indication for CytoSorb(R) treatment (135 patients). Mean APACHE II score in this group was 33.1 +/- 8.4 [range 15-52] with a predicted risk of death of 78%, whereas the observed mortality was 65%. There were no significant decreases in the SOFA scores after treatment (17.2 +/- 4.8 [3-24]). However interleukin-6 levels were markedly reduced after treatment (median 5000 pg/ml before and 289 pg/ml after treatment, respectively). CONCLUSIONS: This third interim report demonstrates the feasibility of the registry with excellent data quality and completeness from 20 study centers. The results must be interpreted with caution, since the numbers are still small; however the disease severity is remarkably high and suggests that adsorber treatment might be used as an ultimate treatment in life-threatening situations. There were no device-associated side effects

Intraoperative transfusion practices in Europe

© 2016 The Author. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.Background: Transfusion of allogeneic blood influences outcome after surgery. Despite widespread availability of transfusion guidelines, transfusion practices might vary among physicians, departments, hospitals and countries. Our aim was to determine the amount of packed red blood cells (pRBC) and blood products transfused intraoperatively, and to describe factors determining transfusion throughout Europe. Methods: We did a prospective observational cohort study enrolling 5803 patients in 126 European centres that received at least one pRBC unit intraoperatively, during a continuous three month period in 2013. Results: The overall intraoperative transfusion rate was 1.8%; 59% of transfusions were at least partially initiated as a result of a physiological transfusion trigger- mostly because of hypotension (55.4%) and/or tachycardia (30.7%). Haemoglobin (Hb)- based transfusion trigger alone initiated only 8.5% of transfusions. The Hb concentration [mean (sd)] just before transfusion was 8.1 (1.7) g dl-1 and increased to 9.8 (1.8) g dl-1 after transfusion. The mean number of intraoperatively transfused pRBC units was 2.5 (2.7) units (median 2). Conclusions: Although European Society of Anaesthesiology transfusion guidelines are moderately implemented in Europe with respect to Hb threshold for transfusion (7-9 g dl-1), there is still an urgent need for further educational efforts that focus on the number of pRBC units to be transfused at this threshold

Intraoperative transfusion practices and perioperative outcome in the European elderly: A secondary analysis of the observational ETPOS study

The demographic development suggests a dramatic growth in the number of elderly patients undergoing surgery in Europe. Most red blood cell transfusions (RBCT) are administered to older people, but little is known about perioperative transfusion practices in this population. In this secondary analysis of the prospective observational multicentre European Transfusion Practice and Outcome Study (ETPOS), we specifically evaluated intraoperative transfusion practices and the related outcomes of 3149 patients aged 65 years and older. Enrolled patients underwent elective surgery in 123 European hospitals, received at least one RBCT intraoperatively and were followed up for 30 days maximum. The mean haemoglobin value at the beginning of surgery was 108 (21) g/l, 84 (15) g/l before transfusion and 101 (16) g/l at the end of surgery. A median of 2 [1–2] units of RBCT were administered. Mostly, more than one transfusion trigger was present, with physiological triggers being preeminent. We revealed a descriptive association between each intraoperatively administered RBCT and mortality and discharge respectively, within the first 10 postoperative days but not thereafter. In our unadjusted model the hazard ratio (HR) for mortality was 1.11 (95% CI: 1.08–1.15) and the HR for discharge was 0.78 (95% CI: 0.74–0.83). After adjustment for several variables, such as age, preoperative haemoglobin and blood loss, the HR for mortality was 1.10 (95% CI: 1.05–1.15) and HR for discharge was 0.82 (95% CI: 0.78–0.87). Preoperative anaemia in European elderly surgical patients is undertreated. Various triggers seem to support the decision for RBCT. A closer monitoring of elderly patients receiving intraoperative RBCT for the first 10 postoperative days might be justifiable. Further research on the causal relationship between RBCT and outcomes and on optimal transfusion strategies in the elderly population is warranted. A thorough analysis of different time periods within the first 30 postoperative days is recommended