Ersson Anders, Beckman Anders, Jarl Johan, Borell Jonas
Department of Intensive Care and Perioperative medicine, Skåne University Hospital, Malmö, Sweden.
Department of Clinical Sciences Malmö, Family Medicine, Lund University, Jan Waldenströms gata 35, 205 02, Malmö, Sweden.
BMC Health Serv Res. 2018 Nov 7;18(1):838. doi: 10.1186/s12913-018-3648-y.
To benefit from the increasing clinical evidence, organisational changes have been among the main drivers behind the reduction of ICU mortality during the last decade. Increasing demand, costs and complexity, amplifies the need for optimisation of clinical processes and resource utilisation. Thus, multidisciplinary teamwork and critical care processes needs to be adapted to profit from increased availability of human skill and technical resources in a cost-effective manner. Inadequate clinical performance and outcome data compelled us to design a quality improvement project to address current work processes and competence utilisation.
During revision period, clinical processes, professional performance and clinical competence were targeted using "scientific production management methodology" approach. As part of the project, an intensivist training program was instituted, and full time intensivist coverage was obtained in the process of creating multi-professional teams, composed of certified intensivists, critical care nurses, assistant nurses, physiotherapists and social counsellors. The use of staff resources and clinical work-processes were optimised in accordance with the outcome of a "value stream mapping". In this process, efforts to enhance the personal dynamics and performance within the teams were paramount. Clinical and economic outcome data were analysed during a seven year follow up period.
• Consecutive reduced overall ICU (24%) and long-term (600 days) mortality. The effect on ICU mortality was especially pronounced in the subgroup of patients > 65 years (30%) • Consecutive reduced length of stay (43%, septic patients) and time on ventilator (for septic patients and patients > 65 years of age (23 resp.52%). • Substantial increase in life years gained (13,140 life years) as well as quality-adjusted life-years (9593 QALY: s) over the study period. • High cost-effectiveness as ICU costs were reduced while patient outcomes were improved. Disregarding the cost reduction in ICU, the intervention is highly cost effective with cost- effectiveness ratios of (75€/QALY) and (55€ / life year) CONCLUSIONS: We have shown favourable results of a QI project aiming to improve the clinical performance and quality through the development of multi-professional interaction, teamwork and systematic revisions of work processes. The economic evaluation shows that the intervention is highly cost-effective and potentially dominating.
为了从日益增多的临床证据中获益，组织变革是过去十年间降低重症监护病房（ICU）死亡率的主要驱动因素之一。需求、成本和复杂性不断增加，这加大了优化临床流程和资源利用的必要性。因此，多学科团队合作和重症监护流程需要进行调整，以便以具有成本效益的方式从增加的人力技能和技术资源中获利。临床绩效和结果数据不足促使我们设计一个质量改进项目，以解决当前的工作流程和能力利用问题。
在修订期间，采用“科学生产管理方法”对临床流程、专业表现和临床能力进行针对性改进。作为项目的一部分，制定了一项重症医学专家培训计划，并在组建由认证重症医学专家、重症监护护士、助理护士、物理治疗师和社会顾问组成的多专业团队的过程中实现了全职重症医学专家覆盖。根据“价值流映射”的结果优化了人员资源的使用和临床工作流程。在此过程中，提升团队内部个人活力和绩效的努力至关重要。在七年的随访期内分析了临床和经济结果数据。
• ICU总体死亡率（24%）和长期（600天）死亡率持续降低。对ICU死亡率的影响在65岁以上患者亚组中尤为明显（30%）。• 住院时间（败血症患者降低43%）和机械通气时间（败血症患者以及65岁以上患者分别降低23%和52%）持续缩短。• 在研究期间，获得的生命年大幅增加（13,140个生命年）以及质量调整生命年（9593个QALY）。• 具有高成本效益，因为在改善患者结果的同时降低了ICU成本。不考虑ICU成本的降低，该干预措施具有很高的成本效益，成本效益比为（75€/QALY）和（55€/生命年）。结论：我们展示了一个旨在通过发展多专业互动、团队合作和系统修订工作流程来提高临床绩效和质量的质量改进项目的良好结果。经济评估表明，该干预措施具有很高的成本效益，并且可能具有主导性。
