The German quality indicators in intensive care medicine 2013

000177 10.3205/000177 urn:nbn:de:0183-0001778 Review Article Übersichtsarbeit The German quality indicators in intensive care medicine 2013 – second edition Intensivmedizinische Qualitätsindikatoren für Deutschland 2013 – zweite Auflage Braun Braun Jan-Peter JP PD Dr. med.

Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Charité Centrum 7, Charitéplatz 1, 10117 Berlin, Germany, Phone: 0049 30 450531012Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Germany

Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Charité Centrum 7, Charitéplatz 1, 10117 Berlin, Deutschland, Tel.: 0049 30 450531012Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Deutschland

jan.braun@charite.de author Kumpf Kumpf Oliver O

Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Germany

Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Deutschland

author Deja Deja Maria M

Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Germany

Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Deutschland

author Brinkmann Brinkmann Alexander A

Department of Anaesthesiology and Intensive Care Medicine, Klinikum Heidenheim, Germany

Klinik für Anästhesiologie und Intensivmedizin, Klinikum Heidenheim, Deutschland

author Marx Marx Gernot G

Department of Intensive Care Medicine, Universitätsklinikum RTWH Aachen, Germany

Klinik für Intensivmedizin, Universitätsklinikum RWTH Aachen, Deutschland

author Bloos Bloos Frank F

Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany

Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Deutschland

author Kaltwasser Kaltwasser Arnold A

German Society of Special Nursing (DGF), Berlin, Germany

Deutsche Gesellschaft für Fachkrankenpflege (DGF), Berlin, Deutschland

author Dubb Dubb Rolf R

German Society of Special Nursing (DGF), Berlin, Germany

Deutsche Gesellschaft für Fachkrankenpflege (DGF), Berlin, Deutschland

author Muhl Muhl Elke E

Department of Surgery, Medical University of Schleswig Holstein, Luebeck, Germany

Klinik für Chirurgie, Universitätsklinikum Schleswig Holstein, Campus Lübeck, Deutschland

author Greim Greim Clemens C

Department of Anaesthesiology and Intensive Care Medicine, Klinikum Fulda, Germany

Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Fulda, Deutschland

author Bause Bause Hanswerner H

Quality Committee of the State Chamber of physicians Hamburg, previous Department of Anaesthesiology and Intensive Care Medicine, Asklepiosklinikum Altona, Hamburg, Germany

Qualitätsausschuss Ärztekammer Hamburg, ehemals Klinik für Anästhesiologie und operative Intensivmedizin, Asklepiosklinikum Altona, Hamburg, Deutschland

author Weiler Weiler Norbert N

Department of Anaesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany

Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Schleswig Holstein, Kiel, Deutschland

author Chop Chop Ines I

German Medical Association, Berlin, Germany

Bundesärztekammer, Berlin, Deutschland

author Waydhas Waydhas Christian C

Department of Trauma and Reconstructive Surgery, University Hospital Essen, Germany

Klinik für Unfall- und Wiederherstellungschirurgie, Universitätsklinikum Essen, Deutschland

author Spies Spies Claudia C

Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Germany

Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Charité – Universitätsmedizin Berlin, Deutschland

author German Medical Science GMS Publishing House

Düsseldorf

610 quality management intensive care medicine quality indicators peer review Qualitätsmanagement Intensivmedizin Peer Review Qualitätsindikatoren 20130624 2013071620130717 engl germ 1612-3174 11 GMS German Medical Science GMS Ger Med Sci 09 20130717PDF with attachments Qualitätsindikatoren sind elementare Bestandteile des Qualitätsmanagements. Die Qualitätsindikatoren für die Intensivmedizin der Deutschen Interndisziplinären Vereinigung für Intensivmedizin (DIVI) aus dem Jahre 2010 sind nun im Rahmen der geplanten Geltungsdauer überarbeitet und angepasst worden. Insgesamt wurde ein Indikator ersetzt und drei weitere zum Teil wesentlich überarbeitet. Der alte Indikator I „Oberkörperhochlagerung“ wurde durch den Indikator „Tägliche multiprofessionelle, klinische Visite mit Dokumentation von Tageszielen“ ersetzt und in den neu geschaffenen Indikator IV „Weaning und Maßnahmen zur Vermeidung von ventilatorassoziierten Pneumonien (kurz: Weaning/VAP Bundle)“ (VAP = ventilator-assoziierte Pneumonie) integriert, der auf ein Verringerung der VAP-Inzidenz abzielt. Der Indikator VIII „Dokumentation von strukturierten Angehörigengesprächen“ wurde weiter präzisiert. Der Indikator X „Leitung der Intensivstation durch einen Facharzt mit Zusatzbezeichnung Intensivmedizin, der keine anderen klinischen Aufgaben hat“ anhand der aktuellen Studienlage ebenfalls präzisiert. Die aktualisierten Qualitätsindikatoren sind Bestandteil der intensivmedizinischen Peer Reviews. Ihre nächste Aktualisierung ist für das Jahr 2016 geplant. 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</PlainText></TextGroup> “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 indic<TextGroup><PlainText>ator</PlainText></TextGroup> 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.</Pgraph></Abstract> <TextBlock language="en" linked="yes" name="Introduction"> <MainHeadline>Introduction</MainHeadline><Pgraph>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 <TextLink reference="1"></TextLink>. 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 <TextGroup><PlainText>inte</PlainText></TextGroup>rest 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:</Pgraph><Pgraph><UnorderedList><ListItem level="1"><Mark1>R</Mark1>elevant for a problem</ListItem><ListItem level="1"><Mark1>U</Mark1>nderstandable </ListItem><ListItem level="1"><Mark1>M</Mark1>easurable, with good validity and reliability</ListItem><ListItem level="1"><Mark1>B</Mark1>ehaviourable </ListItem><ListItem level="1"><Mark1>A</Mark1>chievable and feasible </ListItem></UnorderedList></Pgraph><Pgraph>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.</Pgraph><Pgraph>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% <TextLink reference="2"></TextLink>. </Pgraph><Pgraph>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.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Einleitung"> <MainHeadline>Einleitung</MainHeadline><Pgraph>Für eine Gültigkeit von 2 Jahren wurde 2010 die erste Version der intensivmedizinischen Qualitätsindikatoren für Deutschland publiziert <TextLink reference="1"></TextLink>. Damit war es erstmals gelungen, Qualitätsindikatoren für die operativen und konservativen intensivmedizinischen Bereiche in Deutschland zu erarbeiten. Die Akzeptanz der Qualitätsindikatoren ist sehr groß. Auf den intensivmedizinischen Kongressen ist das Interesse an den Qualitätsindikatoren und deren Umsetzung im Alltag anhaltend gewachsen. Die Erfahrungen aus den intensivmedizinischen Peer Reviews zeigen, dass die Qualitätsindikatoren einen hohen Umsetzungsgrad auf den Intensivstationen haben. Dies sind Belege dafür, dass die Qualitätsindikatoren die Anforderungen der RUMBA-Regel erfüllen:</Pgraph><Pgraph><UnorderedList><ListItem level="1"><Mark1>R</Mark1>elevant für das Problem</ListItem><ListItem level="1"><Mark1>U</Mark1>nderstandable (verständlich formuliert)</ListItem><ListItem level="1"><Mark1>M</Mark1>essbar sein, mit hoher Zuverlässigkeit und Gültigkeit</ListItem><ListItem level="1"><Mark1>B</Mark1>ehaviourable (veränderbar durch das Verhalten)</ListItem><ListItem level="1"><Mark1>A</Mark1>chievable and feasible (Erreichbar und durchführbar)</ListItem></UnorderedList></Pgraph><Pgraph>Die intensivmedizinischen Qualitätsindikatoren haben den Alltag auf den Intensivstationen qualitativ verändert. Das mag zum einen daran liegen, dass die Zahl der Qualitätsindikatoren auf eine handhabbare Größe von zehn begrenzt wurde, zum anderen mag ein Vorteil der intensivmedizinischen Qualitätsindikatoren darin liegen, dass die Kernprozesse des intensivmedizinischen Alltag darin abgebildet werden: Beatmung, antiinfektive Therapie, Analgesie, Sedierung und Delir-Behandlung, Ernährung, Hygiene, kontrollierte Hypothermie, und Angehörigenmanagement. Ferner findet sich das Strukturkriterium der Personalbesetzung einer Intensivstation als Indikator wieder. </Pgraph><Pgraph>Gelebte Qualität zu fördern bleibt der Anspruch der intensivmedizinischen Qualitätsindikatoren. Ohne die Messbarkeiten von Qualitäten lassen sich Veränderungen nicht darstellen. Französische Kollegen konnten anhand eines Score-Systems darstellen, welchen Umsetzungsgrad von verschiedenen Qualitätsdimensionen sie auf französischen Intensivstationen evaluiert haben <TextLink reference="2"></TextLink>. Die Autoren stellen dabei fest, dass im Median diese Qualitäten zu ca. 60% umgesetzt waren, wobei die jeweils besten Intensivstationen bezogen auf die untersuchten Qualitäten etwa einen Erfüllungsgrad von ca. 80% hatten. </Pgraph><Pgraph>Wenn man bei jedem Intensivmediziner die Intention voraussetzt, im Patienteninteresse, die Intensivmedizin bestmöglich zu organisieren, dann sind Maßnahmen, die dazu führen, die Patientenversorgung auf Intensivstationen zu optimieren, höchst willkommen. Dieses Ziel muss man bei der Erstellung von Qualitätsindikatoren vor Augen haben.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="International comparison of quality indicators in intensive care medicine"> <MainHeadline>International comparison of quality indicators in intensive care medicine</MainHeadline><Pgraph>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 <TextLink reference="3"></TextLink>. A five round Delphi-process with an agreement rate of at least 90% yielded the following indicators: <LineBreak></LineBreak><LineBreak></LineBreak>Structural indicators </Pgraph><Pgraph><UnorderedList><ListItem level="1">The intensive care unit fulfils national requirements to provide intensive care</ListItem><ListItem level="1">24-h availability of a consultant level intensivist </ListItem><ListItem level="1">Adverse event reporting-system</ListItem></UnorderedList></Pgraph><Pgraph>Process indicators</Pgraph><Pgraph><UnorderedList><ListItem level="1">Presence of routine multi-disciplinary clinical ward rounds </ListItem><ListItem level="1">Standardized hand-over procedure for patients discharge</ListItem></UnorderedList></Pgraph><Pgraph>Outcome-indicators</Pgraph><Pgraph><UnorderedList><ListItem level="1">Reporting and analysis of standardised mortality ratio (SMR)</ListItem><ListItem level="1">ICU re-admission rate within 48 h of ICU discharge</ListItem><ListItem level="1">Rate of central venous catheter-related blood stream infection</ListItem><ListItem level="1">Rate of unplanned endotracheal extubations </ListItem></UnorderedList></Pgraph><Pgraph>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 (<Mark1>KISS</Mark1>) (<Hyperlink href="http://www.nrz-hygiene.de/surveillance/kiss/">http://www.nrz-hygiene.de/surveillance/kiss/</Hyperlink>). 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. </Pgraph><Pgraph>We do not intend to diminish the relevance of these <TextGroup><PlainText>ind</PlainText></TextGroup>icators 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.</Pgraph><Pgraph>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 <TextLink reference="4"></TextLink>. 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 monit<TextGroup><PlainText>oring</PlainText></TextGroup> 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). </Pgraph><Pgraph>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 indic<TextGroup><PlainText>ators</PlainText></TextGroup> 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 <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>. 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 <TextLink reference="1"></TextLink>.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Intensivmedizinische Qualitätsindikatoren im internationalen Vergleich"> <MainHeadline>Intensivmedizinische Qualitätsindikatoren im internationalen Vergleich</MainHeadline><Pgraph>Eine Task Force on Safety and Quality der European Society of Intensive Care Medicine (ESICM) hat 2012 eine Liste von Indikatoren zur Verbesserung von Patientensicherheit und Qualität in der Intensivmedizin publiziert <TextLink reference="3"></TextLink>. Nach fünf Runden eines Delphi-Verfahrens hat man sich unter der Maßgabe eines mindestens 90%igen Konsensus auf folgende Indikatoren geeinigt:<LineBreak></LineBreak><LineBreak></LineBreak>Strukturindikatoren</Pgraph><Pgraph><UnorderedList><ListItem level="1">Die Intensivstation erfüllt nationale Standards der Intensivmedizin </ListItem><ListItem level="1">24-stündige Verfügbarkeit eines Fach-/Oberarztes mit Bezeichnung Intensivmedizin</ListItem><ListItem level="1">Ein „adverse event“-Reporting-System</ListItem></UnorderedList></Pgraph><Pgraph>Prozessindikatoren</Pgraph><Pgraph><UnorderedList><ListItem level="1">Multidisziplinäre Visiten auf der Intensivstation in der Routine</ListItem><ListItem level="1">Standardisiertes Verfahren (inklusive standardisierter Dokumentation) zur Überleitung von intensivmedizinischen Patienten auf Normalstationsbereiche. </ListItem></UnorderedList></Pgraph><Pgraph>Outcome-Indikatoren</Pgraph><Pgraph><UnorderedList><ListItem level="1">Report der standardisierten Mortalisätsrate (SMR)</ListItem><ListItem level="1">48-stündige Wiederaufnahmerate von Normalstation zurück auf eine Intensivstation</ListItem><ListItem level="1">Rate der katheterassoziierten Blutstrominfektionen</ListItem><ListItem level="1">Rate der ungeplanten Extubationen</ListItem></UnorderedList></Pgraph><Pgraph>Diese Europäischen Qualitäts- und Sicherheitsindikatoren beschreiben durchweg alltägliche Probleme bzw. Ereignisse. Bezogen auf deutsche intensivmedizinische Verhältnisse werden die SMR oder die 48 h-Wiederaufnahmerate im intensivmedizinischen Kerndatensatz der DIVI erfasst. Die Registrierung von katheterassoziierten Blutstrominfektionen ist u.a. Gegenstand des Krankenhaus-Infektions-Surveillance-Systems (<Mark1>KISS</Mark1>) (<Hyperlink href="http://www.nrz-hygiene.de/surveillance/kiss/">http://www.nrz-hygiene.de/surveillance/kiss/</Hyperlink>). Die Teilnahme an solchen Surveillance-Systemen setzt natürlich auch die technischen Übertragungsmöglichkeiten der Daten voraus, was mangels einheitlicher Standards in Krankenhäusern per se häufig als Problem genannt wird. Die Rate der ungeplanten Extubationen erscheint in der täglichen Messung technisch ebenfalls problembehaftet, zumal bei Zunahme von nicht-invasiven Beatmungen und unter Anwendung der Analgosedierungsleitlinien die Semantik des Begriffes „ungeplant“ nicht unkritisch zu bewerten ist. So darf es nicht Ziel einer Kennzahl „ungeplante Extubation“ sein, die Patienten wieder tief zu sedieren. </Pgraph><Pgraph>Es soll die Bedeutung der europäischen Indikatoren mit diesen kurzen Anmerkungen nicht geschmälert werden. Inhaltlich setzen diese Indikatoren Impulse für die Neuauflage der deutschen intensivmedizinischen Qualitätsindikatoren. Eine Redundanz von Kennzahlen, die aus unterschiedlichen Systemen in Deutschland erhoben werden, soll mit den Qualitätsindikatoren ebenfalls vermieden werden. </Pgraph><Pgraph>Für die deutschen intensivmedizinischen Qualitätsindikatoren der ersten Version von 2010 gilt folgendes: Im internationalen Vergleich sind die Prozessindikatoren in Deutschland „überrepräsentiert“. Im Vergleich mit sieben Ländern, die ebenfalls Qualitätsindikatoren in der Intensivmedizin erarbeitet haben, werden hauptsächlich Ergebnisindikatoren aufgeführt, wie z.B. standardisierte Mortalitätsrate (SMR), Reintubationsrate, Patientenzufriedenheit, Wideraufnahmerate, Beatmungsdauer oder Bettenbelegungsrate. Dagegen bilden sich in den deutschen intensivmedizinischen Qualitätsindikatoren eher Prozesse ab <TextLink reference="4"></TextLink>. Die Gesundheitssysteme in verschiedenen Ländern bieten der Intensivmedizin unterschiedliche Rahmenbedingungen. Die in den Qualitätsindikatorenlisten unserer europäischen Nachbarländer enthaltenen Outcome-Indikatoren sind beispielsweise zum Teil Gegenstand des deutschen intensivmedizinischen Kerndatensatzes (SMR und 48 h-Wiederaufnahmerate). Der „adverse event“-Indikator „Dekubitus-Rate“ wird als Generalindikator der Bundesgeschäftsstelle Qualitätssicherung gGmbH (BQS) bereits in den deutschen Krankenhäusern abgebildet. Inzidenz von nosokomialen Infektionen wie i.v.-Katheterinfektionen oder ventilatorassoziierten Pneumonien (VAP) sind Gegenstand der o.g. nationalen Surveillance-Systeme (KISS). </Pgraph><Pgraph>Die deutschen intensivmedizinischen Qualitätsindikatoren sind im Kontext gemeinsam mit anderen qualitätsverbessernden Verfahren und Systemen zu sehen und stellen bei dem großen Thema der Qualitätsverbesserung der intensivmedizinischen Versorgung der Patienten nur einen Teilaspekt dar. Redundanz mit bestehenden qualitätssichernden Systemen soll vermieden werden. Im pragmatischen Sinne muss es daher explizit als Stärke der deutschen Qualitätsindikatoren genannt werden, dass die Umsetzung der Qualitätsindikatoren auf den Intensivstationen unproblematisch und an keine tiefgreifenden Strukturveränderungen geknüpft ist, außer der Bereitschaft der Akteure, den intensivmedizinischen Alltag qualitativ zu verändern. Die Selbstbewertung wird durch die Qualitätsindikatoren ermöglicht ebenso wie die Fremdbewertung durch externe Peer Reviewer <TextLink reference="5"></TextLink>, <TextLink reference="6"></TextLink>. Es bleibt die Kernintention der Qualitätsindikatoren, die intensivmedizinischen Kernprozesse entsprechend der aktuellen intensivmedizinischen Evidenzlage zu verändern, damit evidenzbasierte „good practice“ schneller den Weg an das Krankenbett findet <TextLink reference="1"></TextLink>. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Development of the second edition of quality indicators for the ICU"> <MainHeadline>Development of the second edition of quality indicators for the ICU</MainHeadline><Pgraph>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 <TextGroup><PlainText>ind</PlainText></TextGroup>icators for intensive care medicine for publication. </Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Erstellung der zweiten Version der intensivmedizinischen Qualitätsindikatoren"> <MainHeadline>Erstellung der zweiten Version der intensivmedizinischen Qualitätsindikatoren</MainHeadline><Pgraph>Da sich die wissenschaftliche Evidenz mit der Zeit verändert, ist es notwendig, dass auch die Qualitätsindikatoren regelmäßig einer Prüfung unterzogen werden hinsichtlich ihrer Gültigkeit, der Verbesserung des Patienten-Outcomes zu dienen. Der nationalen Steuerungsgruppe für das intensivmedizinische Peer Review System ist durch die DIVI hierbei die Rolle zugeteilt worden, die Überarbeitung der intensivmedizinischen Qualitätsindikatoren in einem regelmäßigen zweijährigen Zyklus redaktionell zu übernehmen. Der Auftrag beinhaltete, die Zahl der bisherigen zehn Indikatoren nicht zu überschreiten, um die Praktikabilität im Alltag nicht durch eine große Zahl von Indikatoren zu behindern. Im Mai 2012 hat die Steuerungsgruppe begonnen das Verfahren der Überarbeitung der intensivmedizinischen Qualitätsindikatoren zu organisieren. Zunächst wurden die in der DIVI organisierten Fachgesellschaften angeschrieben mit der Bitte in den jeweiligen wissenschaftlichen Arbeitskreisen die Bearbeitung der Qualitätsindikatoren zu übernehmen. Im November 2012 wurden die Vorschläge aus den Fachgesellschaften zusammengetragen. Im Dezember wurde diese neue Vorschlagsliste überarbeitet und anschließend in einer weiteren Delphirunde erneut zur Überarbeitung vorgelegt. Im April wurden keine weiteren Änderungen mehr registriert. Die zweite Auflage der intensivmedizinischen Qualitätsindikatoren wurde im Mai 2013 durch Präsidiumsbeschluss der DIVI bestätigt und die Freigabe zur Publikation erteilt. </Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="The newly developed QI"> <MainHeadline>The newly developed QI</MainHeadline><Pgraph>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 <AttachmentLink attachmentNo="1"/> all indicators are presented in their final consented version.</Pgraph><SubHeadline>QI I – Daily multi-professional ward rounds with the documentation of daily therapy goals</SubHeadline><Pgraph>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 <TextLink reference="7"></TextLink>. 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. </Pgraph><Pgraph>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. </Pgraph><SubHeadline>QI II – Monitoring sedation, analgesia, delirium</SubHeadline><Pgraph>The QI II has not been changed. No new evidence regarding this topic has been published. The S3-Guideline is still in effect <TextLink reference="8"></TextLink>. Preliminary unpublished data from peer reviews show potential for improvement in this field in intensive care medicine. </Pgraph><SubHeadline>QI III – Lung protective ventilation</SubHeadline><Pgraph>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 <TextLink reference="9"></TextLink>. </Pgraph><SubHeadline>QI IV – Weaning and other measures to prevent ventilator associated pneumonias </SubHeadline><Pgraph>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. </Pgraph><Pgraph>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. </Pgraph><Pgraph>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:</Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">Elevation of the upper body more than 30° is only rarely achieved</ListItem><ListItem level="1" levelPosition="2" numString="2.">The necessary duration of elevation is unclear or if it even might interfere with other therapeutic or prophylactic measures (pressure ulcers etc.)</ListItem></OrderedList></Pgraph><Pgraph>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 aspira<TextGroup><PlainText>tion.</PlainText></TextGroup> 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 emphas<TextGroup><PlainText>ize</PlainText></TextGroup> avoidance of solely flatness. The other measures mentioned in the QI are examples which have been shown to be relevant for patient outcome. </Pgraph><Pgraph>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. </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">Weaning, measured from the patient file</ListItem><ListItem level="1" levelPosition="2" numString="2.">VAP-bundle, measured from the patient file and nursing documentation.</ListItem></OrderedList></Pgraph><SubHeadline>QI V – Early and adequate initiation of antibiotic therapy</SubHeadline><Pgraph>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. </Pgraph><Pgraph>Overall the application of antibiotic stewardship programmes in this context is recommended <TextLink reference="10"></TextLink>. 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 <TextLink reference="11"></TextLink>.</Pgraph><SubHeadline>QI VI – Therapeutic hypothermia after cardiac arrest </SubHeadline><Pgraph>This indicator has not been changed. The European guidelines have additionally been changed with regard to therapeutic hypothermia <TextLink reference="12"></TextLink>. 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. </Pgraph><SubHeadline>QI VII – Early enteral nutrition</SubHeadline><Pgraph>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. </Pgraph><SubHeadline>QI VIII – Documentation of structured relative-/next-of-kin communication</SubHeadline><Pgraph>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 defini<TextGroup><PlainText>tions</PlainText></TextGroup> 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. </Pgraph><SubHeadline>QI IX – Hand disinfectant consumption </SubHeadline><Pgraph>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. </Pgraph><SubHeadline>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</SubHeadline><Pgraph>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 <TextLink reference="13"></TextLink>. 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 Intensivmed<TextGroup><PlainText>izin</PlainText></TextGroup>, 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.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Die neuen intensivmedizinischen Qualitätsindikatoren für Deutschland"> <MainHeadline>Die neuen intensivmedizinischen Qualitätsindikatoren für Deutschland</MainHeadline><Pgraph>Wie schon bei der Publikation der ersten intensivmedizinischen Qualitätsindikatoren wird auch in der zweiten Version zu jedem Qualitätsindikator ein Kommentar präsentiert und im Anhang 1 <AttachmentLink attachmentNo="1"/> wird die Liste der derzeit gültigen Qualitätsindikatoren in der Originalversion dargestellt.</Pgraph><SubHeadline>QI I – Tägliche multiprofessionelle, klinische Visite mit Dokumentation von Tageszielen/eines Tagesziels</SubHeadline><Pgraph>Die tägliche Festlegung von Tageszielen im multiprofessionellen Team, welches mindestens aus ärztlichen und pflegerischen Mitarbeitern der Intensivstation besteht wurde erstmals von Pronovost et. al im Jahre 2003 publiziert <TextLink reference="7"></TextLink>. Seither sind einige Publikationen zu diesem Thema erschienen. Die „daily goal form“, die im Universitätsklinikum John Hopkins in Baltimore erstmals verwendet wurde, ist mittlerweile vielfach verwendet und in unterschiedlichen Krankenhäusern oder Regionen in modifizierter Form in den klinischen Alltag integriert worden. Die gemeinsame Festlegung von Tageszielen für den Patienten im Team verbessert nachweislich die Kommunikation des Behandlungsteams, macht die Behandlungsziele transparenter und erhöht die Patientensicherheit mit einem positiven Effekt auf das Patienten-Outcome. </Pgraph><Pgraph>Die Etablierung des neuen QI I auf den deutschen Intensivstationen wird zu tiefgreifenden Veränderungen in den Tagesabläufen führen. Die Standarddokumentationen, ob papiergestützt oder in elektronischer Form, werden nachhaltig verändert. Die Transparenz über Festlegungen wird steigen. Damit verbunden ist die Nachprüfbarkeit von erreichten Zielen. Eine solche nachhaltige Veränderung des Tagesablaufes von Intensivstationen erfordert die Aufmerksamkeit aller Beteiligten. Die Autoren empfehlen den Verantwortlichen der Intensivstationen diese Veränderungen in Form von Projekten umzusetzen. Den Anbietern von Dokumentationsprodukten für die Intensivmedizin wird nahe gelegt, Lösungen anzubieten, die das Prozessorientierte Arbeiten mit Tageszielen erleichtert. </Pgraph><SubHeadline>QI II – Monitoring von Sedierung, Analgesie und Delir</SubHeadline><Pgraph>Der QI II wurde unverändert übernommen. Die Evidenzlage hat sich zum diesem Thema nicht verändert. Die S3-Leitlinie ist weiterhin gültig <TextLink reference="8"></TextLink>. In noch nicht publizierten Auswertungen aus den intensivmedizinischen Peer Reviews ließ sich feststellen, dass bei der Umsetzung der Leitlinie noch erhebliches Verbesserungspotential besteht. </Pgraph><SubHeadline>QI III – Lungenprotektive Beatmung</SubHeadline><Pgraph>Gleiches wie für den QI II gilt auch für den QI III. Die Evidenzlage für die lungenprotektive Beatmung ist weiterhin hoch und die Umsetzung im klinischen Alltag leider immer noch niedrig ausgeprägt. Die Diskrepanz von theoretischem Wissen der Beteiligten und der Realisierung am intensivmedizinischen Beatmungsbett ist gut publiziert worden <TextLink reference="9"></TextLink>.</Pgraph><SubHeadline>QI IV – Weaning und Maßnahmen zur Vermeidung von ventilatorassoziierten Pneumonien </SubHeadline><Pgraph>Die umfangreichste Modifikation der neuen QIs hat im Indikator IV stattgefunden. Der alte QI I (Oberkörperhochlagerung) und der alte QI IV (Weaning) haben das gleiche Qualitätsziel verfolgt: die Reduktion der Inzidenz von ventilatorassoziierten Pneumonien (VAP). Die VAP ist ein wichtiges Intensivmedizinisches Krankheitsbild. In den USA ist die Vermeidung der VAP zu einem zentralen Qualitätsindikator geworden. Die Vergütung der durch VAP entstehenden Kosten einer Intensivstation wird hierbei u.a. in Frage gestellt.</Pgraph><Pgraph>Der positive Effekt des Weanings auf die VAP-Vermeidung liegt maßgeblich im Faktor Zeit begründet. Je schneller ein Patient von der Beatmung entwöhnt werden kann, desto geringer ist das Risiko einer ventilatorassoziierten Pneumonie. Das Weaning per se ist jedoch ein sehr komplexer Prozess und ist inhaltlich sehr stark verknüpft mit dem Sedierungskonzept einer Intensivstation. Die Vermeidung der Atrophie der Atemmuskulatur ist hierbei ein zentraler pathophysiologischer Faktor. Die leitlinienkonforme Analgosedierung ist Voraussetzung für erfolgreiches Weaning. Der Erfolg ist an sehr gut auf einander abgestimmte Standards gekoppelt. </Pgraph><Pgraph>Der positive Effekt der Oberkörperhochlagerung auf die VAP-Vermeidung kann nach heutigem Wissen nicht kommentarlos bestätigt werden. Die Studienlage ist dünn und die Umsetzung der Oberkörperhochlagerung ist im klinischen Alltag aus zwei Gründen nicht überprüfbar: </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">die Gradzahl von >/= 30° wird nur selten umgesetzt</ListItem><ListItem level="1" levelPosition="2" numString="2.">es ist nicht klar über welche Zeiträumer die Lagerung umgesetzt wird und welche anderen Maßnahmen (z.B. Dekubitus-Vermeidung) dadurch behindert werden.</ListItem></OrderedList></Pgraph><Pgraph>Die mangelhafte Praktikabilität ist als Ergebnis in vielen Peer Reviews belegt worden. Der Effekt der Oberkörperhochlagerung auf die VAP Vermeidung liegt in der physikalischen Verminderung von Reflux/Regurgitation aus dem oberen GI-Trakt, d.h. die Verminderung der Aspirationsrate ist die physiologische Endstrecke der Oberkörperhochlagerung. Mittlerweile konnte gezeigt werden, dass auch das Gegenteil von Oberkörperhochlagerung, nämlich die Kopftieflagerung ebenfalls zur Reduktion von Aspiration beiträgt. Wenn es jedoch hauptsächlich um die Vermeidung der Aspiration von pathogenen Erregern geht, gibt es viele Publikationen aus unterschiedlichen Ländern, die Maßnahmen zur Vermeidung von VAP (VAP Bundle) als effektiv beschreiben. Betrachtet man nur die Outcome-Ergebnisse bleiben einige Maßnahmen als VAP Bundle stehen, die Ihren positiven Effekt belegen können (Lagerungsprotokoll, Händedesinfektion bei Maßnahmen an den Atemwegen, Mundpflege und orale Dekontamination, Vermeidung oraler Aspiration z.B. durch Cuffdruckmessungen, subglottische Sekretabsaugung. Lagerung ist hierbei als Maßnahme zu verstehen, die das ausschließliche Flachlagern vermeidet und trägt damit zur Verminderung der VAP Inzidenz bei. Die anderen aufgeführten Maßnahmen sind exemplarisch zu verstehen, weil für jede Maßnahme jeweils ein outcomerelevanter Effekt gezeigt werden konnte</Pgraph><Pgraph>Die Komplexität der VAP Vermeidung haben die Autoren versucht zu ordnen, indem der Qualitätsindikator auf zwei Säulen beruht, die beide für sich betrachtet, nachprüfbare Prozesse im klinischen Alltag darstellen. </Pgraph><Pgraph><OrderedList><ListItem level="1" levelPosition="1" numString="1.">Weaning: nachprüfbar in der Patientenakte</ListItem><ListItem level="1" levelPosition="2" numString="2.">VAP-Bundle: Nachprüfbar in der Krankenakte, inklusive Pflegedokumentation</ListItem></OrderedList></Pgraph><SubHeadline>QI V – Frühzeitige und adäquate Antibiotikatherapie</SubHeadline><Pgraph>Die Inhalte dieses Indikators wurden nicht verändert, da sich die Evidenzlage hierzu nicht verändert hat. Es hat sich in Erfahrung der intensivmedizinischen Peer Reviews gezeigt, dass sich die Anwendung von Sepsis Bundles im Alltag als Herausforderung präsentiert. Das frühzeitige Erkennen von SIRS/Infektions-Zeichen beim Patienten und die adäquate Therapie mit Antiinfektiva stellen daher hohe Ansprüche an die Organisation der Intensivstation. Die Verwendung von "Antibiotic stewardship" Programmen wird hierbei empfohlen <TextLink reference="10"></TextLink>. Für die adäquate anitiinfektive Therapie ist ferner die Verwendung von Resistenzdaten von größter Bedeutung. Die Teilnahme an nationalen Surveillance-Programmen (KISS) ist dringend zu fordern und ist im intensivmedizinischen Alltag leider noch nicht in der Breite etabliert <TextLink reference="11"></TextLink>.</Pgraph><SubHeadline>QI VI – Therapeutische Hypothermie nach Herzstillstand</SubHeadline><Pgraph>Dieser Indikator ist nicht verändert worden. Die aktuelle europäische Leitlinie wurde diesbezüglich zuletzt ergänzt <TextLink reference="12"></TextLink>. Es scheint nicht zuletzt durch breit angelegte Kampagnen ein Bewusstsein für die Notwendigkeit von neuroprotektiven Maßnahmen zu existieren. Die Autoren halten es für sinnvoll, die Umsetzung des QI VI in den Krankenhäusern gesondert zu evaluieren, da das Ereignis Reanimation an Stichtagen, etwa bei einem Peer Review naturgemäß nur selten nachprüfbar ist. </Pgraph><SubHeadline>QI VII – Frühe enterale Ernährung</SubHeadline><Pgraph>Dieser Indikator wurde nicht verändert. In den vergangenen Jahren sind zahlreiche Publikationen zum Thema Ernährung von Intensivpatienten erschienen. Hierbei hat sich die Evidenz für die parenterale Ernährung verändert. Die frühe enterale Ernährung bleibt nach wie vor ein anzustrebendes Ziel. Insgesamt ist neben der Forderung die Ernährung auf „natürlichem“ Wege anzubieten die adäquate Nährstoffzusammensetzung und das Energieangebot für den Patienten zu beachten.</Pgraph><SubHeadline>QI VIII – Dokumentation von strukturierten Angehörigengesprächen</SubHeadline><Pgraph>Dieser Indikator wurde modifiziert. In Peer Reviews wurde beobachtet, dass die Dokumentation von Angehörigengesprächen auf Intensivstationen nicht befriedigend umgesetzt ist. Es fehlt die Zielorientierung, d.h. die Inhalte der Dokumentation lassen häufig nicht erkennen, welche Themen mit den Angehörigen besprochen wurden und welche gemeinsamen Festlegungen im (mutmaßlichen) Interesse des Patienten getroffen wurden. Es erschien daher notwendig, den Indikator zu differenzieren. Es wird deutlich, dass sich die Dokumentationsvorlagen auf den Intensivstationen den Erfordernissen dieses Indikators anpassen sollten.</Pgraph><SubHeadline>QI IX – Händedesinfektionsmittelverbrauch</SubHeadline><Pgraph>Dieser Indikator wurde unverändert übernommen. Die unzureichende Händedesinfektion im Alltag macht es notwendig, diesen Indikator weiterhin zu fokussieren. In den Peer Reviews wurde deutlich, dass eine Unsicherheit bei der Anwendung des Indikators besteht. Es muss hierbei wiederholt betont werden, dass die Erfassung der verbrauchten Menge von Händedesinfektionsmittel einer Intensivstation nicht ausreicht, um den Indikator zu erfüllen. Es geht konkret um den Bezug der Desinfektionsmittelmenge zu den Belegungstagen einer Intensivstation! Die im Indikator angegebene Bezugsgröße soll erfüllt werden, um der Maßgabe eines adäquaten Desinfektionsmittelverbrauchs gerecht zu werden.</Pgraph><SubHeadline>QI X – Leitung der Intensivstation durch einen Facharzt mit Zusatzbezeichnung Intensivmedizin, der keine anderen klinischen Aufgaben hat, Präsenz eines Facharztes mit Zusatzbezeichnung Intensivmedizin in der Kernarbeitszeit und Gewährleistung der Präsenz von intensivmedizinisch erfahrenem ärztlichem und pflegerischem Personal über 24 h</SubHeadline><Pgraph>Dieser Indikator wurde modifiziert. Die Evidenzlage zu den Inhalten dieses Indikators ist sehr hoch zu bewerten. Zur adäquaten Versorgung von intensivmedizinischen Patienten ist die 24-stündige Präsenz eines erfahrenen und qualifizierten pflegerischen und ärztlichen Teams notwendig. Die aktuelle Studienlage zeigt ferner, dass in der Kernarbeitszeit, d.h. in der Zeit, in der wichtige Entscheidungen im interdisziplinären Kontext zu treffen sind und die Verfügbarkeit aller Entscheidungsträger gegeben ist, die Präsenz eines Facharztes mit Zusatzbezeichnung (= erfahrener und qualifizierter Intensivmediziner) notwendig ist <TextLink reference="13"></TextLink>. Dieser präsente Intensivmediziner kann aber muss nicht identisch sein mit dem Leiter der Intensivstation. Der Leiter der Intensivstation darf keine anderen klinischen Aufgaben auf sich vereinen als die fachliche Leitung der Intensivstation. Der Leiter der Station kann ein Chefarzt oder ein leitender Oberarzt sein. Dies entspricht den Anforderungen der DIVI. Dieser Indikator legt inhaltlich ferner fest, dass die pflegerische Besetzung der Station bei beatmeten Patienten (hierzu müssen auch non-invasiv beatmete Patienten gerechnet werden) ein Verhältnis von einer Pflegekraft auf zwei Patienten nicht unterschreiten darf.</Pgraph></TextBlock> <TextBlock language="en" linked="yes" name="Notes"> <MainHeadline>Notes</MainHeadline><SubHeadline>Authorship</SubHeadline><Pgraph>Jan-Peter Braun and Oliver Kumpf contributed equally to this article.</Pgraph><SubHeadline>Competing interests</SubHeadline><Pgraph>The authors declare that they have no competing interests.</Pgraph></TextBlock> <TextBlock language="de" linked="yes" name="Anmerkungen"> <MainHeadline>Anmerkungen</MainHeadline><SubHeadline>Autorenschaft</SubHeadline><Pgraph>Jan-Peter Braun und Oliver Kumpf haben zu diesem Artikel in gleichem Maße beigetragen.</Pgraph><SubHeadline>Interessenkonflikte</SubHeadline><Pgraph>Die Autoren erklären, dass sie keine Interessenkonflikte in Zusammenhang mit diesem Artikel haben.</Pgraph></TextBlock> <References linked="yes"> <Reference refNo="1"> <RefAuthor>Braun JP</RefAuthor> <RefAuthor>Mende H</RefAuthor> <RefAuthor>Bause H</RefAuthor> <RefAuthor>Bloos F</RefAuthor> <RefAuthor>Geldner G</RefAuthor> <RefAuthor>Kastrup M</RefAuthor> <RefAuthor>Kuhlen R</RefAuthor> <RefAuthor>Markewitz A</RefAuthor> <RefAuthor>Martin J</RefAuthor> <RefAuthor>Quintel M</RefAuthor> <RefAuthor>Steinmeier-Bauer K</RefAuthor> <RefAuthor>Waydhas C</RefAuthor> <RefAuthor>Spies C</RefAuthor> <RefAuthor> NeQuI (quality network in intensive care medicine)</RefAuthor> <RefTitle>Quality indicators in intensive care medicine: why? 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