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CHAPTER 6: Assessing Cost-Effectiveness in the Intensive Care Unit 37

them to improve care and should also be scalable—able to be aggregated
to the health system, state, and national levels. For example, CLABSI • Pronovost PJ, Goeschel CA, Marsteller JA, et al. Framework
for patient safety research and improvement. Circulation.
can be reported at an intensive care unit level, hospital level, or state/
national level. 4 2009;119(2):330-337.
With the demand to improve patient safety increasing within • Pronovost PJ, Holzmueller CG, Martinez E, et al. A practical tool
health care organizations, many hospitals have responded by creating to learn from defects in patient care. Jt Comm J Qual Patient Saf.
scorecards to evaluate and share progress in improving quality and 2006;32(2):102-108.
safety. 55,56 Within the critical care unit, a quality and safety scorecard • Pronovost PJ, Rosenstein BJ, Paine L, et al. Paying the piper:
is attractive because hospital leaders, clinicians, and other stakehold- investing in infrastructure for patient safety. Jt Comm J Qual
ers can quickly obtain a broad overview of patient safety performance Patient Saf. 2008;34(6):342-348.
across different measures, either over time or relative to a benchmark. • Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rigorous
These scorecards may include measures required by the CMS, The measurement, and collaboration to eliminate central catheter-
Joint Commission, and insurers, as well as measures developed by associated bloodstream infections. Crit Care Med. 2010;38(8
individual hospitals for local improvement. Such an ICU safety score- suppl):S292-S298.
card may be a valid and practical tool to track progress of a unit’s
efforts to improve patient safety and answer the question “How safe • Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The
is my ICU?” 57 daily goals communication sheet: a simple and novel tool for
Berenholtz and colleagues have described a model for such an improved communication and care. Jt Comm J Qual Patient Saf.
57
ICU scorecard to assist in measuring and monitoring patient safety. This 2008;34(10):608-613.
scorecard can be applied to an individual ICU or aggregated for an indi- • Winters B, Custer J, Galvagno SM Jr, et al. Diagnostic errors in the
vidual hospital, health system, state, or country. Outcome measures are intensive care unit: a systematic review of autopsy studies. BMJ
stratified into two categories. One category uses valid rate-based mea- Qual Saf. 2012;21(11):894-902.
sures to evaluate: How often do we harm patients? (outcome measure) • Winters BD, Gurses AP, Lehmann H, et al. Clinical review: checklists—
and How often do we provide the interventions that patients should translating evidence into practice. Crit Care. 2009;13(6):210.
receive? (process measure). The second category includes measures
that we cannot express as valid rates: How do we know we learned from
defects? (structural measure) and How well have we created a culture REFERENCES
of safety? (context measure). Note that these measures move the focus
away from using mortality rates, a very imperfect outcome measure for Complete references available online at www.mhprofessional.com/hall
evaluating quality and safety concerns. 58
The first step in developing a safety scorecard to measure and moni-
tor safety in the ICU is to convene a multidisciplinary panel, which may
include senior and departmental leaders, physicians, nurses, and rep-
resentatives from departments of performance improvement/quality CHAPTER Assessing Cost-Effectiveness
assurance, hospital epidemiology, and information systems. The second
step is to gain consensus about measures that should be included on the 6 in the Intensive Care Unit
safety scorecard. There are several potential measures for each domain
on the scorecard, which should be selected based on the answers to three David J. Wallace
questions: Are the measures important? Are the measures valid? Can we Derek C. Angus
use these measures to improve patient safety in our organization? This
55
framework is based on the premise that the goal of the scorecard is to
monitor progress in improving patient safety over time or relative to a KEY POINTS
benchmark, thus pushing the organization to stop conceptualizing safety
as a dichotomous variable (safe or unsafe) and start viewing safety as a • Critical care is expensive for patients, hospitals, and society.
continuous variable (is it improving?). • Both overall health care expenditures and the proportion dedi-
cated to critical care are increasing.
• Cost-effectiveness studies are an important component of critical
care valuation, both for new and existing therapies.
KEY REFERENCES
• Market forces alone cannot be expected to result in optimal pub-
• Berenholtz SM, Lubomski LH, Weeks K, et al. Eliminating central lic health—policies informed by cost-effectiveness contribute to
line-associated bloodstream infections: a national patient safety improve critical care delivery and efficiency.
imperative. Infect Control Hosp Epidemiol. 2014;35(1):56-62.
• Berenholtz SM, Pustavoitau A, Schwartz SJ, Pronovost PJ. How
safe is my intensive care unit? Methods for monitoring and mea- Pluck the goose so as to obtain the most feathers
surement. Curr Opin Crit Care. 2007;13(6):703-708. with the least hissing.
• Martinez EA, Donelan K, Henneman JP, et al. Identifying mean- —Jean-Baptiste Colbert,
ingful outcome measures for the intensive care unit. Am J Med Minister of Finance to King Louis XIV of France
Qual. 2014;29(2):144-152.
• Pronovost P, Weast B, Rosenstein B, et al. Implementing and vali- Critical care medicine is expensive for patients, hospitals, and soci-
dating a comprehensive unit-based safety program. J Patient Saf. ety. In 2005, Medicare and Medicaid costs for critical care were $81.7
2005;1(1):33-40. billion, accounting for 4.1% of national health expenditures and 0.66%
1
• Pronovost PJ, Berenholtz SM, Needham DM. Translating evidence of the gross domestic product. The scale of critical care delivery is also
into practice: a model for large scale knowledge translation. BMJ. expanding, with an increasing number of hospital beds allocated to inten-
2008;337:a1714. sive care, increasing number of patient days spent in intensive care units
(ICUs), and increasing occupancy rates. These two factors, growing
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