Keep an Eye on Costs

(1)

Keep an eye on costs

Keep

an

Eye

on

Costs

(Erasmus

Room)

Tuesday 24 March 2009

Manu Malbrain

Intensive

Care

Unit

ZiekenhuisNetwerk Antwerpen

Campus

Stuivenberg

Antwerpen,

Belgium

Pulsion Session

(2)

2 Manu Malbrain

• ICU Director and manager ZNA STER

• Founding President WSACS (www.wsacs.org)

• Chairman WCACS 2007 (www.wcacs.org)

• Educational Grant: 2003 ESICM Chris Stoutenbeek Award

• Member Medical Advisory Board

– Pulsion Medical

Systems

– KCI

Benelux

– Spiegelberg

– Holtech

Medical

– Neutec

• European Patent Holder CiMON (PMS)

• Research Project: Draeger, Edwards, Bard, Wolfe Tory

• Fees

‐

Honoraria: GSK, MSD

Biggest Bias = WSACS

Thanks to F. Michard

(3)

WSACS

Jan De Waele, B CTWG

Zsolt Baogh, AUS Secretary WCACS

Michael Sugrue, AUS President

Manu Malbrain, B Founding President

Treasurer

Rao Ivatury, USA Vice-President

Mike Cheatham, USA President-Elect

WSACS Executive Committee 2007-2009: Your Servants…

(4)

4 €3500

Costs a lot

No teaching

Self development

Costs Nothing

A lot of teaching

Self development

MANAGEMENT SCHOOL

(5)

Who actually uses

less invasive HD

(6)

What type

of

LIHD?

‐

NiCO

₂

‐

LiDCO

‐

PiCCO

‐

Doppler

‐

Vigileo

(7)

7

0

5

10

15

20

25

30

35

40

45

50 %

Intermittent

PAC

Continuous

PAC

Doppler

Pulse Contour

Other

Neil 2003

Availability of Cardiac Output

Equipment in UK ICU’s

Availability of Cardiac Output

Equipment in UK ICU’s

(8)

8 Ideal

System

Ideal

System

Real Time beat to beat CO

Real Time Preload + Afterload

Adequacy data

Real

Time

beat

to

beat

CO

Real

Time

Preload

+

Afterload

Adequacy

data

Minimally invasive

Widely applicable

Minimally

invasive

Widely

applicable

Simple to Operate and Understand

Measured variables

Simple

to

Operate

and

Understand

Measured

variables

Clear Data Display + Interpretation

Clear

Data

Display

+

Interpretation

Nurse driven at the bedside

Nurse

driven

at

the

bedside

Neonates to adults

Neonates

to

adults

Ideal Cardiac Output Monitor

(9)

9 LiDCO

LiDCO

NiCO

2 NiCO

2 CEDVi

CEDVi

Monitor

PiCCO

Tonometer

Evita 4

HemoSonic

Ideal Situation ?

Why $AV€ costs?

(10)

10 • Risen

by

329%/

20 years

• 30%

of

ICU

patients

• Carries

a

high

mortality

• Most

common

cause

of

death

in

ICU

• Worldwide

1400

deaths/day

• In

the

TOP

‐

league

of

death

causes

SEPSIS cost implications

(11)

11 HOS mortality n(%)

ICU mortality n(%)

Admissions

Severe

sepsis

or

septic

shock

Total 21,025

Total 6,534 (31.1%)

Total 8,372 (39.8%)

ICNARC 6 month Raw data, prior to adjustment

for 65% submission, 70% admission

a UK perspective

(12)

12 Lung

1 _Colon

2 _Breast

3 _Sepsis

4 cancers

1,2,3_{www.statistics.gov.uk,,} 4_{Intensive Care National Audit Research Centre (2005)}

0

5

10

15

20

25

30

35 Lung

Colon

Breast

Sepsis

a UK perspective

(13)

13

(14)

(15)

15 LiDCO

LiDCO

NiCO

2 NiCO

2 CEDVi

CEDVi

Monitor

PiCCO

Tonometer

Evita 4

HemoSonic

Ideal Situation ?

How to $AV€ costs?

(16)

16 CO$T$ FOR KNOWL€DG€

0 5000 10000 15000 20000 25000 device PiCCO LiDCO NiCO2 HemoSonic CEDVI 0 50 100 150 200 250 300 350 400 450 500 device PiCCO Lidco NiCO Hemosonic CEDVI 0 1 2 3 4 5 6 7 device PiCCO Lidco NiCO Hemosonic CEDVI 0 5 10 15 20 25 device PiCCO Lidco NiCO Hemosonic CEDVI

DEVICE

SET-UP

MEASURE

_DAY

(17)

17

0

100

200

300

400

500

600 -1

1

3

5

7

9

11

13

15 Time (days)

C

o

s

t (

€

) .

PiCCO

LiDCO

NiCO2

HemoSonic

CEDVI

(18)

18 Cumulative Cost (€)

0

500 1000

1500

2000

2500

3000

3500

4000

1

2

3

4

5

6

7

8

9 10 11 12 13 14 15

Time (days)

CEDVI

LiDCO

PiCCO

NiCO2

HemoSonic

PAC

PiCCO

LiDCO

Malbrain M. Yearbook ISICEM 2005: 603-31

(19)

19 SCORES

0% 10% 20% 30% 40% 50% 60% 70% 80% Cost PiCCO Lidco NiCO Hemosonic CEDVI Effectiveness

CO$T

€FF€CT

_€FF€CT

0% 10% 20% 30% 40% 50% 60% 70% Cost-Effectiveness PiCCO LiDCO NiCO HemoSonic CEDVI

(20)

20 LiDCO

_PiCCO

NiCO

HEMOSONiC

CO$T

€FF€CT

RATiO

Malbrain M. Yearbook ISICEM 2005: 603-31

(21)

21 How

to

be

More

Cost

Effective?

n

$P€ND MOR€

MORE

COSTS

=

MORE

EFFECTIVE

?

o

$AV€ MOR€

LESS

COSTS

=

MORE

EFFECTIVE

?

p

$€€ MOR€

(22)

How

to

be

more

cost

effective

$€€

MOR€

THAN

OTH€RS

$€€ MOR€

(23)

23 $€€

MOR€

THAN

OTH€RS

n

_o

p

q

r

(24)

24 THE MORE YOU LOOK

THE MORE YOU SEE

THE MORE YOU LEARN

THE MORE YOU KNOW

$€€

MOR€

THAN

OTH€RS

TO SEE MORE

WHAT YOU KNOW

n

_o

p

q

r

YOU WILL LEARN

TODAY

(25)

25 MAP=51

CI=2.1

LACTATE=6

CVP=5

PAOP=7

GEDVi=580

P/F=179

EVLWi=21

$€€

MOR€

THAN

OTH€RS

(26)

26 MAP=51

CI=2.1

LACTATE=6

(27)

27 PAOP=25

GEDVi=575

P/F=124

After Thoracocenthesis 1050mL

EVLWi=8

Pleural effusions

Atelectasis

Hemorrhage

Herniation

Diaphragm

Pleural pressure ?

PEEP ? - IAP ?

Cardiac compliance?

Lung compliance?

$€€

MOR€

THAN

OTH€R$

(28)

28 • Fick

– Difficult, large room for

error, “Gold” standard

– NiCO

2 • Bioimpedance

– Variable ICU accuracy

– Cardiodynamics

• Doppler

– Accurate, but user

dependent

– HemoSonic, Deltex, WAKI

• Pulse

Contour

Analysis

– PiCCO

– PulseCO

– Vigileo

• Thermodilution

– Vigilance PAC, CEDVi

– (PiCCO)

• Indicator

Dilution

– Invasive

– (LiDCO)

Available technologies for

continuous Cardiac Output

Available technologies for

continuous Cardiac Output

(29)

29 Evidence Based Medicine

n

Does

my new monitoring

device does

as

well as

the

gold

standard?

o

Does

my new monitoring

device give

new or additional information?

p

Does

the

interpretation of

the

data

change my treatment?

q

Does

the

new

‐

variable

‐

driven treatment

change patient outcome?

SV

GEDVi

EVLWi

DO

₂

$€€

MOR€

THAN

OTH€RS

(30)

30 The

Parachute

Study

Gordon C S Smith, Jill P Pell BMJ 2003; 327:1459-60

• Widely used

• Gravitational challenge

9 Prevent death

9 Prevent injury

• Adverse effects

9 Failure

9 Iatrogenic

• Studies free fall

9 no 100% mortality

• Widely used

• Gravitational challenge

9 Prevent death

9 Prevent injury

• Adverse effects

9 Failure

9 Iatrogenic

• Studies free fall

9 no 100% mortality

WHAT DO WE KNOW

_{WHAT THIS STUDY ADDS}

• No RCCT on parachute

• Basis for parachute use

9 Purely observational

• Efficacy explained by

9 Healthy cohort

• He who believes in EBM

9 Comes down

9 to earth

9 with a bump…

• No RCCT on parachute

• Basis for parachute use

9 Purely observational

• Efficacy explained by

9 Healthy cohort

• He who believes in EBM

9 Comes down

9 to earth

(31)

31 $€€ MOR€ THAN OTH€R$

SV

GEDVi

_EVLWi

(32)

32 Improve Outcome

Use the right parameters

FLOW

PRELOAD

ORGAN

O

₂

XYGEN

(33)

33 Improve Outcome

Use the right parameters

FLOW

PRELOAD

ORGAN

O

₂

XYGEN

SV/CO

GEDVi/SVV

PPV/SVRi

dPmax

GEF/EVLWi

S

_cv

VO

₂

VO

₂

/DO

₂

(34)

34 ARE

YOU

GETTING

ENOUGH

FOR

(35)

35 WiTH

LeSS

WiTH

LeSS

Do

MoRE

Do

(36)

36 $€€ MOR€ THAN OTH€R$

(37)

SV/CO

(38)

38 Landmark PAPER

Landmark PAPER

(39)

Optimisation PROTOCOL

• Using

a

PAC

does

not

alter

outcome

• Protocolised care

affects

outcome

– Postop complications

↓

– ICU

and

HOS

stay

↓

– Total

cost

↓

(40)

40 SV/CO

SV/CO

Control

group

Protocol

group

Control

group

Protocol

group

Control

group

Protocol

group

Control

group

Protocol

group

Sinclair

Wakeling

_Wakeling

McKendry

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.

Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory status after cardiac surgery.

British Medical Journal 2004; 329(7460): 258.

McKendry M, McGloin H, Saberi D, Caudwell L, Brady AR, Singer M.

Randomised controlled trial assessing the impact of a nurse deli

Randomised controlled trial assessing the impact of a nurse delivered, flow monitored protocol for optimisation of circulatory svered, flow monitored protocol for optimisation of circulatory status after cardiac surgery.tatus after cardiac surgery.

British Medical Journal 2004; 329(7460): 258.

(41)

41 SV/CO

SV/CO

McKendry BMJ 2004; 329: 258

McKendry

(42)

42 SV/CO

SV/CO

• 174 CABG pts analysed

• Protocol: SVI > 35 ml/m

2 • Postop complications:

26 (2 deaths) vs.

17 (4 deaths)

• HOS stay reduced

from 13.9 to 11.4 days

• HOS bed days reduced: 18%

• ICU bed usage reduced: 23%

McKendry BMJ 2004; 329: 258

McKendry

BMJ 2004; 329: 258

(43)

43 Sinclair S et al. British Medical Journal 1997; 315(7113): 909-12

Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture

Sinclair S et al.

British Medical Journal 1997; 315(7113): 909

-

12

12 Intraoperative

Intraoperative

intravascular volume optimisation and length of hospital stay a

fter repair of proximal femoral fracture

SV

Flow

_Flow

CO

_CO

40 patients

Hip replacement

40 patients

Hip replacement

(44)

44 Sinclair S, James S, Singer M

British Medical Journal 1997; 315(7113): 909-12

Sinclair S, James S, Singer M

British Medical Journal 1997; 315(7113): 909

-

12

12 HOS

_ac

HOS

_ac

Discharge

_time

HOS

_HOS

_tot

40 patients

Hip replacement

40 patients

(45)

45 Wakeling HG et al. Br J Anaesth 2005: 95(5): 634-42

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery

Wakeling

HG et al. Br J

Anaesth

2005: 95(5): 634

-

42

42 Intraoperative

Intraoperative

oesophageal Doppler guided fluid management shortens postoperat

ive hospital stay after major bowel surgery

(46)

46 $€€ MOR€ THAN OTH€R$

SV

(47)

47 Control

group

Protocol

group

Control

group

Protocol

group

Control

group

Protocol

group

Control

group

Protocol

group

PRELOAD

Lopes/Angus

Göpfert

_Göpfert

Csontos

(48)

48 Göpfert MS, Reuter DA, Akyol D, Lamm P, Kilger E, Goetz AE.

Goal-directed fluid management reduces vasopressor and catecholamine use in cardiac surgery patients

.

Intensive Care Med 2007; 33: 96-103

Göpfert

MS, Reuter DA,

Akyol

D,

Lamm

P,

Kilger

E, Goetz AE.

Goal

-

directed fluid management reduces

vasopressor

and catecholamine use in cardiac surgery patients

.

Intensive Care Med 2007; 33: 96

-

103

103 GEDVi

GEDVi

Less pressors

80 CABG

patients

80 CABG

patients

(49)

49 Lopes MR, Oliveira MA, Pereira VO, Lemos IP, Auler JO Jr, Michard F.

Goal-directed fluid management based on pulse pressure variation monitoring during high risk surgery

Crit Care 2007;11(5):

R100

Lopes MR, Oliveira MA, Pereira VO,

Lemos

IP,

Auler

JO

Jr

,

Michard

F.

F. Goal

Goal

-

directed fluid management based on pulse pressure variation moni

toring during high risk surgery

Crit

Care 2007;11(5):

R100

Less complications

33 patients

High risk surgery

33 patients

High risk surgery

Shorter stay

PPV

(50)

50 Csontos C, Foldi V, Fischer T, Bogar L.

Arterial thermodilution in burn patients suggests a more rapid fluid administration during early resuscitation.

Acta Anaesthesiol Scand 2008; 52:742-9

Csontos

C,

Foldi

V, Fischer T,

Bogar

L.

L. Arterial

Arterial

thermodilution

in burn patients suggests a more rapid fluid administration dur

ing early resuscitation.

Acta

Anaesthesiol

Scand 2008; 52:742

-

9

9 Less MOF

Less MOF

24 patients

>15% TBSA burns

24 patients

>15% TBSA burns

Higher S

_cv

O

₂

Higher S

_cv

O

₂

ITBVi

(51)

51 $€€ MOR€ THAN OTH€R$

SV

(52)

52 Control

group

Protocol

group

Control

group

Protocol

group

ORGAN FUNCTION

Mitchell JP et al. Am Rev Respir Dis 1992; 145(5): 990-8

Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization

.

Mitchell JP et al. Am Rev

Respir

Dis

1992; 145(5): 990

-

8

8 Improved outcome based on fluid management in critically ill pat

Improved outcome based on fluid management in critically ill pat

ients requiring pulmonary artery catheterization

.

PROTOCOL

52 patients

EVLWi

Fluid resitriction

PROTOCOL

52 patients

EVLWi

Fluid resitriction

CONTROL

49 patients

PAOP

CONTROL

49 patients

PAOP

Mitchell

EVLWi

(53)

53 $€€ MOR€ THAN OTH€R$

SV

GEDVi

_EVLWi

(54)

54 DO

₂

DETERMINANTS

DO

₂

(55)

55 DO

₂

DO

₂

Direct COSTS

“…a very small investment for a much greater return…”

(56)

56 SvO

₂

DETERMINANTS

SvO

₂

(57)

SvO

₂

(58)

58 S

_cv

O

₂

S

_cv

O

₂

Rivers

(59)

59 Control

group

Protocol

group

Control

group

Protocol

group

OXYGENATION

Rivers E. et al. N Engl J Med 2001; 345(19): 1368-77

Early goal-directed therapy in the treatment of severe sepsis and septic shock

Rivers E. et al. N

Engl

_Engl

J Med 2001; 345(19): 1368

_{J Med 2001; 345(19): 1368}

-

_-

77 ₇₇

Early goal

-

directed therapy in the treatment of severe sepsis and septic sh

ock

PROTOCOL

130 patients

EGDT

PROTOCOL

130 patients

EGDT

CONTROL

133 patients

standard

CONTROL

133 patients

standard

S

_cv

O

₂

S

_cv

O

₂

Rivers

(60)

60 RCCT’s showing benefit

RCCT’s showing benefit

EBM = 17 RCCT’s

(61)

61 $€€ MOR€ THAN OTH€R$

SV

GEDVi

_EVLWi

(62)

62 YOU NEED TO $P€ND TO…

SAVE LIVES

SAVE

TIME

_MONEY

$AV€

SEE MORE

(63)

63 YOU NEED TO $P€ND TO…

(64)

64 YOU NEED TO $P€ND TO…

(65)

65 YOU NEED TO $P€ND TO…

(66)

(67)

67 Hospital LOS reduction

Hospital LOS reduction

Savings per patient (€)

_{Savings per patient (€)}

1740

2400

1200

1500

1260

200 200 200 200 200

1540

2200

1000

1300

1060

Net Savings/patient (€)

(68)

(69)

69 WiTH PiCCO

2 YOU

$€€ MOR€ THAN OTH€R$

SV

GEDVi

_EVLWi

(70)

70 YOU NEED TO $P€ND TO…

SAVE LIVES

SAVE

TIME

_MONEY

$AV€

SEE MORE

(71)

71 The

bottom

line

is…

Join the WSACS clinical trials working group

Leave your e-mail at WSACS Booth!

(72)

It

is

time

to

pay

attention

www.wsacs.org

June 25-27, 2009

ACS

Update

‐

workshop

ISICEM

– Brussels

23 march

2009

www.intensive.org

Visit the WSACS Booth 11.002!

(73)

73 Join

WSACS

‐

Information

www.wsacs.org

Visit the WSACS Booth: 11.002

www.wsacs.org

Main Entrance HALL 11