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[english] Introduction: Quality improvement and safety in intensive care are rapidly evolving topics. However, there is no gold standard for assessing quality improvement in intensive care medicine yet. In 2007 a pilot project in German intensive care units (ICUs) started using voluntary peer reviews as an innovative tool for quality assessment and improvement. We describe the method of voluntary peer review and assessed its feasibility by evaluating anonymized peer review reports and analysed the thematic clusters highlighted in these reports.Methods: Retrospective data analysis from 22 anonymous reports of peer reviews. All ICUs – representing over 300 patient beds – had undergone voluntary peer review. Data were retrieved from reports of peers of the review teams and representatives of visited ICUs. Data were analysed with regard to number of topics addressed and results of assessment questionnaires. Reports of strengths, weaknesses, opportunities and threats (SWOT reports) of these ICUs are presented. Results: External assessment of structure, process and outcome indicators revealed high percentages of adherence to predefined quality goals. In the SWOT reports 11 main thematic clusters were identified representative for common ICUs. 58.1% of mentioned topics covered personnel issues, team and communication issues as well as organisation and treatment standards. The most mentioned weaknesses were observed in the issues documentation/reporting, hygiene and ethics. We identified several unique patterns regarding quality in the ICU of which long-term personnel problems und lack of good reporting methods were most interestingConclusion: Voluntary peer review could be established as a feasible and valuable tool for quality improvement. Peer reports addressed common areas of interest in intensive care medicine in more detail compared to other methods like measurement of quality indicators.

[english] 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 indic “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 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.[german] 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.

We present a novel computational model for the dynamics of alveolar recruitment/derecruitment (RD), which reproduces the underlying characteristics typically observed in injured lungs. The basic idea is a pressure‐ and time‐dependent variation of the stress‐free reference volume in reduced dimensional viscoelastic elements representing the acinar tissue. We choose a variable reference volume triggered by critical opening and closing pressures in a time‐dependent manner from a straightforward mechanical point of view. In the case of (partially and progressively) collapsing alveolar structures, the volume available for expansion during breathing reduces and vice versa, eventually enabling consideration of alveolar collapse and reopening in our model. We further introduce a method for patient‐specific determination of the underlying critical parameters of the new alveolar RD dynamics when integrated into the tissue elements, referred to as terminal units, of a spatially resolved physics‐based lung model that simulates the human respiratory system in an anatomically correct manner. Relevant patient‐specific parameters of the terminal units are herein determined based on medical image data and the macromechanical behavior of the lung during artificial ventilation. We test the whole modeling approach for a real‐life scenario by applying it to the clinical data of a mechanically ventilated patient. The generated lung model is capable of reproducing clinical measurements such as tidal volume and pleural pressure during various ventilation maneuvers. We conclude that this new model is an important step toward personalized treatment of ARDS patients by considering potentially harmful mechanisms—such as cyclic RD and overdistension—and might help in the development of relevant protective ventilation strategies to reduce ventilator‐induced lung injury (VILI). [ABSTRACT FROM AUTHOR]

Intestinal edema remains a serious clinical problem, and novel approaches to study its pathophysiology are needed. It was our aim to develop a long-term stable isolated perfused rat small bowel preparation permitting analysis of vascular, luminal, interstitial, and lymphatic compartments and to demonstrate the utility of this model by studying the effects of the proinflammatory mediator platelet-activating factor (PAF). A temperature-controlled chamber with an integrated balance was designed to perfuse isolated intestines through the mesenteric artery and the gut lumen. Steroids or oxygen carriers were not needed. Functional and morphological integrity of the tissue was preserved for several hours as confirmed by oxygen consumption, venous lactate-to-pyruvate ratio, arterial and venous pH, lactose digestion and galactose uptake, intravascular and luminal pressures, maintained fluid homeostasis, gut motility, and quantitative light microscopic analysis. Administration of PAF caused typical effects such as vasoconstriction, gut atony, and loss of galactose uptake. PAF also elicited a transient loss of 20% of the perfusate liquid from the mesenteric vascular bed, two-thirds of which were transferred to the lumen. All these responses were entirely reversible. This new model provides detailed insights into the physiology of the small intestine and will allow to study fundamental processes such as fluid homeostasis, barrier functions, transport mechanisms, and immune responses in this organ. Using this model, here we show a dramatic and yet reversible response of the rat small bowel to PAF, suggesting luminal water clearance as a novel safety factor in the intestine that may be of clinical relevance. intestine physiology; fluid balance; platelet-activating factor doi: 10.1152/ajpgi.00313.2009