In medicine the benefits of treatment are always weighed against possible harms. In these times of budgetary constraints financial considerations also come even more into focus. Costeffectiveness in medicine works at many levels. In clinical trials the cost of quality-adjusted life years (QALYs) may be one of the outcomes measured. At a department or hospital level, directors need to consider the cost-effectiveness of staffing, procedures or prescribing practices, for example. Cost-effectiveness is pertinent when looking at introducing new treatments, but it is also a tool to evaluate existing treatments and procedures.
In the first article in our cover story Diana Lebherz-Eichinger, Barbara Gutenbrunner, Albert Reiter, Georg A. Roth, Christian J. Herold and Claus Krenn write about their study of the economic impact of omitting routine chest radiographs (CXR) in a university ICU. They also conducted a prospective observational micro-costing exercise to identify the current costs of radiodiagnostic pathways, and compared the CXR cost calculation between a university hospital and a regional hospital ICU. They argue that routine procedures should be evaluated on their contribution to diagnosis, economic aspects and the patients’ benefit, and that cost calculations should be regularly adapted to reflect reality. Staying with imaging, next Diku Mandavia argues the case for ultrasound-guided needle procedures. He explains that ultrasound guidance may significantly reduce serious adverse events and the cost of care in patients.
In the Matrix section, Maarten Nijsten and Jan Bakker explain that the use of lactate measurements in critically ill patients is at a level where in some cases it may be considered lactate monitoring. They discuss the central metabolic role of lactate in animal metabolism, why lactate is mainly a marker of stress and how this translates into its unique diagnostic utility in many acute conditions. They also look to a future role for computerised lactate decision support. Next, Jacqueline Pflaum-Carlson, Jayna Gardner-Gray, Gina Hurst and Emanuel P. Rivers review early sepsis management, concluding that the question remains whether an invasive or noninvasive method (with or without central venous pressure) confers improved mortality. Last, Heidi Wimmers writes about the comprehensive traceability system for drugs that her hospital implemented, thus increasing the protection of patients from falsified, expired or recalled medicine.
In our Management section Alessandro Barelli, Roberta Barelli, Antonio Gulli and Massimo Antonelli describe the role of simulation in intensive care education and training. Next, Peter Brindley explains the basics of communicating about difficult medical decisions and outlines the communications tools and bundles that can provide structure and reliability to complex communication. He cautions, however, that they should never make interactions robotic and devoid of personal connection.
Paul E. Pepe is interviewed for this issue. He looks back on 35 years of public service in emergency medicine and the innovative research he has conducted. He also expands on his mantra “a gram of good pre-hospital care saves a kilogram of ICU care” and what the definition of success is for an ICU director.
In my role as President of the World Federation of Societies of Intensive and Critical Care Medicine (WFSICCM), I am looking forward to meeting many of you in Seoul for the WFSICCM congress from 29 August – 1 September (an interview on this role is on page 92). Korea is well-known for the quality of its healthcare and contribution to the medical literature, and we are delighted to feature Korea as our Country Focus. Dong Chan Kim, President of the Korean Society of Critical Care Medicine (KSCCM) and Sungwon Na, Secretary General of the KSCCM outline the past, the present and the future of critical care medicine in Korea. Dong Chan Kim with Sang-Min Lee, Director of Academic Board of the KSCCM write about hot topics in Korea, including the variance of ICU treatment among institutions and the recent quality assessment that should improve the quality of ICU care further.
As well as our Agenda listing upcoming intensive and critical care congresses, we include an interview with Roger Harris from smacc (social media and critical care), whose 3rd congress will be held in Chicago from 23-26 June. As always, if you would like to get in touch, please email [email protected]