Impact of standard procedures and clinical standards on cost-effectiveness and intensive care unit performance in adult patients after cardiac surgery

Objective: To investigate the impact of organizational procedures on intensive care unit (ICU) performance and cost-effectiveness after cardiac surgery. Design: Prospective study. Setting: Cardiothoracic ICU at a university hospital. Patients: Thousand five hundred twenty-six consecutive patients over a period of 18 months. Interventions: The first 6 months were used as the control period. Afterwards selected organizational changes were introduced, such as written standard procedures, time schedules and discharge reports. Measurements: Demographic data, surgical procedures, length of ICU and hospital stay and hospital outcome were recorded. Severity of illness was assessed daily using Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II) and Organ Failure Score (OFS). Intensity of treatment and nursing care was monitored by the Therapeutic Intervention Scoring System (TISS). RIYADH ICU Program (RIP 5.0) was used to determine the relationship of observed to predicted mortality (standardized mortality ratio SMR) and the effective costs per survivor. Main results: SMR decreased continuously after the establishment of new management procedures while all other factors all other factors remained unchanged. Comparing outcome according to APACHE II on ICU admission demonstrated a significantly increased ICU performance in high risk patients with an APACHE II of 20-30 points (p < 0.05) while effective costs per survivor decreased significantly from DM 29,988 to DM 13,568 DM (p < 0.05). Conclusions: Organizational changes can improve ICU performance and cost-effectiveness after cardiac surgery. The RIP may be used to monitor the clinical and economical effects of change.