Interventions to promote cost-effectiveness in adult Intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

doi:10.21203/rs.3.rs-3375711/v1

Background

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

Methods

A three-round modified online Delphi process, using a web-based platform sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilised a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering group endorsed interventions that were identified as ‘critical’ by more than 50% of steering group members. These interventions and experts’ comments were summarized as final considerations for best practice.

Results

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering group endorsed 9 ‘critical’ best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

Conclusions

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Delphi Technique

Health Care Costs

Health Resources

Intensive Care Units

Quality of Health Care

There is a growing recognition among healthcare stakeholders of the responsibility that providers must deliver value-based healthcare wherein the cost of care assumes a crucial role as an outcome [1, 2]. Intensive care treatments represent a significant proportion of increasing healthcare costs [3]. To comprehensively assess the economic viability of various interventions, cost-effectiveness analysis serves as a valuable tool by examining both the costs and health outcomes associated with these interventions [4]. Despite the high costs involved, there are very few cost-effectiveness studies in Intensive Care Units (ICUs), with an average of 4.6 studies per year [4].

Whilst numerous policies and research efforts have aimed to improve the quality of critical care delivery, less attention has been focused on ways to achieve cost-effectiveness [3]. Only a few interventions have demonstrated improved clinical outcomes in critical care. Heterogeneity among critical care patients who present with varied diagnoses and require a range of different interventions also make it difficult to conduct cost-effectiveness studies focused on single items. In addition, there are no universally acceptable ways to measure ICU-related costs [5–12]. Most studies describe projected benefits or estimate potential cost savings only [5]. Previous studies have used ICU length of stay (LOS) as a composite measure of costs and resource use [6]. However, the relationship between the cost of care and the ICU LOS is imperfect [7–10]. Another complicating factor is that the total ICU costs are composed of both fixed and variable costs, of which fixed costs are estimated to constitute nearly 80% of ICU costs [11, 12].

The COVID-19 pandemic has changed the dynamics of ICU care significantly. Unfortunately, at beginning of the pandemic, ICUs were not prepared for the surge of sick patients [13]. Global supply-chain disruptions have prompted healthcare organizations to change their focus from ‘just in time’ to ‘just in case’ e.g., ensuring effective critical care surge response, including consideration to ICU staffing models, having national or regional strategic reserves of personal protective equipment, devices, consumables, and pharmaceuticals [14, 15]. There is a need to implement cost-effective measures without compromising the safe delivery of value-based healthcare for patients and maintaining a buffer for ‘just-in-case’ scenarios. Unfortunately, there is limited literature available to guide this, hence we planned a multidisciplinary and multinational Delphi study to gather expert opinions and consensus to identify inTerventions tO Promote coSt-effectiveness In aDult intEnsive care units (TOPSIDE study).

We followed ‘Guidance on Conducting and REporting DElphi Studies’ (CREDES) guidelines to plan and present the Delphi study results [16]. The National Healthcare Group (NHG) Domain-Specific Review Board (DSRB), Singapore approved the study with a waiver of informed consent due to the non-interventional, Delphi survey design (NHG DSRB reference number − 2023/00414). Consent was implied when experts participated in the Delphi process by completing the online surveys.

Purpose and rationale:

Delphi techniques are widely used in healthcare to answer relevant questions where the research is limited, ethically/logistically difficult or the evidence is equivocal [17]. Previously, Delphi methods have been used in the ICU settings to reach a consensus on a standard set of ICU discharge criteria [18], to optimize clinically relevant drug-drug interactions [19], to develop a set of ‘top tips’ for good healthcare communication [20], to define competencies [21] or research priorities [22, 23]. Therefore, we sought to identify the interventions to promote cost-effectiveness using a modified e-Delphi methodology.

Expert panel:

Experts were identified from a convenience sample of multinational subject matter experts through peer recommendation. We used World Health Organization (WHO) endorsed categorization of countries according to Gross National Income (GNI) per capita [24]. Our definition of being an expert was defined as being an ICU clinician (doctors, nurses and allied health professionals) and/or an administrator with extensive ICU clinical and health care service management experience of at least 5 years.

Experts were contacted through emails. Like previously published guidelines, the decision regarding the number of experts was made as a pragmatic choice; a key consideration was to ensure good representation with qualified intensive care providers [25]. Patients or the public were not involved in the study. We formed a core group of 13 experts to steer the study and associated discussions (AK, JML, KCS, SR, MC, CB, ACM, RDS, SR, JPF, VMN, BKR, RCM).

The Delphi study was conducted from November 2022 to February 2023, followed by steering group discussions in March-June 2023. With regards to the time management between the Delphi rounds, experts were given three weeks to respond to each round, with 2 reminders, a week apart.

This was a modified Delphi survey with a succinct mixed qualitative and quantitative approach. The Delphi surveys were administered through Welphi™ (www.welphi.com), which is an online survey platform that is specifically designed for Delphi studies. This allowed the inclusion of experts from diverse geographical areas and allowed participation in an asynchronous, online, and interactive way. Additionally, the process of collating the results was streamlined with the use of this online platform.

Round 1 consisted of an open-ended questionnaire. Experts were requested to categorize proposed interventions into four sub-categories, following principles of high-value health care which have previously shown promise in lowering costs [26]. This list of principles termed “A CEO checklist for high-value health care” have been used to describe opportunities to improve the value of health care according to the following four domains:

1. Foundational elements: Developing a culture of continuous improvement, through quality improvement methodology [27–29].
2. Infrastructure fundamentals: Implementing evidence-based care, information technology best practices, efficient care delivery, and the sustainable use of resources [30–33].
3. Care delivery priorities: Integrated and coordinated care delivery, through team-based approaches and shared decision-making [34–36].
4. Reliability and feedback: Embedding safeguards, anti-microbial stewardship and being transparent within the health service [26].

In the first Delphi round, experts were invited to list and provide comments regarding interventions that promote cost-effectiveness considering resource limitations, especially in the peri pandemic era. Individual responses were collated and converted into a list of 60 interventions for the second round. Round two of the Delphi process was composed of quantitative as well as qualitative components. All the experts from round 1 were included in round 2, irrespective of whether they had responded earlier, as the first round was deemed exploratory in nature. The experts were able to see the questionnaire, along with anonymized responses from round 1 before scoring in round 2 [Supplementary Fig. 1]. This provided an opportunity for them to revise their judgments based on comments from their peers. The experts were requested to rate the proposed interventions on a 5-point Likert scale (ranging from strongly agree, agree, neutral, disagree to strongly disagree) along with an opportunity to offer optional narrative comments on each statement.

At the end of round 2, qualitative and quantitative data were collated. The items from round 2 were retained for round 3, which was quantitative in nature. The third round only included experts who had responded in the second round. As before, the experts were able to see the same questionnaire from the previous round, along with anonymized responses before re-scoring [Supplementary Fig. 2].

We adopted a dynamic approach regarding the number of rounds, with subsequent rounds incorporated if the steering group deemed it necessary for further clarification [37]. Like previous studies, we observed that there were no changes in experts’ ratings between rounds two and three [38], and the steering committee decided that another round was not warranted.

Definition and attainment of consensus:

We applied previously published consensus criteria for Delphi studies to the quantitative results of 3 rounds [27]. Interventions with over 70% consensus (scored as ‘strongly agree/agree’) which < 15% respondents scored as ‘strongly disagree and disagree’, were recommended as cost-effective measures. Conversely, if over 70% of experts disagreed on an intervention (by scoring strongly disagree or disagree), with fewer than 15% agreement (strongly agree and agree), this intervention was considered as ‘undesirable’. An intervention was classified as achieving ‘no consensus’ if neither criterion was met. We also compared the list of interventions between rounds 2 and 3 to assess for impact of peer opinion among the experts.

These consensus items endorsed by the Delphi experts were subjected to iterative discussions among the members of the steering group through face-to-face interactions, online video meetings and email discussions. The steering group voted to reach agreement on a list of ‘critical’ interventions that formed the basis of consensus statement and best practice considerations. One expert (AK) excused himself from the final voting due to risk of bias in view of access to identifiable comments as the lead administrator of Delphi process. Items identified as ‘critical’ required consensus by more than 50% of steering group members.

A total of 61 experts participated in the Delphi study (Table 1).

Table 1

Baseline characteristics of experts (n = 61)
Panel composition (n = 61)	Physicians (n = 50, 82%), Nurses (n = 5, 8%), Medical Administrators (n = 3, 5%), and Allied health - respiratory therapists and pharmacists (n = 3, 5%)
Country category, according to GNI per capita	Low- and middle-income countries (n = 26, 43%)		High-income countries (n = 35, 67%)
Country category, according to GNI per capita	Low and Low-middle-income countries n = 17 - India n = 1 - Bangladesh n = 1 - Egypt n = 1 - Nepal n = 1 - Philippines n = 1 - Sri Lanka	Upper middle-income countries n = 2 - Malaysia n = 1 - Thailand n = 1 - Turkiye	n = 8 - Singapore n = 8 - USA n = 5 - UK n = 3 - Australia n = 2 - Dubai n = 2 - Italy n = 2 - Portugal n = 1 - France n = 1 - Greece n = 1 - Japan n = 1 - New Zealand n = 1 - South Korea
Steering group (n = 13)	n = 4 - India	NA	n = 3 – USA n = 2 - Singapore n = 2 - UK n = 1 - Australia n = 1 - Italy

Of the 61 experts, 30 (49%) completed all three rounds of the Delphi surveys. The response rates were 52% for round 1 (32/61), 56% for round 2 (34/61) and 88% for round 3 (30/34, the denominator being the number of experts who responded to round 2 of the Delphi survey), respectively (Fig. 1).

A total of 60 interventions were identified at the end of round 1 and the same 60 formed the basis for rounds 2 and 3. Of the 60 interventions, 50 interventions reached consensus criteria after round 2 and the same 50 items achieved consensus in round 3 as well (Table 2). Of note, 31 (51%) of these interventions achieved a consensus of 90% and above after round three.

Table 2

Interventions endorsed by Delphi study, categorized into nine sub-groups
	Infrastructure fundamentals	Care delivery priorities	Foundational elements	Reliability and feedback
Pandemic preparedness	1. Optimize resource usage for pandemics	2. Establish a multidisciplinary disaster/pandemic response team	3. Audit compliance to best practices in a pandemic situation
ICU Organization	4. Standardize and establish governance of ICU set-ups (integrated or otherwise) at regional/ national levels 5. Availability of all the concerned experts including all laboratory services 6. Develop an international consensus report on the Green ICU concept. 7. Counselling rooms with Hospital Information System accessibility within that room 8. Point of care diagnostics 9. Structural elements (Hospital level) # 10. Structural elements (ICU design) #	11. Champion-led team approach # 12. Multidisciplinary patient care model (Multidisciplinary team consisting of a trained intensivist, a trained ICU nurse, physiotherapist, pharmacist, speech pathologist, etc.) 13. Early mobilization 14. Team building and support 15. Multidisciplinary approach to implementing end-of-life interventions focused on patient- and family-centric care	16. Ensure institutional and ICU leadership support	17. Provide access to cost (and charge) information for treating teams 18. Benchmark units at the National (or regional) level
Establishing and pursuing standards of care			19. Quality audits to identify cost-reduction opportunities 20. Multidisciplinary Practice Evaluation Programs, involving a wide range of ICU professionals. Engagement with hospital administrators in setting quality indicators 21. Standardize practice through protocols/ care pathways and ongoing audits 22. Set-up evidence-based standards of care, including interventions for which there is limited or no evidence. 23. Establish standard ICU audit guidelines, adapted to local circumstances.	24. Critical incident report system 25. Regular surveillance and monitoring of the clinical practice with feedback to the ICU team
Resource optimization	26. Dynamic staff roster to accommodate even distribution according to workload 27. Cost-effective sterilization practices 28. ICU equipment and devices related		29. Audit of consumable usage 30. Reduce frequency of laboratory tests and radiological tests through Quality Initiatives 31. Rationalize transfusion practices	32. Rationalize the use and having a stewardship approach towards critical resources
ICU/ HDU Admission & Discharge optimization		33. Careful discharge planning 34. Appropriate use of ICU/ HDU resources		35. Review of failed discharges/ ICU re-admission to identify opportunities for improvement 36. Audit of time taken for ICU admission from Emergency Department/ Wards
Expanding the scope of the ICU beyond the four walls of the ICU	37. Develop step-down units and long-term care units 38. Appropriate remote monitoring in step-down units 39. Utilize tele-ICU to bring down ICU costs as well as support under-served areas	40. ICU-team-led Outreach services on wards 41. Establish a multidisciplinary rapid response team led by ICU
Competencies and Training of staff	42. Develop and Maintain Competency 43. Continuous training & education		44. Audits of staff competency, training of staff
Infection Control measures				45. Hand hygiene monitoring 46. Set-up governance of antibiotic stewardship institutionally 47. Set-up anti-microbial stewardship including Infectious diseases-ICU rounds 48. Healthcare acquired infections prevention
Electronic Health Records	49. Electronic Health Records in ICUs			50. Electronic health records to increase accountability
# Details in supplementary table 1
HDU – High dependency unit, ICU – Intensive care unit

Ten interventions did not achieve Delphi consensus for prioritization (Table 3).

Table 3

– Cost-effective interventions which did not achieve Delphi consensus for prioritization at this time
Cost-effective interventions which did not achieve Delphi consensus for prioritization at this time	Degree of endorsement (Strongly agree and agree) in round 3
Infrastructure fundamentals
1. Integrated ICU model preferable to Emergency Department-based ICU/ Specialty-based ICUs	74% (However, >/= 15% Strongly disagree and disagree)*
2. Creating Critical Care Nurse Consultants, Physician Assistants as part of the critical care team	66%
3. A combined ICU & HDU model	62%
4. Low-cost wearable devices to replace the expensive commercial equipment for physiological monitoring	56%
5. Opportunities to use artificial intelligence	55%
6. Hand-held imaging devices like ultrasound probes attached to smartphones.	55%
7. Surgical intermediate care unit as cost-saving alternative to ICU care	41%
8. Use of disposable items over reusable	29%
Care delivery priorities
9. Post-intensive care outpatient clinics under the supervision of intensivists	63%
Reliability and feedback
10. Linking KPIs to physician/ unit remuneration	41%

HDU – High dependency unit, ICU – Intensive care unit

* One intervention, namely, “Integrated ICU model preferable to ED-based ICU/ Specialty-based ICUs” scored more than 70% agreement in both rounds; however, the disagreement was 15% and we counted this intervention as a “Cost-effective interventions which did not achieve Delphi consensus for prioritization at this time”

The structured details of qualitative responses from rounds 1 and 2 are presented separately (Supplementary Table 1).

Thereafter, the steering group endorsed 11 interventions that were identified as ‘critical’ by more than 50% of steering group members. These interventions and experts’ comments were summarized as 9 final considerations for best practice:

1) Adoption of multi-disciplinary patient care model:

• Multi-disciplinary team should consist of skilled professionals with expertise in critical care (intensivist, ICU nurse, and allied health) and conduct daily rounds. Multidisciplinary care could expedite timely ICU discharge, early extubation, and early mobilization.

2) Development and maintenance of staff competency, and audit:

• ICU staff should be supported in developing and maintaining critical care competency and skills to develop a continuous learning process. Development of core curriculum and structured training programmes for staff across all relevant professional groups, and mapping training onto that curriculum would further help with credentialling and ensuring standardisation of ICU knowledge.

• Additionally, staff competency should be regularly audited and reviewed with participation of all stakeholders. Consideration should be given for ongoing personal performance evaluation plan for each physician and end of year evaluation.

3) Development of step-down units and long-term care units:

• Definition of ICU versus 'high dependency/ step-down/ long-term care units' should be established as agreed upon at regional/ national level. Consideration should be given to standard policies, good governance, and appropriately trained and skilled workforce.

4) Organization of tele-ICU services to bring down ICU costs as well as support under-served areas:

• Telemedicine and remote review should be considered where access to physical presence of a trained ICU team is not possible. Any such advice should be based on a thorough assessment based on clinical, laboratory, and radiological data. A professional relationship between the remote expert and the on-site team with the ability to provide on-site visits or patient transport if required, should be considered. There should be governance and feedback process to oversee the service.

5) Adoption of dynamic staff roster to accommodate even distribution according to workload:

• ICUs should adopt a rationale staffing approach introduced with flexible and even distribution of staff according to the workload, to avoid burn out and exhaustion. However, this approach should also consider the challenge of work-life balance and staff retention.

6) Implementation of end-of-life (EOL) interventions:

• Consideration should be given to multidisciplinary approach focused on patient- and family centric EOL care, which could avoid un-necessary ICU admissions, avoid prolonged ICU stays, with many problems in withdrawing the already instituted care, thereby reducing futile treatment costs. Additionally, the specific skills and expertise required should be part of the core curriculum for intensivists and other critical care professionals.

7 Adoption of early mobilization:

• Early mobilization provided by the designated ICU physiotherapist and nursing team would help in enhancing ICU recovery in patients at the earliest opportunity and can facilitate early discharge.

8 An international consensus effort on Green ICU concept:

• E.g., utilization of energy efficient lighting, recycling of non-contaminated plastic waste should be considered.

9 Implementation of audits to promote a culture of continuous quality improvement:

Multidisciplinary Practice Evaluation Programs should involve as many ICU professionals as possible, collaborate with nursing staff, and engage with administration in setting quality indicators.
Standard ICU audit guidelines, adapted to local circumstances should be implemented (e.g., Guidelines for Provision of Intensive Care Services by Intensive Care Society [37].
Frequency of laboratory and radiological tests should be reduced through quality improvement methodology.

We conducted a multidisciplinary and multinational e-Delphi survey followed up with iterative discussions among the steering group, to gather expert consensus to identify interventions that promote cost-effectiveness in adult ICUs. Final best practice considerations include adoption of a multidisciplinary ICU model, strong focus on staff training and competency assessment, and audits to objectively promote a culture of continuous improvement, thus ensuring high quality of critical care services whether within or outside ICUs. Additionally, implementation of a dynamic staff roster, multidisciplinary approach to implementing EOL care, early mobilization and promoting international consensus efforts on Green ICU concept were endorsed. These findings represent to our knowledge the first time a Delphi study has been used to address the complex issue of cost-effectiveness with a global appeal involving experts from across varied healthcare systems, going beyond regional boundaries. These best practice considerations should be equally applicable to low-income as well as middle-high income countries; albeit need tailoring according to local resources.

Many of the proposed best practice considerations are supported by previous studies suggesting outcome benefits including actual or hypothetical cost benefits, though cost-effectiveness was not studied, e.g., case of multidisciplinary team model [40–42]. One systematic review of cost-related impacts from utilizing respiratory therapists to deliver care showed both direct and indirect cost reductions, which were achieved through protocol utilization, specialized expertise, and autonomous decision making [42].

Best practice consideration to develop step-down units, long-term care units, and tele-ICUs comes with an emphasis on ensuring appropriate staffing, adequate resources, and robust governance process. On the other hand, previously published literature is equivocal with regards to endorsing other speciality ICUs (e.g., surgical intermediate care units, emergency department-based ICU) manned by non-ICU teams, despite the availability of positive studies [5, 30, 43]. This hesitancy may be due to concerns regarding quality of care being provided by non-ICU teams and highlights the need to ensure standardization irrespective of clinical team involved.

Similarly, audits to promote a culture of continuous improvement [27–29], multidisciplinary team approach to implementing EOL care [35, 36], and early mobilization [44] have shown cost benefits. Multidisciplinary team approach comprising physicians, clinical nurse specialists and/ or palliative team focused on improving communication with patients and patients' families at the end-of-life reduced LOS and lowered ICU costs and significantly improved nurse-assessed quality of dying [35, 36]. A systematic review comprising twenty-three randomized control trials involving 2,308 critically ill patients showed that early mobilization decreased the incidence of ICU acquired weakness at hospital discharge, increased the number of ventilator-free days during hospitalization, and increased the discharged-to-home rate; as well as non-significant improvement in mortality (28-day, ICU, and hospital). However, substantial heterogeneity among the included studies, and the low quality of the evidence, warrants caution. Our Delphi survey adds weight of expert consensus to the existing evidence.

These consensus statements hold even more importance in the post-pandemic era of ‘just-in-case’, with competing priorities for the finite resources available. The WHO has recently declared an end to COVID-19 as a global health emergency in May 2023. Few of the interventions proposed by Delphi experts were categorized under pandemic preparedness (optimization of resource usage during the pandemic setting, establishment of a multidisciplinary disaster/pandemic response team and emphasis on audit to ensure compliance to best practices in a pandemic situation). As this Delphi survey was conceived and conducted during the pandemic period, experts’ emphasis on pandemic preparedness is not surprising. However, these considerations are equally applicable to the non-pandemic times.

Interestingly, several of the proposed interventions did not reach consensus despite some proposed benefits in previous studies, e.g., low-cost wearables combined with artificial intelligence for physiological monitoring, point-of-care diagnostic and imaging devices, and use of disposable items over reusable [32]. Possible reasons could be that such interventions need upfront expenses with unclear cost recovery downstream.

Our Delphi study has several limitations. We involved a convenience sample of experts. While these individuals had many years of ICU experience, it is possible they did not consider all the related issues e.g., regional variations in practice due to regulatory issues surrounding ICU setups, availability of drugs and devices. Although we had a reasonable geographic (excluding African countries) and national income-level (excluding low-income countries) spread of experts, the opinions may not represent those from areas which are not covered. However, the experts did represent a good mix of intensive care professionals from low-middle-income, and high-income countries.

Secondly, there was no patient involvement as well as no distinct stakeholder groups. This may have limited the ability of our findings to fully represent a holistic perspective and failure to highlight any disparate views. Our relatively small number of stakeholders and higher attrition in non-physician categories precluded such groupings. However, even in a multiple-panel study consisting of different stakeholder groups, it is difficult to ascertain what weightings should be given to each group and there is no current guidance on this.

Additionally, our Delphi study asked the experts to categorize proposed interventions into four sub-categories, following principles of high-value health care which have previously shown promise in lowering costs [26]. These principles however were not critical care specific, were derived from one high-income nation and were opinions only from senior hospital administrators.

Lastly, we had a low response rate of just over 50% between round 1 and round 2. However, we were able to achieve a response rate of 88% in the third round. Attrition bias can occur when the participants that do not respond in subsequent rounds have different views from their peers who continue to participate. However, when we compared the round 3 and round 2 results, we observed no variation in opinions and a retention of > 80% which is considered satisfactory as per published literature [22].

Overall, these best practice considerations need to be studied further. We believe that these best practice considerations should be equally applicable to low-income as well as middle-high income countries; albeit need tailoring according to local resources. Future research should focus on thoughtfully bundled interventions, tailored to regional needs.

We present consensus statement and best practice considerations of interventions to promote cost-effectiveness in adult ICUs. The best practice considerations include adoption of a multidisciplinary ICU model of care, focus on staff training and competency, ongoing quality audits, implementation of dynamic staff rostering, multidisciplinary approach to implementing EOL care, early mobilization and promoting international consensus efforts on Green ICU concept. Stakeholders such as government bodies and professional societies must lead the efforts to identify locally applicable specifics with the available resources, while working within these best practice considerations.

CREDES - Conducting and REporting DElphi Studies

DSRB - Domain-Specific Review Board,

EOL - end-of-life

GNI - Gross National Income

ICU - Intensive Care Units

LOS - Length of stay

WHO - World Health Organization (WHO)

Ethics approval and consent to participate: The National Healthcare Group (NHG) Domain-Specific Review Board (DSRB), Singapore approved the study with a waiver of informed consent due to the non-interventional, Delphi survey design (NHG DSRB reference number - 2023/00414).

Consent for publication: Not applicable

Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests: The authors declare that they have no competing interests.

Funding: The study was not funded.

Authors’ contributions: AK, JML, and RCM contributed to the concept, design, analysis of data and contributed to writing the original draft of the manuscript. CB contributed to the design and editing the manuscript. KCS, SR, MC, VMN, and BKR contributed to writing the original draft of the manuscript. ACM and RDS contributed to review and editing the manuscript.

All authors read and approved the final manuscript.".

Acknowledgements: We like to thank steering group members who shared their valuable knowledge and experiences:

Sumit Ray, Head of Department, Critical Care Medicine & Medical Director at Holy Family Hospital, Delhi, India
Javier Perez Fernandez, Baptist Hospital of Miami, Miami, FL, USA

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No competing interests reported.

Interventions to promote cost-effectiveness in adult Intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

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Journal Publication

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Abstract

Background

Methods

Results

Conclusions

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Background

METHODS

Purpose and rationale:

Expert panel:

Definition and attainment of consensus:

RESULTS

DISCUSSION

CONCLUSION

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1