ICU Resources Research Articles

Intensive care outflow limitationfrequency, etiology, and impact

Objective: To assess the frequency, causes, and effect of unsuccessful discharge decisions from the ICU. Setting: An 11-bed general intensive care unit of a 750-bed urban university hospital, tertiary referral center and level one trauma center. Design: A prospective, observational study. Patients: All ICU patients judged appropriate for discharge by the ICU attending physician. Measurements and results: A total of 856 attempted discharges in 706 patients were analyzed over 16 months. Of these, 703 (82%) were successful within 24 hours. Of the remaining 153 unsuccessful discharges, 51 (33%) were deferred because of medical deterioration, 32 (21%) at the request of the ward physicians or nurses and 70 (46%) because of administrative difficulties (lack of ward bed space or disagreement over admitting service). When compared to patients successfully discharged on the first attempt, those whose discharge was deferred had a significantly longer ICU admission prior to the first discharge attempt (median 4d v 3d, P = .009), and a higher proportion required intermediate care (48% v 26%, P < .001). Both these factors were independently associated with unsuccessful discharge in a logistic regression analysis (OR 1.04, 95%CI 1.02, 1.06, P = .0001, OR 2.05 95%CI 1.30, 3.26, P = .002, respectively). Deferred discharges accounted for 153 days of ICU care (2.6% of the total) and were associated with ICU overflow on 118 days (2% of all ICU days). Conclusion: ICU outflow limitation occurs in up to 1 in 6 discharges. It can be due to medical deterioration, level of care issues or administrative problems, and may lead to inefficient use of ICU resources.

Early Invasive Revascularisation for Patients Critically Ill After Acute Myocardial Infarction: Impact on Outcome and ICU Resource Utilisation

Early Invasive Revascularisation for Patients Critically Ill After Acute Myocardial Infarction: Impact on Outcome and ICU Resource Utilisation

Trauma in the elderly: intensive care unit resource use and outcome.

As the population ages, the elderly will constitute a prominent proportion of trauma patients. The elderly suffer more severe consequences from traumatic injuries compared with the young, presumably resulting in increased resource use. In this study, we sought to examine ICU resource use in trauma on the basis of age and injury severity. This study was a retrospective review of trauma registry data prospectively collected on 26,237 blunt trauma patients admitted to all trauma centers (n = 26) in one state over 24 months (January 1996-December 1997). Age-dependent and injury severity-dependent differences in mortality, ICU length of stay (LOS), and hospital LOS were evaluated by logistic regression analysis. Elderly (age > or = 65 years, n = 7,117) patients had significantly higher mortality rates than younger (age < 65 years) trauma patients after stratification by Injury Severity Score (ISS), Revised Trauma Score, and other preexisting comorbidities. Age > 65 years was associated with a two- to threefold increased mortality risk in mild (ISS < 15, 3.2% vs. 0.4%; < 0.001), moderate (ISS 15-29, 19.7% vs. 5.4%; < 0.001), and severe traumatic injury (ISS > or = 30, 47.8% vs. 21.7%; < 0.001) compared with patients aged < 65 years. Logistic regression analysis confirmed that elderly patients had a nearly twofold increased mortality risk (odds ratio, 1.87; confidence interval, 1.60-2.18; < 0.001). Elderly patients also had significantly longer hospital LOS after stratifying for severity of injury by ISS (1.9 fewer days in the age 18-45 group, 0.89 fewer days in the age 46-64 group compared with the age > or = 65 group). Mortality rates were higher for men than for women only in the ISS < 15 (4.4% vs. 2.6%, < 0.001) and ISS 15 to 29 (21.7% vs. 17.6%, = 0.031) groups. ICU LOS was significantly decreased in elderly patients with ISS > or = 30. Age is confirmed as an independent predictor of outcome (mortality) in trauma after stratification for injury severity in this largest study of elderly trauma patients to date. Elderly patients with severe injury (ISS > 30) have decreased ICU resource use secondary to associated increased mortality rates.

Decompressive surgery in the treatment of traumatic brain injury.

According to European Brain Injury Consortium (EBIC) and American Brain Injury Consortium (ABIC) guidelines for severe head injuries, decompressive craniectomy is one therapeutic option for brain edema that does not respond to conventional therapeutic measures. As a result of the failure of all recently developed drugs to improve outcome in this patient group, decompressive craniectomy has experienced a revival during the last decade. Although class I studies of this subject are still lacking, there is strong evidence from prospective, uncontrolled trials that such an operation improves outcome in general and also has beneficial effects on various physiologic parameters that are known to be independent predictors for poor outcome. Whether this operation should be performed in a protocol-driven or in a prophylactic manner remains unclear. Decompressive craniectomy may, however, be the only method available in developing countries with limited ICU and monitoring resources. Prospectively controlled and randomized studies to definitively evaluate the effect of this old neurosurgical method on outcome in patients with traumatic brain injury (TBI) are forthcoming.

Customized prediction models based on APACHE II and SAPS II scores in patients with prolonged length of stay in the ICU.

To study customized APACHE II and SAPS II models in predicting hospital death in patients with a prolonged length of stay in the ICU. Prospectively collected database. Thirteen ICUs with 5-10 beds in Finnish secondary referral hospitals. None. The database was collected between 1994 and 1999 and included 23,953 ICU admissions. In order to customize the original APACHE II and SAPS II models and to validate the models, the database was randomly divided into customization data ( n=12,064) and into validation data ( n=11,889). Logistic regression analysis was used for customization. As the length of the ICU stay was prolonged, the calibration and discrimination of both customized models worsened gradually in the validation data. Patients whose ICU stay lasted 7 days or longer (1,312 patients) consumed more than one half of all ICU days and TISS-points. Among these patients, goodness-of-fit statistics was 221.5 and 306.3 ( P<0.0001 for both) and the areas under ROC curve 0.65 and 0.62 for the customized APACHE and SAPS models, respectively. The models underestimated the risk of death in the low range and overestimated it in the high range of predicted mortality. On the other hand, both models discriminated well between survivors and non-survivors if the ICU stay was 2 days or less. Despite customization, the predictive models may not support clinical decision-making in those patients who require a high share of resources. More relevant instruments are needed for the prediction of outcome of patient groups who consume the major part of ICU resources.

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate.

To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. Observational prospective multicenter study. Eighty-six medical-surgical ICUs in Spain, including coronary patients. We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

The effects of nursing staff inexperience (NSI) on the occurrence of adverse patient experiences in ICUs

Although many studies have attempted to define levels of staff experience appropriate for the care of critically ill patients, minimal data is available on the effect of nursing staff inexperience (NSI) on the occurrence of incidents in the intensive care environment. The Australian Incident Monitoring Study in Intensive Care Units (AIMS-ICU), an anonymous, voluntary incident reporting system, can help to identify problems in which NSI may be implicated. NSI may be an incident in itself or contribute to the occurrence of other incidents. The objective of this paper was to identify incidents associated with NSI and estimate their effect on the quality of patient care. Incidents related to NSI were extracted from the AIMS-ICU database and analysed using descriptive methodology. Seven hundred and thirty five reports covering 1,472 incidents were identified as relating to NSI. Of these, 282 were described in the narrative section and 453 were selected as a contributing factor by the reporter. Major categories for the 1,472 incidents included airway and ventilation (317) drugs and therapeutics (468), procedures, lines and equipment (219), patient environment (234) and unit management (234). An undesirable major adverse patient outcome was selected in 20 per cent of reports. NSI associated incidents reported to AIMS-ICU suggest that NSI can have a negative impact on the quality of care delivered to critically ill patients as shown by the occurrence and outcome of incidents related to such inexperience. Errors are more likely to occur when NSI is combined with staff shortage, inadequate supervision and high unit activity. When rostering or employing staff, nurse managers and educators must consider the special requirements of inexperienced nurses. Safe patient care requires these issues be included in discussions about ICU resource allocation.

Comparison of two cohort of patients with severe tetanus in ICU

Tetanus is a toxic disease produced by Clostridium tetani mostly prevented by immunization, but it is still prevalent in the Third World, has a high mortality rate and uses a high number of ICU resources. Our objective is to show our experience in two different periods managing this disease.

The utility of venous lactate to triage injured patients in the trauma center

Background: Field triage criteria for trauma patients results in over-triage rates of 30% to 50% to achieve under-triage rates of 10%. This large number of patients may stress trauma center resources. Elevated arterial lactate (ALAC) levels have been shown to be a marker of serious injury but the need for arterial sampling limits the utility of the determination. The goal of this study was: 1) to determine the correlation between venous lactate (VLAC) and ALAC; 2) to determine whether VLAC could identify those patients with serious injuries; and 3) to compare an elevated VLAC level against standard triage criteria (STC) in their ability to identify major injury. Study Design: Arterial and venous samples for blood gas and lactate analyses were obtained in 375 patients within 10 minutes of patient arrival to the trauma center. Arterial and venous samples were drawn within 2 minutes of each other, placed on ice, and analyzed within 10 minutes of sampling. The location of sampling was left to physician discretion. Data collected included injury mechanism, demographics, admission vital signs, emergency department disposition, length of stay, and injury severity scores (ISS). Admission to the ICU, need for emergency operation, length of stay, and death were noted. Emergency medical service staff were queried to determine which standard triage criteria (STC) were fulfilled. Results: The mean ALAC was 3.11 mmol/L (SD 3.45, 95% confidence interval [CI] 2.67 to 3.55) and mean VLAC was 3.43 mmol/L (SD 3.41, 95% CI 2.96 to 3.90). There was no significant difference between ALAC and VLAC. The correlation between ALAC and VLAC was 0.94 (95% CI 0.94 to 0.96, p = 0.0001). An elevated VLAC predicted moderate to severe injury and there was a significant association between an increased lactate and maximum Abbreviated Injury Score (AIS) of 4 and 5 (ANOVA, F = 8.26, p < 0.001). Patients with VLAC ≥ 2 mmol/L had significantly increased relative risks of ISS ≥ 13, death, admission to the ICU, and length of stay > 2 days. In comparison with STC, a VLAC ≥ 2 mmol/L decreased under-triage in patients with ISS ≥ 13 by one half (11% versus 24%) for patients with ISS ≥ 13 and decreased over-triage by 28% (46% versus 64%). These data were most pronounced for patients injured in motor vehicle collisions. Conclusions: VLAC is an excellent approximation for ALAC. A VLAC ≥ 2 mmol/L appears to predict an ISS ≥ 13, the need for ICU resources, and prolonged hospital stays. VLAC was significantly better than STC in all patients and was most useful in victims of blunt trauma, especially motor vehicle collisions.

Patient Management Strategies to Contain Cost in the ICU

Despite consuming a large proportion of health care resources, efforts to develop unified strategies by which to reduce ICU costs have been stymied by the existing heterogeneity in their organization and management. Local practice variations, coupled with deficient scientific data by which to optimize the effectiveness of care, has left a precise characterization of the absolute requirement for ICU resources open to significant debate. In addition to personal practice heuristics, resource use and associated costs are influenced by severity of illness, case mix and length of stay.

ROUTINE ICU ADMISSION IS NOT REQUIRED AFTER CARDIAC SURGERY

S82 INTRODUCTION: Efficient resource utilization has resulted in a change in the way care is delivered to patients having cardiac surgery. [1] "Fasttrack" cardiac anesthesia allows early extubation and is part of any multidisciplinary "fasttrack" cardiac surgery program. Routine admission to ICU remains part of most "fasttrack" programs. Most patients are admitted because they are intubated and require cardiac monitoring. We present data that suggests that the admission to ICU after cardiac surgery is not required in the majority of cases. METHODS: In 1995, a "fasttrack" cardiac surgery protocol (we called our program a Facilitated Recovery Program; "fasttrack" may have some pejorative connotations) was developed in order to expand the program at our Centre. This includes "fasttrack" anesthesia, an initial 4-6 hour PACU-based recovery directed by both the Anesthesiologist and Cardiac Surgeon, elimination of routine ICU admission, and further recovery in a cardiac surgery stepdown unit (no facilities for IV vasodilators, vasopressors, mechanical ventilation, PA catheters, and maximum nurse:patient ratio 1:2). For this paradigm to become accepted, it was gradually introduced. In 1996, we initially selected 1 patient/week; by January 1997, most patients were being considered for this program. Final determination of recovery site is made after separation from CPB, and in some cases, after initial admission to PACU. We reviewed our OR, Health Records, ICU, and Cardiac Anesthesia databases for the years 1994-1997 for the pertinent data. Chi-square, Wilcoxon rank-sum, Mantel-Haenzel trend test, and ANOVA were used where appropriate to analyze the data. RESULTS: Most patients are extubated within 2 hours; the reintubation rate is low. There is a large reduction in ICU utilization (Table 1), shown as the % admissions and ICUdays/100cases/year (p<0.001, 1997 vs. all previous years and trend). The chance of ICU admission from stepdown is low. As expected, ICU LOS in 1997 was longer than in 1996 (p<0.01). APACHE II increased (p<0.01, 1997 vs. all previous yrs. as well as trend). There has been no significant change in mortality.Table 1DISCUSSION: A multidisciplinary program for cardiac surgery based on early extubation and PACU/stepdown-based recovery can dramatically and safely reduce ICU use. The acuity and LOS of patients admitted to the ICU increases, possibly reflecting a more prudent use of ICU resources. There may be large potential cost savings with this model of care. The majority of cardiac surgery patients can be considered for this type of Facilitated Recovery Program. As the number of patients in this study is relatively small, a ongoing analysis of the risk factors that may predict ICU admission is being done.

ICU resource allocation: life in the fast lane

In 1973, the then United States President, Jimmy Carter, addressed the issue of declining petroleum resources and increasing automobile traffic by the institution of a rationing plan that mandated decreasing consumption fairly and equitably across the entire population of consumers. The national speed limit (NSL) decreased from 70 to 55 miles per hour, and, according to experts, constituted the perfect rationing plan [1]. It affected only those who used a scarce resource (gasoline) and it applied to all equally. In a perfect world, it should have been an extremely effective conservation method. However, many motorists in the USA were not eager to participate in this utopian plan designed to rescue the whole. American motorists traditionally drive at a speed that is comfortable for them, considering the surrounding circumstances regardless of a posted limit. The Federal Government assigning a speed that did not feel comfortable to the average motorist virtually guaranteed eventual noncompliance [2]. This otherwise fair rationing plan set the stage for a roadway game of evasion, detection, and escalating technology supporting both sides [3]. The law was eventually repealed because it could not be enforced [4]. As a practical matter, motorists who would comply with the law would not exceed 55 miles per hour regardless of the NSL. Motorists who, for whatever reason choose to exceed the speed limits, will always try to stack the deck in their favor when dealing with speed limit enforcement. As technology for detecting speeders improved, so did the technology for detecting detectors [5]. And so a fair and equitable rationing plan designed to benefit the whole at the cost of minimal individual conformation failed because the administrative cost of enforcing individual compliance effaced the advantage [6].

Pediatric Risk of Admission (PRISA): A Measure of Severity of Illness for Assessing the Risk of Hospitalization From the Emergency Department

Study objective: The development and validation of a pediatric emergency department severity of illness assessment method, using hospital admission as the primary outcome. Methods: A random sample of 25% of ED charts from 4 consecutive months in a university-affiliated pediatric hospital was reviewed, after exclusion of children with minor injuries and children triaged to the nonurgent clinic. Sampled data included components of the medical history, physical findings, physiologic variables, diagnoses, and ED therapies. Univariate and multivariate logistic regression analyses, with bootstrapping validation, were performed to develop a bias-corrected model estimating the probability of hospital admission. Results: Of the 2,683 ED patients whose records were reviewed, 643 (24%) were admitted to the hospital. The final model, which yielded a Pediatric Risk of Admission (PRISA) score, included the following: 3 components of the medical history, 3 chronic disease factors, 9 physiologic variables, 2 therapies, and 4 interaction terms. Overall, the number of hospital admissions was well predicted in both the 80% development and 20% validation samples. In the former, 514 admissions were predicted and 514 were observed; in the latter, 126.9 admissions were predicted and 129 were observed. The Hosmer-Lemeshow goodness-of-fit test demonstrated good agreement between observed and expected admissions in consecutive deciles of admission probability; total χ 2 was 10.49 ( P=.233) for the development sample and 11.85 ( P=.222) for the validation sample. The areas under the receiver operating characteristic curves (±SE) were .86±.011 and .825±.024, respectively. As the risk of hospital admission increased, the proportions of patients using unique hospital-based resources and using ICU resources increased, and the proportion of patients dying increased. Conclusion: The probability of admission to the hospital can reliably be estimated from data available during the pediatric ED stay. Applications for this method include studies of quality and efficiency of care and measurements of severity of illness. [Chamberlain JM, Patel KM, Ruttimann UE, Pollack MM: Pediatric Risk of Admission (PRISA): A measure of severity of illness for assessing the risk of hospitalization from the emergency department. Ann Emerg Med August 1998;32:161-169.]

Measuring Resource Use in the ICU With Computerized Therapeutic Intervention Scoring System-Based Data

In this era of health-care reform, there is increasing need to monitor and control health-care resource consumption. This requires the development of measurement tools that are practical, uniform, reproducible, and of sufficient detail to allow comparison among institutions, among select groups of patients, and among individual patients. We explored the feasibility of generating an index of resource use based on the Therapeutic Intervention Scoring System (TISS) from hospital electronic billing data. Such an index is potentially comparable across institutions, allows assessment of care at many levels, is well understood by clinicians, and captures many of the resources relevant to the ICU. We developed an automated mapping of the hospital billing database into the different items of TISS and generated computerized active TISS scores on 1,372 ICU days. The computerized score was then validated by comparison to prospectively gathered active TISS scores by trained data collectors. Eight ICUs within a university teaching institution. We studied 1,229 general medical and surgical ICU patients. None. Active TISS scores ranged from 0 to 31 points. The two scores were well correlated (R2=0.53) and highly calibrated (as assessed by regression of active TISS on mean computerized active TISS [R2=0.85]). The scores were identical on 756 days (55.6%) and differed by < or = 3 TISS points on an additional 387 (28.2%) days. Interreliability assessment suggested substantial agreement (kappa statistic=0.71). The discriminatory power of the computerized score to identify different levels of ICU resource use was excellent as assessed by area under the receiver operating characteristics curves at four threshold points (0.91, 0.87, 0.89, and 0.88). Performance of the computerized score was similar across medical, coronary, and surgical ICU patient groups. An automated algorithm can reproduce valid TISS scores from standard hospital billing data, allowing comparison of patients and groups of patients in order to better understand ICU resource use.

Ethical allocation of ICU resources: a view from the USA.

Ethical allocation of ICU resources: a view from the USA.

Ethical allocation of ICU resources: A view from the USA

Ethical allocation of ICU resources: A view from the USA

The Use of Risk Predictions to Identify Candidates for Intermediate Care Units: Implications for Intensive Care Utilization and Cost

To develop a predictive equation that estimates the probability of life-supporting therapy among ICU monitor admissions and to explore its potential for reducing cost and improving ICU utilization. Prospective inception cohort analysis. Forty-two ICUs in 40 US hospitals with more than 200 beds and a consecutive sample of 17,440 ICU admissions. A multivariate equation was developed to estimate the probability of life support for ICU monitoring admissions during an entire ICU stay. Demographic, physiologic, and treatment information obtained during the first 24 h in the ICU and over the first 7 ICU days. The most important determinants of subsequent risk for life-supporting (active) treatment were diagnosis, the acute physiology score of APACHE III, age, operative status, and the patient's location and hospital length of stay before ICU admission. Among 8,040 ICU monitoring admissions, 6,180 (76.8%) had a low (< 10%) risk for receiving active treatment during the ICU stay; 95.6% received no subsequent active treatment. Review of outcomes and the type and amount of therapy received suggest that most low-risk ICU monitor admissions could be safely cared for in an intermediate care setting. Objective predictions can accurately identify groups of ICU admissions who are at a low risk for receiving life support. This capability can be used to assess ICU resource use and develop strategies for providing graded critical care services at a reduced cost.

The modifying influence of anaesthesia on postoperative protein catabolism

We studied two groups of six patients scheduled for gastrointestinal surgery; they were allocated randomly to receive high- or low-dose fentanyl anaesthesia. The confounding effect of protein balance, before the trauma of surgery, on postoperative nitrogen excretion was controlled by standardized protein intake before operation, supplemented by adequate calories. The high-dose group had significantly lower stress levels during surgery, assessed by arterial blood concentrations of cortisone, adrenaline and glucose. After operation, protein catabolism was measured for 7 days. The high-dose group had significantly lower postoperative excretion of ammonia and slightly lower excretion of urea and 3-methylhistidine. Low-stress anaesthesia may thus diminish postoperative catabolism, which could be important in frail patients by reducing mortality, ICU resources, or both.

Intensive Care Unit Resource Utilisation

The cost-effectiveness of the Intensive Care Unit after three decades of development has yet to be demonstrated. Accurate ICU resource allocation is limited by our inability to measure cost-effectiveness. Measurement tools have been developed and refined that will give a prediction of in-hospital mortality of groups of critically ill patients. However, these measures will not predict with certainty individual patient outcomes, and take no account of quality of life. Methodology to examine long-term outcome and quality of life after intensive care is still in its infancy. Measurement of ICU cost is limited by a lack of cost-accounting models that not only reflect true cost but that are clinically applicable.

Anaesthesia for coronary artery surgery--a plea for a goal-directed approach.

The purpose of the current literature review was to examine whether changes in current anaesthetic techniques are warranted for patients undergoing coronary artery surgery in light of recent information presented in the literature. The objectives of a cardiac anaesthetic technique are to maintain haemodynamic stability and myocardial oxygen balance, minimize the incidence and severity of ischaemic episodes, be aware of cardiopulmonary bypass-induced pharmacokinetic changes, and facilitate early tracheal extubation if appropriate. Many techniques have been utilized. Provided attention is paid to the details of managing myocardial oxygen supply and demand, none has emerged as superior in preventing intraoperative myocardial ischaemia. Silent myocardial ischaemia (i.e., ischaemia occurring in the absence of haemodynamic aberrations) is common throughout the perioperative period and may occur even in the presence of an appropriately used anaesthetic technique. The incidence and severity appear to be greatest in the postoperative period when the effects of anaesthesia are dissipating. The use of high-dose opioid anaesthesia may no longer be the most appropriate technique to facilitate the anaesthetic objectives. The role of pain management in altering the incidence of ischaemia requires further study. Increased waiting lists for cardiac surgery and ever-diminishing resources should prompt a re-evaluation of early extubation (i.e., within eight hours) as a method of improving utilization of scarce ICU resources. It is suggested that this should be possible with currently available agents to achieve the anaesthetic objectives. Future suggestions for research in this area are made.