Therapeutic Intervention Scoring System Scores Research Articles

Variation in severity-adjusted resource use and outcome in intensive care units

PurposeIntensive care patients have increased risk of death and their care is expensive. We investigated whether risk-adjusted mortality and resources used to achieve survivors change over time and if their variation is associated with variables related to intensive care unit (ICU) organization and structure.MethodsData of 207,131 patients treated in 2008–2017 in 21 ICUs in Finland, Estonia and Switzerland were extracted from a benchmarking database. Resource use was measured using ICU length of stay, daily Therapeutic Intervention Scoring System Scores (TISS) and purchasing power parity-adjusted direct costs (2015–2017; 17 ICUs). The ratio of observed to severity-adjusted expected resource use (standardized resource use ratio; SRUR) was calculated. The number of expected survivors and the ratio of observed to expected mortality (standardized mortality ratio; SMR) was based on a mortality prediction model covering 2015–2017. Fourteen a priori variables reflecting structure and organization were used as explanatory variables for SRURs in multivariable models.ResultsSMR decreased over time, whereas SRUR remained unchanged, except for decreased TISS-based SRUR. Direct costs of one ICU day, TISS score and ICU admission varied between ICUs 2.5–5-fold. Differences between individual ICUs in both SRUR and SMR were up to > 3-fold, and their evolution was highly variable, without clear association between SRUR and SMR. High patient turnover was consistently associated with low SRUR but not with SMR.ConclusionThe wide and independent variation in both SMR and SRUR suggests that they should be used together to compare the performance of different ICUs or an individual ICU over time.

Score Therapeutic Intervention Scoring System de ingreso a la unidad de cuidados intensivos como predictor de mortalidad intra-hospitalaria

ObjectivesA retrospective study was conducted with the aim of evaluating the Therapeutic Intervention Scoring System (TISS) as a predictor of hospital mortality in the Intensive Care Unit (ICU). PatientsThe TISS values were measured on admission and on discharge in 718 patients admitted to the ICU of the Casal Ramos Hospital-Venezuela between 2010 and 2013. The variables included the hospitalization days and status on discharge (dead or alive). ResultsThe TISS mean on admission was 26±9 points and 21±9 points on discharge, with a mean of 9±11 days of hospitalisation and survival of 64.7%. On analysing the survival correlation using TISS score, we obtained a R2 od 0.92 at admission with a P<.0001, in the other hand, the discharge TISSS we obtained a R2 0.83 with a P<.0001 was observed. No correlation was observed between the admission TISS and hospita-lisation days. As regards, survival and mortality discrimination value of a TISS>20 points, the area under the curve was 0.66±0.1 (P<.0001) with a sensitivity of 82.3-90.1%, and a specificity of 41.7-51.3%. ConclusionsA TISS score >20 points has a high sensitivity, but poor specificity to predict mortality in the ICU, making it necessary to use other scales to predict patient outcome on ICU admission.

The impact of organ dysfunction in cirrhosis: Survival at a cost?

The incidence of cirrhosis and subsequent development of organ dysfunction (OD) requiring intensive care unit (ICU) support is rising. Historically, critically ill cirrhotics are perceived as having poor prognosis and substantial cost of care. The aim was to prospectively analyse resource utilisation and cost of a large cohort of patients (n=660) admitted to a Liver ICU from 2000 to 2007 with cirrhosis and OD. Child Pugh, MELD, SOFA, APACHE II, and organ support requirements were collected. The Therapeutic Intervention Scoring System (TISS) score, a validated tool for estimating cost in ICU, was calculated daily. Logistic regression was used to determine independent predictors of increased cost. Alcohol was the most common etiology (47%) and variceal bleeding (VB) the most common reason for admission (35%). Invasive ventilatory support was required in 74% of cases, vasopressors in 49%, and 50% required renal replacement therapy. Forty-nine per cent of non-transplanted patients survived to ICU discharge. Median TISS score and ICU cost per patient were 261 and €14,139, respectively. VB patients had the highest survival rates (53% vs. 24%; p<0.001) and lower associated cost. A combination of VB (OR 0.48), need for ventilation (OR 2.81), low PO(2)/FiO(2) on admission (OR 0.97), and lactate (OR 0.93) improved cost prediction on multivariate analysis (AUROC 0.7; p<0.001) but organ failure scores per se were poor predictors of cost. Patients with cirrhosis and OD result in considerable resource expenditure but have acceptable hospital survival. Further health economic assessment and outcome prediction tools are required to appropriately target resource utilisation.

Increased model for end-stage liver disease score at the time of liver transplant results in prolonged hospitalization and overall intensive care unit costs

Organ allocation based on Model for End-Stage Liver Disease (MELD) resulted in decreased waiting list mortality in the United States. However, reports suggest an increase in resource utilization as a consequence of this. The aim of this study is to assess the correlation of MELD at transplant with post-liver transplant (LT) intensive care unit (ICU) costs. We assessed clinical and demographic variables of 402 adult patients who underwent LT at King's College Hospital, London, UK, between January 2000 and December 2003. ICU cost calculations were based on the therapeutic intervention scoring system (TISS). Graft quality was assessed using the donor risk index (DRI). Patients with a MELD score > 24 had significantly longer post-LT ICU stay (P < 0.0001) and total post-LT hospital stay (P = 0.008). In addition, they had significantly increased TISS scores, ICU cost, and need for renal replacement therapy (RRT) (P < 0.001). MELD score (by point) and MELD > 24 was associated with prolonged ICU stay (P = 0.004 and P = 0.005, respectively). On univariate analysis, etiology of alcohol-related liver disease (ALD), repeat LT, Budd-Chiari syndrome, and refractory ascites were associated with prolonged ICU stay. Using multivariate analysis, MELD > 24, refractory ascites, ALD and Budd-Chiari syndrome were associated with prolonged ICU stay. There was no association between using grafts with higher DRI and longer ICU stay, need for RRT, increased cost, or hospital survival on univariate analyses (P = not significant). Use of MELD as a method of organ allocation results in significant increase in ICU cost after LT. Using TISS as surrogate marker for ICU costs reveals that the cost implications are related to the need for RRT and prolonged ICU stay.

Critical care in the emergency department

The volume and duration of stay of the critically ill in the emergency department (ED) is increasing and is affected by factors including case-mix, overcrowding, lack of available and staffed intensive care beds and an ageing population. The purpose of this study was to describe the clinical activity associated with these high-acuity patients and to quantify resource utilization by this patient group. The study was a retrospective review of ED notes from all patients referred directly to the intensive care team over a 6-month period from April to September 2004. We applied a workload measurement tool, Therapeutic Intervention Scoring System (TISS)-28, which has been validated as a surrogate marker of nursing resource input in the intensive care setting. A nurse is considered capable of delivering nursing activities equal to 46 TISS-28 points in each 8-h shift. The median score from our 69 patients was 19 points per patient. Applying TISS-28 methodology, we estimated that 3 h 13 min nursing time would be spent on a single critically ill ED patient, with a TISS score of 19. This is an indicator of the high levels of personnel resources required for these patients in the ED. ED-validated models to quantify nursing and medical staff resources used across the spectrum of ED care is needed, so that staffing resources can be planned and allocated to match service demands.

Changes in hospital costs after introducing an intermediate care unit: a comparative observational study

IntroductionThe high cost of critical care resources has resulted in strategies to reduce the costs of ruling out low-risk patients by developing intermediate care units (IMCs). The aim of this study was to compare changes in total hospital costs for intensive care patients before and after the introduction of an IMC at the University Hospital Maastricht.MethodsThe design was a comparative longitudinal study. The setting was a university hospital with a mixed intensive care unit (ICU), an IMC, and general wards. Changes in total hospital costs were measured for patients who were admitted to the ICU before and after the introduction of the IMC. The comparison of interest was the opening of a six-bed mixed IMC.ResultsThe mean total hospital cost per patient increased significantly. Before the introduction of the IMC, the total hospital cost per patient was €12,961 (± €14,530) and afterwards it rose to €16,513 (± €17,718). Multiple regression analysis was used to determine to what extent patient characteristics explained these higher hospital costs using mortality, type of stay, diagnostic categories, length of ICU and ward stay, and the Therapeutic Intervention Scoring System (TISS) as predictors. More surgical patients, greater requirements of therapeutic interventions on the ICU admission day, and longer ICU stay in patients did explain the increase in hospital costs, rather than the introduction of the IMC.ConclusionAfter the introduction of the IMC, the higher mean total hospital costs for patients with a high TISS score and longer ICU stay explained the cost increase.

Usefulness of Severity-of-Illness Scores Based on Admission Data Only in Nosocomial Infection Surveillance Systems

Surveillance of nosocomial infection (NI) and the use of reference data for comparison is recommended to improve the quality of patient care. In addition to standardization according to device use, another stratification of reference data according to patients' severity-of-illness scores is often required for benchmarking in intensive care units (ICUs). To determine whether severity-of-illness scores on admission to the ICU are sufficient data for predicting the development of NI. This study was performed in an interdisciplinary ICU at a teaching hospital. Two scores were studied: the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Therapeutic Intervention Scoring System (TISS). The patient's clinical condition was evaluated on admission and reevaluated daily during the period before the development of NI. In addition, we recorded the number of intubations for every patient-day, the age and sex of the patients, and their history of operations. The Fisher exact test and the stepwise multiple logistic regression model were applied to identify significant predictors of NI. During a 12-month period, 270 patients with ICU stays of more than 24 hours were included in the study. Sixty-nine NIs were identified (incidence, 25.6 cases per 100 patients [95% confidence interval, 19.9-32.3]). A mean APACHE II score and a mean TISS score above the median for these scores, duration of ventilation above the median in the period before the development of NI, and patient age were significantly associated with the development of NI; the score data on admission provided a clearly poorer prediction. The APACHE II and TISS scores on admission are not useful predictors for NI in ICUs.

"Oldest old" patients in intensive care: prognosis and therapeutic activity

In view of ethical considerations and the limited resources in intensive care medicine, the present investigation aims to give a descriptive overview of the prognosis and therapeutic activity for the oldest age group of elderly patients admitted to an intensive care unit (ICU) in comparison with younger ICU patients. 3069 patients admitted to the ICU during a seven-year period were categorized into four age groups: under 65 years (48%), 65 to 74 years (26%), 75 to 85 years (22%) and 85 years or older (5%). Type and reason for ICU admission, length of ICU stay, severity of illness as measured by the simplified acute physiology score (SAPS)-II, level of provided care as measured by the simplified therapeutic intervention scoring system (TISS)-28, and vital status at the date of ICU discharge were recorded. The ICU mortality rate of patients aged 85 years or older was significantly higher than in patients under 65 (OR of mortality: 1.8, p < 0.001). Non-survivors had higher SAPS II levels (even when excluding age points) in all age groups, but higher daily average TISS points only in patients under 85. The daily average TISS score was negatively correlated to age (r = -0.03; p < 0.001) and was significantly lower in the oldest group when compared with all the younger groups (p < 0.001). The oldest patients had a significantly shorter length of stay (median: 2; interquartile range [IQR] 1-3, p < 0.001) than the younger patient groups. Within the very elderly population, age is an important and independent predictor of mortality, but acute severity of illness is even more strongly associated with mortality. Consequently, age alone may be an inappropriate criterion for allocation of ICU resources.

Nursing intensity and patient classification at an adult intensive care unit (ICU)

ICUs have been using patient information systems for several years now and a huge amount of data is recorded every day. Still nursing research has only limited evidence on how the data recorded in these systems are used. Two of the items systematically recorded in Finnish patient information systems are patient classification and nursing intensity. The aim of this pilot study was to: Use the systematically recorded data of one intensive care unit and discover which variables correlate with or have a statistical relationship to patient classification and nursing intensity. The study uses a descriptive statistical approach and the material has been investigated, retrospectively. The material consisted of information system data on 1737 patients at one Finnish intensive care unit in 2003. Altogether 15,866 patient classifications were made during 1 year. A statistically moderate dependence and a strong correlation (r=0.40) were found between nursing intensity, patient's age, sex and type of intensive care in the case of female emergency non-operative patients and between nursing intensity. That is, the older the female emergency non-operative patient, the higher the assessment of nursing intensity was. Also the correlation between Therapeutic Intervention Scoring System (TISS) scores and nursing intensity was found to be statistically strong (r=0.57). Despite the strong correlation the average TISS score in this study can only account for 32% of the patient's average nursing intensity during the period of treatment.

Excess mortality in winter in Finnish intensive care

In the general population, mortality from acute myocardial infarctions, strokes and respiratory causes is increased in winter. The winter climate in Finland is harsh. The aim of this study was to find out whether there are seasonal variations in mortality rates in Finnish intensive care units (ICUs). We analysed data on 31,040 patients treated in 18 Finnish ICUs. We measured severity of illness with acute physiology and chronic health evaluation II (APACHE II) scores and intensity of care with therapeutic intervention scoring system (TISS) scores. We assessed mortality rates in different months and seasons and used logistic regression analysis to test the independent effect of various seasons on hospital mortality. We defined 'winter' as the period from December to February, inclusive. The crude hospital mortality rate was 17.9% in winter and 16.4% in non-winter, P = 0.003. Even after adjustment for case mix, winter season was an independent risk factor for increased hospital mortality (adjusted odds ratio 1.13, 95% confidence interval 1.04-1.22, P = 0.005). In particular, the risk of respiratory failure was increased in winter. Crude hospital mortality was increased during the main holiday season in July. However, the severity of illness-adjusted risk of death was not higher in July than in other months. An increase in the mean daily TISS score was an independent predictor of increased hospital mortality. Severity of illness-adjusted hospital mortality for Finnish ICU patients is higher in winter than in other seasons.

Risk Factors for Candidemia in Pediatric Patients With Congenital Heart Disease

To identify the main risk factors for the acquisition of candidemia in children with congenital heart disease (CHD) in order to improve the clinical management of these patients. A case-control study. A large tertiary-care referral center in Spain with a pediatric intensive care unit (PICU) to which more than 500 children with CHD are admitted annually. All patients had CHD and were admitted to the PICU during 1995-2000. Case patients were defined as patients with candidemia, and control patients were defined as patients without candidemia. Twenty-eight case patients and 47 control subjects were included in the study. Case patients were younger (mean age [+/-SD], 12.5+/-32.0 vs 38.0+/-48.0 months; P<.01) and had a longer median PICU stay (19 vs 4 days; P<.01), and a greater percentage of case patients previously had Candida species isolated from specimens other than blood (eg, bronchial aspirates, urine, or skin specimens) (39% vs 4%; P<.01). Severity of clinical condition, as measured by the Therapeutic Intervention Scoring System (TISS) 1 week after PICU admission (odds ratio, 1.15; 95% confidence interval, 1.05-1.26; P<.01), and receipt of antibiotic treatment for more than 5 days (odds ratio, 13.42; 95% confidence interval, 1.31-137.13; P=.03) were independently associated with the development of candidemia. Patients with CHD who have a high TISS score 1 week after PICU admission and patients who have received prolonged antibiotic therapy should be considered at high risk for candidemia. Our results suggest that shorter courses of antibiotic therapy, routine surveillance culture for Candida species, and initiation of preemptive or empirical antifungal treatment could help in the clinical management of these patients.

The proportion of intensive care unit admissions related to alcohol use: a prospective cohort study

Alcohol abuse is a risk factor for serious illnesses, and a history of chronic alcohol abuse adversely affects the outcome of critically ill patients. It is not known what proportion of intensive care unit (ICU) admissions is related to alcohol use. Therefore, we investigated the proportion of emergency admissions related to alcohol. A prospective cohort study was conducted in a university hospital ICU. All adult patients (n = 893) who underwent emergency admission to our ICU during a period of 1 year were studied. The admitting physician determined whether there was a relationship between alcohol use and admission. ICU and hospital mortality and ICU length of stay (LOS) were recorded. The Therapeutic Intervention Scoring System (TISS) was used for ICU resource use estimation. There was a relationship between alcohol use and admission in 24% (215/893) of admissions and, in 156/893 admissions (17.5%), this seemed to be definite. ICU LOS was 1.2 days (0.7; 2.3) (median; interquartile range) for alcohol-related and 1.8 days (0.9; 3.6) for other admissions (P < 0.001). Patients with alcohol-related admissions consumed 17.8% of ICU patient-days and 18.7% of all accumulated TISS scores. ICU (8.8 vs. 10.5%, P = 0.603) and hospital (19.1 vs. 20.2%, P = 0.769) mortalities were no different between alcohol-related and other admissions. ICU admission is very often related to long-term chronic and/or occasional alcohol use.

Characteristics and outcomes for critically ill patients with prolonged intensive care unit stays*

Prolonged stay in the intensive care unit (ICU) is associated with high mortality, morbidity, and costs. Identifying those patients who are most likely to benefit from an extended ICU stay would be helpful in guiding clinical decisions. We sought to describe the characteristics and outcomes for a heterogeneous group of patients who required a prolonged ICU stay. Observational study. Adult ICUs of three teaching and five community hospitals. The study group comprised 5,881 patients consecutively admitted to the ICUs during a 10-month period. A prolonged stay was defined as one >21 days at teaching hospitals and >10 days at community hospitals. For patients meeting the criteria of prolonged stay, Therapeutic Intervention Scoring System (TISS) score and Multiple Organ Dysfunction Score (MODS) were measured prospectively from days 10 and 21 in community and teaching hospitals, respectively, and retrospectively before this. Prolonged-stay patients represented 5.6% of ICU admissions and 39.7% of ICU bed-days. Compared with short-stay patients, they were significantly older and had higher admission Acute Physiology and Chronic Health Evaluation (APACHE) II scores (p < .01). ICU and hospital mortality for prolonged-stay patients were 24.4% and 35.2%, respectively, compared with 11% and 15.9% for short-stay patients (p < .001). Mean admission TISS and MODS scores for prolonged-stay patients were 30.8 (sd, 11.1) and 4.8 (sd, 3.3) respectively. For prolonged-stay patients the dominant reason for ICU care was multiple organ failure (37.8%), ventilator support (30.7%), or nonventilated single organ failure (31.5%). Hospital mortality was highest in the group with multiple organ failure (53%). We developed a method to broadly classify a heterogeneous population of prolonged-stay ICU patients on the basis of MODS and the ICU interventions received. Mortality among prolonged-stay patients was highest for those with multiple organ failure. Future research should evaluate whether the proposed classification system can be used to influence the delivery of ICU care.

Efficacy and outcome of intensive care in pediatric oncologic patients.

Because the long-term survival of children with cancer has dramatically improved because of multimodal treatment strategies, intensive care medicine has become more relevant for these patients. This study was performed to assess the efficacy of intensive care medicine in newly diagnosed pediatric oncologic patients and in patients under ongoing oncologic treatment. A retrospective analysis of children admitted to the pediatric intensive care unit (PICU) of the University Hospital Duesseldorf for life-threatening conditions between 1995 and 1999 was performed to identify those patients with an oncologic condition. University hospital. A total of 123 patients were identified. Children admitted for uncomplicated postoperative care and children admitted after bone marrow transplantation were excluded from this analysis. Forty-eight patients could be divided into two groups. Group A contained children admitted to the PICU at the time of cancer diagnosis and group B children receiving ongoing oncologic treatment. The evaluation included diagnosis, risk factors, complications leading to PICU admission, PICU therapy, and outcome. Statistical analysis included evaluation of Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) scores. Respiratory insufficiency was the leading diagnosis for PICU admission, whereas in the remaining children cardiovascular insufficiency, renal failure, neurologic impairment, ileus, and tumor-associated complications led to PICU admission. The number of organ failures was correlated to outcome. All children but one of group A could be discharged from the PICU, whereas 12 of 35 children in group B died, despite intensive care treatment attempts. The PRISM and TISS scores at admission to the PICU were significantly higher in children who did not survive the period of intensive care treatment in group B. However, all patients with a PRISM score of >20 died. Diagnosis of cancer does not exclude potential benefit from intensive care medicine in these children, although severe complications might affect the prognosis.

Course and outcome of obstetric patients in a general intensive care unit

To characterize the course, interventions required to achieve predetermined end-points and outcome of obstetric patients admitted to a general intensive care unit. A retrospective case series study was performed including all pregnant patients admitted to an 8-bed general intensive care unit at a tertiary care university-affiliated hospital over a 4-year period. All patients referred by the obstetricians were admitted. Patients were divided into two groups: group 1, (n = 19) those requiring mechanical ventilatory support and group 2, (n = 27) those requiring intensive monitoring. Data collected included demographics, reason for admission, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intervention Scoring System (TISS) scores, intensive care unit course, types of interventions used and outcome. End-points of therapy included systolic blood pressure 110-150 mmHg, urine output > or = 1 cc/kg/h and oxygen saturation > 95%. Over the study period, 46 obstetric patients were admitted to the intensive care unit, representing 0.2% of all deliveries and an intensive care unit utilization rate of 2.3%. Commonest admission diagnoses were pregnancy-induced hypertension and hemorrhage. Reason for admission was mechanical ventilation in 41% while 59% were admitted for monitoring. Median length of stay was 25 +/- 80.9 (mean 48.8) hours. The median APACHE II score was 6 +/- 3.9 (mean 7.24) and the TISS score was > 20 in both groups. Only one patient died (mortality rate 2.3%). Despite a short length of stay and low APACHE score, the high TISS score in obstetric patients admitted for both ventilation and monitoring suggests that these patients require a level of intervention and care typically provided by a general intensive care unit.

Correlation of TISS and Nurse Dependency scores with the pilot version of the SOPRA score

A number of severity of illness scoring systems have been developed and are widely used in intensive care practice. The Therapeutic Intervention Scoring System (TISS) is used as a tool for assessing severity of illness, therapeutic and nursing manpower requirements as well as cost-benefit analysis.1 TISS uses over 70 variables, however it does not take into account non-interventional demands on time such as communications and support for relatives. The Lincolnshire demand model for Nurse Dependency (ND) adapted from an earlier model2 is used in our ICU, scoring 1, 2 or 3 with increasing dependence. The Intensive Care National Audit and Research Centre (ICNARC) Working Group released a pilot version of their System of Patient Related Activities (SOPRA) at the Riverside/ICS Meeting in December 1998. SOPRA is intended to indicate the degree of care necessary when treating a critically ill patient. In one score it is hoped to assess the intensity of impact each patient made on the work of the ICU that day. The aim of this study was to test for any association between TISS, SOPRA and ND scores. Daily TISS, SOPRA and ND scores were recorded over a period of 2 months on all patients on our ICU. The results were analysed using non-parametric tests, Spearman's correlation and linear regression methods. We recorded 488 scores for each system (Table 24). Median SOPRA score was 25 (range 12–60), that of TISS was 34 (11–73). There was no correlation between SOPRA and ND scores (r2 = 0.18). There was no correlation between TISS and ND (r2 = 0.14). Despite many similarities between SOPRA and TISS their correlation was poor (r2 = 0.49). Our nursing staff found the SOPRA score more specific and less subjective than TISS. It was also felt to be more representative of current Intensive Care practice. We conclude that the SOPRA and TISS are significantly different scoring systems despite having many common factors. However further evaluation is required to identify any advantage SOPRA may offer over TISS.

A simple method for calculating the required size of a high dependency unit

As part of a business plan for the establishment of a high dependency unit (HDU) in a 742 bedded acute teaching hospital, a study was carried out to establish the number of beds required. The hospital already had a six-bed intensive care unit (ICU), with a seventh bed staffed part-time to provide postoperative care for elective surgical cases. Over a 2-week period, one investigator (JAG) visited each of 16 acute wards daily, to identify patients appropriate for HDU admission. He also visited the ICU to identify any patients for whom HDU would provide a step-down facility, and examined operating theatre recovery records to identify any patients who could not be returned to the general ward within 3 h following their surgery. At each visit, the nurse in charge was asked to identify any patients requiring additional nursing care or in need of increased monitoring. Each patient was assessed using the Therapeutic Intervention Scoring System (TISS).1 A score of greater than 10 indicated suitability for HDU admission. Physiological and biochemical data were also collected to allow calculation of each patient's Simplified Acute Physiology Score (SAPS II)2 and hence calculation of predicted mortality. During the 14 day period, 35 patients were identified as requiring additional care. Their mean TISS score was 14.1 (range 10–33) and their mean predicted mortality was 5.7% (0–19.6%). Each patient had a predicted average HDU stay of 2.2 days (1–5 days) to give a total of 76 patient days. The occupancy of the proposed HDU ranged from 3 to 8 patients per day with a mean of 5.4 per day, suggesting that an HDU containing a minimum of six beds would be appropriate to serve the needs of the hospital.

Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments.

Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses. To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists. Prospective cohort study. 5 U.S. teaching hospitals between 1989 and 1994. 1298 patients hospitalized with an exacerbation of congestive heart failure. Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994. Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]). In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.

Relationship between TISS and ICU cost.

To determine whether the therapeutic intervention scoring system (TISS) reliably reflects the cost of the overall intensive care unit (ICU) population, subgroups of that population and individual ICU patients. Prospective analysis of individual patient costs and comparison with TISS. Adult, 12 bedded general medical and surgical ICU in a university teaching hospital. Two hundred fifty-seven consecutive patients including 52 coronary care (CCU), 99 cardiac surgery (CS) and 106 general ICU (GIC) cases admitted to the ICU during a 12-week period in 1994. A total of 916 TISS-scored patient days were analysed A variable cost (VC) that included consumables and service usage (nursing, physiotherapy, radiology and pathology staff costs) for individual patients was measured daily. Nursing costs were calculated in proportion to a daily nursing dependency score. A fixed cost (FC) was calculated for each patient to include medical, technical and clerical salary costs, capital equipment depreciation, equipment and central hospital costs. The correlation between cost and TISS was analysed using regression analysis. For the whole group (n = 257) the average daily FC was pound sterling 255 and daily VC was pound sterling 541 (SEM 10); range pound sterling 23-pound sterling 2,806. In the patient subgroups average daily cost (FC + VC) for CCU was pound sterling 476 (SEM 17.5), for CS pound sterling 766 (SEM 13.8) and for GIC pound sterling 873 (SEM 13.6). In the group as a whole, a strong correlation was demonstrated between VC and the TISS for each patient day (r = 0.87, p < 0.001) and this improved further when the total TISS score was compared with the total VC of the entire patient episode (r = 0.93, p < 0.001). This correlation was maintained in CCU, CS and GIC patient cohorts with only a small median difference between actual and predicted cost (2.2 % for GIC patients). However, in the individual patient, the range of error was up to +/- 65 % of the true variable cost. For the whole group the variable cost per TISS point was pound sterling 25. These results demonstrate that TISS reliably measures overall ICU population costs as well as those of the subgroups CCU, CS and GIC. However, the relationship between TISS and cost is less reliable for the individual patient.

Resting energy expenditure and nitrogen balance in critically ill pediatric patients on mechanical ventilation.

Nutritional support is important in critically ill patients, with variable energy and nitrogen requirements (e.g., sepsis, trauma, postsurgical state) in this population. This study investigates how age, severity of illness, and mechanical ventilation are related to resting energy expenditure (REE) and nitrogen balance. Nineteen critically ill children (mean age, 8 +/- 6 [SD] y and range 0.4-17.0 y) receiving total parenteral nutrition (TPN) were enrolled. We used indirect calorimetry to measure REE. Expected energy requirements (EER) were obtained from Talbot tables. Pediatric Risk of Mortality (PRISM) and Therapeutic Intervention Scoring System (TISS) score were calculated. Total urinary nitrogen was measured using the Kjeldahl method. PRISM and TISS scores were 9 +/- 5 and 31 +/- 6 points, respectively. REE was 62 +/- 25 kcal.kg-1.d-1, EER was 42 +/- 11 kcal.kg-1. d-1, and caloric intake was 49 +/- 22 kcal.kg-1.d-1. Nitrogen intake was 279 +/- 125 mg.kg-1.d-1, total urinary nitrogen was 324 +/- 133 mg.kg-1.d-1, and nitrogen balance was -120 +/- 153 mg.kg-1.d-1. The protein requirement in this population was approximately 2.8 g.kg-1.d-1. These critically ill children were hypermetabolic, with REE 48% higher (20 kcal.kg-1.d-1) than expected. Nitrogen balance significantly correlated with caloric and protein intake, urinary nitrogen, and age, but not with severity of illness scores or ventilatory parameters.