Use Of Intensive Care Unit Resources Research Articles

Respiratory intensive care unit resource use and outcomes in Taiwan.

Based on a revision of Donabedian's classic structure, process, and outcome conceptual framework, this study examined the relationship between resource use (length of stay) and outcome (transfer status) in two respiratory intensive care units (ICUs). Medical records of respiratory ICU patients (N = 194) from a medical center in northern Taiwan were reviewed. Data collection focused on patient demographic profile (age, gender, and medical diagnosis), Acute Physiology and Chronic Health Evaluation (APACHE) score, nursing diagnoses, ICU length of stay, and transfer status. The results indicate that patients with lower APACHE scores and more nursing diagnoses had a longer ICU length of stay. In addition, both the number of nursing diagnoses and APACHE scores significantly explained the variance in the length of stay. Nonetheless, a higher APACHE score was correlated with a poor transfer status. These findings indicate that, in addition to the traditional indicators, nursing diagnoses may be a vital variable in predicting ICU length of stay. The results also imply that patients with lower APACHE scores are in better physical condition and are therefore institutionalized longer in ICUs.

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.

Cost calculation and budgeting: the effect of a training session on the skills of medical directors and head nurses in European intensive care units

Reports the results of a study aimed to assess the influence of cost calculation and budgeting training on the financial skills of medical professionals in European intensive care units (ICUs). Focuses on a test devised to measure cost calculation and budgeting skills of the medical directors and head nurses in 13 European countries. The test comprises two equivalent measurements. The training consists of an introduction to the main principles of cost calculation and budgeting. Emphasizes similarities with the profit sector. A set of guidelines on cost calculation and budgeting has been composed and tailored to the needs of ICU management. The results show that a rather introductory training of medical doctors and head nurses of ICUs dramatically improves their costing and budgeting skills. Therefore such a training should be a component in a comprehensive strategy to improve cost‐awareness in ICUs, eventually resulting in a more efficient use of ICU resources.

Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma.

We have previously documented that the admission systemic inflammatory response syndrome (SIRS) score, calculated with four variables-temperature, heart rate, neutrophil count, and respiratory rate-is a significant predictor of outcome in trauma (n = 4,887). The objective of this current study was to validate our previous findings in a larger trauma patient population, to analyze the predictive accuracy of the four individual components of the SIRS score (temperature, heart rate, neutrophil count, and respiratory rate), and to assess whether the admission SIRS score is an accurate predictor of intensive care unit (ICU) resource use in trauma. Prospective data were collected on 9,539 patients admitted to a Level I trauma center over a 30-month period (January 1997-July 1999). Patients were stratified by age, sex, race, and Injury Severity Score (ISS). SIRS score was calculated at admission, and SIRS was defined as a SIRS score > or = 2. SIRS score was validated as a significant independent predictor of outcome in trauma by logistic regression analysis after controlling for age and ISS. Of the four SIRS variables, hypothermia (temperature < 36 degrees C) was the most significant predictor of mortality after controlling for age and ISS. Leukocytosis (neutrophil count > 12,000/mm3) was the most significant predictor of total hospital length of stay. SIRS scores of > or = 2 were increasingly predictive of mortality and ICU admission by logistic regression analysis (p < 0.001). These data provide further validation that an admission SIRS score of > or = 2 is a significant independent predictor of outcome and ICU resource use in trauma. Temperature (hypothermia) is the individual component of the SIRS score with the greatest predictive accuracy. SIRS score should be calculated on all trauma admissions.

Multicenter outcome study of cancer patients admitted to the intensive care unit: a probability of mortality model.

To develop prospectively and validate a model for probability of hospital survival at admission to the intensive care unit (ICU) of patients with malignancy. This was an inception cohort study in the setting of four ICUs of academic medical centers in the United States. Defined continuous and categorical variables were collected on consecutive patients with cancer admitted to the ICU. A preliminary model was developed from 1,483 patients and then validated on an additional 230 patients. Multiple logistic regression modeling was used to develop the models and subsequently evaluated by goodness-of-fit and receiver operating characteristic (ROC) analysis. The main outcome measure was hospital survival after ICU admission. The observed hospital mortality rate was 42%. Continuous variables used in the ICU admission model are PaO2/FiO2 ratio, platelet count, respiratory rate, systolic blood pressure, and days of hospitalization pre-ICU. Categorical entries include presence of intracranial mass effect, allogeneic bone marrow transplantation, recurrent or progressive cancer, albumin less than 2.5 g/dL, bilirubin > or = 2 mg/dL, Glasgow Coma Score less than 6, prothrombin time greater than 15 seconds, blood urea nitrogen (BUN) greater than 50 mg/dL, intubation, performance status before hospitalization, and cardiopulmonary resuscitation (CPR). The P values for the fit of the preliminary and validation models are .939 and .314, respectively, and the areas under the ROC curves are .812 and .802. We report a disease-specific multivariable logistic regression model to estimate the probability of hospital mortality in a cohort of critically ill cancer patients admitted to the ICU. The model consists of 16 unambiguous and readily available variables. This model should move the discussion regarding appropriate use of ICU resources forward. Additional validation in a community hospital setting is warranted.

How Essential Is the Intensive Care Unit After Carotid Endarterectomy?

This study was designed to determine whether a short recovery room stay could safely and accurately predict which patients required the Intensive Care Unit (ICU) after carotid endarterectomy (CEA). After review of the records of all patients who underwent CEA at the author's insti tution between 1988 and 1990, a set of criteria was developed for selecting which patients required the ICU postoperatively. These indications included postoperative neurologic changes, cardiac irritability or ischemia, prolonged need for vasoactive medication, and wound hematomas that might compromise the patient's airway. Between January 1, 1991 and June 30, 1996, 342 CEAs were performed at the author's institution. Forty-two (12%) patients required the ICU postoperatively; 23 had unstable blood pressure, seven had cardiac problems, 10 had neurologic problems (7 permanent, 3 transient), and three had neck hematomas. One patient originally in the ICU for hypertension was transferred back after developing an intracerebral hemorrhage on postoperative day 2, and one patient was transferred into the ICU for unstable blood pressure that developed on the vascular floor. Preoperative risk factors, indications for operation, and anesthetic technique did not predict which patients would need the ICU. Two patients died within 30 days. There were no readmissions after discharge. Selection of patients for ICU admission after CEA can be safely and accurately deter mined during a 3-hour stay in the recovery room postoperatively. This selection results in efficient use of ICU resources and tremendous cost savings. By adherence to the protocol, 88% of patients did not need ICU after CEA.

Do-Not-Resuscitate Orders in Intensive Care Units

Objectives. —To describe the characteristics of patients with do-not-resuscitate (DNR) orders and the frequency and timing of these orders in a representative sample of intensive care units (ICUs) and to compare practices from 1980 to 1990. Design. —Prospective inception cohort. Setting. —A total of 42 ICUs in 40 US hospitals with 200 or more beds; 26 randomly selected hospitals and 14 large, tertiary care hospitals that volunteered to be studied. Participants. —A consecutive sample of 17440 ICU admissions from 1988 to 1990. Measurements. —Patient demographic characteristics, comorbid conditions, disease, and physiological abnormalities. Main Outcome Measures. —Frequency and timing of DNR orders; ICU resource use before and after DNR orders; and patients' hospital and ICU discharge status. Results. —Physicians wrote DNR orders for 1577 ICU admissions (9%) (hospital range, 1.5% to 22%). Patients with ICU DNR orders were older, more functionally impaired, had more comorbid illness, a higher severity of illness, and required the use of more ICU resources compared with patients without DNR orders. Compared with data from a similar survey from 1979 to 1982, ICU DNR orders were more frequent in 1988 to 1990 (9% vs 5.4%; P P P P Conclusions. —Over the last decade physicians and patients' families set limits earlier and more frequently in cases likely to have poor outcomes. We attribute this change to a greater dialogue about setting limits to care and a greater knowledge of treatment outcomes among physicians and families. These changes in practice preceded implementation of the Patient Self-determination Act, designed to ensure patient autonomy for decisions about life-sustaining therapy. ( JAMA . 1993;270:2213-2217)

Do-Not-Resuscitate Orders in Intensive Care Units

To describe the characteristics of patients with do-not-resuscitate (DNR) orders and the frequency and timing of these orders in a representative sample of intensive care units (ICUs) and to compare practices from 1980 to 1990. Prospective inception cohort. A total of 42 ICUs in 40 US hospitals with 200 or more beds; 26 randomly selected hospitals and 14 large, tertiary care hospitals that volunteered to be studied. A consecutive sample of 17,440 ICU admissions from 1988 to 1990. Patient demographic characteristics, comorbid conditions, disease, and physiological abnormalities. Frequency and timing of DNR orders; ICU resource use before and after DNR orders; and patients' hospital and ICU discharge status. Physicians wrote DNR orders for 1577 ICU admissions (9%) (hospital range, 1.5% to 22%). Patients with ICU DNR orders were older, more functionally impaired, had more comorbid illness, a higher severity of illness, and required the use of more ICU resources compared with patients without DNR orders. Compared with data from a similar survey from 1979 to 1982, ICU DNR orders were more frequent in 1988 to 1990 (9% vs 5.4%; P < .001) and preceded 60% of all in-unit deaths compared with only 39% in 1979 to 1982 (P < .001). Do-not-resuscitate orders were written sooner (for 3.6% vs 2.0% of patients on day 1 in the ICU) and patients with DNR orders remained in the ICU longer in 1988 to 1990 (2.8 vs 1.4 days) than in 1979 to 1982, and had lower ICU and hospital mortality rates (64% vs 74%, P < .001; and 85% vs 94%, P < .001). Over the last decade physicians and patients' families set limits earlier and more frequently in cases likely to have poor outcomes. We attribute this change to a greater dialogue about setting limits to care and a greater knowledge of treatment outcomes among physicians and families. These changes in practice preceded implementation of the Patient Self-determination Act, designed to ensure patient autonomy for decisions about life-sustaining therapy.

Cost-effective use of the surgical intensive care unit.

AbstractThe intensive care unit (ICU) continues to be a large user of resources. There is a continued need for a balance of cost‐effective utilization and quality patient care. A data base of information currently exists that defines those groups of patients in whom reasonable success in resource allocation can be anticipated. In other cases, attempts are being made to define variables that adequately predict survival so they can be used to effect care decisions. Although some progress has been made, considerable work is needed to achieve both of these.For surgeons, the ICU has become an essential “part of the knife.” It is a necessity in modern high‐technology care and has become an essential element in surgical training programs. The use of the ICU for currently conceived high‐risk patients is now commonplace. A growing database supports this preoperative use of ICU resources. Techniques are now available to make ICU care more cost‐effective. Tools such as not having routine orders, daily rewriting of all orders, review of drug orders, and the utilization of the laboratory and radiographic resources have already reduced significantly the real cost of using these life‐saving facilities.