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Gosula V, Hariharan S. Costs of Providing Intensive Care for Adult Non-survivors in a Caribbean Teaching Hospital. Cureus 2020; 12:e12141. [PMID: 33489553 PMCID: PMC7813520 DOI: 10.7759/cureus.12141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Intensive Care Unit (ICU) is a resource intense area consuming a vast majority of the hospital's budget. This study aimed to determine the costs of providing critical care to non-survivors in an adult ICU at a tertiary care teaching hospital in the Caribbean. Methods A chart review of non-survivors over a period of nine months was done in an adult ICU. Admission diagnoses, Simplified Acute Physiology Score (SAPS II) score, daily laboratory investigations, drugs, and all therapeutic interventions including mechanical ventilation were recorded. Activity-based costs were prospectively estimated by data obtained from ICU flowsheets, nursing-activity scores, and various hospital departments. Results A total of 316 days of ICU intervention data were collected from the 39 non-survivors enrolled. The median patient age was 56 years. The median ICU length of stay (LOS) and the median duration of mechanical ventilation were five days. The median SAPS II score was 62. One-third of patients had cardiovascular problems and 28% were surgical patients. The total cost of providing ICU care for the non-survivors was US$ 765,233 with an average cost of US$ 19,621 per patient. Human resources (39%) and consumables (29%) were the highest components of costs. Patients who had a cardiac arrest before admission consumed more resources. A higher SAPS II score predicted a shorter LOS (p=0.01) and lower costs (p=0.03). Conclusions ICU care for non-survivors consume significantly high resources. Stringent admission protocols and consideration of medical futility at an earlier stage, using prognostic models and clinical criteria may prevent unnecessary interventions and costs.
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Affiliation(s)
- Venkata Gosula
- Anaesthesia and Intensive Care, Eric Williams Medical Sciences Complex, Trinidad, TTO
| | - Seetharaman Hariharan
- Anaesthesia and Intensive Care, The University of the West Indies - St. Augustine, St. Augustine, TTO
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Karagoz S, Tekdos Seker Y, Cukurova Z, Hergunsel O. The Effectiveness of Scoring Systems in the Prediction of Diagnosis-Based Mortality. Ther Apher Dial 2019; 23:418-424. [PMID: 30520234 DOI: 10.1111/1744-9987.12780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Accepted: 11/30/2018] [Indexed: 12/01/2022]
Abstract
Scoring systems are used for mortality and morbidity rating in intensive care conditions, prognosis prediction, standardization of scientific data and the monitoring of clinical quality. The aim of this study was to retrospectively analyze the efficacy of APACHE II (Acute Physiology and Chronic Health Evaluation), APACHE IV and SAPS (Simplified Acute Physiology Score) III prognostic scorings in the prediction of mortality and disease severity of patients admitted to the Anesthesia and Reanimation Clinic Intensive Care Unit (ICU) in Bakırköy Dr. Sadi Konuk Training and Research Hospital according to general and specific diagnoses. A total of 1896 patient files were included in the study. With the exception of single system or head trauma patient groups, a statistically significant difference was found in the mortality prediction rates in all other diagnosis groups (P < 0.05). The discrimination calculated with AUROC fields was sufficient in all groups, and calibration was evaluated as good except for the neurological and neurosurgical patient group. In respect of standard mortality prediction, APACHE II and IV were good in cases of sepsis, and SAPS III made almost exact predictions for cardiovascular diseases, APACHE II for neurological diseases, and APACHE IV for gastrointestinal system diseases. From the results of this study, it was seen that different scoring systems vary in predictions according to the diagnoses, therefore, it can be recommended that the diagnosis should be taken into account more when applying scoring systems.
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Affiliation(s)
- Selda Karagoz
- Department of Anaesthesiology, University of Healthy Sciences, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Yasemin Tekdos Seker
- Department of Anaesthesiology, University of Healthy Sciences, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Zafer Cukurova
- Department of Anaesthesiology, University of Healthy Sciences, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Oya Hergunsel
- Department of Anaesthesiology, University of Healthy Sciences, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
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Semei-Spencer TT, Kinthala S, Fakoory M, Gaskin P, Hariharan S, Areti YK. Outcomes and Health-related Quality of Life following Intensive Care Unit Stay in Barbados. W INDIAN MED J 2014; 63:447-53. [PMID: 25781281 PMCID: PMC4655689 DOI: 10.7727/wimj.2013.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Accepted: 10/25/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To evaluate the hospital outcome and health-related quality of life (HRQOL) in adult patients admitted to intensive care units (ICUs) in Barbados. METHODS A prospective observational study was done in the medical and surgical intensive care units of the Queen Elizabeth Hospital, Barbados, to evaluate the outcomes and HRQOL in adult patients. The acute physiology and chronic health evaluation (APACHE) IV score was applied on admission to one hundred and fifty patients admitted to the ICUs. The HRQOL was evaluated by using Short Form 36 (SF-36) in 63 survivors, three months after ICU discharge. RESULTS There was no significant difference between medical and surgical ICUs with respect to age, gender, APACHE IV scores, 90-day mortality, and length of stay. The mean (± SD) APACHE IV score was 42.6 (± 23.7). The observed mortality was 32.7% and the standardized mortality ratio (SMR) was 1.85. The APACHE IV scores were significantly higher in non-survivors compared to survivors (p < 0.001). Patients with APACHE IV of > 45, and who were ventilated in the first 24 hours had the highest mortality (66%). The mean ICU length of stay was 7.2 days. CONCLUSION In this study, the SF-36 scores in all eight dimensions indicated that the HRQOL in the majority of the survivors was average or above average. There was a significant negative correlation between APACHE IV score and the SF-36 score.
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Affiliation(s)
- T T Semei-Spencer
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados
| | - S Kinthala
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados.
| | - M Fakoory
- Department of Anaesthesia, Queen Elizabeth Hospital, Martindales Road, St Michael, Barbados
| | - P Gaskin
- Essential National Health Research, Faculty of Medical Sciences, The University of the West Indies, Cave Hill, Barbados
| | - S Hariharan
- Anaesthesia and Intensive Care Unit, Department of Clinical Surgical Sciences, The University of the West Indies, St Augustine, Trinidad and Tobago
| | - Y K Areti
- Department of Anaesthesia and Intensive Care, Faculty of Medical Sciences, the University of the West Indies, Cave Hill, Barbados
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Managing healthcare performance in analytical framework. BENCHMARKING-AN INTERNATIONAL JOURNAL 2008. [DOI: 10.1108/14635770810887249] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Hariharan S, Chen D, Merritt-Charles L. Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison. Anaesthesia 2007; 62:244-9. [PMID: 17300301 DOI: 10.1111/j.1365-2044.2007.04953.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.
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Affiliation(s)
- S Hariharan
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St. Augustine, Trinidad and Tobago, West Indies.
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Hariharan S, Chen D, Merritt-Charles L, Bobb N, DeFreitas L, Esdelle-Thomas JMA, Charles D, Colley K, Renaud E. The utilities of the therapeutic intervention scoring system (TISS-28). Indian J Crit Care Med 2007. [DOI: 10.4103/0972-5229.33387] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Hariharan S, Zbar A. Risk Scoring in Perioperative and Surgical Intensive Care Patients: A Review. ACTA ACUST UNITED AC 2006; 63:226-36. [PMID: 16757378 DOI: 10.1016/j.cursur.2006.02.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE Assessing the risk and predicting the outcome of surgery, trauma, and surgical intensive care is an important aspect of perioperative practice. There have been attempts to devise and validate many scoring systems to predict the prognosis of patients having a similar severity of illness. This article reviews some of the commonly used systems with respect to their development, strengths, and limitations. SOURCES Published literature describing risk assessment scores and physiologic scoring systems for preoperative assessment, trauma, and surgical intensive care patients. PRINCIPAL FINDINGS Risk scores used in preoperative evaluation assist the clinician in optimizing the patient before, during, and after surgery. Scoring systems applied in intensive care units are useful as guidelines rather than accurate predictors of prognosis for individual patient. Many models are used for audit purposes, and some are used as performance measures and quality indicators of a unit; however, both utilities are controversial because of poor adjustment of these systems to case-mixtures. CONCLUSIONS Risk assessment scores may assist in the perioperative risk evaluation with respect to organ systems. Prognostication of critically ill patients belonging to a category of illness may be done using physiological scoring systems taking into account the difference in the case-mix of the particular unit.
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Affiliation(s)
- Seetharaman Hariharan
- Department of Anesthesia and Intensive Care, The University of the West Indies, St. Augustine, Trinidad, West Indies.
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Hariharan S, Dey PK, Chen DR, Moseley HSL, Kumar AY. Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units. J Crit Care 2005; 20:117-24; discussion 124-5. [PMID: 16139151 DOI: 10.1016/j.jcrc.2005.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. MATERIALS AND METHODS Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. RESULTS The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70% and 64% with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. CONCLUSIONS Analytic hierarchy process is a very useful model to measure the global performance of an ICU.
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Affiliation(s)
- Seetharaman Hariharan
- Anaesthesia and Intensive Care, The University of the West Indies, St. Augustine, Trinidad and Tobago.
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Jonnalagadda R, Walrond ER, Hariharan S, Walrond M, Prasad C. Evaluation of the reasons for cancellations and delays of surgical procedures in a developing country. Int J Clin Pract 2005; 59:716-20. [PMID: 15924601 DOI: 10.1111/j.1742-1241.2004.00354.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Data on all patients scheduled to have elective and emergency surgeries during the period of 6 weeks from September 1999 to October 1999 were prospectively collected to determine scheduled starting times, actual starting times, completion times, causes for delays and cancellations. Of 840 procedures scheduled during the study period, 594 (71%) were available for analysis. Eighty-nine per cent of cancellations occurred in patients undergoing elective surgery. The common causes of cancellations were non-availability of beds in recovery room (RR) (15%), patients not showing up (9%), improper pre-operative patient preparation (13%), unavailability of nurses (11%) and anaesthetists (8%). Twenty-three per cent of the cancellations were day cases. Public patients were cancelled more frequently than private patients. Surgical procedures started on time in only 7% of patients. The most common cause of delay was due to delayed transport of patients to the operating theatre (17%). Optimal utilisation of operating theatres in our situation may be effected by increasing the bed-strength of ICUs to free the RR, proper pre-operative work up, adequate counselling of day-care surgery patients and efficient floor management of the operating theatre.
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Affiliation(s)
- R Jonnalagadda
- Department of Surgery, Queen Elizabeth Hospital, Barbados, West Indies.
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Hariharan S, Dey PK, Moseley HSL, Kumar AY, Gora J. A new tool for measurement of process‐based performance of multispecialty tertiary care hospitals. Int J Health Care Qual Assur 2004; 17:302-12. [PMID: 15552385 DOI: 10.1108/09526860410557552] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an increasing need of a model for the process-based performance measurement of multispecialty tertiary care hospitals for quality improvement. Analytic hierarchy process (AHP) is utilized in this study to evolve such a model. Each step in the model was derived by group-discussions and brainstorming sessions among experienced clinicians and managers. This tool was applied to two tertiary care teaching hospitals in Barbados and India. The model enabled identification of specific areas where neither hospital performed very well, and helped to suggest recommendations to improve those areas. AHP is recommended as a valuable tool to measure the process-based performance of multispecialty tertiary care hospitals.
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Affiliation(s)
- Seetharaman Hariharan
- School of Clinical Medicine and Research, University of West Indies, Queen Elizabeth Hospital, Bridgetown, Barbados
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Hariharan S, Moseley HSL, Kumar AY, Walrond ER, Jonnalagadda R. Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country. Can J Anaesth 2003; 50:847-52. [PMID: 14525828 DOI: 10.1007/bf03019385] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To analyze the characteristics of moribund patients in a surgical intensive care unit (ICU) and highlight the dilemmas inherent in treating such patients. METHODS Data on all patients admitted to the surgical ICU during the period of three years from July 1999 to June 2002 were collected prospectively. Data were collected on very ill patients who died, in whom it appeared obvious that treatment could not have improved their condition and whose death could have been anticipated. The case notes were subjected to further analysis to determine the difficulties encountered in managing patients whose therapy was considered to be futile. RESULTS Of 662 admissions, 100 (15.1%) died and 30 (4.5%) patients were treated aggressively, even after a prognosis which reflected futile treatment. The overall mean length of stay for survivors was 7.5 +/- 9.0 [standard deviation (SD)] days and that for the non-survivors was 12.8 +/- 18.1 (SD; P < 0.001). The cost incurred for the treatment of non-survivors was significantly higher than that for the surviving patients. The factors relating to the decisions to continue futile therapy were age of the patient, legal considerations, family wishes and differing opinions between treating physicians. CONCLUSION Consideration of futility during end-of-life care did not receive adequate attention in this unit which incurred additional human and material resources.
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Affiliation(s)
- Seetharaman Hariharan
- Department of Anaesthesia, Surgery and Surgical Intensive Care, Queen Elizabeth Hospital, Barbados, West Indies.
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Hariharan S, Nanduri SB, Moseley HSL, Areti KY, Jonnalagadda R. Spectrum of microbes and antimicrobial resistance in a surgical intensive care unit, Barbados. Am J Infect Control 2003; 31:280-7. [PMID: 12888763 DOI: 10.1067/mic.2003.67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND To survey the epidemiologic findings of infections and antibiotic resistance patterns in the surgical intensive care unit (ICU) of a tertiary care university teaching hospital. METHODS The microbiologic culture-sensitivity reports of patients admitted to a surgical ICU were prospectively studied for 6 months each of 3 consecutive years. The antibiotic usage for these patients also was studied concurrently. Reports from general surgical wards for 6 months of 1 year also were analyzed for comparison. The common specimens assayed microbiologically were tracheal aspirate, urine, blood, wound swabs, invasive catheter tips, and screening swabs for methicillin-resistant Staphylococcus aureus. RESULTS The organisms reported were Enterobacteriaceae, Pseudomonas species, S aureus, and enterococci. Organisms were highly resistant to amoxicillin and first-generation cephalosporins because of the wide use of these drugs in the hospital. Pseudomonas species showed a 25% increase in resistance to piperacillin-tazobactam and an 18% increase to ciprofloxacin, which was correlated with the increased use of these antimicrobial agents (82% and 200% increases, respectively) in the unit during the 3 years. There was no increase in the resistance to ceftazidime because it is used less often. The resistance to ciprofloxacin, piperacillin-tazobactam, and ceftazidime was significantly greater in the ICU than in the general surgical wards in the same study period. CONCLUSIONS The study provided data of antimicrobial resistance in a developing country with tourism as the main industry for epidemiologic comparison with other countries.
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