Results and costs of intensive care in a tertiary university hospital from 1996-2000

Risk factors and predictive model for pulmonary complications in patients transferred to ICU after hepatectomy

OBJECTIVE

Postoperative pulmonary complications (PPCs) seriously harm the recovery and prognosis of patients undergoing surgery. However, its related risk factors in critical patients after hepatectomy have been rarely reported. This study aimed at analyzing the factors related to PPCs in critical adult patients after hepatectomy and create a nomogram for prediction of the PPCs.

METHODS

503 patients' data were collected form the Peking University People's Hospital. Multivariate logistic regression analysis was used to identify independent risk factors to derive the nomogram. Nomogram's discriminatory ability was assessed using the area under the receiver operating characteristic curve (AUC), and calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and calibration curve.

RESULTS

The independent risk factor for PPCs are advanced age (odds ratio [OR] = 1.026; P = 0.008), higher body mass index (OR = 1.139; P < 0.001), lower preoperative serum albumin level (OR = 0.961; P = 0.037), and intensive care unit first day infusion volume (OR = 1.152; P = 0.040). And based on this, we created a nomogram to predict the occurrence of PPCs. Upon assessing the nomogram's predictive ability, the AUC for the model was 0.713( 95% CI: 0.668-0.758, P<0.001). The Hosmer-Lemeshow test (P = 0.590) and calibration curve showed good calibration for the prediction of PPCs.

CONCLUSIONS

The prevalence and mortality of postoperative pulmonary complications in critical adult patients after hepatectomy are high. Advanced age, higher body mass index, lower preoperative serum albumin and intensive care unit first day infusion volume were found to be significantly associated with PPCs. And we created a nomogram model which can be used to predict the occurrence of PPCs.

The Costs of Caring for Patients in a Tertiary Referral Australian Intensive Care Unit

We determined the direct cost of an Intensive Care Unit (ICU) bed in a tertiary referral Australian ICU and the cost drivers thereof, by retrospectively analysing a number of prospectively designed Hospital- and Unit-specific electronic databases. The study period was a financial year, from 1 July 2002 to 30 June 2003. There were 1615 patients occupying 5692 fractional occupied bed days at a total cost of A$15,915,964, with an average length of stay of 3.69 days (range 0.5–77, median 1.06, interquartile range 2.33). The main cost driver not incorporated into this analysis was blood products (paid for centrally). The average costs of an ICU day and total stay per patient were A$2670 and A$9852 respectively. Staff-related charges were 68.76%, with consumables related expenditure making up 19.65%, clinical support services 9.55% and capital equipment 2.04%. Overtime charges and nursing agency staff were 19.4% of staff-related charges (2.9% for agency staff), 3.9% lower than expenditure associated with full-time employment charges, such as pension and leave. The emergency nature of ICU means it is difficult to accurately set a nursing establishment to cater for all admissions and therefore it is hard to decide what is an acceptable percentage difference between agency/overtime costs compared with the costs associated with full-time staff appointments. Consumable expenditure is likely to increase the most with new innovation and therapies. Using protocol driven practices may tighten and control costs incurred in ICU.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study

OBJECTIVES

Nurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS).

RESEARCH METHODOLOGY/DESIGN

A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse.

SETTING

Three intensive care units in a university hospital and one in a regional hospital in Norway.

MAIN OUTCOME MEASURES

Nurse staffing costs, NAS and NEMS.

RESULTS

For merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9-23.1 euros in the units, which was comparable to 53.3-81.5 euros for 1 NEMS point.

CONCLUSION

A significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients' nursing care needs. The NAS makes nurses' workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

The use of extracorporeal carbon dioxide removal to avoid intubation in patients failing non-invasive ventilation--a cost analysis

Background

To evaluate the economic implications of the pre-emptive use of extracorporeal carbon dioxide removal (ECCO₂R) to avoid invasive mechanical ventilation (IMV) in patients with hypercapnic ventilatory insufficiency failing non-invasive ventilation (NIV).

Methods

Retrospective ancillary cost analysis of data extracted from a recently published multicentre case–control-study (n = 42) on the use of arterio-venous ECCO₂R to avoid IMV in patients with acute on chronic ventilatory failure. Cost calculations were based on average daily treatment costs for intensive care unit (ICU) and normal medical wards as well as on the specific costs of the ECCO₂R system.

Results

In the group treated with ECCO₂R IMV was avoided in 90 % of cases and mean hospital length of stay (LOS) was shorter than in the matched control group treated with IMV (23.0 vs. 42.0 days). The overall average hospital treatment costs did not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of patients with chronic obstructive pulmonary disease (COPD) revealed significantly lower median ICU length of stay (11.0 vs. 35.0 days), hospital length of stay (17.5 vs. 51.5 days) and treatment costs for the ECCO₂R group (19.610 vs. 46.552 €, p = 0.01).

Conclusions

Additional costs for the use of arterio-venous ECCO₂R to avoid IMV in patients with acute-on-chronic ventilatory insufficiency failing NIV may be offset by a cost reducing effect of a shorter length of ICU and hospital stay.

Economic evaluation in critical care: a focus on severe sepsis in oncology

Hospital care, physician and clinical services, and prescription drugs continue to drive healthcare expenditures across healthcare systems and nations. The critical-care setting, owing to the complexity and intensity of care, is a high user of the resources that drive healthcare spending. Information regarding the cost and effectiveness of critical-care therapies is necessary to properly guide care and policies for this unique population. Many challenges exist for conducting and comparing economic evaluation in critical care. Recently, recommendations on cost and cost-effectiveness analysis in critical care have been developed that will guide future research. A focus area, severe sepsis in oncology, is reviewed to highlight the challenges and opportunities of economic evaluation in this setting.

Peer reviewing critical care: a pragmatic approach to quality management

Critical care medicine frequently involves decisions and measures that may result in significant consequences for patients. In particular, mistakes may directly or indirectly derive from daily routine processes. In addition, consequences may result from the broader pharmaceutical and technological treatment options, which frequently involve multidimensional aspects. The increasing complexity of pharmaceutical and technological properties must be monitored and taken into account. Besides the presence of various disciplines involved, the provision of 24-hour care requires multiple handovers of significant information each day. Immediate expert action that is well coordinated is just as important as a professional handling of medicine's limitations.Intensivists are increasingly facing professional quality management within the ICU (Intensive Care Unit). This article depicts a practical and effective approach to this complex topic and describes external evaluation of critical care according to peer reviewing processes, which have been successfully implemented in Germany and are likely to gain in significance.

Intensive care costs of acute poisoning cases

AIM

To examine the costs of acute poisoning patients admitted to an intensive care unit.

METHODS

Retrospective review of intensive care unit records of patients admitted for treatment of acute poisoning from January 1, 2002 to September 30, 2006.

RESULTS

The study group consisted of 94 patients and 18.1% of them died in the intensive care unit. The 62 suicidal cases were significantly younger than the accidental cases (p = 0.006). The average cost per intensive care unit stay was US $821 +/- 1149 (US $711 +/- 695 for suicidal and US $1,036 +/- 1,713 for accidental cases).

CONCLUSIONS

Poisoned patients admitted to an intensive care unit represent a considerable cost for the health care system in Turkey.

A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units

Introduction

Intensive care unit (ICU) costs account for up to 20% of a hospital's costs. We aimed to analyse the individual patient-related cost of intensive care at various hospital levels and for different groups of disease.

Methods

Data from 51 ICUs all over Germany (15 primary care hospitals and 14 general care hospitals, 10 maximal care hospitals and 12 focused care hospitals) were collected in an observational, cross-sectional, one-day point prevalence study by two external study physicians (January–October 2003). All ICU patients (length of stay > 24 hours) treated on the study day were included. The reason for admission, severity of illness, surgical/diagnostic procedures, resource consumption, ICU/hospital length of stay, outcome and ICU staffing structure were documented.

Results

Altogether 453 patients were included. ICU (hospital) mortality was 12.1% (15.7%). The reason for admission and the severity of illness differed between the hospital levels of care, with a higher amount of unscheduled surgical procedures and patients needing mechanical ventilation in maximal care hospital and focused care hospital facilities. The mean total costs per day were €791 ± 305 (primary care hospitals, €685 ± 234; general care hospitals, €672 ± 199; focused care hospitals, €816 ± 363; maximal care hospitals, €923 ± 306), with the highest cost in septic patients (€1,090 ± 422). Differences were associated with staffing, the amount of prescribed drugs/blood products and diagnostic procedures.

Conclusion

The reason for admission, the severity of illness and the occurrence of severe sepsis are directly related to the level of ICU cost. A high fraction of costs result from staffing (up to 62%). Specialized and maximum care hospitals treat a higher proportion of the more severely ill and most expensive patients.

Patient severity as an indicator of nursing workload in the intensive care unit

The importance of measuring nursing workload in the intensive care unit (ICU) has been supported by both an increasing demand for nursing personnel and the relationship of nursing workload with patient safety. According to previous studies, the correlation between clinical severity of ICU patients and nursing workload measured by Therapeutic Intervention Scoring System has been estimated to be particularly high. The aim of this study was to investigate whether clinical severity of ICU patients can be used for the prediction of nursing workload on a daily basis. All patients admitted in the ICU of the General University Hospital of Patras for a 5-month period were enrolled in the study. Projet de Recherche en Nursing (PRN) Réa and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of patients were calculated, the first on a daily basis and the second on the day of admission. Simple linear regression was used for statistical analysis of data. One hundred thirty-eight patients were studied. A progressive increase in mean daily PRN Réa of patients all along the amplitude of APACHE II values was shown. APACHE II could predict 25.6% (p < 0.01) of the daily variability of PRN Réa of patients. Regarding categories of PRN Réa, respiration, communication, diagnostic methods and treatments were significantly predicted by APACHE II. APACHE II explained higher proportions of PRN Réa in medical male patients aged >60 years. Clinical severity of the ICU patients measured by APACHE II is an important early indicator of daily nursing workload, especially of care demands associated with respiration, diagnostic methods and treatments.

[Analysis of personnel costs after reorganization of intensive care using calculated diagnosis-related groups comparative data. An investigation at the Charité Berlin]

BACKGROUND

In an extensive project intensive care units (ICUs) of the Charité University Hospital were reorganized. The aim of this investigation was to determine if staff costs after this reorganization are financed by modular profits of diagnosis-related groups (DRGs).

METHODS

Staff costs of all non-pediatric intensive care units, including ICUs, intermediate care units and post-anaesthesia care units (PACUs) in the Charité University Hospital were compared with the modular profits of all DRGs of patients older than 14 years in 2005. These DRGs were converted into the German refined DRG (GDRG) system 4.0 from 2006 with calculations based on actual income for medical doctors and nurses in 2006. Due to changed wage agreements for the incomes of physicians in 2006 there was an increase of costs. For the other professional groups an increase in income is expected, which cannot be estimated at present.

RESULTS

The calculation revealed that staff costs of the ICUs at the Charité University Hospital based on a current German mean base rate of 2,836 EUR were 4.2% above the modular profits of the DRGs. As a result of a structural reorganization of the ICUs, the costs of staff could be adapted to the modular profits. Under the conditions of the actual reduced base rate of Berlin of 2,955 EUR the costs and profits were nearly equal. As the financial impact of the reorganization of the ICUs will take full effect in the coming years, it can be anticipated that with an expected base rate of 2,949 EUR in 2010 the intensive care medicine of a University hospital in Germany can become profitable.

DISCUSSION

The spectrum of intensive care medicine at the Charité University Hospital covers the maximum range of operative and non-operative medicine. After an extensive reorganization of the ICUs under the aspect of staff costs, intensive care medicine can become profitable under the 4.0 G-DRG system. With consequent reorganization the cost efficiency of staff can be optimized, particularly in the setting of high-end intensive care medicine.

Outcome from intensive care after cardiac arrest: comparison between two patient samples treated in 1986-87 and 1999-2001 in Finnish ICUs

BACKGROUND

The aim of the study was to find out whether the characteristics of patients and the outcome from intensive care after cardiac arrest have changed over time.

METHODS

Two nationwide databases were compared: (i) The Finnish National Intensive Care Study data in 1986-87 and (ii) data on 28,640 admissions to Finnish ICUs in 1999-2001. Patients whose reason for ICU admission was cardiac arrest were included. The former study included 604 patients treated in 18 medical and surgical ICUs in and the latter 1036 patients in 25 medical and surgical ICUs. Data on the components of Acute Physiology and Chronic Health Evaluation (APACHE II) were prospectively collected in both study periods. Logistic regression analysis was used to test the independent contribution of the study period on hospital mortality.

RESULTS

In 1986-87, patients were younger and the proportion of males was lower than in 1999-2001. The hospital mortality in 1986-87 was 61.3% and in 1999-2001 59.1% (P= 0.396). Among patients aged < 57 years, the hospital mortality in 1986-87 was 62.1% and in 1999-2001 48.8% (P < 0.01). In multivariate analysis, controlling for age, gender, Glasgow coma score (GCS), chronic health evaluation points and source of admission, treatment during 1986-87 was an independent predictor for hospital death among all patients (OR 1.273; 95% CI 1.015-1.594), those aged < 57 years (OR 1.959; 95% CI 1.270-3.021) and among males (OR 1.384; 95% CI 1.050-1.825).

CONCLUSION

Since the late 1980s, the outcome from intensive care after cardiac arrest may have improved especially among younger patients and males.

Possibilities for cost containment in intensive care

An intensive care unit (ICU) is valuable but consumes a disproportionately high amount of health-care resources. Accordingly, cost containment has been deemed a mandatory task. A review of the literature from many countries was completed to determine the strategies for reducing the cost of care in the ICU. The results of this review show that cost reduction can be achieved by using a variety of the following strategies: (i) instituting a closed ICU, where all the patient care is directed by intensivists or full-time critical care trained physicians; (ii) the utilization of interdisciplinary approaches to the care of patients in the ICU; (iii) developing and implementing a program of television-guided remote intensivists; (iv) the use of an alerting and reminding system; and (v) increasing the number of intermediate care beds for patients who require only monitoring and intensive nursing. The conclusion reached is that many of these strategies provide evidence for hospital manager decisions regarding cost containment strategies for the delivery of health care in the ICU.

Workload of postanaesthesia care unit nurses and intensive care overflow

The admission of intensive care unit (ICU) overflow patients in the post anaesthesia care unit (PACU) has come about as a result of an increasing demand for ICU services, which is not followed by a respective increase in the number of available beds. This has raised many concerns from nurses, with extensive workload and lack of personnel being the most important. This study was conducted in the General University Hospital of Patras, Greece, from 1 January 2003 to 30 June 2004. Admissions of ICU patients in the PACU were recorded and Project Research in Nursing (PRN), a Canadian workload measurement system, was used to estimate nursing workload. One hundred and three ICU patients were admitted and they stayed for a total time of 2812 hours. PRN scores of these ICU patients were much higher than for post anaesthesia patients. Clinically important increases of total PRN score, total care time and nursing personnel needs were evident in the presence of an ICU overflow patient during all shifts. Unless there is the appropriate number of personnel, increases in total care time are likely to lead to the neglect of post anaesthesia patients' needs.