Benefits of High-Intensity Intensive Care Unit Physician Staffing under the Affordable Care Act

Interventions to promote cost-effectiveness in adult intensive care units: consensus statement and considerations for best practice from a multidisciplinary and multinational eDelphi study

BACKGROUND

There is limited evidence to guide interventions that promote cost-effectiveness in adult intensive care units (ICU). The aim of this consensus statement is to identify globally applicable interventions for best ICU practice and provide guidance for judicious use of resources.

METHODS

A three-round modified online Delphi process, using a web-based platform, sought consensus from 61 multidisciplinary ICU experts (physicians, nurses, allied health, administrators) from 21 countries. Round 1 was qualitative to ascertain opinions on cost-effectiveness criteria based on four key domains of high-value healthcare (foundational elements; infrastructure fundamentals; care delivery priorities; reliability and feedback). Round 2 was qualitative and quantitative, while round 3 was quantitative to reiterate and establish criteria. Both rounds 2 and 3 utilized a five-point Likert scale for voting. Consensus was considered when > 70% of the experts voted for a proposed intervention. Thereafter, the steering committee endorsed interventions that were identified as 'critical' by more than 50% of steering committee members. These interventions and experts' comments were summarized as final considerations for best practice.

RESULTS

At the conclusion of round 3, consensus was obtained on 50 best practice considerations for cost-effectiveness in adult ICU. Finally, the steering committee endorsed 9 'critical' best practice considerations. This included adoption of a multidisciplinary ICU model of care, focus on staff training and competency assessment, ongoing quality audits, thus ensuring high quality of critical care services whether within or outside the four walls of ICUs, implementation of a dynamic staff roster, multidisciplinary approach to implementing end-of-life care, early mobilization and promoting international consensus efforts on the Green ICU concept.

CONCLUSIONS

This Delphi study with international experts resulted in 9 consensus statements and best practice considerations promoting cost-effectiveness in adult ICUs. Stakeholders (government bodies, professional societies) must lead the efforts to identify locally applicable specifics while working within these best practice considerations with the available resources.

Perioperative risk factors associated with ICU intervention following select neurosurgical procedures

BACKGROUND/OBJECTIVE

Following cranial neurosurgical procedures, intensive care unit (ICU) admission is routine; however, our institution's growing referral network has led to more frequent bed shortages. Consequently, there are increased requests to transfer our postoperative patients out of the ICU early in the monitoring window. We aimed to find risk factors to prioritize which postoperative neurosurgical patients that should remain in the unit.

PATIENTS AND METHODS

An unmatched case-control study was conducted following retrospective chart review of patients who underwent common cranial procedures between August 2015 and June 2016 at our institution. Patients receiving postoperative ICU intervention were defined as cases. Several perioperative events were investigated for association with postoperative ICU level care. Individual risk factors were analyzed using Chi-squared tests for categorical variables (reported as odds ratio) and independent sample two tailed t-tests for continuous variables. Regression models were used for multivariate analysis.

RESULTS

We identified 282 patients who met inclusion criteria, with 148 cases and 134 controls and no statistically significant differences between group demographics. Elective cases carried an odds ratio (OR 0.12, 95 % CI 0.05-0.26, p < 0.001), suggesting decreased likelihood of postoperative intensivist intervention. Single variable analysis showed ICU level of care was more more likely with general anesthesia (OR 3.72, 95 % CI 1.90-7.25, p < 0.001) and American Society of Anesthesiologists (ASA) class IV patients (OR 3.28, 95 % CI 1.59-6.78, p < 0.001). Continuous variables (blood loss and operative time) both demonstrated statistically significant differences (p < 0.001) between case and control groups with higher blood loss (100 ± 167 mL) and operative times (245 ± 119 min) seen in the ICU intervention group. Our regression model identified non-elective cases, operative time, and blood loss having associations with postoperative intensivist intervention.

CONCLUSION

Growing demand for ICU beds at our institution has us looking for more objective data guiding decisions on lower-risk patients who could transfer early out of the ICU in times of overcapacity. Elective endovascular aneurysm treatment and DBS are cranial procedures least likely to receive postoperative ICU level intervention. Consideration to procedural blood loss of 100 cc or more and operative time greater than 4 h should also be given as these risk factors were associated with more likely needing postoperative ICU intervention. These results should not spur drastic changes in ICU protocols, but continued quality improvement projects should investigate these correlations to add more objective data for ICU utilization.

How Effective are Intensive Care Unit Beds Used in Our Region?

Objective

The demand for critical care facilities is also growing in our country. The aim of the present study was to investigate the incidence and causes of inappropriate admissions to adult intensive care units (ICUs) in our region to facilitate the planning of bed numbers.

Methods

A team of specialists made an unannounced visit to level 1, 2 and 3 adult ICUs in 12 hospitals in our region between June 2014 and January 2015. A total of 290 ICU patients were evaluated.

Results

The rate of inappropriate ICU admission was 55.9%, and the most common reason was the lack of a lower level ICU. Palliative patients comprised 35.5% of the ICU patients, 68% of whom should have been in home care. The rate of inappropriate admission was 16.7% higher in open ICUs than in closed ICUs.

Conclusion

Our results indicate that instead of increasing the number of beds in level 2 and 3 ICUs, hospitals should increase the number of level 1 ICU beds. In addition, we believe that the existing beds could be utilised more effectively if all ICUs implemented a closed management style and if there was better coordination between ICUs.

Variability in the structure and care processes for critically injured children: A multicenter survey of trauma bay and intensive care units

PURPOSE

Evaluate national variation in structure and care processes for critically injured children.

METHODS

Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use.

RESULTS

About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type.

CONCLUSION

Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care.

Intensive Care Unit Staff and Resource Utilization: Is It an Effective Factor?

BACKGROUND

The aim of present study was to determine the impact of two different ICU management model, open and semi closed, on resources utilization in intensive care unit.

METHOD

Retrospective cohort analysis using data from hospital database was applied to compare the effect of ICU management model on ICU length of stay and bed disposition of 1064 patients admitted to the general ICU of Imam Khomeini Hospital of Tehran, Iran during the two consecutive 12-month periods from Mar, 2009 to Feb, 2010.

RESULTS

In open and semi closed interval 380 and 684 patients were admitted to ICU respectively. There was no significant difference in age, gender and severity of illness (based on APACHE-II score) and nurse to bed ratio between two groups. Average ICU length of stay, net mortality rate and bed turnover rate were lower in semi closed model than open model management significantly (P<0.05).

CONCLUSION

Semi closed model improves patient care and lead to lower mortality rate and resources utilization too.