Charging for intensive care using direct nursing hours as the cost marker

Staff cost in direct nursing care at an intensive care unit

This quantitative case study aimed to learn and analyze the personnel cost in nursing direct care in the intensive care unit. We opted to use a therapeutic intervention score index, TISS-28, for the analysis of the indirect gravity of patients and the dimension of the nursing staff working time. Evaluating the cost by a gravity score presented to be a logical and relatively simple method to allocate costs per patient in the intensive care unit. In this exploratory and descriptive study, the average TISS-28 per patient was 31 points, requiring a daily expenditure of care hours of R$ 298.69. It was evidenced in this study that personnel costs are variable since there are patients with different complexities. Therefore is possible to estimate the nursing staff cost by assessing its work load.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

ICU admission is very often related to long-term chronic and/or occasional alcohol use.

Comparative costing analysis of intensive care services between Hungary and United Kingdom

OBJECTIVE

The study presents the findings of the first National Intensive Care Cost Block Analysis in Hungary.

METHODS

There were 13 Intensive Care Units (ICUs) involved in this study: 5 University Hospitals, 6 District County Hospitals and 2 City Hospitals. The annual costs of ICUs were measured by "top-down" approach based on Cost Block Method. Annual expenditure of 3 cost blocks was collected for year 2000: clinical support, consumables and staff costs. On top of the annual costs, we collected general ICU data and Top 10 drugs of each unit. Our data was compared to National Cost Block data of United Kingdom.

RESULTS

There were 9313 patients involved in the study. The median (IQR) ICU occupancy rate was 67% (62-79), mortality was 21% (11-26). The mean cost per bed was 30,990 Euro (SD 12,573) and 144 Euro (SD 63,1) per patient day. Clinical support services were accounted for 9.6% of resources, consumables for 60.6% and staff costs for 29.8%.

CONCLUSIONS

Intensive care costs are very low in Hungary compared to other European countries. The difference is explained by the cheaper staff cost, but the lower number of nurses per ICU bed contributes as well.

Nursing activities score

OBJECTIVES

The instruments used for measuring nursing workload in the intensive care unit (e.g., Therapeutic Intervention Scoring System-28) are based on therapeutic interventions related to severity of illness. Many nursing activities are not necessarily related to severity of illness, and cost-effectiveness studies require the accurate evaluation of nursing activities. The aim of the study was to determine the nursing activities that best describe workload in the intensive care unit and to attribute weights to these activities so that the score describes average time consumption instead of severity of illness.

DESIGN

To define by consensus a list of nursing activities, to determine the average time consumption of these activities by use of a 1-wk observational cross-sectional study, and to compare these results with those of the Therapeutic Intervention Scoring System-28.

SETTING

A total of 99 intensive care units in 15 countries.

PATIENTS

Consecutive admissions to the intensive care units.

INTERVENTION

Daily recording of nursing activities at a patient level and random multimoment recording of these activities.

RESULTS

A total of five new items and 14 subitems describing nursing activities in the intensive care unit (e.g., monitoring, care of relatives, administrative tasks) were added to the list of therapeutic interventions in Therapeutic Intervention Scoring System-28. Data from 2,041 patients (6,451 nursing days and 127,951 multimoment recordings) were analyzed. The new activities accounted for 60% of the average nursing time; the new scoring system (Nursing Activities Score) explained 81% of the nursing time (vs. 43% in Therapeutic Intervention Scoring System-28). The weights in the Therapeutic Intervention Scoring System-28 are not derived from the use of nursing time.

CONCLUSIONS

Our study suggests that the Nursing Activities Score measures the consumption of nursing time in the intensive care unit. These results should be validated in independent databases.

Outcomes of and Resource Consumption by High-Cost Patients in the Intensive Care Unit

• Background Care of patients in an intensive care unit is among the most costly in hospitals. Little is known about high-cost patients within the intensive care unit or their outcomes of care.

• Objectives To examine outcomes of and resource consumption by high-cost adult patients who received care in an intensive care unit at an academic medical center.

• Methods Data on patients admitted during the period January 1, 1995, through June 30, 1999, were analyzed retrospectively. An intensive care unit database, the hospital discharge data set, and a cost-accounting data set were used to determine the total intensive care unit cost for the hospitalization. Patients were then stratified into cost deciles. Hospital and intensive care unit outcomes for patients in the top decile were compared with those of patients in the other deciles.

• Results Cost data were available on 10606 of the 11244 patients who received care in an intensive care unit. Patients in the top decile accounted for 48.7% of all intensive care unit costs, and 67.6% of this group survived to discharge despite prolonged care. Patients transferred from an outside hospital were more likely to be in the top decile, have a longer stay in the intensive care unit, or die than were the other patients.

• Conclusions A small group of patients accounts for a disproportionately higher amount of intensive care unit resources but has a relatively high survival rate. This cohort should be treated as an intact group that is not amenable to traditional cost-cutting measures.

Scoring systems for assessing organ dysfunction and survival

Sepsis is an ongoing disease process carrying a high risk of organ failure and death. Scoring systems to determine disease severity and risk of mortality may be useful in patient management and clinical trial enrollment, although the role of either type of score in the determination of admission or discharge criteria or in decisions relating to the continuation or withholding of treatment remains controversial. General scoring systems have been developed to quantify the severity of illness and the risk of mortality in ICU patients. Ideally, these should be customized before use in patients with septic shock, but in general noncustomized models are used, and this potential limitation should be acknowledged. Prognostic scores are remarkably reliable at predicting outcome in groups of patients and give an indication of severity of disease on admission, but they are unable to provide detail on how a patient is responding to treatment or on the disease progression. Organ function scores, however, can be assessed repeatedly and used to define a patient's progress. This approach can thus be used to evaluate individual patient care, to identify patients for enrollment in clinical trials or epidemiologic analyses, and to assess morbidity measures in clinical trials of new interventions. Organ dysfunction scores are just that, descriptors of organ dysfunction, and although high values correlate well with mortality, prognostication is not their prime aim; organ dysfunction scores and outcome prediction scores should rather be viewed as complementary systems in the description of ICU populations.

The clinical management database

The clinical management database utilizes ICU patient data in aggregate to examine quality of care and resource utilization at the population level. As clinicians become accountable for efficiency and quality, this type of database is essential to understand the results of care. This article reviews the challenges of evaluating cost and quality including the potential for bias and measurement error. A practical approach to starting a database is outlined with examples and suggestions.

An audit of deaths occurring in hospital after discharge from the intensive care unit

The aim of the study was to conduct an audit of patients who died in the ward after discharge from the intensive care unit (ICU). Clinical records of those who died in the ward following discharge between 1991 and 1997 were reviewed. Patients were retrospectively grouped according to whether death was expected, unexpected or likely to die within one year. The causes of death, times in ICU and hospital, demographics, and APACHE II scores were compared. Ninety-nine patients were studied, of whom 60 were triaged to the ward expected to die at the time of ICU discharge. Five of the patients were classified as not expected to die. Of the remaining 34 patients, 65% were debilitated with more than one organ disease and 62% eventually had some treatment withdrawn on the ward. After discharge from ICU, no obvious ward treatment deficiencies were found to contribute to death. However, of those who were admitted to the ICU from the ward and who later died when back in the ward, there seemed to be avoidable events pre-ICU admission in eight (36%) patients, some of which may have contributed to the later death of the patient.

Partner notification in the real world: a four site time-allocation study

BACKGROUND AND OBJECTIVES

Although partner notification has been a long-standing intervention and prevention strategy for sexually transmitted diseases (STD), variations in partner notification practices across sites have never been documented.

GOALS OF THE STUDY

To describe provider-assisted partner notification practices in four STD programs in the United States.

STUDY DESIGN

Eleven disease intervention specialists (DIS) in each of three urban sites and seven DIS in one rural site documented their activities and clients for 14 working days using a personal digital assistant.

RESULTS

Of 2,506 recorded activity hours across sites, 37.4% of the recorded time was spent on partner notification (PN) activities with 1148 clients. Field visits to locate contacts accounted for the largest proportion of time spent on PN. Overall, PN clients were cases of or were contacts to nonprimary and secondary (P&S) syphilis (39.6%), gonorrhea (25.5%), chlamydia (18.0%), HIV/AIDS (10.4%), and P&S syphilis (6.5%).

CONCLUSION

The activities which constitute PN, the diseases for which PN is used, and the time spent on each PN client vary across sites. More research is needed on the determinants of these variations and their association with the ultimate goal of disease prevention.

Evaluation of proposed casemix criteria as a basis for costing patients in the adult general intensive care unit

This study analyses the relationship between the actual patient-related costs of care calculated for 145 patients admitted sequentially to an adult general intensive care unit and a number of factors obtained from a previously described consensus of opinion study. The factors identified in the study were suggested as potential descriptors for the casemix in an intensive care unit that could be used to predict the costs of care. Significant correlations between the costs of care and severity of illness, workload and length of stay were found but these failed to predict the costs of care with sufficient accuracy to be used in isolation to define isoresource groups in the intensive care unit. No associations between intensive care unit mortality, reason for admission and intensive and unit treatments and costs of care were found. Based on these results, it seems that casemix descriptors and isoresource groups for the intensive care unit that would allow costs to be predicted cannot be defined in terms of single factors.