Changes in hospital costs after introducing an intermediate care unit: a comparative observational study

The Role of Intermediate Care in Supporting Critically Ill Patients and Critical Care Infrastructure

Intermediate care (IC) is used for patients who do not require the human and technological support of the intensive care unit (ICU) yet require more care and monitoring than can be provided on general wards. Though prevalent in many countries, there is marked variability in models of organization and staffing, as well as monitoring and interventions provided. In this article, the authors will discuss the historical background of IC, review the impact of IC on ICU and IC patient outcomes, and highlight where future studies can shed light on how to optimize IC organization and outcomes.

Utility of Intermediate Care Units: A Systematic Review Study

Intermediate care units (IMCUs) have become increasingly important in the care of critical and semi-critical patients, particularly during the COVID-19 pandemic. However, there is still no clear definition of their structural characteristics, specialties, types of patients, and the benefits they provide. The aim of this work is to describe the current state of implementation and operation of IMCUs in hospitals and patient care. To achieve this goal, a systematic review was conducted in the Web of Science, Scopus and CINAHL databases, along with a hand search. The research yielded 419 documents, of which 26 were included in this review after applying inclusion and exclusion criteria. The results were highly diverse and were categorized based on the following topics: material resources, human resources, continuity of care, and patient benefits. Despite the different objectives outlined in the studies, all of them demonstrate the numerous benefits provided by an IMCU, along with the increased relevance of this type of unit in recent years. Therefore, this systematic review highlights the benefits of IMCUs in the care of critical patients, as well as the role of health workers in these units.

Patient Characteristics and Severity Trajectories in a Pediatric Intermediate Care Unit

OBJECTIVES

To describe the characteristics of patients admitted to Pediatric Intermediate Care Units (PImCU) and to assess their illness severity trajectories.

METHODS

This prospective, observational, multicentre cohort study was conducted in seven French PImCUs between September 2012 and January 2014. All consecutive patients aged under 18 were included. The severity of illness was evaluated through the Paediatric Advanced Warning Score (PAWS), measured every 8 h for each patient. A latent class mixed model was used to identify severity trajectory classes.

RESULTS

A total of 2868 patients were included. The median [interquartile range] age was 29 [5-103] mo and the median length of stay was 1 [1-3] d. The primary indication for admission was respiratory (44%). Almost 3% of the patients were subsequently transferred to a pediatric intensive care unit. Three severity trajectory classes were identified. In one class, comprising the largest proportion of patients, the PAWS was low on admission and did not change markedly over time. In this class, patients were older and had a shorter length of stay. The other two classes were characterized by a higher PAWS on admission and rapid or slow improvement. These patients were more severely ill, mostly due to respiratory failure.

CONCLUSIONS

A large proportion of patients had a stable profile and no signs of severity which suggests that the stay in PImCU was not indicated but a part of these patients have remained stable perhaps because of the advanced monitoring and intensive nursing in these units.

CLINICAL TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov Protocol, Identifier: NCT02304341, ClinicalTrials.gov .

Cost comparisons and factors related to cost per stay in intensive care units in Belgium

BACKGROUND

Given the variability of intensive care unit (ICU) costs in different countries and the importance of this information for guiding clinicians to effective treatment and to the organisation of ICUs at the national level, it is of value to gather data on this topic for analysis at the national level in Belgium. The objectives of the study were to assess the total cost of ICUs and the factors that influence the cost of ICUs in hospitals in Belgium.

METHODS

This was a retrospective cohort study using data collected from the ICUs of 17 Belgian hospitals from January 01 to December 31, 2018. A total of 18,235 adult ICU stays were included in the study. The data set was a compilation of inpatient information from analytical cost accounting of hospitals, medical discharge summaries, and length of stay data. The costs were evaluated as the expenses related to the management of hospital stays from the hospital's point of view. The cost from the hospital perspective was calculated using a cost accounting analytical methodology in full costing. We used multivariate linear regression to evaluate factors associated with total ICU cost per stay. The ICU cost was log-transformed before regression and geometric mean ratios (GMRs) were estimated for each factor.

RESULTS

The proportion of ICU beds to ward beds was a median [p25-p75] of 4.7% [4.4-5.9]. The proportion of indirect costs to total costs in the ICU was 12.1% [11.4-13.3]. The cost of nurses represented 57.2% [55.4-62.2] of direct costs and this was 15.9% [12.0-18.2] of the cost of nurses in the whole hospital. The median cost per stay was €4,267 [2,050-9,658] and was €2,160 [1,545-3,221] per ICU day. The main factors associated with higher cost per stay in ICU were Charlson score, mechanical ventilation, ECMO, continuous hemofiltration, length of stay, readmission, ICU mortality, hospitalisation in an academic hospital, and diagnosis of coma/convulsions or intoxication.

CONCLUSIONS

This study demonstrated that, despite the small proportion of ICU beds in relation to all services, the ICU represented a significant cost to the hospital. In addition, this study confirms that nursing staff represent a significant proportion of the direct costs of the ICU. Finally, the total cost per stay was also important but highly variable depending on the medical factors identified in our results.

Using exogenous organizational and regional hospital attributes to explain differences in case-mix adjusted hospital costs

Diagnosis-related group (DRG) hospital reimbursement systems differentiate cases into cost-homogenous groups based on patient characteristics. However, exogenous organizational and regional factors can influence hospital costs beyond case-mix differences. Therefore, most countries using DRG systems incorporate adjustments for such factors into their reimbursement structure. This study investigates structural hospital attributes that explain differences in average case-mix adjusted hospital costs in Switzerland. Using rich patient and hospital-level data containing 4 million cases from 120 hospitals across 3 years, we show that a regression model using only five variables (number of discharges, ratio of emergency/ambulance admissions, rate of DRGs to patients, expected loss potential based on DRG mix, and location in large agglomeration) can explain more than half of the variance in average case-mix adjusted hospital costs, capture all cost variations across commonly differentiated hospital types (e.g., academic teaching hospitals, children's hospitals, birth centers, etc.), and is robust in cross-validations across several years (despite differing hospital samples). Based on our findings, we propose a simple practical approach to differentiate legitimate from inefficiency-related or unexplainable cost differences across hospitals and discuss the potential of such an approach as a transparent way to incorporate structural hospital differences into cost benchmarking and payment schemes.

[Health economic evaluation of an internal medicine intermediate care unit (IMC) with gastroenterological focus at a maximum care university hospital - Evaluating the Profitability of Intermediate Care (IMC) in modern University Hospital Gastroenterology]

Intermediate care (IMC) units meet the complex treatment needs of patients with specific diseases and/or those requiring advanced nursing care and can help turning the occupancy management of intensive care unit (ICU) beds more efficient. Despite the exclusion of nursing staff costs from the Diagnosis-Related-Groups (DRG) reimbursement system, prolonged periods of below-average monthly revenues due to loss of complex DRGs and/or misallocation/blocking of IMC beds can lead to a fixed cost refinancing problem; this again brings to the fore the question of the profitability of an IMC unit. Thus, the aim of this work has been to evaluate the profitability of a gastroenterological IMC, as part of an interdisciplinary medical IMC (MIMC) at the University Hospital Essen, for the period 01.01.2014-31.12.2016. Retrospectively, 1015 cases of the MIMC ward of the Department of Gastroenterology and Hepatology (Med.G./MIMC; N=12 beds) were examined with regard to length of stay (LoS), admission/main diagnosis, procedures provided as well as secondary diagnoses, revenues, age, and sex (median patient age 57 years; ♂ 61%, ♀ 39%). Overall, 85% of DRG reimbursements comes from treatment cases within the top 20 base DRGs; these highlight the hepatology focus of Med.G./MIMC. The case-mix (CM) monthly average is 65; the CM index (CMI), which has significant seasonal variation (analogous to CM), monthly average is 10.891 (2014-2016). The average LoS on the Med.G./MIMC is 12.3 days, which is significantly higher than the average LoS in German hospitals (7.2 days). Concrete economic assessment of Med.G./MIMC reveals that the inpatient revenues increase from € 2.90 million to € 3.72 million (2014-2016). Thus, there is a positive development of primary revenues from € 2.98 million (2014) to € 3.56 million (2015) to € 3.81 million (2016), with largely constant expenses in the area of primary costs and of claimed secondary services. Empirically, taking into account the potential interdisciplinary synergy effects, this can be considered as an exceptionally good health economic development/outcome.

Identification and assessment of a comprehensive set of structural factors associated with hospital costs in Switzerland

Structural factors can influence hospital costs beyond case-mix differences. However, accepted measures on how to distinguish hospitals with regard to cost-related organizational and regional differences are lacking in Switzerland. Therefore, the objective of this study was to identify and assess a comprehensive set of hospital attributes in relation to average case-mix adjusted costs of hospitals. Using detailed hospital and patient-level data enriched with regional information, we derived a list of 23 cost predictors, examined how they are associated with costs, each other, and with different hospital types, and identified principal components within them. Our results showed that attributes describing size, complexity, and teaching-intensity of hospitals (number of beds, discharges, departments, and rate of residents) were positively related to costs and showed the largest values in university (i.e., academic teaching) and central general hospitals. Attributes related to rarity and financial risk of patient mix (ratio of rare DRGs, ratio of children, and expected loss potential based on DRG mix) were positively associated with costs and showed the largest values in children's and university hospitals. Attributes characterizing the provision of essential healthcare functions in the service area (ratio of emergency/ ambulance admissions, admissions during weekends/ nights, and admissions from nursing homes) were positively related to costs and showed the largest values in central and regional general hospitals. Regional attributes describing the location of hospitals in large agglomerations (in contrast to smaller agglomerations and rural areas) were positively associated with costs and showed the largest values in university hospitals. Furthermore, the four principal components identified within the hospital attributes fully explained the observed cost variations across different hospital types. These uncovered relationships may serve as a foundation for objectifying discussions about cost-related heterogeneity in Swiss hospitals and support policymakers to include structural characteristics into cost benchmarking and hospital reimbursement.

Adult Pulmonary Intensive and Intermediate Care Units: The Italian Thoracic Society (ITS-AIPO) Position Paper

The imbalance between the prevalence of patients with acute respiratory failure (ARF) and acute-on-chronic respiratory failure and the number of intensive care unit (ICU) beds requires new solutions. The increasing use of non-invasive respiratory tools to support patients at earlier stages of ARF and the increased expertise of non-ICU clinicians in other types of supportive care have led to the development of adult pulmonary intensive care units (PICUs) and pulmonary intermediate care units (PIMCUs). As in other European countries, Italian PICUs and PIMCUs provide an intermediate level of care as the setting designed for managing ARF patients without severe non-pulmonary dysfunction. The PICUs and PIMCUs may also act as step-down units for weaning patients from prolonged mechanical ventilation and for discharging patients still requiring ventilatory support at home. These units may play an important role in the on-going coronavirus disease 2019 pandemic. This position paper promoted by the Italian Thoracic Society (ITS-AIPO) describes the models, facilities, staff, equipment, and operating methods of PICUs and PIMCUs.

Physicians Leading Physicians: A Physician Engagement Intervention Decreases Inappropriate Use of IICU Level of Care Accommodations

Following the adoption of an acuity-adaptable unit model in an academic medical center, a $13M increase in cost of intermediate intensive care unit (IICU) accommodations was observed. The authors followed A3 methodology to determine the root cause of this increase and developed a 3-prong intervention centered on physician engagement, given that physicians have the ability to order a patient's level of care. This intervention consisted of: (1) identifying physician champions to promote appropriate IICU use, (2) visual changes to essential electronic medical record tools, and (3) data-driven feedback to physician champions. In the year following intervention deployment, average IICU length of stay decreased from 1.08 to 0.62 days and average IICU use decreased from 21.4% to 12.3%, corresponding to ~$5.7M cost savings with no significant change in balancing measures observed. Together, these results demonstrate that a multicomponent intervention aimed at engaging physicians reduced inappropriate IICU use with no increase in adverse events.

Delay in ICU transfer is protective against ICU readmission in trauma patients: a naturally controlled experiment

Background

Unplanned intensive care unit (ICU) readmission—ICU bounce back (ICUbb)—is associated with worse outcomes. Patients not requiring organ system support or intensive nursing are deemed ‘ICU discharge ready’ and transfer orders are placed. However, actual transfer only occurs when an appropriate, non-ICU bed is available. This is dependent on inherent system inefficiencies resulting in a naturally controlled experiment between when patients actually transfer: Early (<24 hours) or Delayed (>24 hours) transfers, after order placement. This study leverages that natural experiment to determine if additional ICU time is protective against ICUbb. We hypothesize that Delayed transfer is protective against ICUbb.

Methods

Using a retrospective, cohort design, we queried a trauma research repository and electronic medical record during a 10-year period to capture traumatized patients admitted to the ICU. Patients were categorized into Early (<24 hours) or Unintended-Delayed (>24 hours) groups based on actual transfer time after order placement. Patient characteristics (age, Charlson Comorbidity Index (CCI)) and Injury Severity Score (ISS) were analyzed. Univariate and multivariate analyses were performed to compare ICUbb rates among Early and Unintended-Delayed groups.

Results

Of the 2004 patients who met the criteria, 1690 fell into the Early group, and 314 fell into the Delayed. The Early group was younger (mean age 52±23 vs. 55±22 years), had fewer comorbidities (median CCI score 1 (0, 3) vs. 2 (1, 3)), and was less injured (median ISS 17 (10–22) vs. 17 (13–25)), all p<0.05. Overall, 113 (5.6%) patients experienced ICUbb: Early 109 (6.5%) versus Unintended-Delay 4 (1.3%), p<0.05. By regression analysis, age, CCI, and ISS were independently associated with ICUbb while Delayed transfer was protective.

Discussion

Despite higher age, CCI score, and ISS, the Unintended-Delayed group experienced fewer ICUbb. After controlling for age, CCI and ISS, Delayed transfer reduced ICUbb risk by 78%. Specific care elements affording this protection remain to be elucidated.

Level of evidence

Level III.

Study type

Therapeutic study.

A Systematic Review of the Impact of Surgical Special Care Units on Patient Outcomes and Health Care Resource Utilization

Perioperative intermediate care units (termed surgical special care units) have been widely implemented across health systems because they are believed to improve surveillance and management of high-risk surgical patients. Our objective was to conduct a systematic review to investigate the effects of a 3-level model of perioperative care delivery (ie, ward, surgical special care unit, or intensive care unit) compared to a 2-level model of care (ie, ward, intensive care unit) on postoperative outcomes. Our protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42015025155). Randomized controlled studies and nonrandomized comparator studies were included. We performed a systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and the Cochrane library (inception - 11/2017). The primary outcome was mortality; secondary outcomes included length of stay and hospital costs. We identified 1995 citations with our search, and 21 studies met eligibility criteria (2 randomized controlled studies and 19 nonrandomized comparator studies; 44,134 patients in total). Surgical special care units were characterized by continuous monitoring (12 studies), the absence of mechanical ventilation (8 studies), nurse-to-patient ratios (range, 1:2-1:4), and number of beds (median: 5; range: 3-33). Thirteen studies reported on mortality. Notable findings included no observed difference in overall in-hospital mortality, but an apparent increase in intensive care unit mortality in a 3-level model of care. This may reflect a decanting of lower acuity patients from the intensive care unit to the surgical special care unit. No significant difference was found in hospital length of stay; however, 2 studies demonstrated reductions in hospital costs with the implementation of a surgical special care unit. Significant clinical and methodological heterogeneity precluded pooled analysis. Given the prevalence of surgical special care units, the results of our review suggest that additional methodologically rigorous investigations are needed to understand the effect of these units on the surgical population.

Assessment of need for lower level acuity critical care services at a tertiary acute care hospital in Canada: A prospective cohort study

PURPOSE

Critical care beds are commonly described in three levels (highest level 3, lowest level 1). We aimed to describe the actual level of care for patients assigned to level 2 in a tertiary hospital with inadequate level 1 bed capacity.

MATERIALS AND METHODS

Prospective cohort study with daily assessment of level of care. The primary outcome was the proportion of patients who could be triaged to level 1 for the entirety of their ICU stay. Secondary outcomes included the percentage of patients who could receive level 1 care on any given day.

RESULTS

289 patients originally classified as level 2 were assessed for the primary, and 335 for the secondary outcomes. 14.9% could be level 1 for their entire ICU stay. 20.6%, once appropriate for level 1, remained in that level for the rest of their ICU stay. 23.6% of the assessments were suitable for level 1 on any given day.

CONCLUSION

In a single centre, 14.9% of level 2 patients could have been cared for in a lower acuity bed for the entirety of their ICU stay. We believe this methodology is reproducible and can help resource allocation with regard to the high demand for critical care beds.

The intermediate care unit as a cost-reducing critical care facility in tertiary referral hospitals: a single-centre observational study

OBJECTIVES

To determine whether and to what extent the surgical intermediate care unit (IMCU) reduces healthcare costs.

DESIGN

Retrospective cohort study.

SETTING

The mixed-surgical IMCU of a tertiary academic referral hospital.

PARTICIPANTS

All admissions (n=2577) from 2012 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measure was the hypothetical cost savings due to the presence of the IMCU. For this, each admission day was classified as either low-acuity or high-acuity, based on the Therapeutic Intervention Scoring System-28, the required specific nursing interventions and the indication for admission at the IMCU. Costs (2018) used were €463 per hospital ward, €1307 per IMCU and €2224 per intensive care unit (ICU) admission day. Savings were calculated by subtracting the actual IMCU costs from the hypothetical costs in the absence of the IMCU.

RESULTS

There were 9037 admission days (n=2577 admissions) at the IMCU. The proportion of high-acuity admissions was 87.6%. Total costs at the IMCU were €11.808 888. Total hypothetical costs in absence of the IMCU were €18.115 284. Total cost savings were thus €6.306 395, or €1.576 599, per year.

CONCLUSIONS

The surgical IMCU may substantially reduce societal healthcare costs, making it a cost saving alternative to ICU care. Constant adequate triage is essential to optimise its potential.

Intermediate Care Units: A Survey of Organization Practices Across the United States

PURPOSE

Intermediate care units (IMCUs) represent an alternative care setting with nurse staffing levels between those of the general ward and the intensive care unit (ICU). Despite rising prevalence, little is known about IMCU practices across US hospitals. The purpose of this study is to characterize utilization patterns and assess for variation.

MATERIALS AND METHODS

A 14-item survey was distributed to a random nationwide sample of pulmonary and critical care physicians between January and April 2017.

RESULTS

A total of 51 physicians from 24 different states completed the survey. Each response represented a unique institution, the majority of which were public (59%), academic (73%), and contained at least 1 IMCU (65%). Of the IMCUs surveyed, 58% operated as 1 mixed unit that admitted medical, cardiac, and surgical patients as opposed to having separate subspecialty units. Ninety-one percent of units admitted step-down patients from the ICU, but 39% of units accepted a mix of step-up patients, step-down patients, postoperative patients, and patients from the emergency department. Intensivists managed care in 21% of units whereas 36% had no intensivist involvement.

CONCLUSION

Organization practices vary considerably between IMCUs across institutions. The impact of different organization practices on patient outcomes should be assessed.

An Evaluation of the Role of an Intermediate Care Facility in the Continuum of Care in Western Cape, South Africa

Background: A comprehensive primary healthcare (PHC) approach requires clear referral and continuity of care pathways. South Africa is a lower-middle income country (LMIC) that lacks data on the role of intermediate care (IC) services in the health system. This study described the model of service provision at one facility in Cape Town, including reason for admission, the mix of services and skills provided and needed, patient satisfaction, patient outcome and articulation with other services across the spectrum of care.

Methods: A multi-method design was used. Sixty-eight patients were recruited over one month in mid-2011 in a prospective cohort. Patient data were collected from clinical record review and an interviewer-administered questionnaire, administered shortly after admission to assess primary and secondary diagnosis, referring institution, knowledge of and previous use of home based care (HBC) services, reason for admission and demographics. A telephonic questionnaire at 9-weeks post-discharge recorded their vital status, use of HBC post-discharge and their satisfaction with care received. Staff members completed a self-administered questionnaire to describe demographics and skills. Cox regression was used to identify predictors of survival.

Results: Of the 68 participants, 38% and 24% were referred from a secondary and tertiary hospital, respectively. Stroke (35%) was the most common single reason for admission. The three most common reasons reported why care was better at the IC facility were staff attitude, the presence of physiotherapy and the wound care. Even though most patients reported admission to another health facility in the preceding year, only 13 patients (21%) had ever accessed HBC and only 25% (n=15) of discharged patients used HBC post-discharge. Of the 57 patients traced on follow-up, 21(37%) had died. The presence of a Care-plan was significantly associated with a 62% lower risk of death (hazard ratio: 0.38; CI 0.15–0.97). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks.

Conclusion: Clients understood this service as a caring environment primarily responsible for rehabilitation services. A Care-plan beyond admission could significantly reduce mortality. There was poor referral to and poor articulation with HBC services. IC services should be recognised as an integral part of the health system and should be accessible.

Intermediate Care Unit After Cardiac Surgery: Impact on Length of Stay and Outcomes

INTRODUCTION AND OBJECTIVES

Current postoperative management of adult cardiac surgery often comprises transfer from the intensive care unit (ICU) to a conventional ward. Intermediate care units (IMCU) permit hospital resource optimization. We analyzed the impact of an IMCU on length of stay (both ICU and in-hospital) and outcomes (in-hospital mortality and 30-day readmissions) after adult cardiac surgery (IMCU-CS).

METHODS

From November 2012 to April 2015, 1324 consecutive patients were admitted to a university hospital for cardiac surgery. In May 2014, an IMCU-CS was established for postoperative care. For the purposes of this study, patients were classified into 2 groups, depending on the admission period: pre-IMCU-CS (November 2012-April 2014, n=674) and post-IMCU-CS (May 2014-April 2015, n=650).

RESULTS

There were no statistically significant differences in age, sex, risk factors, comorbidities, EuroSCORE 2, left ventricular ejection fraction, or the types of surgery (valvular in 53%, coronary in 26%, valvular plus coronary in 11.5%, and aorta in 1.8%). The ICU length of stay decreased from 4.9±11 to 2.9±6 days (mean±standard deviation; P<.001); 2 [1-4] to 1 [0-3] (median [Q1-Q3]); in-hospital length of stay decreased from 13.5±15 to 12.7±11 days (mean±standard deviation; P=.01); 9 [7-13] to 9 [7-11] (median [Q1-Q3]), in pre-IMCU-CS to post-IMCU-CS, respectively. There were no statistically significant differences in in-hospital mortality (4.9% vs 3.5%; P=.28) or 30-day readmission rate (4.3% vs 4.2%; P=.89).

CONCLUSIONS

After the establishment of an IMCU-CS for postoperative cardiac surgery, there was a reduction in ICU and in-hospital mean lengths of stay with no increase in in-hospital mortality or 30-day readmissions.

A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion

BACKGROUND

Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date.

METHODS

We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients' hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion.

RESULTS

Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios.

CONCLUSIONS

In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.

Utilisation of Intermediate Care Units: A Systematic Review

Background. The diversity in formats of Intermediate Care Units (IMCUs) makes it difficult to compare data from different settings. The purpose of this article was to describe and quantify these different formations and utilisation. Methods. We performed a systematic review extracting geographic location, nomenclature used, admitting specialties, open (admitting specialist in charge) or closed (intensivist/generalist in charge) management format, location in hospital, number of beds, nursing workload, medical staff to patient ratios, and modalities—possibilities and limitations—implemented. Results. Nomenclature used was High Dependency Unit (56.8%) or Intermediate Care Unit (24.3%), with the latter one increasingly being used recently. The median number of beds was 6 (IQR 4–10). Location (p < 0.001) and admitting specialties (p = 0.03) were related to the management format. IMCUs integrated or adjacent to Intensive Care Units were more often capable of using single vasoactive medication (p = 0.025). The mean nurse to patient ratio was 1 to 2.5. Conclusions. IMCUs often have a specific task in a hospital, which is reflected in location, format, and utilisation. The management format depends on location and admitting specialist while incorporated supportive treatment modules reflect its function. Common IMCU denominators are continuous monitoring and respiratory support, without mechanical ventilation and multiple vasoactive medications.

Pediatric intermediate care and pediatric intensive care units: PICU metrics and an analysis of patients that use both

PURPOSE

To examine how intermediate care units (IMCUs) are used in relation to pediatric intensive care units (PICUs), characterize PICU patients that utilize IMCUs, and estimate the impact of IMCUs on PICU metrics.

MATERIALS & METHODS

Retrospective study of PICU patients discharged from 108 hospitals from 2009 to 2011. Patients admitted from or discharged to IMCUs were characterized. We explored the relationships between having an IMCU and several PICU metrics: physical length-of-stay (LOS), medical LOS, discharge wait time, admission severity of illness, unplanned PICU admissions from wards, and early PICU readmissions.

RESULTS

Thirty-three percent of sites had an IMCU. After adjusting for known confounders, there was no association between having an IMCU and PICU LOS, mean severity of illness of PICU patients admitted from general wards, or proportion of PICU readmissions or unplanned ward admissions. At sites with an IMCU, patients waited 3.1h longer for transfer from the PICU once medically cleared (p<0.001).

CONCLUSIONS

There was no association between having an IMCU and most measures of PICU efficiency. At hospitals with an IMCU, patients spent more time in the PICU once they were cleared for discharge. Other ways that IMCUs might affect PICU efficiency or particular patient populations should be investigated.

[Complications and monitoring standards after elective craniotomy in Germany]

BACKGROUND

The increasing endeavors to make inpatient treatment processes more effective leads to a reduction of the length of stay in hospital and minimization of postoperative monitoring. Therefore, the aim of our study was to determine potential postoperative complications for neurosurgical patients undergoing elective surgery with respect to assessment of the relevance for intensive medical care. Furthermore, our approach was compared with the standard of postoperative care of such patients in Germany.

METHODS

All 499 patients scheduled for elective craniotomy at our institute from 2010-2013 could be included corresponding to various treatment criteria for vascular diseases, such as aneurysms, arteriovenous malformation (AVM) and cavernous hemangioma as well as supratentorial and infratentorial tumors, transsphenoidally operated pituitary adenomas and stereotactic biopsies. All complications could be collated and categorized according to major and minor complications. Furthermore, a survey was conducted among 155 neurosurgical hospitals and departments with respect to the preferred postoperative monitoring strategy for the named treatment categories.

RESULTS

The numbers of major complication were in accordance with data from other studies and although minor complications (13.4% in our collective) are rarely recorded in the literature, they do however indicate an adequate postoperative inpatient monitoring. The results of the survey showed a broad preference for intensive care unit monitoring of patients undergoing elective craniotomy in Germany.

CONCLUSION

The undisputed gold standard of postoperative monitoring of neurosurgical patients undergoing elective surgery is still the intensive care unit. Although more flexible surveillance modalities are available, a cost-driven restructuring of postoperative monitoring and in particular reduction of the length of stay in hospital must be subjected to detailed scrutinization.

Hospital length of stay following admission for traumatic brain injury in a Canadian integrated trauma system: A retrospective multicenter cohort study

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of disability in children and young adults and costs CAD$3 billion annually in Canada. Stakeholders have expressed the urgent need to obtain information on resource use for TBI to improve the quality and efficiency of acute care in this patient population. We aimed to assess the components and determinants of hospital and ICU LOS for TBI admissions.

METHODS

We performed a retrospective multicenter cohort study on 11,199 adults admitted for TBI between 2007 and 2012 in an inclusive Canadian trauma system. Our primary outcome measure was index hospital LOS (admission to the hospital with the highest designation level). Index LOS was compared to total LOS (all consecutive admissions related to the injury). Expected LOS was calculated by matching TBI admissions to all-diagnosis hospital admissions by age, gender, and year of admission. LOS determinants were identified using multilevel linear regression.

RESULTS

Geometric mean total LOS was 1day longer than geometric mean index LOS (12.6 versus 11.7 days). Observed index and ICU LOS were respectively 4.2days and 2.5days longer than that expected according to all-diagnosis admissions. The six most important determinants of LOS were discharge destination, severity of concomitant injuries, extracranial complications, GCS, TBI severity, and mechanical ventilation, accounting for 80% of explained variation.

CONCLUSIONS

Results of this multicenter retrospective cohort study suggest that hospital and ICU LOS for TBI admissions are 56% and 119% longer than expected according to all-diagnosis admissions, respectively. In addition, hospital LOS is underestimated when only the index visit is considered and is largely influenced by discharge destination and extracranial complications, suggesting that improvements could be achieved with better discharge planning and interventions targeting prevention of in-hospital complications. This study highlights the importance of considering TBI patients as a distinct population when allocating resources or planning quality improvement interventions.

Operating a Monitoring Unit in the Geriatric Department: Effects on Outcomes

OBJECTIVES

To compare the effect of a five-bed geriatric monitoring unit (MU) on in-hospital mortality and length of stay with the effect of usual care in a geriatric hospital department and a medical MU.

DESIGN

Prospective, case-control, noninterventional study.

PARTICIPANTS

All individuals hospitalized for 24 hours or longer in the geriatric MU (n = 89, aged 53-101, mean age 82.2 ± 9.6) over a period of 5 months (January-May 2015); individuals admitted to the geriatric department (n = 178, aged 55-100, mean age 83.2 ± 9.8), matched at a ratio of 1:2 according to sex, age ±5 years, and need for mechanical ventilation; and individuals admitted to a similar five-bed medical MU (n = 95, aged 35-90, mean age 68.2 ± 14.4) during the same period.

MEASUREMENTS

Primary outcome was in-hospital mortality.

RESULTS

The predicted death rate was 49 ± 26 for participants in the geriatric MU, 39.6 ± 27 for those in the medical MU (P = .02), and 36.7 ± 27 for those in the geriatric department (P < .001). Observed in-hospital mortality was higher for geriatric MU participants (n = 40, 44.9%) than for the department control group (n = 48, 27%) (P = .002), although the mortality ratios (actual divided by predicted death rates) of these two groups were similar, indicating that the more severely ill participants in the geriatric MU did better than control participants in the departments, in particular those requiring hemodynamic pressure support and those with acute renal failure.

CONCLUSION

For elderly, severely ill adults, care in a geriatric MU was associated with lower in-hospital mortality than care in the hospital geriatric ward and a longer stay and may be an alternative to medical MU admission.

Rising Billing for Intermediate Intensive Care among Hospitalized Medicare Beneficiaries between 1996 and 2010

RATIONALE

Intermediate care (i.e., step-down or progressive care) is an alternative to the intensive care unit (ICU) for patients with moderate severity of illness. The adoption and current use of intermediate care is unknown.

OBJECTIVES

To characterize trends in intermediate care use among U.S. hospitals.

METHODS

We examined 135 million acute care hospitalizations among elderly individuals (≥65 yr) enrolled in fee-for-service Medicare (U.S. federal health insurance program) from 1996 to 2010. We identified patients receiving intermediate care as those with intensive care or coronary care room and board charges labeled intermediate ICU.

MEASUREMENTS AND MAIN RESULTS

In 1996, a total of 960 of the 3,425 hospitals providing critical care billed for intermediate care (28%), and this increased to 1,643 of 2,783 hospitals (59%) in 2010 (P < 0.01). Only 8.2% of Medicare hospitalizations in 1996 were billed for intermediate care, but billing steadily increased to 22.8% by 2010 (P < 0.01), whereas the percentage billed for ICU care and ward-only care declined. Patients billed for intermediate care had more acute organ failures diagnoses codes compared with general ward patients (22.4% vs. 15.8%). When compared with patients billed for ICU care, those billed for intermediate care had fewer organ failures (22.4% vs. 43.4%), less mechanical ventilation (0.9% vs. 16.7%), lower mean Medicare spending ($8,514 vs. $18,150), and lower 30-day mortality (5.6% vs. 16.5%) (P < 0.01 for all comparisons).

CONCLUSIONS

Intermediate care billing increased markedly between 1996 and 2010. These findings highlight the need to better define the value, specific practices, and effective use of intermediate care for patients and hospitals.

The impact of the organization of high-dependency care on acute hospital mortality and patient flow for critically ill patients

RATIONALE

Little is known about the utility of provision of high-dependency care (HDC) that is in a geographically separate location from a primary intensive care unit (ICU).

OBJECTIVES

To determine whether the availability of HDC in a geographically separate unit affects patient flow or mortality for critically ill patients.

METHODS

Admissions to ICUs in the United Kingdom, from 2009 to 2011, who received Level 3 intensive care in the first 24 hours after admission and subsequently Level 2 HDC. We compared differences in patient flow and outcomes for patients treated in hospitals providing some HDC in a geographically separate unit (dual HDC) with patients treated in hospitals providing all HDC in the same unit as intensive care (integrated HDC) using multilevel mixed effects models.

MEASUREMENTS AND MAIN RESULTS

In 192 adult general ICUs, 21.4% provided dual HDC. Acute hospital mortality was no different for patients cared for in ICUs with dual HDC versus those with integrated HDC (adjusted odds ratio, 0.94 [0.86-1.03]; P = 0.16). Dual HDC was associated with a decreased likelihood of a delayed discharge from the primary unit. However, total duration of critical care and the likelihood of discharge from the primary unit at night were increased with dual HDC.

CONCLUSIONS

Availability of HDC in a geographically separate unit does not impact acute hospital mortality. The potential benefit of decreasing delays in discharge should be weighed against the increased total duration of critical care and greater likelihood of a transfer out of the primary unit at night.

Does intermediate care improve patient outcomes or reduce costs?

ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.

The role of stepdown beds in hospital care

Stepdown beds provide an intermediate level of care for patients with requirements somewhere between that of the general ward and the intensive care unit. Models of care include incorporation of stepdown beds into intensive care units, stand-alone units, or incorporation of beds into standard wards. Stepdown beds may be used to provide a higher level of care for patients deteriorating on a ward ("step-up"), a lower level of care for patients transitioning out of intensive care ("stepdown") or a lateral transfer of care from a recovery room for postoperative patients. These units are one possible strategy to improve critical care cost-effectiveness and patient flow without compromising quality, but these potential benefits remain primarily theoretical as few patient-level studies provide concrete evidence. This narrative review provides a general overview of the theory of stepdown beds in the care of hospitalized patients and a summary of what is known about their impact on patient flow and outcomes and highlights areas for future research.

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

Introduction

The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU.

Methods

An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days).

Results

One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002).

Conclusions

The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment.

Trial registration

Clinicaltrials.gov NCT01422070. Registered 19 August 2011.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0551-8) contains supplementary material, which is available to authorized users.

Hospital length of stay after admission for traumatic injury in Canada: a multicenter cohort study

OBJECTIVE

To describe acute care length of stay (LOS) over all consecutive hospitalizations for the injury and according to level of care [intensive care unit (ICU), intermediate care, general ward], compare observed and expected LOS, and identify predictors of LOS.

BACKGROUND

Prolonged LOS has important consequences in terms of costs and outcome, yet detailed information on LOS after trauma is lacking.

METHODS

This multicenter retrospective cohort study was based on adults discharged alive from a Canadian trauma system (1999-2010; n = 126,513). Registry data were used to calculate index LOS (LOS in trauma center with highest designation level) and were linked to hospital discharge data to calculate total LOS (all consecutive hospitalizations for the injury). Expected LOS was obtained by matching general provincial discharge statistics to study data by year, age, and sex. Potential predictors of LOS were evaluated using linear regression.

RESULTS

Mean index and total LOS were 8.6 and 9.4 days, respectively. ICU, intermediate care unit, and general ward care constituted 8.9%, 2.5%, and 88.6% of total hospital days. Observed mean index and ICU LOS in our trauma patients were 2.9 and 1.3 days longer than expected LOS (P < 0.0001). The strongest determinants of index LOS were discharge destination, age, transfer status, and injury severity.

CONCLUSIONS

Results suggest that acute care LOS after injury is underestimated when only information on the index hospitalization is used and that ICU or intermediate care constitute an important part of LOS. This information should be used to inform the development of an informative and actionable quality indicator.

Readmission To Intensive Care Unit After Coronary Bypass Operations in the Short Term

OBJECTIVE

Intensive care unit (ICU) readmissions after coronary bypass (CABG) operations occur in a significant number of patients, and the prognosis is poor. We analyzed the risk factors for ICU readmissions after CABG operations.

METHODS

We retrospectively analyzed the prospectively collected data of 679 coronary bypass patients operated in a single institution in order to evaluate the risk factors for readmittance to the ICU with logistic regression analysis. The outcome results of patients readmitted to the ICU (Group R) and others (Group N) were compared.

RESULTS

Thirty-six (5.3%) patients were readmitted to the ICU. Postoperative in-hospital mortality and pulmonary and neurologic morbidity occurred in 43 (6.3%), 135 (19.9%), and 46 (6.8%) patients, respectively. The comparison of groups showed that mortality and morbidity were significantly higher in Group R compared to Group N (mortality 16.7% vs. 5.9, p=0.029; pulmonary morbidity 66.7% vs. 17.3%, p=0.0001; neurologic morbidity 38.9% vs. 5.0%, p=0.0001). Features associated with readmission included presence of left ventricular dysfunction preoperatively[odds ratio (OR)=4.1; 95% confidence interval (CI)=1.4-12.5; p=0.013], advanced NYHA Class (OR=5.3; 95% CI=1.3-21.7; p=0.022), pulmonary complications (OR=7.3; 95% CI=2.1-25.5; p=0.002), and neurologic complications (OR=4.6; 95% CI=1.3-16.7; p=0.021).

CONCLUSION

Patients readmitted to the ICU postoperatively have higher rates of mortality and pulmonary and neurologic morbidity after coronary bypass operations. Left ventricular dysfunction, advanced NYHA class, and postoperative pulmonary and neurologic complications are significant risk factors for readmission to the ICU.

The effects of discharge to an intermediate care unit after a critical illness: a 5-year cohort study

PURPOSE

The impact of the intermediate care unit (IMCU) on post-intensive care unit (ICU) outcomes is controversial.

MATERIALS AND METHODS

We analyzed admissions from January 2003 to December 2008 from a mixed ICU in a teaching hospital in Brazil with a high patient-to-nurse ratio (3.5:1 on the ICU, 11:1 on the IMCU, 20-25:1 on the ward). A retrospective propensity-matched analysis was performed with data from 690 patients who were discharged after at least 3 days of ICU stay.

RESULTS

Of the 690 patients, 160 (23%) were discharged to the IMCU. A total of 399 propensity-matched patients were compared: 298 were discharged to the ward and 101 were discharged to the IMCU. Ninety-day mortality rate was similar between the IMCU and ward patients (22% vs 18%, respectively, P = .37), as was the unplanned ICU readmission rate (P = .63). In a multivariate logistic regression, discharge to the IMCU had no effect on the 90-day mortality rate (P = .27).

CONCLUSIONS

In a resource-limited setting with a high patient-to-nurse ratio, discharge to IMCU had no impact on 90-day mortality rate and on unplanned readmission rate. The impact of discharge to the IMCU on the outcome for critically ill patients should be evaluated in further studies.

Perioperative assessment of the patients in intensive care unit

OBJECTIVE

To evaluate the preoperative condition and the surgical procedure of surgical patients in a general intensive care unit of a university hospital, relating them to morbidity and mortality.

METHODS

We studied the medical records of patients undergoing medium and large surgical procedures, admitted to the general intensive care unit. We analyzed: demographic data, clinical records personal history and laboratory tests, both preoperatively and on admission to the intensive care unit, imaging, operative reports, anesthetic reports and antibiotic prophylaxis. After admission, the variables studied were: length of stay, type of nutritional support, use of thromboprophylaxis, mechanical ventilation, description of complications and mortality.

RESULTS

We analyzed 130 medical records. Mortality was 23.8% (31 patients), Apache II greater than 40 was observed in 57 patients undergoing major surgery (64%), ASA classification e" II was observed in 16 patients who died (51.6%), the length of stay in the intensive care unit ranged from one to nine days and was observed in 70 patients undergoing major surgery (78.5%), the use of mechanical ventilation for up to five days was observed in 36 patients (27.7%), hypertension was observed in 47 patients (47.4%), the most frequent complication was sepsis.

CONCLUSION

the correct stratification of surgical patient determines their early discharge and reduced exposure to random risk.

Surgical intensive care unit - essential for good outcome in major abdominal surgery?

PURPOSE

Surgical intensive care units (ICU) play a pivotal role in perioperative care of patients undergoing major abdominal surgery. Differences in quality of care provided by medical staff in ICUs may be linked to improved outcome. This review aims to elucidate the relationship between quality of care at various ICUs and patient outcome, with the ultimate aim of identifying key measures for achieving optimal outcome.

METHODS

We reviewed the literature in PubMed to identify current ICU structural and process concepts and variations before evaluating their respective impact on quality of care and outcome in major abdominal surgery.

RESULTS

ICU leadership, nurse and physician staffing, and provision of an intermediate care unit are important structural components that impact on patients' outcome. A "mixed ICU" model, with intensivists primarily caring for the patients in close cooperation with the primary physician, seems to be the most effective ICU model. Surgeons' involvement in intensive care is essential, and a close cooperation between surgeons and anesthesiologists is vital for good outcome. Current general process concepts include early mobilization, enteral feeding, and optimal perioperative fluid management. To decrease failure-to-rescue rates, procedure-specific intensive care processes are particularly focused on the early detection, assessment, and timely and consistent treatment of complications.

CONCLUSIONS

Several structures and processes in the ICU have an impact on outcome in major abdominal surgery. ICU structures and care processes connected with optimal outcome could be transmitted to other centers to improve outcome, independent of procedure volume.

Increased model for end-stage liver disease score at the time of liver transplant results in prolonged hospitalization and overall intensive care unit costs

Organ allocation based on Model for End-Stage Liver Disease (MELD) resulted in decreased waiting list mortality in the United States. However, reports suggest an increase in resource utilization as a consequence of this. The aim of this study is to assess the correlation of MELD at transplant with post-liver transplant (LT) intensive care unit (ICU) costs. We assessed clinical and demographic variables of 402 adult patients who underwent LT at King's College Hospital, London, UK, between January 2000 and December 2003. ICU cost calculations were based on the therapeutic intervention scoring system (TISS). Graft quality was assessed using the donor risk index (DRI). Patients with a MELD score > 24 had significantly longer post-LT ICU stay (P < 0.0001) and total post-LT hospital stay (P = 0.008). In addition, they had significantly increased TISS scores, ICU cost, and need for renal replacement therapy (RRT) (P < 0.001). MELD score (by point) and MELD > 24 was associated with prolonged ICU stay (P = 0.004 and P = 0.005, respectively). On univariate analysis, etiology of alcohol-related liver disease (ALD), repeat LT, Budd-Chiari syndrome, and refractory ascites were associated with prolonged ICU stay. Using multivariate analysis, MELD > 24, refractory ascites, ALD and Budd-Chiari syndrome were associated with prolonged ICU stay. There was no association between using grafts with higher DRI and longer ICU stay, need for RRT, increased cost, or hospital survival on univariate analyses (P = not significant). Use of MELD as a method of organ allocation results in significant increase in ICU cost after LT. Using TISS as surrogate marker for ICU costs reveals that the cost implications are related to the need for RRT and prolonged ICU stay.

["Surgical intermediate care unit" outcomes, facts and experiences after 5 years]

The increasing economic pressure has resulted in strategies to use efficient treatment forms. The aim of our study was to evaluate to which extent the intermediate care unit (IMC-unit) relieves the intensive care unit and the wards. We analyzed: patient population, age, gender, admission criteria and the rate of patients with intensive nursing procedures between January 1, 2005 and December 31, 2007. The level of care was calculated according to the standard patient categories. The mean age amounted to 58.9 years. Intensive care patients made up 43.6% and patients from the emergency ward 36.6% of the total IMC-allocation. After IMC care 54.3% of all IMC-patients could be taken over by wards. The confused patients amounted to 27.5% and isolated patients 4.3%. The average care intensity amounted to 4.5 hours per patient daily and the mean length of stay in hospital was 9 days. Particularly the relief of nursing intensity and the possibility of primary treatment of severely injured persons reflect the requirements of IMC.