The utilities of the therapeutic intervention scoring system (TISS-28)

Critical care nursing service costs: Comparison of the top-down versus bottom-up micro-costing approach in Brazil

AIM

To estimate the nursing service costs using a top-down micro-costing approach and to compare it with a bottom-up micro-costing approach.

BACKGROUND

Accurate data of nursing cost can contribute to reliable resource management.

METHOD

We employed a retrospective cohort design in an adult intensive care unit in São Paulo. A total of 286 patient records were included. Micro-costing analysis was conducted in two stages: a top-down approach, whereby nursing costs were allocated to patients through apportionment, and a bottom-up approach, considering actual nursing care hours estimated by the Nursing Activities Score (NAS).

RESULTS

The total mean cost by the top-down approach was US$1,640.4 ± 1,484.2/patient. The bottom-up approach based on a total mean NAS of 833 ± 776 points (equivalent to 200 ± 86 hr of nursing care) yielded a mean cost of US$1,487.2 ± 1,385.7/patient. In the 268 patients for whom the top-down approach estimated higher costs than the bottom-up approach, the total cost discrepancy was US$4,427.3, while for those costed higher based on NAS, the total discrepancy was US$436.9. The top-down methodology overestimated costs for patients requiring lower intensity of care, while it underestimated costs for patients requiring higher intensity of care (NAS >100).

CONCLUSIONS

The top-down approach may yield higher estimated ICU costs compared with a NAS-based bottom-up approach.

IMPLICATIONS FOR NURSING MANAGEMENT

These findings can contribute to an evidence-based approach to budgeting through reliable costing methods based on actual nursing workload, and to efficient resource allocation and cost management.

The development and validation of a resource consumption score of an emergency department consultation

Background

Emergency Department (ED) visits and health care costs are increasing globally, but little is known about contributing factors of ED resource consumption. This study aims to analyse and to predict the total ED resource consumption out of the patient and consultation characteristics in order to execute performance analysis and evaluate quality improvements.

Methods

Characteristics of ED visits of a large Swiss university hospital were summarized according to acute patient condition factors (e.g. chief complaint, resuscitation bay use, vital parameter deviations), chronic patient conditions (e.g. age, comorbidities, drug intake), and contextual factors (e.g. night-time admission). Univariable and multivariable linear regression analyses were conducted with the total ED resource consumption as the dependent variable.

Results

In total, 164,729 visits were included in the analysis. Physician resources accounted for the largest proportion (54.8%), followed by radiology (19.2%), and laboratory work-up (16.2%). In the multivariable final model, chief complaint had the highest impact on the total ED resource consumption, followed by resuscitation bay use and admission by ambulance. The impact of age group was small. The multivariable final model was validated (R² of 0.54) and a scoring system was derived out of the predictors.

Conclusions

More than half of the variation in total ED resource consumption can be predicted by our suggested model in the internal validation, but further studies are needed for external validation. The score developed can be used to calculate benchmarks of an ED and provides leaders in emergency care with a tool that allows them to evaluate resource decisions and to estimate effects of organizational changes.

Oral thyroxin supplementation in infants undergoing cardiac surgery: A double-blind placebo-controlled randomized clinical trial

BACKGROUND

Decreases in serum total thyroxin and total triiodothyronine occurs after cardiopulmonary bypass, and is reflected as poor immediate outcome. We studied effects of oral thyroxin supplementation in infants who underwent open-heart surgery.

METHODS

In this prospective study, 100 patients were randomized into 2 groups: 50 in the thyroxin group (TH) and 50 in the placebo group (PL). Patients in the TH group received oral thyroxin (5 μg/kg) 12 hours before surgery and once daily for the remainder of their intensive care unit (ICU) stay. Data on intraoperative and postoperative variables were recorded. Cardiac index (CI) was measured. Perioperative serum thyroid hormone levels and serum interleukin-6 and tumor necrosis factor-α were measured. Secondary analysis was performed by dividing patients into simple and complex subcategories.

RESULTS

Results of the primary analysis indicated a higher CI in the TH compared with the PL. In the complex category, the mean duration of mechanical ventilation was 3.85 ± 0.93 and 4.66 ± 1.55 days in the TH and PL, respectively (P = .001). Mean ICU stay was 6.79 ± 2.26 and 8.33 ± 3.09 days (P = .03), and mean hospital stay was 15.70 ± 4.77 and 18.90 ± 4.48 days (P = .01) in the TH and PL, respectively. There were no significant differences between the TH and the PL in the simple category. CI was higher in the TH at all time points (P = .004). The average therapeutic intervention scoring system scores for the first 2 days were higher in the PL in the complex category.

CONCLUSIONS

Oral thyroxin supplementation improves the CI and reduces the inotropic requirement. In addition, it reduces the duration of mechanical ventilation, ICU and hospital stay, and therapeutic intervention scoring system in infants after surgery for complex congenital heart defects.

Scope of nursing care in Polish intensive care units

INTRODUCTION

The TISS-28 scale, which may be used for nursing staff scheduling in ICU, does not reflect the complete scope of nursing resulting from varied cultural and organizational conditions of individual systems of health care.

AIM

The objective of the study was an attempt to provide an answer to the question what scope of nursing care provided by Polish nurses in ICU does the TISS-28 scale reflect?

MATERIAL AND METHODS

The methods of working time measurement were used in the study. For the needs of the study, 252 hours of continuous observation (day-long observation) and 3.697 time-schedule measurements were carried out.

RESULTS

The total nursing time was 4125.79 min. (68.76 hours), that is, 60.15% of the total working time of Polish nurses during the period analyzed. Based on the median test, the difference was observed on the level of χ(2) = 16945.8,P < 0.001 between the nurses' workload resulting from performance of activities qualified into the TISS-28 scale and load resulting from performance of interventions within the scopes of care not considered in this scale in Polish ICUs.

CONCLUSIONS

The original version of the TISS-28 scale does not fully reflect the workload among Polish nurses employed in ICUs.

Critical care in Colombia: differences between teaching and nonteaching intensive care units. A prospective cohort observational study

OBJECTIVE

The aim of this study was to determine the differences in the efficacy and efficiency in providing critical care to hospitalized patients in teaching vs nonteaching intensive care units (ICUs) in Colombia.

METHODS

A prospective cohort observational study was conducted.

LOCATION

This study was conducted in 11 teaching and 8 nonteaching ICUs. From June 1 until December 31, 2005, data on 826 patients admitted consecutively to teaching ICUs and 825 patients admitted to nonteaching ICUs were analyzed.

MEASUREMENTS

Acute Physiology and Chronic Health Evaluation II, Simplified Therapeutic Intervention Scoring System, ICU discharge status (dead or alive) and ICU length of stay, and standardized mortality ratios were considered in this study. A logistic regression and robust linear regression were performed.

RESULTS

There were no differences in mortality (P = .25). Standardized mortality was less than 1 for both types of units. The teaching ICUs length of stay was 1 day longer (P < .01). Resource use is 25% higher in teaching units (P = .01). When the Simplified Therapeutic Intervention Scoring System score on the last day was from 21 to 35, a higher ratio of patients from the nonteaching ICUs was observed going floor or home when discharged from the ICU (P < .01).

CONCLUSIONS

Nonteaching ICUs discharge patients earlier than do teaching ICUs, but the effect of it remains to be clarified with further studies addressing questions as what happens after ICU discharge.