Estimation of direct cost and resource allocation in intensive care: correlation with Omega system

Impact of Isolation Time of COVID-19 Patients in Intensive Care Unit on Healthcare Workers Contamination and Nursing Care Intensity

Background

The optimal isolation time of COVID-19 patients in intensive care unit (ICU) is debated. We investigated the impact of two different COVID-19 patient isolation time strategies on healthcare workers (HCW) contamination, intensity of nursing care and potential associated adverse events.

Methods

We prospectively included all consecutive COVID-19 patients and HCW in our ICU in the first two pandemic waves (March to May 2020 and August to November 2020). Specific isolation measures for COVID-19 patients were released after two negative RT-PCR assays in the first wave and 14 days after the onset of symptoms in the second wave. Contamination of HCW was assessed at the end of each pandemic wave by combining both a RT-PCR assay and a serological test.

Results

Overall, 117 COVID-19 patients and 73 HCW were included. Despite an earlier release from isolation after ICU admission in the second than in the first wave [6 (4–8) vs. 15 (11–19) days, p < 0.01], the proportion of HCW with a positive serological test (16 vs. 17%, p = 0.94) or with a positive RT-PCR assay (3 vs. 5%, p = 0.58) was not different between the two waves. Although a lower nurse-to-bed ratio, the intensity of nursing care was higher in the second than in the first wave. A longer isolation time was associated with accidental extubation (OR = 1.18, 95%CI:1.07–1.35, p = 0.005) but neither with ventilator-associated pneumonia nor with dysglycemia.

Conclusion

A shorter isolation time of COVID-19 patients in ICU was not associated with higher HCW contamination, while a longer isolation time seemed to be associated with higher accidental extubation.

Economic model of albumin infusion in septic shock: The EMAISS study

BACKGROUND

The cost-effectiveness of albumin-based fluid support in patients with septic shock is currently unknown.

METHODS

In a simulation study, we compared standard medical practice and systematic 20% albumin infusion. The study population consisted of patients with septic shock admitted to one of the 28 ICUs belonging to the Cub-Réa regional database between 1 January 2014 and 31 December 2016. Cost estimates were based on French diagnosis-related groups and fixed daily prices. Estimation of mortality reduction relied on ALBIOS trial data documenting a Risk Ratio of 0.87 in a non-preplanned subgroup of patients with septic shock. Life expectancy was estimated with follow up data of 184 patients with septic shock admitted in the year 2000 in the same ICUs. Several sensitivity analyses were performed including a one-way Deterministic Sensitivity Analysis (DSA) and a Probabilistic multivariate Sensitivity Analysis (PSA).

RESULTS

About 6406 patients were included. In the base-case scenario, the mean live years gained with albumin was 0.49. The mean extra cost of using albumin was €480 per year. The cost per year gained was €974. Sensitivity analyses confirmed the robustness of the results. The probability of albumin being cost-effective was 95% and 97% for a threshold fixed at €20 000 and €30 000 per life-year saved, respectively.

CONCLUSION

Based on the risk reduction observed in the septic shock subgroup analysis of the ALBIOS dataset, the application of the ALBIOS trial results to Cub-Réa data may suggest that albumin infusion is likely cost-effective in septic shock.

Epidemiology of infective endocarditis in French intensive care units over the 1997-2014 period-from CUB-Réa Network

Background

Few studies focus only on severe forms of infective endocarditis, for which organ failure requires admission to an intensive care unit (ICU). This study aimed to describe demographical, comorbidities, organ failure, and pathogen-related characteristics in a population of critically ill patients admitted to ICU for infective endocarditis and to identify risk factors of in-ICU mortality.

Methods

Retrospective observational multicenter (N = 34) study of the CUB-Rea register, based on ICD-10 coding rules, between 1997 and 2014 in France including ICU patients managed for infective endocarditis. In-ICU mortality associated factors were assessed by multivariate logistic regression including an interrupted time analysis of three periods (1997–2003, 2004–2009, and 2010–2014).

Results

Four thousand four hundred five patients admitted in ICU for infective endocarditis were included. We observed an increase in endocarditis prevalence, as well as an increase in organ failure severity over the three periods. In addition, valve surgery was more frequently performed (27%, 31%, and 42%, P < 0.0001) while in-ICU mortality significantly decreased (28%, 29%, and 23%, P < 0.001). Since 2010, a significant increase in the trends’ slope of incidence for Streptococcus sp. and Staphylococcus sp. was observed with no change concerning intracellular bacteria, Enterococcus sp. or Candida sp. slope trends. In multivariate analysis, age, SAPS2, organ failure, stroke, and Staphylococcus sp. were associated with ICU mortality. Conversely, surgery, intracardiac devices, male gender, and Streptococcus sp.-related infective endocarditis were associated with a better outcome.

Conclusions

Our study reveals a shifting landscape of infective endocarditis epidemiology in French ICUs, characterized by reduced in-ICU mortality despite higher severity, more surgery, and substantial changes in microbial epidemiology.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2387-8) contains supplementary material, which is available to authorized users.

Relationship between availability of physiotherapy services and ICU costs

OBJECTIVE

To determine whether 24-h availability of physiotherapy services decreases ICU costs in comparison with the standard 12 h/day availability among patients admitted to the ICU for the first time.

METHODS

This was an observational prevalence study involving 815 patients ≥ 18 years of age who had been on invasive mechanical ventilation (IMV) for ≥ 24 h and were discharged from an ICU to a ward at a tertiary teaching hospital in Brazil. The patients were divided into two groups according to h/day availability of physiotherapy services in the ICU: 24 h (PT-24; n = 332); and 12 h (PT-12; n = 483). The data collected included the reasons for hospital and ICU admissions; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; IMV duration, ICU length of stay (ICU-LOS); and Omega score.

RESULTS

The severity of illness was similar in both groups. Round-the-clock availability of physiotherapy services was associated with shorter IMV durations and ICU-LOS, as well as with lower total, medical, and staff costs, in comparison with the standard 12 h/day availability.

CONCLUSIONS

In the population studied, total costs and staff costs were lower in the PT-24 group than in the PT-12 group. The h/day availability of physiotherapy services was found to be a significant predictor of ICU costs.

Demographic Changes in Intensive Care Units in Korea over the Last Decade and Outcomes of Elderly Patients: A Single-Center Retrospective Study

Background

Aging is a significant issue worldwide, and Korea is one of the most rapidly aging countries. Along with the demographic transition, the age structure of intensive care unit (ICU) patients changes as well.

Methods

The aim of this study was to analyze the change in age distribution of the ICU patients over the last 10 years and its effect on clinical outcomes. Single-center, retrospective analysis of all patients aged ≥18 years admitted to either the medical or surgical ICU at St. Paul’s Hospital, The Catholic University of Korea, between January 2005 and December 2014 was conducted. For clinical outcome, in-hospital mortality, duration of ICU stay, and hospital stay were analyzed. Cost analysis was performed to show the economic burden of each age strata.

Results

A total of 10,366 ICU patients were admitted to the chosen ICUs during the study period. The proportion of elderly patients aged ≥65 years increased from 47.9% in 2005 to 63.7% in 2014, and the proportion of the very elderly patients aged ≥80 years increased from 12.8% to 20.7%. However, this increased proportion of elderly patients did not lead to increased in-hospital mortality. The percent of ICU treatment days attributable to elderly patients increased from 51.1% in year 2005 to 64.0% in 2014. The elderly ICU patients were associated with higher in-hospital mortality compared to younger age groups.

Conclusions

The proportion of elderly patients admitted to ICUs increased over the last decade. However, overall in-hospital mortality has not increased during the same period.

Treatment intensity, age and outcome in medical ICU patients: results of a French administrative database

Background

Intensive care unit (ICU) patients are aging, and older age has been associated with higher mortality in ICU. As previous studies have reported that older age was also associated with less intensive treatment, we investigated the relationship between age, treatment intensity and mortality in medical ICU patients.

Methods

Data were extracted from the administrative database of 18 medical ICUs. Patients with a unique medical ICU stay and a Simplified Acute Physiology Score II (without age-related points) >15 were included. Treatment intensity was described with a novel indicator, which is a four-group classification based upon the most frequent ICU procedures. The relationship between age, treatment intensity and hospital mortality was analyzed with the estimation of standardized mortality ratio in the four groups of treatment intensity.

Results

A total of 23,578 patients, including 3203 patients aged ≥80 years, were analyzed. Hospital mortality increased from 13 % for the younger patients (age < 40 years) to 38 % for the older patients (age ≥ 80 years), while Simplified Acute Physiology Score II (without age-related points) increased only from 36 (age < 40 years) to 43 (age ≥ 80). Hospital mortality increased with age in the four groups of treatment intensity. Standardized mortality ratio increased with age among the patients with less intensive treatment but was not associated with age among the patients with the highest treatment intensity.

Conclusion

Our results support the fact that the increase in mortality with age among ICU patients is not related to an increase in severity. Using a new tool to estimate ICU treatment intensity, our study suggests that mortality of ICU patients increases with age whatever the treatment intensity is. Further investigations are required to determinate whether this increase in mortality among older ICU patients is related to undertreatment or to a lower efficiency of organ support treatment.

The Economic and Humanistic Burden of Severe Sepsis

Sepsis and severe sepsis in particular remain a major health problem worldwide. Their cost to society extends well beyond lives lost, as the impact of survivorship is increasingly felt. A review of the medical literature was completed in MEDLINE using the search phrases "severe sepsis" and "septic shock" and the MeSH terms "epidemiology", "statistics", "mortality", "economics", and "quality of life". Results were limited to human trials that were published in English from 2002 to 2014. Articles were classified by dominant themes to address epidemiology and outcomes, including quality of life of both patient and family caregivers, as well as societal costs. The severity of sepsis is determined by the number of organ failures and the presence of shock. In most developed countries, severe sepsis and septic shock account for disproportionate mortality and resource utilization. Although mortality rates have decreased, overall mortality continues to increase and is projected to accelerate as people live longer with more chronic illness. Among those who do survive, impaired quality of life, increased dependence, and rehospitalization increase healthcare consumption and, along with increased mortality, all contribute to the humanistic burden of severe sepsis. A large part of the economic burden of severe sepsis occurs after discharge. Initial inpatient costs represent only 30 % of the total cost and are related to severity and length of stay, whereas lost productivity and other indirect medical costs following hospitalization account for the majority of the economic burden of sepsis. Timeliness of treatment as well as avoidance of intensive care unit (ICU)-acquired illness/morbidity lead to important differences in both cost and outcome of treatment for severe sepsis and represent areas where improvement in care is possible. The degree of sophistication of a health system from a national perspective results in significant differences in resource use and outcomes for patients with serious infections. Comprehensive understanding of the cost and humanistic burden of severe sepsis provides an initial practical framework for health policy development and resource use.

Amount of care per survivor in young and older patients hospitalized in intensive care unit: a retrospective study

BACKGROUND

It is unknown whether the amount of care deployed in the intensive care unit population divided by the number of survivors, that is, amount of care per survivor including the care performed for nonsurvivors, differs between patients older and younger than 75 years of age.

METHODS

Data were extracted from the computerized files of all 2,220 patients admitted in a medical intensive care unit between January 2009 and December 2010. Patients ≥75 and <75 years old were compared. The Omega score per survivor (OMEGA/S) was calculated in both age groups by dividing the total amount of Omega points, a score of cumulated care load calculated over intensive care unit stay, by the number of survivors in each group.

RESULTS

OMEGA/S was 26% higher in elderly versus younger patients when considering intensive care unit mortality and 40% higher when considering hospital mortality. The absence of difference in raw Omega values between the two groups implies that OMEGA/S differences were related to differences in mortality rate. Simplified Acute Physiology Score II (without age-related points) strata analysis (<20, 20-39, 40-59, 60-79, and ≥80) showed that OMEGA/S in the elderly patients was significantly higher in the first three Simplified Acute Physiology Score II strata only. When calculating by main diagnosis categories, a major increase in the difference of OMEGA/S between elderly and younger patients was observed in cardiac arrest patients due to a major difference in mortality rate.

CONCLUSIONS

Elderly patients required a significantly higher care load per survivor in comparison to younger patients. This excess was mainly due to patients with low initial severity.

Monitoring costs in the ICU: a search for a pertinent methodology

Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.

Increased intensity of treatment and decreased mortality in elderly patients in an intensive care unit over a decade

OBJECTIVES

Data collected from two cohorts of patients aged > or =80 yrs and admitted to an intensive care unit in France were compared to determine whether intensive care unit care and survival had evolved from the 1990s to the 2000s.

DESIGN

Retrospective cohort study on patient data attained during intensive care unit stays.

SETTING

18-bed intensive care unit in an academic medical center.

PATIENTS

Two cohorts of patients aged > or =80 yrs, admitted to an intensive care unit at a 10-yr interval.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The first cohort comprised 348 patients admitted between January 1992 and December 1995, and the second cohort, 373 patients admitted between January 2001 and December 2004. There was no difference in age between the two cohorts, but patients in the second had significantly less history of functional limitation and significantly more acute illness (Simplified Acute Physiology Score II 43 +/- 18 vs. 57 +/- 25, respectively, p < .0001). Patients in the second cohort had a significantly higher Omega Score, had a higher occurrence of renal replacement therapy, and received vasopressors more frequently than the patients in the first cohort, even when adjusted for age, sex, Knaus classification, Simplified Acute Physiology Score II, and intensive care unit admission cause. Intensive care unit mortality was 65% and 64% for the first and second cohorts, respectively. In multivariate analysis (including age, Knaus classification, Simplified Acute Physiology Score II and first vs. second period) for association with intensive care unit survival, the 2001-2004 period was associated with a near tripling of chances of survival (odds ratio 2.9; 95% confidence interval, 1.92-4.47, p < .0001).

CONCLUSIONS

The characteristics and intensity of treatment for elderly people admitted to the intensive care unit changed significantly over a decade. The intensity of treatments has increased over time and survival has improved over time as well. A potential link between increased treatment and improved survival in the elderly may be evoked.

[Impact on morbidity and costs of methicillin-resistant Staphylococcus aureus nosocomial pneumonia in intensive care patients]

OBJECTIVES

Prevention of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections in the intensive care units (ICU) has been recommended for several years. However, the workload and the costs of these programs are to be weighed against the benefit obtained in terms of reduction of morbidity and costs induced by the infection. The purpose of this study was to evaluate the cost and the current morbidity of the infection with MRSA in the ICU.

METHODS

In a retrospective case-control study carried out in 2004, all patients of the 6 intensive care units of a teaching hospital having developed a MRSA nosocomial infection were included. They were paired with controls on the following criteria: department, Simplified Acute Physiology Score II (SAPSII), age (+/- 5 years), type of surgery (for the surgical intensive care units). The duration of hospitalization of the paired control had to be at least equal to the time from admission to infection of the infected patient. The costs were evaluated using the following parameters: scores omega 1, 2 and 3, duration of artificial ventilation, hemodialysis, length of ICU stay, radiological procedures, surgical procedures, total antibiotic cost and other expensive drugs.

RESULTS

Twenty-one patients with MRSA infection were included. All had nosocomial pneumonia. The 21 paired patients were similar with regard to both initial criteria and sex. Hospital mortality was not different between the 2 groups (cases=8; controls=6; p=0.41), as well as median duration of hospital stay (cases=41 days; controls=43 days; p=0.9). The duration of mechanical ventilation, number of hemodialysis or hemofiltration sessions, number of radiological procedures were similar in both groups. The total omega score was not significantly different between cases (median 435; IQR: 218-579) and controls (median 281, IQR: 231-419; p=0.55). The median duration of isolation was 12 days for cases and 0 day for controls (p=0.0007). The pharmaceutical expenditure was significantly higher in cases (median: 1414euro; IQR: 795-4349), by comparison with the controls (median: 877euro, IQR: 687-2496) (p=0.049).

CONCLUSION

In the ICU having set up a policy intended to reduce the risk of MRSA nosocomial infections, MRSA pneumonia does not seem to involve major additional morbidity, as compared to a control population matched for similar severity of illness. It increases modestly the use of the medical resources.

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.

Predictors of 1-year outcome after coiling for poor-grade subarachnoid aneurysmal hemorrhage

OBJECTIVE

To describe features in patients admitted to the intensive care unit (ICU) for poor-grade aneurysmal subarachnoid hemorrhage (SAH) and to identify predictors of 12-month outcome.

METHODS

We conducted a controlled observational study of 51 consecutive patients treated with endovascular coiling within 96 h of rupture for poor-grade aneurysmal SAH (20 men and 31 women, age 54 +/- 12 years). We recorded co-morbidities; initial severity; aneurysm location; occurrence of acute hydrocephalus, initial seizures, and/or neurogenic lung edema; troponin values, Fisher grade; computed tomography (CT) findings; treatment intensity; and occurrence of vasospasm. The brain injury marker S100B was assayed daily over the first 8 days. Glasgow Outcome Scores (GOS) were recorded at ICU discharge, at 6 and 12 months. The main outcome criterion was the 1-year GOS score, which we used to classify patients as having a poor outcome (GOS 1-3) or a good outcome (GOS 4-5).

RESULTS

Overall, clinical status after 1 year was very good (GOS 5) in 41% of patients and good (GOS 4) in 16%. Neither baseline characteristics nor interventions differed significantly between patients with good outcome (GOS 4-5) and those with poor outcome (GOS 1-3). Persistent intracranial pressure elevation and higher mean 8-day S100B value significantly and independently predicted the 1-year GOS outcome (P = 0.008 and P = 0.001, respectively).

CONCLUSIONS

Patients in poor clinical condition after SAH have more than a 50:50 chance of a favorable outcome after 1 year. High mean 8-day S100B value and persistent intracranial hypertension predict a poor outcome (GOS 1-3) after 1 year.

New models for old questions: generalized linear models for cost prediction

BACKGROUND

Generalized linear models (GLMs) have recently been introduced into cost data analysis. GLMs, transformations of the linear regression model, are characterized by a particular response distribution from one of the exponential family of distributions and monotonic link function which relates the response mean to a scale on which additive model effects operate.

OBJECTIVES

This study compared GLMs and ordinary least squares regression (OLS) in predicting individual patient costs in adult intensive care units (ICUs) and sought to define the utility of the inverse Gaussian distribution family within GLMs.

METHODS

A prospective 'ground-up' utilization costing study was performed in three adult university associated ICUs, enrolling consecutive ICU admissions over a 6-month period in 1991. ICU utilization, patient demographic and ICU admission day data were recorded by dedicated data collectors. Model performance was assessed by prediction error [mean absolute error (MAE), root mean squared error (RMSE)] and residual analysis.

RESULTS

The cohort, 1098 patients surviving ICU, was of mean (SD) age 56 (19.5) years and 41% female. Patient costs per ICU episode (1991 A$) were A$6311 (9689), with range A$106 to A$95602. Prediction error for mean costs was minimal (MAE 4780; RMSE 8965) with OLS using heteroscedastic retransformation of log costs and GLM with Gaussian family and log link (MAE 4798; RMSE 8907). Residual analysis suggested optimal overall performance for the above two models and a GLM with inverse Gaussian family and log link.

CONCLUSIONS

Traditional cost models of OLS with (log) cost transformation may be supplemented by appropriately specified GLM which more closely model the error structure.

Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?

OBJECTIVE

To evaluate the effect of tracheostomy on intensive care unit (ICU) and in-hospital mortality for patients requiring prolonged (> 3 days) mechanical ventilation (MV).

DESIGN, SETTING, AND PATIENTS

We retrospectively reviewed the charts of all consecutive patients admitted to our 18-bed tertiary care ICU over 3 yrs (2002-2004) and who received prolonged MV. Outcomes of tracheostomized and nontracheostomized patients were evaluated using univariable and multivariable logistic-regression analyses and by constructing a case-control cohort using a propensity score for performing tracheostomy. MV duration for controls was at least equal to the time from MV onset to tracheostomy for the matched case.

MEASUREMENTS AND MAIN RESULTS

Of the 506 patients requiring prolonged MV, 166 were tracheostomized after a median of 12 days of MV. Nontracheostomized patients had higher ICU (42% vs. 33%, p = .06) and in-hospital (48% vs. 37%, p = .03) mortality rates and shorter MV durations and ICU lengths of stay. Performing a tracheostomy (odds ratio, 0.58; 95% CI, 0.37-0.90) was independently associated with a lower probability of ICU death, even after adjusting for other important prognostic factors. No significant differences were detected between the 120 cases and their matched controls regarding ICU admission and day-3 clinical characteristics. After conditional logistic-regression analysis, tracheostomy was associated with lower risk of ICU (odds ratio, 0.47; 95% CI, 0.24-0.89) and in-hospital (odds ratio, 0.48; 95% CI, 0.25-0.90) death.

CONCLUSIONS

Tracheostomy performed in our ICU for long-term MV patients was associated with lower ICU and in-hospital mortality rates, even after carefully controlling for ICU admission and day-3 clinical and physiologic differences between groups. Whether these results reflect that physicians were able to adequately select for tracheostomy patients who, despite having similar physiologic and demographic variables, had the highest probabilities of survival or that the procedure itself really affected the outcomes of these patients will remain speculative.

Combined measurements of N-terminal pro-brain natriuretic peptide and cardiac troponins in potential organ donors

OBJECTIVE

Brain death may induce cardiac dysfunction. In potential organ donors measurements of N-terminal pro-brain natriuretic peptide (NT-proBNP) and circulating cardiac troponins T and I (cTnT and cTnI), alone or in combination, are performed to investigate the accuracy of these biomarkers for early diagnosis of left ventricular systolic dysfunction.

DESIGN AND SETTING

Prospective study in a multidisciplinary intensive care unit of an university hospital.

PATIENTS

63 brain-dead patients scheduled for multiple organ harvesting.

MEASUREMENTS AND RESULTS

We measured NT-proBNP, cTnT, and cTnI and determined fractional area change (FAC) using transesophageal echocardiography. Forty-five patients had normal FAC, 9 a moderate decrease in FAC (30-50), and 9 a severe decrease in FAC (<or=30%). NT-proBNP and cTnT concentrations were significantly higher in patients with a severe decrease in FAC than in those with a moderate decrease. Combining measurements of these two biomarkers, the sensitivity of the test to predict severe decrease in FAC increased significantly to reach 1.00 compared with the sensitivities of individual measurements. The ROC curve area of combined measurements of NT-proBNP and cTnT was significantly higher than single measurements: 0.87 vs. 0.82 for NT-proBNP, 0.78 for cTnT, and 0.72 for cTnI.

CONCLUSIONS

In potential organ donors the combined measurement of NT-proBNP and cTnT concentrations is more accurate than individual measurement of NT-proBNP, cTnT, and cTnI in the early diagnosis of severe left ventricular systolic dysfunction. These findings may lead to improve the quality of cardiac care of the potential organ donors.

A model for calculating costs of hospital‐acquired infections: an Italian experience

PURPOSE

Many approaches on the economic aspect of hospital acquired infections (HAIs) have two major limitations: first, the lack of distinction between resources attributable to the management of HAI and resources absorbed by the main clinical problem for which the patient was hospitalized, and second, the lack of an adequate method for calculating the relative costs. These assume that the resources used by HAI can be determined by measuring the extra days of length of days (LOS) of infected patients versus non-infected patients and attribute to extra-LOS a value to the mean total cost. The aim of the article is to test a cost-modelling method that could overcome these limitations by applying the appropriateness evaluation protocol to the medical charts of patients with hospital-acquired symptomatic urinary tract infection (UTI) or sepsis, and by using cost-centre accounting.

DESIGN/METHODOLOGY/APPROACH

The paper explains and tests a model for calculating costs of HAIs.

FINDINGS

The data analysis showed that it is not always true that infections protract LOS: five out of 25 sepsis cases have extra-LOS and eight out of 25 UTI cases have extra-LOS, while the cases of sepsis that arose in surgery ward and intensive care units and urinary tract infections in ICU are without prolongation of LOS. The data analysis also showed that, using the mean total cost, the three cases of sepsis in the general surgery and the six in the ICU did not incur costs, nor did the two cases of UTI in ICU, so that they appear to be infections at zero cost. Moreover, the weight of the cost for the bed, or for the diagnostic services, or for the pharmacological treatment, varied widely depending on the site of the HAI and the ward where the patient was hospitalized.

ORIGINALITY/VALUE

The method can be applied in any hospital.

Cost-effectiveness of drotrecogin alfa (activated) in the treatment of severe sepsis with multiple organ failure

OBJECTIVES

The aim of this study was to estimate the expected cost and clinical benefits associated with the use of drotrecogin alfa (activated) (Xigris; Eli Lilly and Company; Indianapolis, IN) in the French hospital setting.

METHODS

The recombinant human activated PROtein C Worldwide Evaluation in Severe Sepsis (PROWESS) study results (1271 patients with multiple organ failure) were adjusted to 9,948 hospital stays from a database of Parisian area intensive-care units (ICUs)-the CubRea (Intensive Care Database User Group) database. The analysis features a decision tree with a probabilistic sensitivity analysis.

RESULTS

The cost per life year gained (LYG) of drotrecogin treatment for severe sepsis with multiple organ failure (European indication) was estimated to be dollars 11,812. At the hospital level, the drug is expected to induce an additional cost of dollars 7545 per treated patient. The incremental cost-effectiveness ratio ranges from dollars 7873 per LYG for patients receiving three organ supports during ICU stay to dollars 17,704 per LYG for patients receiving less than two organ supports.

CONCLUSIONS

Drotrecogin alfa (activated) is cost-effective in the treatment of severe sepsis with multiple organ failure when added to best standard care. The cost-effectiveness of the drug increases with baseline disease severity, but it remains cost-effective for all patients when used in compliance with the European approved indication.

Postoperative Pneumonia after Major Lung Resection

BACKGROUND

Postoperative pneumonia (POP) is a life-threatening complication of lung resection. The incidence, causative bacteria, predisposing factors, and outcome are poorly understood.

DESIGN

Prospective observational study.

METHODS

A prospective study of all patients undergoing major lung resections for noninfectious disease was performed over a 6-mo period. Culture of intraoperative bronchial aspirates was systematically performed. All patients with suspicion of pneumonia underwent bronchoscopic sampling and culture before antibiotherapy.

RESULTS

One hundred and sixty-eight patients were included in the study. Bronchial colonization was identified in 31 of 136 patients (22.8%) on analysis of intraoperative samples. The incidence of POP was 25% (42 of 168). Microbiologically documented and nondocumented pneumonias were recorded in 24 and 18 cases, respectively. Haemophilus species, Streptococcus species, and, to a much lesser extent, Pseudomonas and Serratia species were the most frequently identified pathogens. Among colonized and noncolonized patients, POP occurred in 15 of 31 and 20 of 105 cases, respectively (p = 0.0010; relative risk, 2.54). Death occurred in 8 of 42 patients who developed POP and in 3 of 126 of patients who did not (p = 0.0012). Patients with POP required noninvasive ventilation or reintubation more frequently than patients who did not develop POP (p < 0.0000001 and p = 0.00075, respectively). POP was associated with longer intensive care unit and hospital stay (p < 0.0000001 and p = 0.0000005, respectively). Multivariate analysis showed that chronic obstructive pulmonary disease, extent of resection, presence of intraoperative bronchial colonization, and male sex were independent risk factors for POP.

CONCLUSIONS

Pneumonia acquired in-hospital represents a relatively frequent complication of lung resections, associated with an important percentage of postoperative morbidity and mortality.

Effect of gingival and dental plaque antiseptic decontamination on nosocomial infections acquired in the intensive care unit: a double-blind placebo-controlled multicenter study

OBJECTIVE

To document the effect of gingival and dental plaque antiseptic decontamination on the rate of nosocomial bacteremias and respiratory infections acquired in the intensive care unit (ICU).

DESIGN

Prospective, multicenter, double-blind, placebo-controlled efficacy study.

SETTING

Six ICUs: three in university hospitals and three in general hospitals.

PATIENTS

A total of 228 nonedentulous patients requiring endotracheal intubation and mechanical ventilation, with an anticipated length of stay > or =5 days.

INTERVENTIONS

Antiseptic decontamination of gingival and dental plaque with a 0.2% chlorhexidine gel or a placebo gel, three times a day, during the entire ICU stay.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical characteristics, organ function data (Logistic Organ Dysfunction score), severity of condition (Simplified Acute Physiologic Score), and dental plaque status were assessed at baseline and until 28 days. Bacteriologic sampling of dental plaque and saliva was done every 5 days, and blood, tracheal aspirate, and bronchoalveolar lavage cultures were performed when appropriate. The primary efficacy end point was the incidence of bacteremia, bronchitis, and ventilator-associated pneumonia, expressed as a percentage and per 1000 ICU days. All baseline characteristics were similar between the treated and the placebo groups. The incidence of nosocomial infections was 17.5% (13.2 per 1000 ICU days) in the placebo group and 18.4% (13.3 per 1000 ICU days) in the plaque antiseptic decontamination group (not significant). No difference was observed in the incidence of ventilator-associated pneumonia per ventilator or intubation days, mortality, length of stay, and care loads (secondary end points). On day 10, the number of positive dental plaque cultures was significantly lower in the treated group (29% vs. 66%; p < .05). Highly resistant Pseudomonas, Acinetobacter, and Enterobacter species identified in late-onset ventilator-associated pneumonia and previously cultured from dental plaque were not eradicated by the antiseptic decontamination. No side effect was reported.

CONCLUSIONS

Gingival and dental plaque antiseptic decontamination significantly decreased the oropharyngeal colonization by aerobic pathogens in ventilated patients. However, its efficacy was insufficient to reduce the incidence of respiratory infections due to multiresistant bacteria.

Epidemiology and economic evaluation of severe sepsis in France: age, severity, infection site, and place of acquisition (community, hospital, or intensive care unit) as determinants of workload and cost

PURPOSE

Severe sepsis is a leading cause of death in critically ill patients. We evaluated cost and workload according to infection site, place and time of acquisition, and severity.

MATERIAL AND METHOD

We used a prospective 3-year database from 6 intensive care units (ICUs) including 1698 patients.

RESULTS

Of the 1698 patients, 713 (42%) had severe sepsis at admission and 339 during the ICU stay (211 had both). Mortality was twice as high in patients with than those without ICU-acquired infection, independent of the presence of severe sepsis at admission. The mean (SD; median) cost of severe sepsis was 22 800 (21 400 ; 15 800 ). Among patients with severe sepsis at admission, workload and cost were higher for pneumonia, peritonitis, and multiple-site infections and for hospital-acquired (17,400 [14,700; 17,400]) vs community-acquired infection (12,600 [12,100 ; 8900 ]). Intensive care unit-acquired severe sepsis was associated with greater than 3-fold increases in workload and costs. By multiple linear regression, older age, emergency surgery, septic shock, Acute Physiological and Chronic Health Evaluation II score, and hospital or ICU-acquired severe sepsis were independently associated with higher costs.

CONCLUSIONS

The wide variations in cost and workload invite efforts to identify patient subgroups most likely to benefit from high-cost treatments and from prevention, particularly targeting severe nosocomial infections.

Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter-related bacteremia in intensive care units

OBJECTIVE

To compare the rates of positive quantitative culture (PQC) of arterial catheter (AC) and central venous catheter (CVC) tips and of CVC- and AC-related bacteremia in intensive care unit patients undergoing placement of both ACs and CVCs.

DESIGN

Prospective, descriptive survey. To control for a difference in the severity of patients having an AC or CVC, only patients having both an AC and a CVC were included.

SETTING

An adult, nine-bed medical/surgical intensive care unit at a university teaching hospital.

SUBJECTS

The analysis included 308 CVCs and 299 ACs inserted in 212 severely ill patients, with a mean +/- sd Simplified Acute Physiology Score II of 52 +/- 22 and an intensive care unit mortality of 33% (69 of 212).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The same insertion and maintenance procedures were used for both types of catheter. A PQC was defined by a catheter tip culture yielding >/=10(3) colony forming units/mL. Catheter-related bacteremia was defined by a PQC and a blood culture positive for the same microorganism. The cumulative incidence (PQCs/number of catheters inserted) was 9.4% (29/308) for CVCs and 7.7% (23/299) for ACs (p = .44). Incidence density (PQCs/1,000 catheter days) was 12.0 for CVCs versus 9.3 for ACs. At the femoral site, there was no significant difference between CVCs and ACs in the cumulative incidences and incidence densities of PQCs. Two instances of catheter-related bacteremia were observed, one involving a CVC and one involving an AC.

CONCLUSIONS

Among severely ill patients with both CVCs and ACs, the epidemiology of PQCs of CVCs and ACs is comparable when the same infection control measures are used for the insertion and maintenance of both types of catheters.

Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units

OBJECTIVE

To evaluate the effectiveness of screening strategy and contact precautions for patients with methicillin-resistant Staphylococcus aureus (MRSA).

DESIGN AND SETTING

Prospective observational cohort from 1 February 1995 to 31 December 2001 in three intensive care units (45 beds) in a French teaching hospital.

PATIENTS

8,548 patients admitted to the three ICUs had nasal screening on ICU admission and weekly thereafter. Contact precautions were used in MRSA-positive patients. The following variables were collected: age, gender, severity score, length of stay, workload, and colonization pressure (percentage of patient-days with an MRSA to the number of patient-days in the unit). Alcohol-based handrub solution was introduced in July 2000. We compared the period before this (P1) with that thereafter (P2).

RESULTS

Of the 8,548 admitted patients 554 (6.5%) had MRSA at ICU admission, and 456 of the 7,515 (6.1%) exposed patients acquired MRSA. Acquisition incidence decreased from 7.0% in P1 to 2.8% in P2. Independent variables associated with MRSA acquisition were: age (adjusted odds ratio 1.013), severity score (1.047), length of ICU stay (1.015), colonization pressure (1.019), medical ICU (1.58), and P2 (0.49).

CONCLUSIONS

MRSA control in these ICUs characterized by a high prevalence of MRSA at admission was achieved via multiple factors, including screening, contact precautions, and use of alcoholic handrub solution. Our results after adjustment of risk factors for MRSA acquisition and the steady improvement in MRSA over several years strengthen these findings. MRSA spreading can be successfully controlled in ICUs with high colonization pressure.

Adverse effect on a referral intensive care unitʼs performance of accepting patients transferred from another intensive care unit*

OBJECTIVE

To determine whether observed and predicted mortality for intensive care unit (ICU) transfer admissions is different from non-ICU transfer admissions and how that might affect ICU performance evaluation.

DESIGN, SETTING, AND PATIENTS

We retrospectively analyzed the charts of 3,416 patients admitted to our tertiary referral ICU from January 1995 to December 2001 and evaluated the effect on our performance (based on the Simplified Acute Physiology Score II risk model) of accepting patients transferred from another hospital's ICU.

MAIN RESULTS

During the study period, 597 patients (17%) had been transferred from a non-ICU setting in another hospital (hospital transfer) and 408 (12%) from another hospital's ICU (ICU transfer). ICU mortality and standardized mortality ratios were significantly higher for ICU-transfer patients than for hospital-transfer or directly admitted patients: 34% vs. 23% vs. 17% (p < .0001) and 0.95 (95% confidence interval, 0.83-1.08), 0.82 (95% confidence interval, 0.71-0.95), and 0.62 (95% confidence interval, 0.55-0.68), respectively. ICU-transfer patients had 3.6-fold longer mean ICU stays and 1.9-fold longer durations of mechanical ventilation than directly admitted patients. Hospital-transfer (odds ratio = 1.89) and ICU-transfer patients (odds ratio = 2.41) had significantly higher mortality rates, even after adjustment for case mix and disease severity. Consequently, a benchmarking program adjusting only for these latter variables, but not admission source, would penalize our ICU by 39 excess deaths per 1,000 admissions as compared with another ICU admitting no transfer patients. Finally, patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio = 1.56) as compared with patients directly admitted from the ward of our hospital, confirming the "transfer effect" for this homogeneous patients' subgroup.

CONCLUSIONS

Admission source remains a strong and independent predictor of ICU death, despite adjustment for case mix and disease severity at ICU admission. Specifically, accepting numerous ICU-transfer patients, for whom the probability of ICU death is the most underestimated by a system adjusting only for case mix and disease severity, can adversely affect the evaluation of referral centers' performance. Future benchmarking and profiling systems should evaluate and adequately account for the ICU-transfer factor to provide healthcare payers and consumers with more accurate and valid information on the true performance of referral centers.

Cost calculation and prediction in adult intensive care: a ground-up utilization study

The ability of various proxy cost measures, including therapeutic activity scores (TISS and Omega) and cumulative daily severity of illness scores, to predict individual ICU patient costs was assessed in a prospective "ground-up" utilization costing study over a six month period in 1991. Daily activity (TISS and Omega scores) and utilization in consecutive admissions to three adult university associated ICUs was recorded by dedicated data collectors. Cost prediction used linear regression with determination (80%) and validation (20%) data sets. The cohort, 1333 patients, had a mean (SD) age 57.5 (19.4) years, (41% female) and admission APACHE III score of 58 (27). ICU length of stay and mortality were 3.9 (6.1) days and 17.6% respectively. Mean total TISS and Omega scores were 117 (157) and 72 (113) respectively. Mean patient costs per ICU episode (1991 dollar AUS) were dollar 6801 (dollar 10311), with median costs of dollar 2534, range dollar 106 to dollar 95,602. Dominant cost fractions were nursing 43.3% and overheads 16.9%. Inflation adjusted year 2002 (mean) costs were dollar 9343 (dollar AUS). Total costs in survivors were predicted by Omega score, summed APACHE III score and ICU length of stay; determination R2, 0.91; validation 0.88. Omega was the preferred activity score. Without the Omega score, predictors were age, summed APACHE III score and ICU length of stay; determination R2, 0.73; validation 0.73. In non-survivors, predictors were age and ICU length of stay (plus interaction), and Omega score (determination R2, 0.97; validation 0.91). Patient costs may be predicted by a combination of ICU activity indices and severity scores.

Infections nosocomiales à Staphylococcus aureus résistant à la méthicilline en réanimation médicale polyvalente : facteurs de risque, morbidité et impact économique

OBJECTIVE

Methicillin resistance and infections caused by methicillin-resistant Staphylococcus aureus represent a growing problem and a challenge for health-care institutions. We evaluated risk factors, morbidity and cost of infections caused by methicillin-resistant (MRSA) and methicillin-susceptible (MSSA) Staphylococcus aureus.

DESIGN

We performed an un-matched case-control study in an 20-bed medical intensive care unit from 1994-2001 at Nantes teaching hospital, France. All patients with pneumonia, bacteraemia and urinary MRSA (cases) or MSSA (controls) nosocomial infections were included in the study.

RESULTS

Twenty four patients with MRSA infection were compared to 64 patients with MSSA infections. Patients with MRSA infection were older (56 vs. 45 years, P < 0.01), had longer length of stay (47 vs. 35 days, P < 0.05) and were infected later (22 vs. 10 days, P < 0.00001) than patients with MSSA infection. No difference was observed between the two groups according to the Omega index, acute simplify index and mortality. MRSA infections involved extra cost due to antimicrobial treatment (184 vs. 72 Euros, P < 0.005) and length of stay (37,278 vs. 27,755 Euros, P < 0.05).

CONCLUSION

Patient infected by MRSA seems to be different from patient infected by MSSA but without consequence on Omega index and mortality. But methicillin-resistance involves extra cost due to antimicrobial treatment and length of stay.

Multicentre study of validity and interrater reliability of the modified Nursing Care Recording System (NCR11) for assessment of workload in the ICU

BACKGROUND

Reliable assessment of nursing workload is necessary for the quantitative approach to staffing of intensive care units. The Nursing Care Recording System (NCR11) scores both the nursing contribution to patient care and those related to medical procedures. The purpose of the present work was to compare NCR11 scoring with the Therapeutic Intervention Scoring System (TISS) and Nine Equivalents of Nurse Manpower use Score (NEMS) and to examine the interrater reliability of NCR11 scoring.

METHODS

Bias and precision of workload scores (NCR11 vs. TISS or NEMS) were assessed for 6126 consecutive admissions (23910 ICU-days) at three intensive care units. Inter-rater reliability was analyzed by having nurses at nine ICUs score workload using NCR11 for three dummy intensive care patient cases presented over a 3-year period. Variability in scoring was analyzed using the coefficient of variation.

RESULTS

Agreement between NCR11 and TISS or NEMS was poor and limits of agreement were wide. Linear relationships between NCR11 and TISS or NEMS scores differed between units. Variability in NCR11 scoring decreased significantly from 10.4% to 5.9% between dummy cases 1 and 2 and remained low for patient case 3.

CONCLUSION

The NCR11 does not measure the same elements of workload in the ICU as do TISS and NEMS. Inter-rater reliability with NCR11 is good, showing little variation in scoring between nurses.

Prognosis of patients aged 80 years and over admitted in medical intensive care unit

OBJECTIVE

To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over. DESIGN. Prospective cohort study.

SETTING

A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.

PATIENTS

A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.

MEASUREMENTS AND MAIN RESULTS

Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1-2.6) and severe functional limitation (HR 1.7; 95% CI 1.2-2.6). The IADL was excellent or good for 56% of the surviving patients.

CONCLUSION

Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.

Current epidemiology of septic shock: the CUB-Réa Network

To update the epidemiology of septic shock we analyzed clinical, microbiologic, and outcome variables from 100,554 intensive care unit admissions on the Collège des Utilisateurs de Bases de données en Réanimation (CUB-Réa) database, collected from 22 hospitals over a 8-year period, 1993 to 2000. The overall frequency of septic shock was 8.2 per 100 admissions (i.e., 8,251 stays). It increased from 7.0 (in 1993) to 9.7 per 100 admissions (in 2000). The distribution analysis of the sites of infection and of the types of pathogens showed an increase in the rate of pulmonary infection (p = 0.001) and of multiresistant bacteria-related septic shock (p = 0.001). The crude mortality was 60.1% and declined from 62.1% (in 1993) to 55.9 (in 2000) (p = 0.001). As compared with matched intensive care unit admissions without sepsis, the excess risk of death due to septic shock was 25.7 (95% confidence interval, 24.0-27.3) and the matched odds ratio of death was 3.9 (95% confidence interval, 3.5-4.3). The frequency of septic shock is increasing with more multiresistant strains. Its crude mortality rate is decreasing, but patients with septic shock still have a high excess risk of death than critically ill patients who are nonseptic.

Determinants of postintensive care unit mortality: a prospective multicenter study

OBJECTIVE

Six to 25 percent of patients discharged alive from the intensive care unit (ICU) die before hospital discharge. Although this post-ICU mortality may indicate premature discharge from a full ICU or suboptimal management in the ICU or ward, another factor may be discharge from the ICU as part of a decision to limit treatment of hopelessly ill patients. We investigated determinants of post-ICU mortality, with special attention to this factor.

DESIGN

Prospective, multicenter, database study.

SETTING

Seven ICUs in or near Paris, France.

PATIENTS

A total of 1,385 patients who were discharged alive from an ICU after a stay of > or = 48 hrs; 150 (10.8%) died before hospital discharge. Decisions to withhold or withdraw life-sustaining treatments were implemented in the ICUs in 80 patients, including 47 (58.7%) who died before hospital discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the univariate analysis, post-ICU mortality was associated with advanced age, poor chronic health status, severe comorbidities, severity and organ failure scores (Simplified Acute Physiology Score II, sepsis-related organ failure assessment, and Logistic Organ Dysfunction at admission and at ICU discharge), decisions to withhold or withdraw life-sustaining treatments, and Omega score (reflecting ICU resource utilization and length of ICU stay). Multivariate stepwise logistic regression identified five independent determinants of post-ICU mortality: McCabe class 1 (odds ratio, 0.388 [95% confidence interval, 0.26-0.58]), transfer from a ward (odds ratio, 1.89 [95% confidence interval, 1.27-2.80]), Simplified Acute Physiology Score II score at admission >36 (odds ratio, 1.57 [95% confidence interval, 1.6-2.33]), decisions to withhold or withdraw life-sustaining treatments (odds ratio, 9.64 [95% confidence interval, 5.75-16.6]), and worse sepsis-related organ failure assessment score at discharge (odds ratio, 1.11 [95% confidence interval, 1.03-1.18] per point).

CONCLUSIONS

More than 10% of ICU survivors died before hospital discharge. Determinants of post-ICU mortality included variables reflecting patient status before and during the ICU stay. However, the most powerful predictor of post-ICU mortality was the decision to withhold or withdraw life-sustaining treatments in the ICU, suggesting that the decision has been made not to use the unique services of the ICU for these patients.

Systemic candidiasis in intensive care units: A multicenter, matched-cohort study

OBJECTIVE

To determine the impact of systemic candidiasis on the mortality and length of hospital stay of intensive care unit (ICU) patients and the associated workload.

DESIGN

Multicenter, retrospective, matched-cohort study.

SETTING

Data were retrieved from a computerized database that prospectively collected clinical data submitted by 32 ICUs in the Paris, France area.

PATIENTS

A total of 149 stays with systemic candidiasis, including 104 candidemia, on ICU admission were identified in a 3-year period (1995-1997) among 49,063 admissions (3 per 1,000 admission). A total of 121 cases were matched with patients with no evidence of systemic Candida infection during the hospitalization period under study (same ICU, date of ICU admission, age, sex, simplified acute physiology score (SAPS II), location of the patient before admission, type of admission).

RESULTS

Patients with systemic candidiasis had longer ICU length of stays than controls (25 vs 10 d; P =.001) with a relative risk for death of 2.27 (95% confidence interval, 1.64-3.11; P =.001). There was no difference between patients with systemic candidiasis with or without positive blood culture.

CONCLUSIONS

Systemic Candida infections increased mortality and morbidity in severely ill patients. Optimizing management of such infections is imperative.

"Colonization pressure" and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit

OBJECTIVE

To determine the roles of "colonization pressure," work load or patient severity in patient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs).

DESIGN

Prospectively collected data from October 1996 through December 1998.

SETTING

A 12-bed medical ICU in a university-affiliated general hospital.

PATIENTS

Patients with risk factors for MRSA admitted to the ICU were screened within 72 hours of admission and weekly thereafter. MRSA was considered imported if detected during the first 72 hours of admission and nosocomial if detected only thereafter. Three screening strategies were used on admission during three consecutive periods.

INTERVENTIONS

The unit of time chosen for measurements was the week. Weekly colonization pressure (WCP) was defined as the number of MRSA-carrier patient-days/total number of patient-days. Patient severity (number of deaths, Simplified Acute Physiologic Score [SAPS] II), work load (number of admis sions, Omega score), and colonization pressure (number of MRSA carriers at the time of admission, WCP) were compared with the number of MRSA-nosocomial cases during the following week.

RESULTS

Of the 1,016 patients admitted over 116 weeks, 691 (68%) were screened. MRSA was imported in 91 (8.9%) admitted patients (13.1% of screened patients) and nosocomial in 46 (4.5%). The number of MRSA-nosocomial cases was correlated to the SAPS II (P=.007), the Omega 3 score (P=.007), the number of MRSA-imported cases (P=.01), WCP (P<.0001), and the screening period (P<.0001). In multivariate analysis, WCP was the only independent predictive factor for MRSA acquisition (P=.0002). Above 30% of WCP, the risk of acquisition of MRSA was approximately fivefold times higher (relative risk, 4.9; 95% confidence interval, 1.2-19.9; P<.0001).

CONCLUSION

Acquisition of MRSA in ICU patients is strongly and independently influenced by colonization pressure.

Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay

OBJECTIVE

To examine the outcome, functional autonomy, and quality of life of elderly patients (> or = 70 yrs old) hospitalized for >30 days in an intensive care unit (ICU).

DESIGN

Prospective cohort study.

SETTING

A ten-bed, medical-surgical ICU in a 460-bed, acute care, tertiary, university hospital.

PATIENTS

A consecutive cohort of 75 patients, >70 yrs old, admitted to the ICU from January 1, 1993, to August 1, 1998, for >30 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Severity at admission and of the underlying disease was estimated according to the Simplified Acute Physiologic Score (SAPS II), the Organ Dysfunction and/or Infection (ODIN) score, the McCabe score, and the Knaus classification. Therapeutic intensity was measured through the French Omega scoring system. All patients were mechanically ventilated during their ICU stay. Outcome measurements were made by two cross-sectional studies using telephone interviews on the first week of September 1996 and 1998 with a questionnaire including measures of functional capacity by Katz's Activities of Daily Living, modified Patrick's Perceived Quality of Life score, and the Nottingham Health Profile. The survival rate was 67% in the ICU and 47% in the hospital. A total of 30 patients were alive and able to participate in at least one of the cross-sectional studies. Independence in activities of daily living was decreased significantly after the ICU stay, except for feeding. However, most of the 30 patients remained independent (class A of the Activities of Daily Living index) with the possibility of going home. Perceived Quality of Life scores remained good, even if the patients estimated a decrease in their quality of life for health and memory. Return to society appeared promising regarding patient self respect and happiness with life. The estimated cost by survivor was of 55,272 EUR ($60,246 US).

CONCLUSIONS

This study suggests that persistent high levels of ICU therapeutic intensity were associated with a reasonable hospital survival in elderly patients experiencing prolonged mechanical ventilatory support. These patients presented a moderate disability that influenced somewhat their perceived quality of life. These results are sufficient to justify prolonged ICU stays for elderly patients.