Can the costs of critical care be controlled? Curr Opin Crit Care. 2009;15:591-596. [PMID: 19823083 DOI: 10.1097/mcc.0b013e328332f54f]

Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms

OBJECTIVE

Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs.

METHODS

This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed.

RESULTS

Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges.

CONCLUSION

Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.

Spinal Deformity, Surgery at the Cervicothoracic Junction, and American Society of Anesthesiologists Class Increase the Risk of Post-surgical Intensive Care Unit Treatment after Dorsal Spine Surgery: A Single-Center Multivariate Analysis of 962 Patients

STUDY DESIGN

This was a retrospective multivariate analysis of preoperative risk factors leading to intensive care unit (ICU) admissions in patients undergoing elective or acute dorsal spine surgery.

PURPOSE

Numerous studies have predicted a substantial increase in spine surgeries within the next decades, potentially overwhelming hospitals' resources, including ICU occupancy. Accurate estimates of whether patients need postsurgical ICU treatment are pivotal for both resource allocation and patient safety.

OVERVIEW OF LITERATURE

Risk factors leading to ICU admissions after dorsal spine surgery have been extensively examined for lumbar elective surgery. Studies including other anatomical segments of the spine and nonelective surgery regarding postsurgical ICU treatment probability are lacking.

METHODS

This study was designed to be a single-center multivariate analysis of data retrospectively collected from a tertiary care university hospital. Patients undergoing dorsal spine surgery from 2009 to 2019 were included in this study. The patients' demographic data were analyzed to determine potential preoperative risk factors for ICU admission after surgery using multiple logistic regression.

RESULTS

In our cohort, 962 patients with a mean age of 71.1±0.55 years were included. Surgeries involved 3.24±0.08 spinal levels on average. The incidence of ICU treatment after surgery was 30.4% (n=292). Multivariate logistic regression showed a markedly increased odds ratio (OR) for patients undergoing surgery of the cervicothoracic junction (OR, 8.86) and those undergoing surgery for spinal deformity treatment (OR, 7.7). Additionally, cervical procedures (OR, 3.29), American Society of Anesthesiologists (ASA) class 3-4 (OR, 2.74), spondylodiscitis (OR, 2.47), fusion of ≥3 levels (OR, 1.94), and age >75 years (OR, 1.33) were associated with an increased risk of postsurgical ICU admission.

CONCLUSIONS

The findings highlight the relevance of anatomical location, preoperative diagnosis, ASA class, and length of surgery regarding the predictability of postoperative ICU admission. Our data allowed for more sophisticated estimates regarding the need for ICU treatment after dorsal spine surgery, guiding the surgeon through patient selection, communication, and ICU admission predictability.

Systematic Review of Resource Use and Costs in the Hospital Management of Intracerebral Hemorrhage

BACKGROUND

While clinical guidelines provide a framework for hospital management of spontaneous intracerebral hemorrhage (ICH), variation in the resource use and costs of these services exists. We sought to perform a systematic literature review to assess the evidence on hospital resource use and costs associated with management of adult patients with ICH, as well as identify factors that impact variation in such hospital resource use and costs, regarding clinical characteristics and delivery of services.

METHODS

A systematic literature review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Ovid MEDLINE(R) 1946 to present. Articles were assessed against inclusion and exclusion criteria. Study design, ICH sample size, population, setting, objective, hospital characteristics, hospital resource use and cost data, and main study findings were abstracted.

RESULTS

In total, 43 studies met the inclusion criteria. Pertinent clinical characteristics that increased hospital resource use included presence of comorbidities and baseline ICH severity. Aspects of service delivery that greatly impacted hospital resource consumption included intensive care unit length of stay and performance of surgical procedures and intensive care procedures.

CONCLUSIONS

Hospital resource use and costs for patients with ICH were high and differed widely across studies. Making concrete conclusions on hospital resources and costs for ICH care was constrained, given methodologic and patient variation in the studies. Future research should evaluate the long-term cost-effectiveness of ICH treatment interventions and use specific economic evaluation guidelines and common data elements to mitigate study variation.

Associations of Government-issued ICU Admission Criteria with Clinical Practices, Outcomes, and ICU Bed Occupancy

RATIONALE

In Japan, the government officially issued intensive care unit (ICU) admission criteria that require ICU units to admit patients who need a certain level of monitoring and procedures to ensure their reimbursement for ICU costs from April 2014.

OBJECTIVE

To assess whether the newly issued health policy on ICU admission criteria based on financial incentives for monitoring and procedures had any impact on clinical practices, outcomes, and ICU bed occupancy.

METHODS

Using a nationwide inpatient health claims database in Japan, we identified patients who were admitted to the ICU from April 2012 to March 2018. Outcomes were monitoring and procedures in the ICU, clinical outcomes, and ICU bed occupancy. The outcomes of monitoring and procedures and clinical outcomes were adjusted for patient characteristics. Interrupted time-series analyses were used to compare the trends in outcomes for two separate periods before and after the issue of the new health policy on ICU admission criteria in April 2014.

RESULTS

A total of 1,660,601 patients in 259 ICU-equipped hospitals were eligible. There were significant upward slope changes between the pre- and post-issue periods for all monitoring and procedures in the ICU, including invasive arterial pressure monitoring (5.62% change in trend per year; 95% CI, 4.75%-6.49%) and central venous pressure monitoring (1.22% change in trend per year; 95% CI, 0.78%-1.67%). There was no significant slope change between the pre- and post-issue periods for in-hospital mortality, but there were significant upward slope changes for complications of pneumonia (0.27% change in trend per year; 95% CI, 0.14%-0.39%) and catheter-related bloodstream infection (0.02% change in trend per year; 95% CI, 0.00%-0.14%). There were also significant upward slope changes in length of hospital stay, length of ICU stay, and hospitalization costs between the pre- and post-issue periods. There was no significant slope change between the pre- and post-issue periods for ICU bed occupancy.

CONCLUSIONS

The health policy on ICU admission criteria based on financial incentives for actions taken by providers was associated with increased monitoring and procedures, complications, lengths of hospital and ICU stay, and hospitalization costs without decreasing ICU bed occupancy.

Risk Factors Associated with ICU-Specific Care in Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms

BACKGROUND

Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms.

METHODS

A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs.

RESULTS

A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34-5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97-56.57, p < 0.001) were independent predictors of postoperative ICU-specific needs. The majority of ICU-specific needs (94%, 49 of 52) occurred within 6 h of surgery.

CONCLUSIONS

Our results show that age, procedure duration greater than or equal to 200 min, and intraoperative complication were independent predictors of postoperative ICU-specific needs in patients presenting for elective endovascular treatment of unruptured intracranial aneurysms. The majority of ICU-specific needs and associated complications occurred in the immediate postoperative period. This data can be used to help decide the appropriate postoperative level of care in this patient population.

An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study

BACKGROUND

Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults.

OBJECTIVE

We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission.

METHODS

We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old).

RESULTS

Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051).

CONCLUSION

Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

A Safe Transitions Pathway for post-craniotomy neurological surgery patients: high-value care that bypasses the intensive care unit

OBJECTIVE

High-value medical care is described as care that leads to excellent patient outcomes, high patient satisfaction, and efficient costs. Neurosurgical care in particular can be expensive for the hospital, as substantial costs are accrued during the operation and throughout the postoperative stay. The authors developed a "Safe Transitions Pathway" (STP) model in which select patients went to the postanesthesia care unit (PACU) and then the neuro-transitional care unit (NTCU) rather than being directly admitted to the neurosciences intensive care unit (ICU) following a craniotomy. They sought to evaluate the clinical and financial outcomes as well as the impact on the patient experience for patients who participated in the STP and bypassed the ICU level of care.

METHODS

Patients were enrolled during the 2018 fiscal year (FY18; July 1, 2017, through June 30, 2018). The electronic medical record was reviewed for clinical information and the hospital cost accounting record was reviewed for financial information. Nurses and patients were given a satisfaction survey to assess their respective impressions of the hospital stay and of the recovery pathway.

RESULTS

No patients who proceeded to the NTCU postoperatively were upgraded to the ICU level of care postoperatively. There were no deaths in the STP group, and no patients required a return to the operating room during their hospitalization (95% CI 0%-3.9%). There was a trend toward fewer 30-day readmissions in the STP patients than in the standard pathway patients (1.2% [95% CI 0.0%-6.8%] vs 5.1% [95% CI 2.5%-9.1%], p = 0.058). The mean number of ICU days saved per case was 1.20. The average postprocedure length of stay was reduced by 0.25 days for STP patients. Actual FY18 direct cost savings from 94 patients who went through the STP was $422,128.

CONCLUSIONS

Length of stay, direct cost per case, and ICU days were significantly less after the adoption of the STP, and ICU bed utilization was freed for acute admissions and transfers. There were no substantial complications or adverse patient outcomes in the STP group.

We Need to Talk About Rationing: The Need to Normalize Discussion About Healthcare Rationing in a Post COVID-19 Era

The global COVID-19 pandemic has brought the issue of rationing finite healthcare resources to the fore. There has been much academic debate, media attention, and conversation in the homes of everyday individuals about the allocation of medical resources, diagnostic testing kits, ventilators, and personal protective equipment. Yet decisions to prioritize treatment for some individuals over others occur implicitly and explicitly in everyday practices. The pandemic has propelled the socially taboo and unavoidably prickly issue of healthcare rationing into the public spotlight-and as such, healthcare rationing demands ongoing public attention and transparent discussion. This article concludes that in the aftermath of COVID-19, policymakers should work towards normalizing rationing discussions by engaging in transparent and honest debate in the wider community and public domain. Further, injecting greater openness and objectivity into rationing decisions might go some way towards dismantling the societal taboo surrounding rationing in healthcare.

Historic review of long-term outcomes research

PURPOSE OF REVIEW

This review summarizes the results from long-term intensive care outcome research over the past 50 years. Key findings from early studies are reflected in citations of contemporary research.

RECENT FINDINGS

The postintensive care syndrome (PICS) is a multifaceted entity of residual disability and complications burdening survivors of critical illness. Some interventions applied early in the history of outcomes research have now been confirmed as effective in counteracting specific PICS components.

SUMMARY

Interest in patient-centred outcomes has been present since the beginning of modern intensive care. Findings from early long-term studies remain valid even in the face of contemporary large registries that facilitate follow-up of larger cohorts. A further understanding of the mechanisms leading to experienced physical and psychological impairment of PICS will be essential to the design of future intervention trials.

French ICU's health care workers have a poor knowledge of the cost of the devices they use for patient care: A prospective multicentric study

PURPOSE

ICU patient's care may require the use of onerous devices, which contributes to make this department one of the most expensive in the hospital. It seemed us relevant to assess healthcare workers' (HCWs) knowledge of the cost of the devices daily used in ICU.

MATERIALS AND METHODS

An anonymous questionnaire was administered on a voluntary basis to HCWs of 3 ICUs.

MEASUREMENTS AND MAIN RESULTS

Cost estimations were expressed as percentage of the real cost; an estimation was considered correct if it was ±50% of the true price. 107 HCWs (66 physicians and 41 nurses and nurse aids) answered the survey. Only 29% of estimations were within 50% of the real cost. The prices of the cheapest devices were overestimated, while the costs of the most expensive ones were underestimated. In multivariate analysis, cost less than50 euros [OR = 3.2; CI 95%(1.6-6.3)], professional experience <10 years [OR = 1.5; CI 95%(1.1-2.1)], being a medical student [OR = 2.0; CI 95%(1.3-3.0)], and working in a university affiliated hospital [OR = 0.6; CI 95%(0.4-0.9)] were associated with an incorrect estimation.

CONCLUSIONS

ICU's HCWs have a poor knowledge of the price of devices they regularly use for the care of their patients.

The Boarding Patient: Effects of ICU and Hospital Occupancy Surges on Patient Flow

Patients admitted to a hospital's intensive care unit (ICU) often endure prolonged boarding within the ICU following receipt of care, unnecessarily occupying a critical care bed, and thereby delaying admission for other incoming patients due to bed shortage. Using patient-level data over two years at two major academic medical centers, we estimate the impact of ICU and ward occupancy levels on ICU length of stay (LOS), and test whether simultaneous "surge occupancy" in both areas impacts overall ICU length of stay. In contrast to prior studies that only measure total LOS, we split LOS into two individual periods based on physician requests for bed transfers. We find that "service time" (when critically ill patients are stabilized and treated) is unaffected by occupancy levels. However, the less essential "boarding time" (when patients wait to exit the ICU) is accelerated during periods of high ICU occupancy and, conversely, prolonged when hospital ward occupancy levels are high. When the ICU and wards simultaneously encounter bed occupancies in the top quartile of historical levels-which occurs 5% of the time-ICU boarding increases by 22% compared to when both areas experience their lowest utilization, suggesting that ward bed availability dominates efforts to accelerate ICU discharges to free up ICU beds. We find no adverse effects of high occupancy levels on ICU bouncebacks, in-hospital deaths, or 30-day hospital readmissions, which supports our finding that the largely discretionary boarding period fluctuates with changing bed occupancy levels.

The identification of a subgroup of children with traumatic subarachnoid hemorrhage at low risk of neuroworsening

OBJECTIVEPediatric traumatic subarachnoid hemorrhage (tSAH) often results in intensive care unit (ICU) admission, the performance of additional diagnostic studies, and ICU-level therapeutic interventions to identify and prevent episodes of neuroworsening.METHODSData prospectively collected in an institutionally specific trauma registry between 2006 and 2015 were supplemented with a retrospective chart review of children admitted with isolated traumatic subarachnoid hemorrhage (tSAH) and an admission Glasgow Coma Scale (GCS) score of 13-15. Risk of blunt cerebrovascular injury (BCVI) was calculated using the BCVI clinical prediction score.RESULTSThree hundred seventeen of 10,395 pediatric trauma patients were admitted with tSAH. Of the 317 patients with tSAH, 51 children (16%, 23 female, 28 male) were identified with isolated tSAH without midline shift on neuroimaging and a GCS score of 13-15 at presentation. The median patient age was 4 years (range 18 days to 15 years). Seven had modified Fisher grade 3 tSAH; the remainder had grade 1 tSAH. Twenty-six patients (51%) had associated skull fractures; 4 involved the petrous temporal bone and 1 the carotid canal. Thirty-nine (76.5%) were admitted to the ICU and 12 (23.5%) to the surgical ward. Four had an elevated BCVI score. Eight underwent CT angiography; no vascular injuries were identified. Nine patients received an imaging-associated general anesthetic. Five received hypertonic saline in the ICU. Patients with a modified Fisher grade 1 tSAH had a significantly shorter ICU stay as compared to modified Fisher grade 3 tSAH (1.1 vs 2.5 days, p = 0.029). Neuroworsening was not observed in any child.CONCLUSIONSChildren with isolated tSAH without midline shift and a GCS score of 13-15 at presentation appear to have minimal risk of neuroworsening despite the findings in some children of skull fractures, elevated modified Fisher grade, and elevated BCVI score. In this subgroup of children with tSAH, routine ICU-level care and additional diagnostic imaging may not be necessary for all patients. Children with modified Fisher grade 1 tSAH may be particularly unlikely to require ICU-level admission. Benefits to identifying a subgroup of children at low risk of neuroworsening include improvement in healthcare efficiency as well as decreased utilization of unnecessary and potentially morbid interventions, including exposure to ionizing radiation and general anesthesia.

Developing and Testing a Chart Abstraction Tool for ICU Quality Measurement

Quality measures are increasingly used to measure the performance of providers, hospitals, and health care systems. Intensive care units (ICUs) are an important clinical area in hospitals, given that they generate high costs and present high risks to patients. Yet, currently, few valid and clinically significant ICU-specific outcome measures are reported nationally. This study reports on the creation and evaluation of new abstraction tools that evaluate ICU patients for the following clinically important outcomes: central line-associated bloodstream infection, methicillin-resistant Staphylococcus aureus, gastrointestinal bleed, and pressure ulcer. To allow ICUs and institutions to compare their outcomes, the tools include risk-adjustment variables that can be abstracted from the chart.

Should Emergency Department Patients with End-of-Life Directives be Admitted to the ICU?

BACKGROUND

Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it.

OBJECTIVES

In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU.

DISCUSSION

Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition.

CONCLUSIONS

End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients' values and stated goals of care.

Association between patient classification systems and nurse staffing costs in intensive care units: An exploratory study

OBJECTIVES

Nurse staffing costs represent approximately 60% of total intensive care unit costs. In order to analyse resource allocation in intensive care, we examined the association between nurse staffing costs and two patient classification systems: the nursing activities score (NAS) and nine equivalents of nursing manpower use score (NEMS).

RESEARCH METHODOLOGY/DESIGN

A retrospective descriptive correlational analysis of nurse staffing costs and data of 6390 patients extracted from a data warehouse.

SETTING

Three intensive care units in a university hospital and one in a regional hospital in Norway.

MAIN OUTCOME MEASURES

Nurse staffing costs, NAS and NEMS.

RESULTS

For merged data from all units, the NAS was more strongly correlated with monthly nurse staffing costs than was the NEMS. On separate analyses of each ICU, correlations were present for the NAS on basic costs and external overtime costs but were not significant. The annual mean nurse staffing cost for 1% of NAS was 20.9-23.1 euros in the units, which was comparable to 53.3-81.5 euros for 1 NEMS point.

CONCLUSION

A significant association was found between monthly costs, NAS, and NEMS. Cost of care should be based on individual patients' nursing care needs. The NAS makes nurses' workload visible and may be a helpful classification system in future planning and budgeting of intensive care resources.

Haloperidol for delirium in critically ill patients - protocol for a systematic review

BACKGROUND

In the intensive care unit, the prevalence of delirium is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer intensive care unit stay, increased long-term mortality, and cognitive impairment. Thus, the burden of delirium for patients, relatives, and societies is considerable. The objective of this systematic review was to critically access the evidence of randomised clinical trials on the effects of haloperidol vs. placebo or any other agents for delirium in critically ill patients.

METHODS

We will search for randomised clinical trials in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently screen and select references for inclusion using Covidence, extract data and assess the methodological quality of the included randomised clinical trials using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will analyse the extracted data using Review Manager, STATA 15, and Trial Sequential.

ANALYSIS

The aim of this study was to assess the quality of the evidence, we will create a 'Summary of Findings' table containing our primary and secondary outcomes using the GRADE assessment.

DISCUSSION

Our ambition with this systematic review is to provide reliable and powered evidence to better inform decision makers on the use of or future trials with haloperidol for the management of delirium in critically ill patients.

Data-driven optimization methodology for admission control in critical care units

The decision of whether to admit a patient to a critical care unit is a crucial operational problem that has significant influence on both hospital performance and patient outcomes. Hospitals currently lack a methodology to selectively admit patients to these units in a way that patient health risk metrics can be incorporated while considering the congestion that will occur. The hospital is modeled as a complex loss queueing network with a stochastic model of how long risk-stratified patients spend time in particular units and how they transition between units. A Mixed Integer Programming model approximates an optimal admission control policy for the network of units. While enforcing low levels of patient blocking, we optimize a monotonic dual-threshold admission policy. A hospital network including Intermediate Care Units (IMCs) and Intensive Care Units (ICUs) was considered for validation. The optimized model indicated a reduction in the risk levels required for admission, and weekly average admissions to ICUs and IMCs increased by 37% and 12%, respectively, with minimal blocking. Our methodology captures utilization and accessibility in a network model of care pathways while supporting the personalized allocation of scarce care resources to the neediest patients. The interesting benefits of admission thresholds that vary by day of week are studied.

Next-generation, personalised, model-based critical care medicine: a state-of-the art review of in silico virtual patient models, methods, and cohorts, and how to validation them

Critical care, like many healthcare areas, is under a dual assault from significantly increasing demographic and economic pressures. Intensive care unit (ICU) patients are highly variable in response to treatment, and increasingly aging populations mean ICUs are under increasing demand and their cohorts are increasingly ill. Equally, patient expectations are growing, while the economic ability to deliver care to all is declining. Better, more productive care is thus the big challenge. One means to that end is personalised care designed to manage the significant inter- and intra-patient variability that makes the ICU patient difficult. Thus, moving from current "one size fits all" protocolised care to adaptive, model-based "one method fits all" personalised care could deliver the required step change in the quality, and simultaneously the productivity and cost, of care. Computer models of human physiology are a unique tool to personalise care, as they can couple clinical data with mathematical methods to create subject-specific models and virtual patients to design new, personalised and more optimal protocols, as well as to guide care in real-time. They rely on identifying time varying patient-specific parameters in the model that capture inter- and intra-patient variability, the difference between patients and the evolution of patient condition. Properly validated, virtual patients represent the real patients, and can be used in silico to test different protocols or interventions, or in real-time to guide care. Hence, the underlying models and methods create the foundation for next generation care, as well as a tool for safely and rapidly developing personalised treatment protocols over large virtual cohorts using virtual trials. This review examines the models and methods used to create virtual patients. Specifically, it presents the models types and structures used and the data required. It then covers how to validate the resulting virtual patients and trials, and how these virtual trials can help design and optimise clinical trial. Links between these models and higher order, more complex physiome models are also discussed. In each section, it explores the progress reported up to date, especially on core ICU therapies in glycemic, circulatory and mechanical ventilation management, where high cost and frequency of occurrence provide a significant opportunity for model-based methods to have measurable clinical and economic impact. The outcomes are readily generalised to other areas of medical care.

Intensive care unit drug costs in the context of total hospital drug expenditures with suggestions for targeted cost containment efforts

PURPOSE

To assess costs of intensive care unit (ICU) related pharmacotherapy relative to hospital drug expenditures, and to identify potential targets for cost-effectiveness investigations. We offer the unique advantage of comparing ICU drug costs with previously published data a decade earlier to describe changes over time.

MATERIALS AND METHODS

Financial transactions for all ICU patients during fiscal years (FY) 2009-2012 were retrieved from the hospital's data repository. ICU drug costs were evaluated for each FY. ICU departments' charges were also retrieved and calculated as percentages of total ICU charges.

RESULTS

Albumin, prismasate (dialysate), voriconazole, factor VII and alteplase denoted the highest percentages of ICU drug costs. ICU drug costs contributed to an average of 31% (SD 1.0%) of the hospital's total drug costs. ICU drug costs per patient day increased by 5.8% yearly versus 7.8% yearly for non-ICU drugs. This rate was higher for ICU drugs costs at 12% a decade previous. Pharmacy charges contributed to 17.7% of the total ICU charges.

CONCLUSIONS

Growth rates of costs per year have declined but still drug expenditures in the ICU are consistently a significant driver in this resource intensive environment with a high impact on hospital drug expenditures.

Comparison of awareness of patient parameters between two groups of caregivers in intensive care unit

Aim of the Study:

Materials and Methods:

Results:

Conclusions:

Trends in Critical Care Beds and Use Among Population Groups and Medicare and Medicaid Beneficiaries in the United States: 2000-2010

OBJECTIVES

To analyze patterns of critical care medicine beds, use, and costs in acute care hospitals in the United States and relate critical care medicine beds and use to population shifts, age groups, and Medicare and Medicaid beneficiaries from 2000 to 2010.

DESIGN

Retrospective study of data from the federal Healthcare Cost Report Information System, American Hospital Association, and U.S. Census Bureau.

SUBJECTS

None.

INTERVENTIONS

None.

SETTING

Acute care U.S. hospitals with critical care medicine beds.

MEASUREMENTS AND MAIN RESULTS

From 2000 to 2010, U.S. hospitals with critical care medicine beds decreased by 17% (3,586-2,977), whereas the U.S. population increased by 9.6% (282.2-309.3M). Although hospital beds decreased by 2.2% (655,785-641,395), critical care medicine beds increased by 17.8% (88,235-103,900), a 20.4% increase in the critical care medicine-to-hospital bed ratio (13.5-16.2%). There was a greater percentage increase in premature/neonatal (29%; 14,391-18,567) than in adult (15.9%; 71,978-83,417) or pediatric (2.7%; 1,866-1,916) critical care medicine beds. Hospital occupancy rates increased by 10.4% (58.6-64.6%), whereas critical care medicine occupancy rates were stable (range, 65-68%). Critical care medicine beds per 100,000 total population increased by 7.4% (31.3-33.6). The proportional use of critical care medicine services by Medicare beneficiaries decreased by 17.3% (37.9-31.4%), whereas that by Medicaid rose by 18.3% (14.5-17.2%). Between 2000 and 2010, annual critical care medicine costs nearly doubled (92.2%; $56-108 billion). In the same period, the proportion of critical care medicine cost to the gross domestic product increased by 32.1% (0.54-0.72%).

CONCLUSIONS

Critical care medicine beds, use, and costs in the United States continue to rise. The increasing use of critical care medicine by the premature/neonatal and Medicaid populations should be considered by healthcare policy makers, state agencies, and hospitals as they wrestle with critical care bed growth and the associated costs.

Role of Bronchoscopy in Prompt Discharge From the Intensive Care Unit

BACKGROUND

Intensive care unit (ICU) stays are 2.5 times more costly than other hospital stays, and 93.3% of ICU use is for respiratory disease with ventilator support. The aim of this study was to assess the role of bronchoscopy on discontinuation of mechanical ventilation, and prompt discharge from ICU in our institution.

METHODS

Retrospective review of medical records of patients referred for bronchoscopic intervention for acute respiratory failure from malignant or benign central airway diseases requiring ICU admission.

RESULTS

Twelve critically ill patients were studied. Median (range) age was 63 years (range, 35 to 85 y). Nine (75%) had endotracheal tube, and 3 (25%) had tracheostomy tube. Nine (75%) of 12 patients admitted to ICU could be transferred to general ward after median (range) interval of 2 days (range, 1 to 7 d) after the day of intervention. Median (range) prebronchoscopy and postbronchoscopy PaO2/FiO2 ratio was 102.8 (range, 99.2 to 328) and 180 (range, 129 to 380), respectively, with significant improvement postintervention (P=0.002). Radiologically, all 8 patients with lung atelectasis on presentation experienced complete reexpansion of the lung on the day after bronchoscopic intervention.

CONCLUSION

The majority of patients in our cohort (75%) of benign and malignant etiology could be promptly (within 2 d postbronchoscopy) transferred out from ICU to general ward after successful discontinuation of mechanical ventilation and extubation after bronchoscopic intervention. We advocate early recognition and bronchoscopic intervention in suitable patients.

The impact of nUrsiNg DEliRium Preventive INnterventions in the Intensive Care Unit (UNDERPIN-ICU): A study protocol for a multi-centre, stepped wedge randomized controlled trial

BACKGROUND

Delirium is a common disorder in Intensive Care Unit (ICU) patients and is associated with serious short- and long-term consequences, including re-intubations, ICU readmissions, prolonged ICU and hospital stay, persistent cognitive problems, and higher mortality rates. Considering the high incidence of delirium and its consequences, prevention of delirium is imperative. This study focuses on a program of standardized nursing and physical therapy interventions to prevent delirium in the ICU, called UNDERPIN-ICU (nUrsiNg DEliRium Preventive INterventions in the ICU).

OBJECTIVE

To determine the effect of the UNDERPIN-ICU program on the number of delirium-coma-free days in 28days and several secondary outcomes, such as delirium incidence, the number of days of survival in 28 and 90days and delirium-related outcomes.

DESIGN AND SETTING

A multicenter stepped wedge cluster randomized controlled trial.

METHODS

Eight to ten Dutch ICUs will implement the UNDERPIN-ICU program in a randomized order. Every two months the UNDERPIN-ICU program will be implemented in an additional ICU following a two months period of staff training. UNDERPIN-ICU consists of standardized protocols focusing on several modifiable risk factors for delirium, including cognitive impairment, sleep deprivation, immobility and visual and hearing impairment.

PARTICIPANTS

ICU patients aged ≥18years (surgical, medical, or trauma) and at high risk for delirium, E-PRE-DELIRIC ≥35%, will be included, unless delirium was detected prior ICU admission, expected length of ICU stay is less then one day or when delirium assessment is not possible.

DISCUSSION

For every intervention the balance between putative benefit and potential unwanted side effects needs to be considered. In non-ICU patients, it has been shown that a similar program resulted in a significant reduction of delirium incidence and duration. Recent small studies using multi component interventions to prevent delirium in ICU patients have also shown beneficial effect, without unwanted side effects. We therefore feel that the proportionality of potential positive effects of the UNDERPIN-ICU program, weighed against potential unwanted side effects is favourable. Since this has not been rigorously proven in ICU patients, we will study the effects of this program in ICU patients using a stepped wedge design.

TRIAL REGISTRATION

The study is registered in the clinical trials registry: https://clinicaltrials.gov/.

REPORTING METHOD

Standard Protocol Items: Recommendations for Interventional Trails (SPIRIT).

Pharmacological interventions for delirium in intensive care patients: a protocol for an overview of reviews

BACKGROUND

The prevalence of delirium in intensive care unit (ICU) patients is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer ICU stay, increased long-term mortality and cognitive impairment. Thus, the burden of delirium for patients, relatives and societies is considerable. Today, reviews of randomised clinical trials are produced in large scales sometimes making it difficult to get an overview of the available evidence. A preliminary search identified several reviews investigating the effects of pharmacological interventions for the management and prevention of delirium in ICU patients. The conclusions of the reviews showed conflicting results. Despite this unclear evidence, antipsychotics, in particular, haloperidol is often the recommended pharmacological intervention for delirium in ICU patients. The objective of this overview of reviews is to critically assess the evidence of reviews of randomised clinical trials on the effect of pharmacological management and prevention of delirium in ICU patients.

METHODS/DESIGN

We will search for reviews in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently select references for inclusion using Covidence, extract data and assess the methodological quality of the included systematic reviews using the ROBIS tool. Any disagreement will be resolved by consensus. We will present the data as a narrative synthesis and summarise the main results of the included reviews. In addition, we will present an overview of the bias risk assessment of the systematic reviews.

DISCUSSION

Results of this overview may establish a way forward to find and update or to design a high quality systematic review assessing the effects of the most promising pharmacological intervention for delirium in ICU patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO - CRD42016046628 .

ICU Use and Quality of Care for Patients With Myocardial Infarction and Heart Failure

BACKGROUND

Quality of care for acute myocardial infarction (AMI) and heart failure (HF) varies across hospitals, but the factors driving variation are incompletely understood. We evaluated the relationship between a hospital's ICU or coronary care unit (CCU) admission rate and quality of care provided to patients with AMI or HF.

METHODS

A retrospective cohort study of Medicare beneficiaries hospitalized in 2010 with AMI or HF was performed. Hospitals were grouped into quintiles according to their risk- and reliability-adjusted ICU admission rates for AMI or HF. We examined the rates that hospitals failed to deliver standard AMI or HF processes of care (process measure failure rates), 30-day mortality, 30-day readmissions, and Medicare spending after adjusting for patient and hospital characteristics.

RESULTS

Hospitals in the lowest quintile had ICU admission rates < 29% for AMI or < 8% for HF. Hospitals in the top quintile had rates > 61% for AMI or > 24% for HF. Hospitals in the highest quintile had higher process measure failure rates for some but not all process measures. Hospitals in the top quintile had greater 30-day mortality (14.8% vs 14.0% [P = .002] for AMI; 11.4% vs 10.6% [P < .001] for HF), but no differences in 30-day readmissions or Medicare spending were seen compared with hospitals in the lowest quintile.

CONCLUSIONS

Hospitals with the highest rates of ICU admission for patients with AMI or HF delivered lower quality of care and had higher 30-day mortality for these conditions. Hospitals with high ICU use may be targets to improve care delivery.

Routine Admission to Intensive Care Unit After Cytoreductive Surgery and Heated Intraperitoneal Chemotherapy: Not Always a Requirement

BACKGROUND

Routine postoperative intensive care unit (ICU) observation of patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is driven by historically reported morbidity and mortality data. The validity of this practice and the criteria for ICU admission have not been elucidated.

METHODS

A prospectively maintained database of 1146 CRS/HIPEC procedures performed from December 1991 to 2014 was retrospectively analyzed. Patients with routine postoperative ICU admission were compared with patients sent directly to the surgical floor. To test the safety of non-ICU care practice, patients with less than 48 h ICU admission were compared with patients directly admitted to the floor. Demographics, primary tumor site, comorbidities, estimated blood loss (EBL), extent of CRS, Eastern Cooperative Oncology Group (ECOG) status, and overall survival were analyzed.

RESULTS

Complete data were available for 1064 CRS/HIPEC procedures, of which 244 cases (22.93 %) did not require ICU admission. Multivariate logistic regression identified age [odds ratio (OR) 1.024; p = 0.02], EBL (OR 1.002; p < 0.0001), number of resected organs (OR 1.308; p = 0.01) and ECOG > 2 (OR 6.387; p = 0.003) as predictive variables of postoperative ICU admission. The cohort directly admitted to the floor demonstrated less minor grade I/II morbidity (29 vs. 47 %; p < 0.0001) and similar grade III/IV major morbidity (16.5 vs. 13.4 %; p = 0.3) than the patients admitted to the ICU for less than 48 h.

CONCLUSIONS

ICU observation is not routinely required for all patients treated with CRS/HIPEC. Selective ICU admission based on ECOG status, nutritional status, age, EBL, and CRS extent is safe, with potential implications for hospitalization cost for these complex cases.

Is critical care ready for an economic surrogate endpoint?

Intensive care is expensive, and thus a body of research has focused on strategies to reduce its costs. However, efforts to reduce the total cost of intensive care have met with limited success, partly because of the challenges of calculating how much a day in the ICU actually costs. We discuss these challenges and introduce the concept of total cost savings as an outcome of critical care trials, assuming statistically negative effects on mortality and quality of life.

Organisation and resource management in the intensive care unit: A critical review

Background/Aim:

Patients are admitted to an intensive care unit (ICU) for critical care not available to patients in the general wards, with the potential for reversible organ failure as a key admission criterion. The objective of this integrative review was to examine and discuss the literature pertaining to the environment of the ICU, including unit organisation, staffing and equipment, that underpins the provision of ICU services. This review also aimed to discuss current perspectives on ICU resources and utilisation.

Methods:

To prepare this integrated literature review, computer-assisted searches were conducted using the PubMed/Medline, CINAHL and EMBASE databases. An extensive search of library databases was undertaken using relevant keywords and related article searches. Studies were included if they were rated by a single investigator to have relevant content in these areas. Due to the breadth of the review, a structured approach was taken to integrate the relevant findings.

Results:

There was limited literature examining the relationships between these important areas. There was some evidence that a closed model of ICU care is associated with improved outcomes and less resource utilisation compared with an open model of ICU, although there was conflicting evidence for critical care delivered outside of the ICU. Critical care may be most effectively provided via a team model. The heterogeneity of the ICU setting, in particular the unique aspects of the delivery of ICU care in the Australasian model, hampered the ability to draw broad and clinically meaningful conclusions.

Conclusions:

Due to the increased demand for ICU services, ongoing evaluation of the long-term outcomes of ICU on the efficient use of resources to optimise patient outcomes is imperative. Results from the current evidence base suggest that rather than broad-based adjunctive services, refinement and subsequent evaluation of intensive care services in targeted and specific populations may be required, and that empirical evidence for the support of many organisational, structural, equipment and staffing aspects of ICU service delivery is lacking. Further research is needed to investigate the relationships between existing and conceptual models of care and direct patient outcomes.

Intensive care performance: How should we monitor performance in the future?

Intensive care faces economic challenges. Therefore, evidence proving both effectiveness and efficiency, i.e., cost-effectiveness, of delivered care is needed. Today, the quality of care is an important issue in the health care debate. How do we measure quality of care and how accurate and representative is this measurement? In the following report, several topics which are used for the evaluation of intensive care unit (ICU) performance are discussed: (1) The use of general outcome prediction models to determine the risk of patients who are admitted to ICUs in an increasing variety of case mix for the different intensive care units, together with three major limitations; (2) As critical care outcomes research becomes a more established entity, mortality is now only one of many endpoints that are relevant. Mortality is a limited outcome when assessing critical care performance, while patient interest in quality of life outcomes is relevant; and (3) The Quality Indicators Committee of the Society of Critical Care Medicine recommended that short-term readmission is a major performance indicator of the quality of intensive care medicine.

Increasing critical care admissions from U.S. emergency departments, 2001-2009

OBJECTIVES

Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009.

DESIGN

Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001-2009.

SETTING

National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States.

PATIENTS

: ED patients admitted a critical care unit.

INTERVENTIONS

None.

MEASUREMENTS

Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients.

MAIN RESULTS

Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001-2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day.

CONCLUSIONS

The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.

Impact of bed availability on requesting and offering in-hospital intensive care unit transfers: a survey study of generalists and intensivists

PURPOSE

To evaluate whether bed availability affects a physician's decision to request or offer an intensive care unit (ICU) transfer.

MATERIALS AND METHODS

We administered mail-based surveys to determine the respondents' probability of either requesting an ICU transfer (generalist respondents) or offering an ICU transfer (intensivist respondents). Respondents randomly received clinical vignettes that were identical except for the number of available ICU beds (one or seven available ICU beds). Respondents also made predictions about the patient's outcomes.

RESULTS

Among generalists and intensivists, there were wide ranges in decisions about ICU transfer. In the Generalist ICU request study, the average probability of transfer with one versus seven available ICU beds was 52.2% and 58.5% (P = .41), respectively. In the Intensivist ICU offer study, the average probability of transfer with one versus seven available ICU beds was 62.5% and 57.4% (P = .24), respectively. The most consistent association with decisions about ICU transfer was the predicted probability that a patient would require an ICU bed in the future if not transferred currently.

CONCLUSIONS

There is high variability in the decision to request or offer ICU beds. There was not a significant association between bed availability and ICU transfer decisions.

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.

Homeward bound: an analysis of patients discharged home from an oncologic intensive care unit

PURPOSE

The objectives of our study were to evaluate the characteristics and outcomes of patients discharged home directly from an oncologic intensive care unit (ICU) and their 30-day hospital readmission patterns.

MATERIALS AND METHODS

We retrospectively reviewed ICU discharges over 3 years (2008-2010) and identified patients who were discharged directly home. Demographic, clinical, ICU discharge, and 30-day hospital readmission and mortality rates were analyzed.

RESULTS

Ninety-five patients (3.6%) were discharged home directly from the ICU (average annual rate of 3.9%). ICU diagnoses primarily included respiratory insufficiency, sepsis, cardiac syndromes, and gastrointestinal bleeding. Home discharge occurred most commonly between Thursday and Saturday. Five (5.3%) patients, including 2 hospice patients, died within 30 days of ICU home discharge. Thirty (31.6%) patients were readmitted within 30 days of discharge. The unplanned 30-day readmission rate was 23.2% (22/95) with a median time to hospital readmission of 13 (8-18) days. Most (64%) of the unplanned readmissions were related to the initial ICU admission.

CONCLUSIONS

Home discharge of ICU patients at our institution is infrequent but consistent. Almost one third of these patients were readmitted to the hospital within 30 days. Enhancements to the ICU home discharge process may be required to ensure optimal post-ICU care.

The ethics and reality of rationing in medicine

Rationing is the allocation of scarce resources, which in health care necessarily entails withholding potentially beneficial treatments from some individuals. Rationing is unavoidable because need is limitless and resources are not. How rationing occurs is important because it not only affects individual lives but also expresses society's most important values. This article discusses the following topics: (1) the inevitability of rationing of social goods, including medical care; (2) types of rationing; (3) ethical principles and procedures for fair allocation; and (4) whether rationing ICU care to those near the end of life would result in substantial cost savings.

Costs of critical care medicine

The main drivers of critical care medicine (CCM) costs are the numbers and use of intensive care unit (ICU) beds. The Russell equation, an indirect costing methodology, is most commonly used to estimate national CCM costs. Calculating national CCM costs in a standardized manner remains challenging because there is no universal approach to defining the types of hospitals, ICU beds, days, and billing codes to be included in the overall cost. Although numerous CCM cost-containment strategies have been proposed or implemented, CCM cost reduction remains elusive, and measuring cost remains challenging,given the complexities involved in assessing costs.

Electrolyte orders in the neuroscience intensive care unit: worth the value or waste?

BACKGROUND

To assess the value of the practice of obtaining frequent electrolyte measurements in patients with extended stay in a neuroscience intensive care unit (NICU).

METHODS

We identified consecutive patients 18 years or older, admitted to the NICU between January 1 and July 31, 2009 with length of stay ≥ 5 days. We collected potassium, sodium, magnesium, ionized calcium, phosphorus laboratory measurements and hemoglobin levels, and recorded electrolyte replacement orders and red blood cell transfusions. Average laboratory costs were estimated.

RESULTS

93 patients were included in the study (54 men, mean age 54 years, range 18-85 years). Mean length of stay was 10.4 days (range 5-36 days). Sodium and potassium were the electrolytes most frequently measured (averages of 14.1 and 13.1 per patient, respectively). More than 75% of the results were within normal range for all electrolytes measured and critical values were extremely uncommon. The number of phlebotomies for electrolyte measurements was strongly associated with the degree of hemoglobin drop (P < 0.0001). Electrolyte panels were ordered much more often than individual electrolytes with average cost exceeding $2200 per patient. Replacing half of these electrolyte panels with single sodium or potassium orders would have resulted in savings greater than $100,000 in our population.

CONCLUSIONS

Electrolytes measurements are very frequent in the NICU, but results are most often normal and only exceptionally critical. The phlebotomies required for these tests significantly worsen hemoglobin levels. A more conservative use of electrolyte measurements can result in reduction of blood loss and substantial cost savings.

Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

OBJECTIVES

To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005.

DESIGN

Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland).

SETTING

Nonfederal, acute care hospitals with critical care medicine beds in the United States.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product.

CONCLUSIONS

Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.