Daily cost of an intensive care unit day: The contribution of mechanical ventilation

ArticleinCritical Care Medicine 33(6):1266-71 · July 2005with 60,200 Reads 
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Abstract
To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit. Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database. A total of 253 geographically diverse U.S. hospitals. The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002. None. Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001). Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.

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  • ... Further, the cost of an ICU stay varies depending on the intensity of care but ranges from $1500 to $10,000 per day due to equipment and supply, bed and board, nursing and other personnel, medications, and mechanical ventilation costs. 3 For example, a 14-day neurologic ICU stay can easily translate into an estimated cost of $42,000 (ie, $3000/d  14). Therefore, to reduce overall hospital costs, we hypothesized that a selected group of patients with SAH could be discharged home with outpatient monitoring via transcranial Doppler ultrasonography (TCD) to identify cerebral vasospasm. ...
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    Objective To determine whether earlier hospital discharge is feasible and safe in selected patients with subarachnoid hemorrhage (SAH) using an outpatient “fast-track” protocol. Patients and Methods We conducted a prospective quality improvement cohort study with the primary feasibility end point of patients with SAH deemed safe for discharge by treating team consensus. All patients received detailed education and outpatient transcranial Doppler monitoring; caregivers could contact the on-call team 24-7. Primary safety end points were adverse events after discharge and hospital readmission. Results From January 1, 2010, to January 1, 2015, our center had 377 SAH diagnoses, of which 200 were included in the final cohort, 36 qualifying for fast-track early discharge. The 30-day readmission rate for fast-track patients was 11.0% (4 of 36) compared with 11.4% (18 of 164) for non–fast-track patients. The rate of delayed cerebral ischemia and stroke was 3% (1 of 36) in the fast-track group vs 25.0% (41 of 164) for the non–fast-track group. Adverse events occurred in 11.0% (4 of 36) of the fast-track group compared with 26.0% (43 of 164) in the non–fast-track group. The mean length of stay was reduced 60% from 15 days to 6.6 days in the fast-track group. Conclusion Although our fast-track group was relatively small, data suggested early feasibility and safety in a carefully selected group of patients with SAH. Direct and indirect financial benefits of early discharge over a 5-year period were an estimated savings at least $864,000 in overall costs. A comparative effectiveness study is planned to replicate and validate these results using a larger multicenter design.
  • ... This systematic review showed that patients had a lower risk of requiring more advanced ventilation strategies after receiving HFNC, suggesting that HFNC may meet the demands of breathing support better than COT. Our results were consistent with findings in patients after cardiac surgery [30], for whom HFNC prevented ventilation-related complications and high medical costs [31,32]. ...
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    Introduction: Patients with dyspnea and hypoxemia are common in emergency departments. However, it is unknown whether high-flow nasal cannula (HFNC) reduces the risk of requiring more advanced ventilation support and whether HFNC relieves dyspnea better than conventional oxygen therapy (COT). Areas covered: We searched the PubMed, Cochrane Library, Ovid, and Embase databases from inception to 1 September 2019 to identify relevant randomized controlled trials comparing the effect of HFNC with COT in emergency departments regarding the severity of dyspnea, hospitalization rate, intubation rate, and hospital mortality. We identified four studies. HFNC was associated with lower rate of requiring more advanced ventilation. HFNC reduced the rate of dyspnea, lowered the dyspnea scale score, and decreased patients’ respiratory rate significantly. However, there was insufficient evidence to show a significant effect with HFNC regarding patients’ oxygenation and hospital mortality. Expert opinion: For patients with dyspnea and hypoxemia before hospitalization, the short-term effect of HFNC was undeniable. HFNC reduced the risk of requiring more advanced ventilation and relived dyspnea better than COT. HFNC might be considered as a first line therapy even before making a clear diagnosis for dyspnea. More studies are needed to explore the effect of HFNC on oxygenation and patients’ prognosis.
  • ... Differently from tracheostomy, MV in critical trauma patients represented a daily mean incremental cost of $ 1 522.00/patient/day (39). In severe TBI patients submitted to MV treatment, the median in-hospital expenditures was evaluated at $ 55 267.00 per patient (40). ...
    Article
    Objectives: To elucidate the impact of early tracheostomy on hospitalization outcomes in patients with traumatic brain injury. Data sources: Lilacs, PubMed, and Cochrane databases were searched. The close-out date was August 8, 2018. Study selection: Studies written in English, French, Spanish, or Portuguese with traumatic brain injury as the base trauma, clearly formulated question, patient's admission assessment, minimum follow-up during hospital stay, and minimum of two in-hospital outcomes were selected. Retrospective studies, prospective analyses, and case series were included. Studies without full reports or abstract, commentaries, editorials, and reviews were excluded. Data extraction: The study design, year, patient's demographics, mean time between admission and tracheostomy, neurologic assessment at admission, confirmed ventilator-assisted pneumonia, median ICU stay, median hospital stay, mortality rates, and ICU and hospital costs were extracted. Data synthesis: A total of 4,219 studies were retrieved and screened. Eight studies were selected for the systematic review; of these, seven were eligible for the meta-analysis. Comparative analyses were performed between the early tracheostomy and late tracheostomy groups. Mean time for early tracheostomy and late tracheostomy procedures was 5.59 days (SD, 0.34 d) and 11.8 days (SD, 0.81 d), respectively. Meta-analysis revealed that early tracheostomy was associated with shorter mechanical ventilation duration (-4.15 [95% CI, -6.30 to -1.99]) as well as ICU (-5.87 d [95% CI, -8.74 to -3.00 d]) and hospital (-6.68 d [95% CI, -8.03 to -5.32 d]) stay durations when compared with late tracheostomy. Early tracheostomy presented less risk difference for ventilator-associated pneumonia (risk difference, 0.78; 95% CI, 0.70-0.88). No statistical difference in mortality was found between the groups. Conclusions: The findings from this meta-analysis suggest that early tracheostomy in severe traumatic brain injury patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient's early rehabilitation and discharge.
  • ... The time required to wean patients from mechanical ventilation is proportional to ICU length of stay with 45% of ICU patients experiencing difficult or prolonged weaning (3). Extended time on ventilatory support also increases patient morbidity, mortality, and healthcare costs (4). ...
    Article
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    Objectives: Maintaining diaphragm work using electrical stimulation during mechanical ventilation has been proposed to attenuate ventilator-induced diaphragm dysfunction. This study assessed the safety and feasibility of temporary percutaneous electrical phrenic nerve stimulation on user-specified inspiratory breaths while on mechanical ventilation. Design: Two-center, nonblinded, nonrandomized study. Setting: Hospital ICU. Patients: Twelve patients mechanically ventilated from 48 hours to an expected 7 days. Interventions: Leads were inserted to lie close to the phrenic nerve in the neck region using ultrasound guidance. Two initial patients had left-sided placement only with remaining patients undergoing bilateral lead placement. Percutaneous electrical phrenic nerve stimulation was used for six 2-hour sessions at 8-hour intervals over 48 hours. Measurements and main results: Data collected included lead deployment success, nerve conduction, ventilation variables, work of breathing, electrical stimulation variables, stimulation breath synchrony, and diaphragm thickness measured by ultrasound at baseline, 24, and 48 hours. Primary endpoints included ability to capture the left and/or right phrenic nerves and maintenance of work of breathing within defined limits for 80% of stimulated breaths. Lead insertion was successful in 21 of 22 attempts (95.5%). Analysis of 36,059 stimulated breaths from 10 patients with attempted bilateral lead placement demonstrated a mean inspiratory lag for phrenic nerve stimulation of 23.7 ms (p < 0.001 vs null hypothesis of <88ms). Work of breathing was maintained between 0.2 and 2.0 joules/L 96.8% of the time, exceeding the 80% target. Mean diaphragm thickness increased from baseline by 7.8% at 24 hours (p = 0.022) and 15.0% at 48 hours (p = 0.0001) for patients receiving bilateral stimulation after excluding one patient with pleural effusion. No serious device/procedure-related adverse events were reported. Conclusions: The present study demonstrated the ability to safely and successfully place percutaneous electrical phrenic nerve stimulation leads in patients on mechanical ventilation and the feasibility of using this approach to synchronize electrical stimulation with inspiration while maintaining work of breathing within defined limits.
  • ... Este término hace referencia a la disfunción diafragmática que se produce de forma precoz tras la instauración de la VM 6 . La existencia de DDIV empeora el pronóstico y se asocia a un fracaso en la extubación, con un aumento de los días de VM 7-12 y de la mortalidad [13][14][15][16] . No obstante, en la actualidad no se realiza una monitorización rutinaria de la función diafragmática en muchas unidades, por lo que cabe pensar que esta entidad se encuentra sistemáticamente infradiagnosticada 17 . ...
  • ... This is particularly noteworthy as the presence of pulmonary edema in critically ill patients is associated with higher morbidity, prolonged ICU stays and requirement for mechanical ventilation. Pulmonary edema thus presents a significant burden on the health care system and, more importantly, typically signifies a worsening in the patient's medical prognosis (Edoute et al. 2000;Sakka et al. 2002;Dasta et al. 2005). ...
    Article
    Traditionally, the lung has been excluded from the ultrasound organ repertoire and, hence, the application of lung ultrasound (LUS) was largely limited to a few enthusiastic clinicians. Yet, in the last decades, the recognition of the previously untapped diagnostic potential of LUS in intensive care medicine has fueled its widespread use as a rapid, non-invasive and radiation-free bedside approach with excellent diagnostic accuracy for many of the most common causes of acute respiratory failure, e.g., cardiogenic pulmonary edema, pneumonia, pleural effusion and pneumothorax. Its increased clinical use has also incited attention for the potential usefulness of LUS in preclinical studies with small animal models mimicking lung congestion and pulmonary edema formation. Application of LUS to small animal models of pulmonary edema may save time, is cost-effective, and may reduce the number of experimental animals due to the possibility of serial evaluations in the same animal as compared with traditional end-point measurements. This review provides an overview of the emerging field of LUS with a specific focus on its application in animal models and highlights future perspectives for LUS in preclinical research.
  • ... Owing to the fact that the world is witnessing an overpowering need for ICU with mechanical ventilators, which is creating an economic burden in many countries, comparing the cost-effectiveness of human IL-6 ELISA kit high sensitivity versus the cost of ICU with mechanical ventilators, may create a novel approach to recent COVID-19 positive patients. In France, there have been at least 5433 patients admitted in ICU, with an average length of stay of 15 days [69]. According to a systematic review and meta-regression on the impact of mechanical ventilation on the daily cost of ICU care, a micro-costing study by Lefrant et al. [70] showed that in 23 French ICU showed costs of to €1425 per day. ...
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    Full-text available
    Coronavirus disease 2019 (COVID-19) is a serious illness that has rapidly spread throughout the globe. The seriousness of complications puts significant pressures on hospital resources, especially the availability of ICU and ventilators. Current evidence suggests that COVID-19 pathogenesis majorly involves microvascular injury induced by hypercytokinemia, namely interleukin 6 (IL-6). We recount the suggested inflammatory pathway for COVID-19 and its effects on various organ systems, including respiratory, cardiac, hematologic, reproductive, and nervous organ systems, as well examine the role of hypercytokinemia in the at-risk geriatric and obesity subgroups with upregulated cytokines’ profile. In view of these findings, we strongly encourage the conduction of prospective studies to determine the baseline levels of IL-6 in infected patients, which can predict a negative outcome in COVID-19 cases, with subsequent early administration of IL-6 inhibitors, to decrease the need for ICU admission and the pressure on healthcare systems.
  • ... Cost of ICU was estimated at US$10794.00 if ventilated and US$6667 if not ventilated for the first day, US$4796 if ventilated and US$3968 if not ventilated for the second day, and the remaining days it was estimated at US$3968 if ventilated and US$3184 if not ventilated, as previously reported. 25 Each additional day in hospital (floor) was estimated to be US$1488. 26 Non-operative patients were assessed an estimated US$4558.71 DRG fee based on hospital admission and US$185.32 for management of fracture of the shoulder girdle (CPT 23500 and 23570), as previously reported. ...
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    Background/purpose The combination of ipsilateral floating shoulder and flail chest is a unique injury pattern that has not been previously described in the literature. We termed the injury pattern floating flail chest (FFC). The purpose of this study was to evaluate the effect of operative treatment of the shoulder girdle component to overall hospital length of stay (LOS). Methods Forty-one patients were enrolled between two level I trauma centers identifying with a combination ipsilateral floating shoulder and flail chest injury, 23 treated with operative stabilization and 18 treated non-operatively. This retrospective cohort study evaluated the overall LOS and intensive care unit (ICU) days. Results The operative group had decreased overall LOS (10.1 vs. 19.8 days, p = 0.02) and decreased ICU days (3.4 vs. 10.3, p = 0.04). Conclusion This study describes a unique injury pattern that combines the floating shoulder and flail chest, FFC. Our study suggests that operative treatment of the shoulder girdle may decrease both overall LOS and ICU days in patients with FFC.
  • ... However, patients with NOAF did have prolonged ICU and hospital LOS, which translated into higher costs. The presence of NOAF was also a significant predictor of costs among our cohort, and this was independent of other important factors more commonly associated with cost, including renal replacement therapy and mechanical ventilation [37]. This prolonged LOS was also manifested in increased laboratory, pharmacy, and nursing costs. ...
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    Full-text available
    Background: New-onset atrial fibrillation (NOAF) is commonly encountered in critically ill adults. Evidence evaluating the association between NOAF and patient-important outcomes in this population is conflicting. Furthermore, little is known regarding the association between NOAF and resource use or hospital costs. Methods: Retrospective analysis (2011-2016) of a prospectively collected registry from two Canadian hospitals of consecutive ICU patients aged ≥ 18 years. We excluded patients with a known history of AF prior to hospital admission. Any occurrence of atrial fibrillation (AF) was prospectively recorded by bedside nurses. The primary outcome was hospital mortality, and we used multivariable logistic regression to adjust for confounders. We used a generalized linear model to evaluate contributors to total cost. Results: We included 15,014 patients, and 1541 (10.3%) had NOAF during their ICU admission. While NOAF was not associated with increased odds of hospital death among the entire cohort (adjusted odds ratio [aOR] 1.02 [95% confidence interval [CI] 0.97-1.08]), an interaction was noted between NOAF and sepsis, and the presence of both was associated with higher odds of hospital mortality (aOR 1.28 [95% CI 1.09-1.36]) than either alone. Patients with NOAF had higher total costs (cost ratio [CR] 1.09 [95% CI 1.02-1.20]). Among patients with NOAF, treatment with a rhythm-control strategy was associated with higher costs (CR 1.24 [95% CI 1.07-1.40]). Conclusions: While NOAF was not associated with death or requiring discharge to long-term care among critically ill patients, it was associated with increased length of stay in ICU and increased total costs.
  • ... Since majority fatalities occur in productive age groups of 15-29 years, these injuries have economic burden at the community level and family level. In addition, prolonged hospitalization in ICU is expensive [29] and families of these patients faced with catastrophic costs. Hence, efforts to reduce fatal RTIs is essential through simple interventions such as the use of helmets or applying legal constraints for driving licenses and number of riders for motorcycle drivers, use of seat belts for drivers, and driving within allowed speed limits. ...
  • ... Euros per hospitalization [9]. We could easily speculate that this can be related to the use of costly invasive therapeutic interventions in sepsis [26,27]. ...
    Article
    Full-text available
    Background: While sepsis may have especially marked impacts in young adults, there is limited population-based information on its epidemiology and trends. Methods: Population-based longitudinal study on sepsis in adults aged 20-44 years using the 2006-2015 Spanish national hospital discharge database. Cases are identified by an ICD-9-CM coding strategy. Primary endpoints are incidence and in-hospital mortality. Trends are assessed for annual percentage change (AAPC) in rates using Joinpoint regression models. Results: 28,351 cases are identified, representing 3.06‱ of all-cause hospitalisations and a crude incidence of 16.4 cases/100,000 population aged 20-44. The mean age is 36 years, 58% of cases are men, and around 60% have associated comorbidities. Seen in one third of cases, the source of infection is respiratory. Single organ dysfunction is recorded in 45% of cases. In-hospital mortality is 24% and associated with age, comorbidity and extent of organ dysfunction. Incidence rates increase over time in women (AAPC: 3.8% (95% CI: 2.1, 5.5)), whereas case-fatality decline with an overall AAPC of -5.9% (95% CI -6.6, -5.2). Our results indicate that sepsis is common in young adults and associated with high in-hospital mortality, though it shows a decreasing trend. The substantial increase in incidence rates in women needs further research.
  • ... Intubation to provide assisted ventilation is a serious decision. It is an invasive procedure and the ensuing mechanical ventilation is intensive and costly from the perspectives of medical and nursing care [1]. Intubated patients are normally managed in intensive care unit (ICU). ...
  • ... Intubation to provide assisted ventilation is a serious decision. It is an invasive procedure and the ensuing mechanical ventilation is intensive and costly from the perspectives of medical and nursing care [1]. Intubated patients are normally managed in intensive care unit (ICU). ...
  • ... • Mechanical ventilation can account for as much as onethird the total cost of daily hospital care [1,2]. ...
  • ... We were able to access full-texts of all articles of interest. Of these, 14 articles provided data on the daily costs of ICU stays, but only five articles [2][3][4][5][6] fulfilled our inclusion criteria of also providing information regarding the added costs of mechanical ventilation ( Fig. 1: PRISMA-chart). No additional relevant articles were found in the reference lists of the 14 articles providing data on the daily costs of ICU stay. ...
    Article
    Full-text available
    The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.
  • ... Özellikle ilaç analizlerinde işgücü kaybına bağlı maliyetler her zaman dahil edilemez. Birçok çalışma YBÜ'nin yıllık harcamalarına veya bütçelerine dayanmaktadır; hasta sayısı ve YBÜ'de harcanan günlere, hizmet tutarlarına veya ödenmesi gereken ücretlere dayanmaktadır (15)(16)(17) . Bu çalışmada, her bir hasta için ayrı ayrı hesaplanan her bir fonksiyonel birimin maliyete katkısını görebilmekteyiz. ...
  • ... Este término hace referencia a la disfunción diafragmática que se produce de forma precoz tras la instauración de la VM 6 . La existencia de DDIV empeora el pronóstico y se asocia a un fracaso en la extubación, con un aumento de los días de VM 7-12 y de la mortalidad [13][14][15][16] . No obstante, en la actualidad no se realiza una monitorización rutinaria de la función diafragmática en muchas unidades, por lo que cabe pensar que esta entidad se encuentra sistemáticamente infradiagnosticada 17 . ...
    Article
    información del artículo Historia del artículo: Recibido el 17 de diciembre de 2015 Aceptado el 17 de julio de 2016 On-line el 21 de agosto de 2016 Palabras clave: Diafragma Disfunción diafragmática Ventilación mecánica Ecografía r e s u m e n La afectación muscular del paciente crítico está presente en la mayoría de pacientes que ingresan en el servicio de medicina intensiva (SMI). La alteración, en particular, del músculo diafragmático, inicialmente englobada en esta categoría, se ha diferenciado en los últimos a ˜ nos y se ha demostrado la existencia de una disfunción muscular propia de los pacientes sometidos a ventilación mecánica. En este subgrupo de pacientes encontramos una disfunción muscular que aparece de manera precoz después del inicio de la ventilación mecánica y que se relaciona principalmente con el uso de modalidades control, la presencia de sepsis y/o de fracaso multiorgánico. Aunque se desconoce la etiología concreta que desencadena el proceso, el músculo presenta procesos de estrés oxidativo y alteración mitocondrial que provocan un desequilibrio en la síntesis proteica, con el resultado de atrofia y alteración de la contractilidad y, como consecuencia, una menor funcionalidad. No fue, de hecho, hasta 2004 cuando Vassilakopoulos et al. describieron el término «disfunción diafragmática asociada a ventilación mecánica», que, junto a la lesión por sobredistensión pulmonar y por barotrauma, representan un reto en el día a día de los pacientes ventilados. La disfunción diafragmática tiene influencia en el pronóstico, retardando la extubación, aumentando la estancia hospitalaria y afectando la calidad de vida de estos pacientes en los a ˜ nos siguientes al alta hospitalaria. La ecografía, como técnica no invasiva y accesible en la mayoría de unidades, podría ser de utilidad en el diagnóstico precoz para iniciar, de forma avanzada, la rehabilitación e influir positivamente en el pronóstico de estos enfermos. a b s t r a c t Muscle involvement is found in most critical patients admitted to the intensive care unit (ICU). Diaph-ragmatic muscle alteration, initially included in this category, has been differentiated in recent years, and a specific type of muscular dysfunction has been shown to occur in patients undergoing mechanical ventilation. We found this muscle dysfunction to appear in this subgroup of patients shortly after the start of mechanical ventilation, observing it to be mainly associated with certain control modes, and also with sepsis and/or multi-organ failure. Although the specific etiology of process is unknown, the muscle presents oxidative stress and mitochondrial changes. These cause changes in protein turnover, resulting in atrophy and impaired contractility, and leading to impaired functionality. The term 'ventilator-induced diaphragm dysfunction' was first coined by Vassilakopoulos et al. in 2004, and this phenomenon, along with injury cause by over-distention of the lung and barotrauma, represents a challenge in the daily life of ventilated patients. * Autor para correspondencia. Correo electrónico: jrmasclans@parcdesalutmar.cat (J.-R. Masclans).
  • ... These patients have a very poor prognosis, with a one-year survival rate between 40% and 50% [2]. Prolonged MV also imposes a significant care burden on intensive care units (ICUs) [3]. Successful weaning with sustainable independence from invasive MV is, therefore, pivotal to the management of patients with prolonged MV. ...
    Article
    Full-text available
    Objective Reinstitution of mechanical ventilation (MV) for tracheostomized patients after successful weaning may occur as the care setting changes from critical care to general care. We aimed to investigate the occurrence, consequence and associated factors of MV reinstitution. Methods We analyzed the clinical data and physiological measurements of tracheostomized patients with prolonged MV discharged from the weaning unit to general wards after successful weaning to compare between those with and without in-hospital MV reinstitution within 60 days. Results Of 454 patients successfully weaned, 116 (25.6%) reinstituted MV at general wards within 60 days; at hospital discharge, 42 (36.2%) of them were eventually liberated from MV, 51 (44.0%) remained MV dependent, and 33 (28.4%) died. Of the 338 patients without reinstitution within 60 days, only 3 (0.9%) were later reinstituted with MV before discharge (on day 67, 89 and 136 at general wards, respectively), and 322 (95.2%) were successfully weaned again at discharge, while 13 (3.8%) died. Patients with MV reinstitution had a significantly lower level of maximal expiratory pressure (PEmax) before unassisted breathing trial compared to those without reinstitution. Multivariable Cox regression analysis showed fever at RCC discharge (hazard ratio [HR] 14.00, 95% confidence interval [CI] 3.2–61.9) chronic obstructive pulmonary disease (HR 2.37, 95% CI 1.34–4.18), renal replacement therapy at the ICU (HR 2.29, 95% CI 1.50–3.49) and extubation failure before tracheostomy (HR 1.76, 95% CI 1.18–2.63) were associated with increased risks of reinstitution, while PEmax > 30 cmH2O (HR 0.51, 95% CI 0.35–0.76) was associated with a decreased risk of reinstitution. Conclusions The reinstitution of MV at the general ward is significant, with poor outcomes. The PEmax measured before unassisted breathing trial was significantly associated with the risk of reinstituting MV at the general wards.
  • ... Each year, more than four million acutely ill patients are admitted to intensive care units (ICUs) in the U.S. alone; approximately 500,000 of them do not survive [1][2][3]. In extreme situations, like the current COVID-19 pandemic, ICUs are essential for treating critically ill coronavirus patients. ...
    Article
    Full-text available
    Modern intensive care units (ICU) are equipped with a variety of different medical devices to monitor the physiological status of patients. These devices can generate large amounts of multimodal data daily that include physiological waveform signals (arterial blood pressure, electrocardiogram, respiration), patient alarm messages, numeric vitals data, etc. In order to provide opportunities for increasingly improved patient care, it is necessary to develop an effective data acquisition and analysis system that can assist clinicians and provide decision support at the patient bedside. Previous research has discussed various data collection methods, but a comprehensive solution for bedside data acquisition to analysis has not been achieved. In this paper, we proposed a multimodal data acquisition and analysis system called INSMA, with the ability to acquire, store, process, and visualize multiple types of data from the Philips IntelliVue patient monitor. We also discuss how the acquired data can be used for patient state tracking. INSMA is being tested in the ICU at University Hospitals Cleveland Medical Center.
  • ... It is associated with significant morbidity and premature mortality with a typical hospitalization for survivors that is protracted and requires specialized care [1,2]. SAH is a common neurological reason for intensive care unit admission [3], which itself is resource-intense and a significant driver of hospital cost [4]. These collectively contribute to the substantial burden associated with this disease-similar in magnitude to the much more common ischemic stroke [1]. ...
  • ... Owing to the fact that the world is witnessing an overpowering need for ICU with mechanical ventilators, which is creating an economic burden in many countries, comparing the cost-effectiveness of human IL-6 ELISA kit high sensitivity versus the cost of ICU with mechanical ventilators, may create a novel approach to recent COVID-19 positive patients. In France, there have been at least 5433 patients admitted in ICU, with an average length of stay of 15 days [69]. According to a systematic review and meta-regression on the impact of mechanical ventilation on the daily cost of ICU care, a micro-costing study by Lefrant et al. [70] showed that in 23 French ICU showed costs of to €1425 per day. ...
    Article
    Full-text available
    Coronavirus disease 2019 (COVID-19) is a serious illness that has rapidly spread throughout the globe. The seriousness of complications puts significant pressures on hospital resources, especially the availability of ICU and ventilators. Current evidence suggests that COVID-19 pathogenesis majorly involves microvascular injury induced by hypercytokinemia, namely interleukin 6 (IL-6). We recount the suggested inflammatory pathway for COVID-19 and its effects on various organ systems, including respiratory, cardiac, hematologic, reproductive, and nervous organ systems, as well examine the role of hypercytokinemia in the at-risk geriatric and obesity subgroups with upregulated cytokines’ profile. In view of these findings, we strongly encourage the conduction of prospective studies to determine the baseline levels of IL-6 in infected patients, which can predict a negative outcome in COVID-19 cases, with subsequent early administration of IL-6 inhibitors, to decrease the need for ICU admission and the pressure on healthcare systems.
  • ... Estos elementos se apoyaban también en las estadísticas iniciales acerca del desarrollo del número de contagios* 1 , aunque es legítimo preguntarse hasta qué punto estas diferencias en las estadísticas no reflejaban una diversa actitud diagnóstica, debida al conocimiento, claro en marzo, pero mucho menos en enero-febrero, de que se estaba desarrollando una pandemia. En conjunto, de todos modos, estos elementos jugaban en favor de ese moderado optimismo, aunque permanecían razones de preocupación en esa comparación, tales como la capacidad de respuesta del sector hospitalario, en particular con referencia a la disponibilidad y costo de las unidades de cuidado intensivo 11,12 , y la capacidad de realizar un elevado número de pruebas de la existencia de la infección 13 . ...
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    El viernes pasado, la OMS señaló la gravedad del crecimiento de los contagios en América Latina, definiendo el subcontinente nuevo epicentro de la pandemia, algo difícil de prever cuando, hace aproximadamente dos meses y medio, el número de los contagios por Coronavirus COVID-19 en América Latina no llegaba a 50. Aunque en las dos semanas siguientes hubo un aumento por un factor 100, en esos días varios elementos parecían jugar en favor de un moderado optimismo acerca de la posibilidad de un control razonable del desarrollo de la pandemia, también por efecto de las medidas de contención de la pandemia, que muchos países habían empezado a prescribir. En un comienzo, uno de los factores en el cual se hizo más énfasis fue la edad promedio de los habitantes de la región, menor por casi diez años de la de los países que en ese momento registraban el mayor número de contagios. Esta consideración, acompañada por la observación empírica de que la vulnerabilidad a la pandemia parecía depender fuertemente de la edad, sugería que la región podía ofrecer una resiliencia significativa. Otros elementos considerados fueron el factor climático, dadas las múltiples indicaciones de posibles correlaciones entre el desarrollo de los contagios y características ambientales (temperatura, humedad), la diferente densidad de población, y sobre todo la temprana, en la gran mayoría de los casos inclusive inmediata, respuesta de los gobiernos, que se dio casi contemporáneamente a la que, con demoras y hesitaciones, empezaban a dar los países europeos. Ejemplar en este sentido fue el caso de El Salvador que cerró sus fronteras aun antes de tener un solo caso de contagio.
  • ... Many studies focused on the cost of care for the aged population. 7,[19][20][21][22][23][24][25] Our study showed that craniotomy was the commonest diagnostic groups among ICU patients as well as being the commonest among the high-cost ICU group. Craniotomy was required mostly among those aged 18-45 years and 46-69 years with 90% of the high-cost craniotomy cases being contributed by those of the 18-69 years old group. ...
    Article
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    Purpose: Care at ICUs is expensive and variable depending on the type of care that the patients received. Knowing the characteristics of the patient and his or her disease is always useful for improving health services and cost containment. Patients and methods: An observational study was conducted at four different intensive care units of an academic medical institution. Demographic characteristics, disease-management casemix information, cost and outcome of the high costing decile, and the rest of the cases were compared. Results: A total of 3,220 discharges were included in the study. The high-cost group contributed 35.4% of the ICU stays and 38.8% of the total ICU expenditure. Diseases of the central nervous system had higher odds to be in the top decile of costly patients whereas the cardiovascular system was more likely to be in the non-high cost category. The high-cost patients were more likely to have death as an outcome (19.2% vs 9.3%; p<0.001). The most common conditions that were in the high-cost groups were craniotomy, other ear, nose, mouth, and throat operations, simple respiratory system operations, complex intestinal operations, and septicemia. These five diagnostic groups made up 43% of the high-cost decile. Conclusion: High-cost patients utilized almost 40% of the ICU cost although they were only 10% of the ICU patients. The chances of admission to the ICU increased with older age and severity level of the disease. Central nervous system diseases were the major problem of patients aged 46-69 years old. In addition to cost reduction strategies at the treatment level, detailed analysis of these cases was needed to explore and identify pre-event stage prevention strategies.
  • ... At the same time, prolonged mechanical ventilation accounts for one-third of adult mechanical ventilation and two-thirds of hospital resources. In fact, mechanical ventilation has recently proved particularly costly [12,13]. Studies have shown that the prognosis of patients in ICU is directly related to the workload of staff [14]. ...
  • ... This supportive care of the mechanical ventilation device provides an opportunity for these patients to resolve respiratory failure and its causes. 1 Mechanical ventilation is an aggressive and extremely costly measure. 2 The intensive care unit, although it includes less than 10% of hospital beds, accounts for more than 60% of the total cost of hospitalized patients and almost 40% of the total length of hospital stay. 3 According to estimates from the United States and Western countries, mechanical ventilation is the most cost-effective indicator (p<0.0001) and costs about $ 16 billion to $ 27 billion annually, which imposes significant economic burdens on the health care system. 4 Among the indicators for assessing the respiratory state of patients under mechanical ventilation, respiratory volume, expiratory flow volume, minute ventilation, superficial and fast respiration index, maximum damping pressure, airway resistance, and Raman static compilation were obtained. ...
  • ... Diaphragmatic disuse, atrophy, and ventilator-induced diaphragmatic dysfunction (VIDD) can result from underlying medical illnesses and prolonged use of MV (2,3). VIDD can cause difficulty weaning from MV, prolonged hospitalization, and poor functional outcomes (1,(4)(5)(6). ...
    Article
    Full-text available
    Prolonged mechanical ventilation promotes diaphragmatic atrophy and weaning difficulty. The study uses a novel device containing a transvenous phrenic nerve stimulating catheter (Lungpacer IntraVenous Electrode Catheter) to stimulate the diaphragm in ventilated patients. We set out to determine the feasibility of temporary transvenous diaphragmatic neurostimulation using this device. Design: Multicenter, prospective open-label single group feasibility study. Setting: ICUs of tertiary care hospitals. Patients: Adults on mechanical ventilation for greater than or equal to 7 days that had failed two weaning trials. Interventions: Stimulation catheter insertion and transvenous diaphragmatic neurostimulation therapy up to tid, along with standard of care. Measurements and main results: Primary outcomes were successful insertion and removal of the catheter and safe application of transvenous diaphragmatic neurostimulation. Change in maximal inspiratory pressure and rapid shallow breathing index were also evaluated. Eleven patients met all entry criteria with a mean mechanical ventilation duration of 19.7 days; nine underwent successful catheter insertion. All nine had successful mapping of one or both phrenic nerves, demonstrated diaphragmatic contractions during therapy, and underwent successful catheter removal. Seven of nine met successful weaning criteria. Mean maximal inspiratory pressure increased by 105% in those successfully weaned (mean change 19.7 ± 17.9 cm H2O; p = 0.03), while mean rapid shallow breathing index improved by 44% (mean change -63.5 ± 64.4; p = 0.04). Conclusions: The transvenous diaphragmatic neurostimulation system is a feasible and safe therapy to stimulate the phrenic nerves and induce diaphragmatic contractions. Randomized clinical trials are underway to compare it to standard-of-care therapy for mechanical ventilation weaning.
  • ... MV is a key component of the management of critically ill patients with acute or chronic respiratory failure. However, it is associated with a high mortality [10], with short-and long-term complications [11,12], and requires a complex care level with a substantial impact on hospital resources [13]. ...
    Article
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    Background: Though the prevalence of dementia among hospitalized patients is increasing, there is limited population data in Europe about the use of life-support measures such as invasive mechanical ventilation in these patients. Our objective is to assess whether dementia influences the incidence, outcomes, and hospital resource use in elderly patients undergoing mechanical ventilation. Methods: Using ICD-9-CM codes, all hospitalizations involving invasive mechanical ventilation in adults aged ≥ 65 years were identified in the Spanish national hospital discharge database covering the period 2000-2013. The cases identified were stratified into two cohorts (patients with or without dementia) in which main outcome measures were compared. The impact of dementia on in-hospital mortality and hospital resource use were assessed through multivariable models. Trends were assessed through joinpoint regression analysis and results expressed as average annual percentage change. Results: Of the 259,623 cases identified, 5770 (2.2%) had been assigned codes for dementia. Cases with dementia were older, had a lower Charlson comorbidity score, and less frequently received prolonged mechanical ventilation or were assigned a surgical DRG. Circulatory disease was the most common main diagnosis in both cohorts. No significant impact of dementia was observed on in-hospital mortality (adjusted OR 1.04, [95% CI] 0.98, 1.09). In the cohort with dementia, the incidence of mechanical ventilation underwent an average annual increase over time of 5.39% (95% CI 4.0, 6.7) while this rate was 1.62% (95% CI 0.9, 2.4) in cases without dementia. However, unlike this cohort, mortality in cases with dementia did not significantly decline over time. Geometric mean hospital cost and stay were lower among cases with than without dementia (- 14% [95% CI - 12%, - 15%] and - 12% [95% CI, - 9%, - 14%], respectively), and these differences increased over time. Conclusion: This nationwide population-based study suggests no impact of dementia on in-hospital mortality in elderly patients undergoing invasive mechanical ventilation. However, dementia is significantly associated with shorter stay and hospital costs. Our data also identifies a recent marked increase in the use of this life-support measure in elderly patients with dementia and that this increase is much greater than that observed in elderly individuals without dementia.
  • ... 34 We included cytokine release syndrome and neurological events, which are AEs reported to be associated with CAR T-cell therapy, and categorized them into grades 1 (mild reaction), 2 (moderate reaction), 3 (severe reaction), and 4 or higher (life-threatening reaction) ( Table 1). 36,37 Abbreviations: AE, adverse event; CRS, cytokine release syndrome; NA, not applicable; NE, neurological event. ...
    Article
    Full-text available
    Importance Chimeric antigen receptor (CAR) T-cell therapies are currently administered at a limited number of cancer centers and are primarily delivered in an inpatient setting. However, variations in total costs associated with these therapies remain unknown. Objective To estimate the economic differences in the administration of CAR T-cell therapy by the site of care and the incidence of key adverse events. Design, Setting, and Participants A decision-tree model was designed to capture clinical outcomes and associated costs during a predefined period (from lymphodepletion to 30 days after the receipt of CAR T-cell infusion) to account for the potential incidence of acute adverse events and to evaluate variations in total costs for the administration of CAR T-cell therapy by site of care. Cost estimates were from the health care practitioner perspective and were based on data obtained from the literature and publicly available databases, including the Healthcare Cost and Utilization Project National Inpatient Sample, the Medicare Hospital Outpatient Prospective Payment System, the Medicare physician fee schedule, the Centers for Medicare and Medicaid Services Healthcare Common Procedure Coding System, and the IBM Micromedex RED BOOK. The model evaluated an average adult patient with relapsed or refractory large B-cell lymphoma who received CAR T-cell therapy in an academic inpatient hospital or nonacademic specialty oncology network. Intervention The administration of CAR T-cell therapy. Main Outcomes and Measures Total cost of the administration of CAR T-cell therapy by site of care. The costs associated with lymphodepletion, acquisition and infusion of CAR T cells, and management of acute adverse events were also examined. Results The estimated total cost of care associated with the administration of CAR T-cell therapy was $454 611 (95% CI, $452 466-$458 267) in the academic hospital inpatient setting compared with $421 624 (95% CI, $417 204-$422 325) in the nonacademic specialty oncology network setting, for a difference of $32 987. After excluding the CAR T-cell acquisition cost, hospitalization and office visit costs were $53 360 (65.3% of the total cost) in academic inpatient hospitals and $23 526 (48.4% of the total cost) in nonacademic specialty oncology networks. The administration of CAR T-cell therapy in nonacademic specialty oncology networks was associated with a $29 834 (55.9%) decrease in hospitalization and office visit costs and a $3154 (20.1%) decrease in procedure costs. Conclusions and Relevance The potential availability of CAR T-cell therapies that are associated with a lower incidence of adverse events and are suitable for outpatient administration may reduce the total costs of care by enabling the use of these therapies in nonacademic specialty oncology networks.
  • ... The cost of death in this economic model for both cohorts was equated to an average intensive care unit stay: $31,574. 37 To calculate cost for each Markov utility state per cycle, the mean utility levels of pre-and post-treatment states (from primary data) and the mean costs of pre-and post-treatment states (from available literature) 35,43,44 were used to generate a linear relationship between average cost and HUVs, as CRS-specific health care resource consumption is correlated to the severity of QOL reductions. 15,45 ...
    Article
    Objective Both endoscopic sinus surgery (ESS) and biologic therapies have shown effectiveness for medically‐refractory chronic rhinosinusitis with nasal polyps (CRSwNP) without severe asthma. The objective was to evaluate cost‐effectiveness of dupilumab versus ESS for patients with CRSwNP. Study Design Cohort‐style Markov decision‐tree economic model with a 36‐year time horizon. Methods A cohort of 197 CRSwNP patients who underwent ESS were compared with a matched cohort of 293 CRSwNP patients from the SINUS‐24 and SINUS‐52 Phase 3 studies who underwent treatment with dupilumab 300 mg every 2 weeks. Utility scores were calculated from the SNOT‐22 instrument in both cohorts. Decision‐tree analysis and a 10‐state Markov model utilized published event probabilities and primary data to calculate long‐term costs and utility. The primary outcome measure was incremental cost per quality‐adjusted life year (QALY), which is expressed as an Incremental Cost Effectiveness Ratio. One‐way and probabilistic sensitivity analyses were performed. Results The ESS strategy cost $50,436.99 and produced 9.80 QALYs. The dupilumab treatment strategy cost $536,420.22 and produced 8.95 QALYs. Because dupilumab treatment was more costly and less effective than the ESS strategy, it is dominated by ESS in the base case. One‐way sensitivity analyses showed ESS to be cost‐effective versus dupilumab regardless of the frequency of revision surgery and at any yearly cost of dupilumab above $855. Conclusions The ESS treatment strategy is more cost effective than dupilumab for upfront treatment of CRSwNP. More studies are needed to isolate potential phenotypes or endotypes that will benefit most from dupilumab in a cost‐effective manner. Level of Evidence 2C Laryngoscope, 2020
  • ... Intensive care with ventilation is the most costly form of life saving in hospital care. In the US, the cost of 2 weeks of an intensive care unit is equivalent to about 1 year (100%) of GDP p.c. [50]. In Germany, which might be typical of the rest of Europe, the cost of 2 weeks of intensive care appears to be somewhat lower, around 20,000 euro, or roughly 60% of GDP p.c. [51]. ...
    Preprint
    In response to the rapid spread of the Coronavirus (COVID-19), with ten thousands of deaths and intensive-care hospitalizations, a large number of regions and countries have been put under lockdown by their respective governments. Policy makers are confronted in this situation with the problem of balancing public health considerations, with the economic costs of a persistent lockdown. We introduce a modified epidemic model, the controlled-SIR model, in which the disease reproduction rates evolve dynamically in response to political and societal reactions. Social distancing measures are triggered by the number of infections, providing a dynamic feedback-loop which slows the spread of the virus. We estimate the total cost of several distinct containment policies incurring over the entire path of the endemic. Costs comprise direct medical cost for intensive care, the economic cost of social distancing, as well as the economic value of lives saved. Under plausible parameters, the total costs are highest at a medium level of reactivity when value of life costs are omitted. Very strict measures fare best, with a hands-off policy coming second. Our key findings are independent of the specific parameter estimates, which are to be adjusted with the COVID-19 research status. In addition to numerical simulations, an explicit analytical solution for the controlled continuous-time SIR model is presented. For an uncontrolled outbreak and a reproduction factor of three, an additional 28% of the population is infected beyond the herd immunity point, reached at an infection level of 66%, which adds up to a total of 94%.
  • ... Ancak bir o kadar da önemli diğer karar erken uygulanan weaning ve ekstübasyona bağlı olası komplikasyonların öngörüsüdür. Tüm bu risklerin azaltılması ve mekanik ventilasyonun sonlandırılmasında en uygun zamanlamanın yapılması amacıyla farklı yöntemlerle de olsa günlük spontan solunum denemelerinin yapılması önerilmektedir (22)(23)(24) . Bu çalışmada incelediğimiz yoğun bakım hastalarının 18'inde invaziv mekanik ventilasyon uygulanmaktaydı. ...
  • ... Intensive care units (ICUs) represent one of the largest clinical cost centers in hospitals [1]. Mechanical ventilation (MV) accounts for a significant share of this cost [2]. Patients requiring MV represent a substantial share of all ICU patients and have been shown to account for a disproportionately high share of total ICU costs [2][3][4][5]. ...
    Article
    Full-text available
    Background: Intensive care units represent one of the largest clinical cost centers in hospitals. Mechanical ventilation accounts for a significant share of this cost. There is a relative dearth of information quantifying the impact of ventilation on daily ICU cost. We thus determine daily costs of ICU care, incremental cost of mechanical ventilation per ICU day, and further differentiate cost by underlying diseases. Methods: Total ICU costs, length of ICU stay, and duration of mechanical ventilation of all 10,637 adult patients treated in ICUs at a German hospital in 2013 were analyzed for never-ventilated patients (N = 9181), patients ventilated at least 1 day, (N = 1455) and all patients (N = 10,637). Total ICU costs were regressed on the number of ICU days. Finally, costs were analyzed separately by ICD-10 chapter of main diagnosis. Results: Daily non-ventilated costs were €999 (95%CI €924 - €1074), and ventilated costs were €1590 (95%CI €1524 - €1657), a 59% increase. Costs per non-ventilated ICU day differed substantially and were lowest for endocrine, nutritional or metabolic diseases (€844), and highest for musculoskeletal diseases (€1357). Costs per ventilated ICU day were lowest for diseases of the circulatory system (€1439) and highest for cancer patients (€1594). The relative cost increase due to ventilation was highest for diseases of the respiratory system (94%) and even non-systematic for patients with musculoskeletal diseases (13%, p = 0.634). Conclusions: Results show substantial variability of ICU costs for different underlying diseases and underline mechanical ventilation as an important driver of ICU costs.
  • ... Its application, however, may be associated with serious complications including higher mortality and costs, often directly linked to its duration [1,2]. Consequently, earlier weaning from mechanical ventilation leads to substantial benefits from clinical and non-clinical perspectives [3]. Accordingly, timely weaning from MV represents a crucial process for every patient, since weaning failure is a determinant of the poor outcomes associated with longer duration of MV and longer ICU and hospital stay [4][5][6]. ...
    Article
    Full-text available
    Background The spontaneous breathing trial (SBT) assesses the risk of weaning failure by evaluating some physiological responses to the massive venous return increase imposed by discontinuing positive pressure ventilation. This trial can be very demanding for some critically ill patients, inducing excessive physical and cardiovascular stress, including muscle fatigue, heart ischemia and eventually cardiac dysfunction. Extubation failure with emergency reintubation is a serious adverse consequence of a failed weaning process. Some data suggest that as many as 50% of patients that fail weaning do so because of cardiac dysfunction. Unfortunately, monitoring cardiovascular function at the time of the SBT is complex. The aim of our study was to explore if central venous pressure (CVP) changes were related to weaning failure after starting an SBT. We hypothesized that an early rise on CVP could signal a cardiac failure when handling a massive increase on venous return following a discontinuation of positive pressure ventilation. This CVP rise could identify a subset of patients at high risk for extubation failure. Methods Two-hundred and four mechanically ventilated patients in whom an SBT was decided were subjected to a monitoring protocol that included blinded assessment of CVP at baseline, and at 2 minutes after starting the trial (CVP-test). Weaning failure was defined as reintubation within 48-hours following extubation. Comparisons between two parametric or non- parametric variables were performed with student T test or Mann Whitney U test, respectively. A logistic multivariate regression was performed to determine the predictive value on extubation failure of usual clinical variables and CVP at 2-min after starting the SBT. Results One-hundred and sixty-five patients were extubated after the SBT, 11 of whom were reintubated within 48h. Absolute CVP values at 2-minutes, and the change from baseline (dCVP) were significantly higher in patients with extubation failure as compared to those successfully weaned. dCVP was an early predictor for reintubation (OR: 1.70 [1.31,2.19], p<0.001). Conclusions An early rise in CVP after starting an SBT was associated with an increased risk of extubation failure. This might represent a warning signal not captured by usual SBT monitoring and could have relevant clinical implications.
  • Article
    Background Abdominal aortic aneurysm (AAA) repair is associated with significant morbidity and mortality. As a result, many of these patients are monitored postoperatively in the intensive care unit (ICU). However, little is known about resource utilization and costs associated with ICU admission in this population. We sought to evaluate predictors of total costs among patients admitted to the ICU after repair of nonruptured or ruptured AAA. Methods We retrospectively analyzed prospectively collected data (2011-2016) of ICU patients admitted after AAA repair. The primary outcome was total hospital costs. We used elastic net regression to identify pre-ICU admission predictors of hospitalization costs separately for nonruptured and ruptured AAA patients. Results We included 552 patients in the analysis. Of these, 440 (79.7%) were admitted after repair of nonruptured AAA, and 112 (20.3%) were admitted after repair of ruptured AAA. The mean age of patients with nonruptured AAA was 74 (standard deviation, 9) years, and the mean age of patients with ruptured AAA was 70 (standard deviation, 8) years. Median total hospital cost (in Canadian dollars) was $21,555 (interquartile range, $17,798-$27,294) for patients with nonruptured AAA and $33,709 (interquartile range, $23,173-$53,913) for patients with ruptured AAA. Among both nonruptured and ruptured AAA patients, increasing age, illness severity, use of endovascular repair, history of chronic obstructive pulmonary disease, and excessive blood loss (≥4000 mL) were associated with increased costs, whereas having an anesthesiologist with vascular subspecialty training was associated with lower costs. Conclusions Patient-, procedure-, and clinician-specific variables are associated with costs in patients admitted to the ICU after repair of AAA. These factors may be considered future targets in initiatives to improve cost-effectiveness in this population.
  • Article
    Purpose: To determine the cost-effectiveness of escalating doses of norepinephrine or norepinephrine plus the adjunctive use of vasopressin or angiotensin II as a second-line vasopressor for septic shock. Materials and methods: Decision tree analysis was performed to compare costs and outcomes associated with norepinephrine monotherapy or the two adjunctive second-line vasopressors. Short- and long-term outcomes modeled included ICU survival and lifetime quality-adjusted-life-years (QALY) gained. Costs were modeled from a payer's perspective, with a willingness-to-pay threshold set at $100,000/unit gained. One-way (tornado diagrams) and probabilistic sensitivity analyses were performed. Results: Adjunctive vasopressin was the most cost-effective therapy, and dominated both norepinephrine monotherapy and adjunctive angiotensin II by producing higher ICU survival at less cost. For the lifetime horizon, while norepinephrine monotherapy was least expensive, adjunctive vasopressin was the most cost-effective with an incremental cost-effectiveness ratio of $19,762 / QALY gained. Although adjunctive angiotensin II produced more QALYs compared to norepinephrine monotherapy, it was dominated in the long-term evaluation by second-line vasopressin. Sensitivity analyses demonstrated model robustness and medication costs were not significant drivers of model results. Conclusions: Vasopressin is the most cost-effective second-line vasopressor in both the short- and long-term evaluations. Vasopressor price is a minor contributor to overall cost.
  • Article
    Objectives To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. Design Retrospective cohort analysis. Setting The Pediatric Trauma Quality Improvement Program (TQIP) database Patients One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. Interventions Not applicable. Measurements and Main Results The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. Conclusion Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. Article Tweet Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.
  • Article
    Purpose Invasive mechanical ventilation is a common form of life support provided to critically ill patients. Frailty is an emerging prognostic factor for poor outcome in the Intensive Care Unit (ICU); however, its association with adverse outcomes following invasive mechanical ventilation is unknown. We sought to evaluate the association between frailty, defined by the Clinical Frailty Scale (CFS), and outcomes of ICU patients receiving invasive mechanical ventilation. Methods We performed a retrospective analysis (2011–2016) of a prospectively collected registry from two hospitals of consecutive ICU patients ≥ 18 years of age receiving invasive mechanical ventilation. CFS scores were based on recorded pre-admission function at the time of hospital admission. The primary outcome was hospital mortality. Secondary outcomes included discharge to long-term care, extubation failure at time of first liberation attempt, and tracheostomy. Results We included 8110 patients, and 2529 (31.2%) had frailty (CFS ≥ 5). Frailty was associated with increased odds of hospital death (adjusted odds ratio [aOR]: 1.24 [95% confidence interval [CI] 1.10–1.40) and discharge to long-term care (aOR 1.21 [95% CI 1.13–1.35]). As compared to patients without frailty, patients with frailty had increased odds of extubation failure (aOR 1.17 [95% CI 1.04–1.37]), hospital death following extubation failure (aOR 1.18 [95% CI 1.07–1.28]), tracheostomy (aOR 1.17 [95% CI 1.01–1.36]), and hospital death following tracheostomy (aOR 1.14 [95% CI 1.03–1.25]). Conclusions The presence of frailty among patients receiving mechanical ventilation is associated with increased odds of hospital mortality, discharge to long-term care, extubation failure, and need for tracheostomy.
  • Article
    Background: Delayed hyponatremia is a common complication following transsphenoidal surgery (TSS) of pituitary lesions, which leads to significant patient morbidity, as well as increased hospital costs associated with readmission. Objective: To report the effects of fluid restriction, during a postoperative period of 4 d, to decrease rates and readmissions for hyponatremia in a cohort of patients undergoing TSS. Methods: Because of our observed postoperative rates of hyponatremia, we implemented 1000-mL fluid restriction limited to postoperative days (POD) 4 to 8 in consecutive patients undergoing surgery at our center between March 2018 and January 2019. Patients were monitored for the development of hyponatremia and readmissions. We compared outcomes with those of patients who had undergone TSS prior to fluid restriction. Results: Data from 57 patients who underwent TSS following implementation of fluid restriction were compared to prior patients who underwent TSS without restriction. The rate of hyponatremia in patients (n = 57) prior to fluid restriction was 12.3%. Following implementation of fluid restriction, we had zero cases of hyponatremia or readmissions. We found body mass index to be inversely related to the risk of hyponatremia and readmissions. Furthermore, male gender, follicle stimulating hormone and/or luteinizing hormone staining on pathology, and administration of preoperative and intraoperative glucocorticoids were associated with decreased risk of hyponatremia readmissions. Conclusion: The implementation of 1000-mL fluid restriction between POD 4 and 8 is a highly successful and simple approach to decrease the risk of delayed hyponatremia after TSS.
  • Article
    Patients with intracranial hemorrhage (including intracerebral hemorrhage, subarachnoid hemorrhage, and traumatic hemorrhage) are commonly admitted to the intensive care unit (ICU). Although indications for oral antiplatelet agents are increasing, the impact of preadmission use on outcomes in patients with intracranial hemorrhage admitted to the ICU is unknown. We sought to evaluate the association between preadmission oral antiplatelet use, in-hospital mortality, resource utilization, and costs among ICU patients with intracranial hemorrhage.
  • Article
    We must ask ourselves who will pay for the care of the poor and other basic services if not government? The private sector has apparently not been the solution and blaming inefficient bureaucrats has become an over-used cliché that obscures the basic problem of lack of funding (10). Governments and hospitals are caught with insufficient resources to provide basic healthcare services. In healthcare, a profit-driven private sector has resulted in marked price increases and pays attention to the poor only when a third-party payer reimburses the cost of care. Regardless of the specifics, the last 50 years have demonstrated that any solution that does not involve adequate government funding will not meet the goal of caring for all. However, a tax base allowing sufficient resources needs to be established. Government was the solution in the past and will need to be solution in the future.
  • Article
    Traumatic injury survivors often face a difficult recovery. Surgical and invasive procedures, prolonged monitoring in the intensive care unit (ICU), and constant preventive vigilance by medical staff guide standards of care to promote positive outcomes. Recently, patients with traumatic injuries have benefited from early mobilization, a multidisciplinary approach to increasing participation in upright activity and walking. The purpose of this project was to determine the impact of an early mobility program in the trauma ICU on length of stay (LOS), ventilator days, cost, functional milestones, and rehabilitation utilization. A quality improvement project compared outcomes and cost before and after the implementation of an early mobility program. The trauma team assigned daily mobility levels to trauma ICU patients. Nursing and rehabilitation staff collaborated to set daily goals and provide mobility-based interventions. Forty-four patients were included in the preintervention group and 43 patients in the early mobility group. Physical therapy and occupational therapy were initiated earlier in the early mobilization group (p = .044 and p = .026, respectively). Improvements in LOS, duration of mechanical ventilation, time to out-of-bed activity and walking, and discharge disposition were not significant. There were no adverse events related to the early mobility initiative. Activity intolerance resulted in termination of 7.1% of mobility sessions. The development and initiation of a trauma-specific early mobility program proved to be safe and reduce patient care costs. In addition, the program facilitated earlier initiation of physician and occupational therapies. Although not statistically significant, retrospective data abstraction provides evidence of fewer ICU and total hospital days, earlier extubations, and greater proactive participation in functional activities.
  • Article
    Background: Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. Methods: A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. Results: A total of 1703 patients were included in this study-914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. Conclusions: Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.
  • Article
    Extracorporeal CO2 removal is a highly promising support therapy for patients with hypercapnic respiratory failure but whose clinical implementation and patient benefit is hampered by high cost and highly specialized expertise required for safe use. Current approaches target removal of the gaseous CO2 dissolved in blood which limits their ease of clinical use as high blood flow rates are required to achieve physiologically significant CO2 clearance. Here, a novel hybrid approach in which a zero-bicarbonate dialysis is used to target removal of bicarbonate ion coupled to a gas exchange device to clear dissolved CO2, achieves highly efficiently total CO2 capture while maintaining systemic acid–base balance. In a porcine model of acute hypercapnic respiratory failure, a CO2-reduction of 61.4 ± 14.4 mL/min was achieved at a blood flow rate of 248 mL/min using pediatric-scale priming volumes. The dialyzer accounted for 81% of total CO2 capture with an efficiency of 33% with a minimal pH change across the entire circuit. This study demonstrates the feasibility of a novel hybrid CO2 capture approach capable of achieving physiologically significant CO2 removal at ultralow blood flow rates with low priming volumes while leveraging widely available dialysis platforms to enable clinical adoption.
  • Book
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    The intensive care unit (ICU) of any hospital consumes a large portion of the hospital's budget, which mandates continuous evaluation of the performance of the unit to substantiate its expenditure. Measuring the quality of the performance in the ICU is difficult and complex, however, two identified performance indicators of ICU in terms of effectiveness are length of stay (LOS) of patients, and severity adjusted standardized mortality ratio utilizing a severity related prediction model. Aims: To evaluate the performance in an adult ICU in terms of effectiveness, using predefined targets for the length of stay and standardized mortality ratio, as well as comparison to predicted values. Methods: All discharged patients from our ICU during 2018 were included, the average LOS for all and acute patients, and the mortality rate were calculated, and compared to values predicted by APACHE 4 scoring system. Results: During 2018 we discharged 2769 patients, and 2484 patients met the inclusion criteria. The median LOS for all patients [ 5 (2-12)] was significantly higher than predicted value of 4 (2-11) days (p=0.013), the same was observed for the LOS of acute patients (who spend less than 21 days in ICU), the actual and predicted medians were 4 (2-10) and 3 (2-6) days respectively (p=0.02), however both LOS calculations were within our pre-set targets of 15 days for all and 5 days for acute patients. The actual mortality rate of 12.5% (95% CI 11.2-13.9) was significantly lower than that predicted by the APACHE 4 scoring system (14.6%). Using the actual and predicted mortality rates, the standardized mortality ratio was 0.86. Comparison of the year 2018 to 2017 show a significant reduction of LOS for all patients (p= 0.03), and an insignificant trend toward reduction of mortality rate (p = 0.07) Conclusions: The LOS values for all and acute patients are within targets, and comparable to figures reported in some studies, being above values predicted may be attributed to the fact that APACHE 4 scoring system underestimates LOS. The mortality rate was significantly lower than predicted, and lower than that reported in similar studies. With a standardized mortality ratio of less than 1, there is evidence of an acceptable quality of care in the ICU. However, interventions in the form of performance improvement projects are required to improve the indicators, and consequently the quality of care. There is also improvement in the performance and outcome of our ICU in 2018 as compared to 2017.
  • Article
    PurposePosterior fossa tumor (PFT) resection can be associated with postoperative respiratory failure. We aimed to identify risk factors predicting tracheostomy dependence in children after PFT resection.Methods Retrospective chart review of all children undergoing PFT resection from April 2007 to May 2017 at our institution was performed.ResultsA total of 197 patients were included; 12 (6.1%) required tracheostomy placement at a mean 69.1 days postoperatively (SD 112.7, range 7–388). Patients requiring tracheostomy were younger (3.4 vs. 6.8 years, p < 0.01), more likely to have postoperative dysphagia (91.7% vs. 17.3%, p < 0.01), and more likely to have an ependymoma (41.7% vs. 15.1%, p < 0.01) or astrocytoma (25.0% vs. 8.1%, p < 0.01). Patients with eventual tracheostomy were less likely extubated immediately postoperatively (45.5% vs. 79.6%, p < 0.01), had longer intubation duration postoperatively (5.7 vs. 0.5 days, p < 0.01), and had higher rates of reintubation within 48 h (63.6% vs. 1.3%, p < 0.01). Patients requiring tracheostomy had longer hospital length of stay (45.8 vs. 15.3 days, p < 0.01) and ICU stay postoperatively (13.5 vs. 2.1 days, p < 0.01). Of those requiring tracheostomy, three (25.0%) were decannulated by 1 year postoperatively. Decannulation rates did not vary by age (p < 0.47), extubation failure (p < 0.24), duration of intubation (p < 0.10), tumor histology (p < 0.23), or tumor grade (p < 0.13).Conclusion Lower cranial neuropathy following PFT resection is common. Identifying risk factors correlated with need for tracheostomy can help identify patients who may benefit from early tracheostomy, reducing prolonged intubation trauma, time on mechanical ventilation, and length of stay.
  • Article
    Objectives/Hypothesis To characterize the effects of tracheotomy timing at our institution on intensive care unit (ICU) length of stay (LOS) and overall hospital LOS. Study Design Retrospective cohort study. Methods A retrospective study was performed at a tertiary care medical center for patients undergoing tracheotomy over 2.5 years from January 1, 2016 through June 30, 2018. Demographics, survival, duration of endotracheal intubation, timing of tracheotomy, and ICU and overall hospital LOS were assessed. Tracheotomy was considered early (ET) if it was performed by day 7 of mechanical ventilation and late (LT) thereafter. Readmission, mortality, and costs were also tabulated for each aggregate group. Nonparametric statistics were used to compare results. Results Of the 536 patients included in the analysis, 160 received tracheotomy early and 376 late. Differences between age and sex were not statistically significant. Duration of total ICU stay was shortened by 65% (12.84 ± 17.69 days vs. 38.49 ± 26.61 days; P < .0001), and length of overall hospital course was reduced by 54% (22.71 ± 26.65 days vs. 50.37 ± 34.20 days; P < .0001) in the early tracheotomy group. Observed/expected (O/E) values standardized results to case mix index and revealed LOS of 1.5 for ET and 2.5 for LT, and mortality of 0.76 for ET and 1.25 for LT, and comparable readmissions of both groups. Conclusions Early tracheotomy in ICU patients is associated with earlier ICU discharge, decreased length of overall hospital stay, and lower mortality when controlling for case mix index. Opportunities exist to optimize patient outcomes and O/E performance. Level of Evidence 4 Laryngoscope, 2020
  • Article
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    **Background:** Early identification of acute infections and sepsis remains an unmet medical need. While early detection and initiation of treatment reduces mortality, inappropriate treatment leads to adverse events and the development of antimicrobial resistance. Current diagnostic and prognostic solutions, including procalcitonin, lack required accuracy. A novel blood-based host response test, HostDx™ Sepsis by Inflammatix, Inc., assesses the likelihood of a bacterial infection, the likelihood of a viral infection, and the severity of the condition. **Objectives:** We estimated the economic impact of adopting HostDx Sepsis testing among patients with suspected acute respiratory tract infection (ARTI) in the emergency department (ED). **Methods:** Our cost impact model estimated costs for adult ED patients with suspected ARTI under the standard of care versus with the adoption of HostDx Sepsis from the perspective of US payers. Included costs were those assumed to be associated with an episode of sepsis diagnosis, management, and treatment. Projected accuracies for test predictions, disease prevalence, and clinical parameters was derived from patient-level meta-analysis data of randomized trials, supplemented with published performance data for HostDx Sepsis. One-way sensitivity analysis was performed on key input parameters. **Results:** Compared to standard of care including procalcitonin, the superior test characteristics of HostDx Sepsis resulted in an average cost savings of approximately US$1974 per patient (-31.3%) exclusive of the cost of HostDx Sepsis. Reductions in hospital days (-0.80 days, -36.7%), antibiotic days (-1.49 days, -29.5%), and percent 30-day mortality (-1.67%, -13.64%) were driven by HostDx Sepsis providing fewer “noninformative” moderate risk predictions and more “certain” low- or high-risk predictions compared to standard of care, especially for patients who were not severely ill. These results were robust to changes in key parameters, including disease prevalence. **Conclusions:** Our model shows substantial savings associated with introduction of HostDx Sepsis among patients with ARTIs in EDs. These results need confirmation in interventional trials.
  • Article
    Acute respiratory distress syndrome (ARDS) is the most severe form of acute lung injury, responsible for high mortality and long-term morbidity. As a dynamic syndrome with multiple etiologies, its timely diagnosis is difficult as is tracking the course of the syndrome. Therefore, there is a significant need for early, rapid detection and diagnosis as well as clinical trajectory monitoring of ARDS. Here, we report our work on using human breath to differentiate ARDS and non-ARDS causes of respiratory failure. A fully automated portable 2-dimensional gas chromatography device with high peak capacity (> 200 at the resolution of 1), high sensitivity (sub-ppb), and rapid analysis capability (~ 30 min) was designed and made in-house for on-site analysis of patients’ breath. A total of 85 breath samples from 48 ARDS patients and controls were collected. Ninety-seven elution peaks were separated and detected in 13 min. An algorithm based on machine learning, principal component analysis (PCA), and linear discriminant analysis (LDA) was developed. As compared to the adjudications done by physicians based on the Berlin criteria, our device and algorithm achieved an overall accuracy of 87.1% with 94.1% positive predictive value and 82.4% negative predictive value. The high overall accuracy and high positive predicative value suggest that the breath analysis method can accurately diagnose ARDS. The ability to continuously and non-invasively monitor exhaled breath for early diagnosis, disease trajectory tracking, and outcome prediction monitoring of ARDS may have a significant impact on changing practice and improving patient outcomes.
  • Article
    The smearing estimate is proposed as a nonparametric estimate of the expected response on the untransformed scale after fitting a linear regression model on a transformed scale. The estimate is consistent under mild regularity conditions, and usually attains high efficiency relative to parametric estimates. It can be viewed as a low-premium insurance policy against departures from parametric distributional assumptions. A real-world example of predicting medical expenditures shows that the smearing estimate can outperform parametric estimates even when the parametric assumption is nearly satisfied.
  • Article
    To estimate the incidence of acute respiratory failure (ARF) in the United States and to analyze 31-day hospital mortality among a cohort of patients with ARF. Design and setting: Retrospective cohort drawn from the Nationwide Inpatient Sample of 6. 4 million discharges from 904 representative nonfederal hospitals during 1994. All 61,223 patients in the sample whose discharge records indicated all of the following: acute respiratory distress or failure, mechanical ventilation, > or = 24 h of hospitalization, and age > or = 5 years. An estimated 329,766 patients discharged from nonfederal hospitals nationwide in 1994 met study criteria for ARF. The incidence of ARF was 137.1 hospitalizations per 100,000 US residents age > or = 5 years. Incidence increased nearly exponentially each decade until age 85 years. Overall, 35.9% of patients with ARF did not survive to hospital discharge. At 31 days, hospital mortality was 31.4%. According to the proportional hazards model, significant mortality hazards included age (> or = 80 years and > or = 30 years), multiorgan system failure (MOSF), HIV, chronic liver disease, and cancer. Hospital admission for coronary artery bypass, drug overdose, or trauma other than head injury or burns was associated with a reduced mortality hazard. Interaction was present between age and MOSF, trauma, and cancer. A point system derived from the hazard model classified patients into seven groups with distinct 31-day survival probabilities ranging from 24 to 99%. The incidence of ARF increases markedly with age and is especially high among persons > or = 65 years of age. Nonpulmonary hazards explain short-term (31-day) survival.
  • Article
    Objective. —To determine the prevalence of intensive care unit (ICU)—acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality.
  • Article
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    The objective of this study was to refine the APACHE (Acute Physiology, Age, Chronic Health Evaluation) methodology in order to more accurately predict hospital mortality risk for critically ill hospitalized adults. We prospectively collected data on 17,440 unselected adult medical/surgical intensive care unit (ICU) admissions at 40 US hospitals (14 volunteer tertiary-care institutions and 26 hospitals randomly chosen to represent intensive care services nationwide). We analyzed the relationship between the patient's likelihood of surviving to hospital discharge and the following predictive variables: major medical and surgical disease categories, acute physiologic abnormalities, age, preexisting functional limitations, major comorbidities, and treatment location immediately prior to ICU admission. The APACHE III prognostic system consists of two options: (1) an APACHE III score, which can provide initial risk stratification for severely ill hospitalized patients within independently defined patient groups; and (2) an APACHE III predictive equation, which uses APACHE III score and reference data on major disease categories and treatment location immediately prior to ICU admission to provide risk estimates for hospital mortality for individual ICU patients. A five-point increase in APACHE III score (range, 0 to 299) is independently associated with a statistically significant increase in the relative risk of hospital death (odds ratio, 1.10 to 1.78) within each of 78 major medical and surgical disease categories. The overall predictive accuracy of the first-day APACHE III equation was such that, within 24 h of ICU admission, 95 percent of ICU admissions could be given a risk estimate for hospital death that was within 3 percent of that actually observed (r2 = 0.41; receiver operating characteristic = 0.90). Recording changes in the APACHE III score on each subsequent day of ICU therapy provided daily updates in these risk estimates. When applied across the individual ICUs, the first-day APACHE III equation accounted for the majority of variation in observed death rates (r2 = 0.90, p less than 0.0001).
  • Article
    Critical care resources in the United States are being rationed, that is, not all critical care expected to be beneficial is being provided to all patients who desire it. Although the extent of rationing is uncertain, it is an everyday occurrence in some hospitals and is likely to occur at least some of the time in many hospitals. Substantial evidence suggests that current rationing practices are highly subjective and perhaps inequitable. Critical care is widely believed to be beneficial to many patients, despite a striking dearth of supportive data. Since this type of care is being inequitably denied to some patients, hospitals should either adopt formal rationing guidelines or, alternatively, they should take clear steps to avoid rationing by altering the supply of or the demand for critical care. Reasonable arguments are presented in support of both approaches, as are suggestions for their implementation. KIE Considerable evidence supports the contention that U.S. hospitals ration critical care resources in an informal, often irrational and unfair manner. The value, efficacy, and cost of intensive care units are discussed and two options are proposed to tackle the problem of rationing. Hospitals should either establish formal, specific, and equitable rationing guidelines or, alternatively, develop plans to avoid rationing by increasing the supply of resources or by decreasing the demand for them. It is suggested that demand be decreased by more aggressive discharge or by a system of graded care rather than by denying admission. Arguments in favor of and against rationing are presented. It is concluded that, whichever option is chosen, plans should be developed openly, approved by appropriate supervisory bodies, and brought to the attention of hospital staff and patients.
  • Article
    To determine the prevalence of intensive care unit (ICU)-acquired infections and the risk factors for these infections, identify the predominant infecting organisms, and evaluate the relationship between ICU-acquired infection and mortality. A 1-day point-prevalence study. Intensive care units in 17 countries in Western Europe, excluding coronary care units and pediatric and special care infant units. All patients (> 10 years of age) occupying an ICU bed over a 24-hour period. A total of 1417 ICUs provided 10 038 patient case reports. Rates of ICU-acquired infection, prescription of antimicrobials, resistance patterns of microbiological isolates, and potential risk factors for ICU-acquired infection and death. A total of 4501 patients (44.8%) were infected, and 2064 (20.6%) had ICU-acquired infection. Pneumonia (46.9%), lower respiratory tract infection (17.8%), urinary tract infection (17.6%), and bloodstream infection (12%) were the most frequent types of ICU infection reported. Most frequently reported micro-organisms were Enterobacteriaceae (34.4%), Staphylococcus aureus (30.1%;[60% resistant to methicillin], Pseudomonas aeruginosa (28.7%), coagulase-negative staphylococci (19.1%), and fungi (17.1%). Seven risk factors for ICU-acquired infection were identified: increasing length of ICU stay (> 48 hours), mechanical ventilation, diagnosis of trauma, central venous, pulmonary artery, and urinary catheterization, and stress ulcer prophylaxis. ICU-acquired pneumonia (odds ratio [OR], 1.91; 95% confidence interval[Cl], 1.6 to 2.29), clinical sepsis (OR, 3.50; 95% Cl, 1.71 to 7.18), and bloodstream infection (OR, 1.73; 95% Cl, 1.25 to 2.41) increased the risk of ICU death. ICU-acquired infection is common and often associated with microbiological isolates of resistant organisms. The potential effects on outcome emphasize the importance of specific measures for infection control in critically ill patients.
  • Article
    To study methods for costing hospital services, specifically in relation to multi-unit studies of activity, case mix, severity of illness, outcome, and resource use in adult intensive care units (ICUs). Twenty published cost studies of adult ICUs. The studies are all published in English and are both European and American. Cost studies of adult ICUs published in international journals (English language). Literature survey, where the articles were obtained through MEDLINE and other database searches. Cost of intensive care therapy was compared across the 20 studies. However, as stressed in the article, to compare costs of intensive care therapy across units is not possible for a number of reasons. One of the reasons for this limitation is that the studies employed different approaches to costing and thereby introduced a methodologic bias. In addition, the costing methodology applied in the majority of the studies was wrongly specified in relation to the purpose and viewpoint of the studies. The methodologies for costing ICU therapy are flawed and fail to provide correct answers. In most studies, the study question is not adequately specified and the cost concept used in the studies is not tailored to the purposes of the study. Standardizing the cost model would lead to better, faster, and more reliable costing. This standardized cost model should not be rigid, but adaptable to different decision situations. A decision tree or taxonomy is proposed as a way toward better costing of ICU activity.
  • Article
    Cleveland Health Quality Choice (CHQC) is a unique community-based program designed to provide more efficient delivery of healthcare services through routine collection and dissemination of selected patient interventions and outcomes. This effort, coordinated by a consortium of business, hospital, and medical leaders, provides comparative public data on hospital performance. In the ICU, this effort involves collection of Acute Physiology and Chronic Health Evaluation (APACHE) III, as well as severity and prognostic data. To date, results suggest that a higher percentage of patients admitted to the ICU are at low risk of death or adverse outcome when compared with a national benchmark using APACHE III. Risk-adjusted mortality rates are lower and length of stay is shorter than predicted. CHQC demonstrates that cooperative public efforts, undertaken by groups with often divergent interests and using objective risk estimates, can provide useful data for hospital quality improvement activities and market-based health reform efforts.
  • Article
    In many ICUs, admission and discharge hinge on the need for intubation and ventilatory support. As few as 5% to 10% of ICU patients require prolonged mechanical ventilation, and this patient group consumes > or = 50% of ICU patient days and ICU resources. Prolonged ventilatory support and chronic ventilator dependency, both in the ICU and non-ICU settings, have a significant and growing impact on healthcare economics. In the United States, the need for prolonged mechanical ventilation is increasingly recognized as separate and distinct from the initial diagnosis and/or procedure that leads to hospitalization. This distinction has led to improved reimbursement under the prospective diagnosis-related group (DRG) system, and demands more precise accounting from healthcare providers responsible for these patients. Using both published and theoretical examples, mechanical ventilation in the United States is discussed, with a focus on cost containment. Included in the discussion are ventilator teams, standards of care, management protocols, stepdown units, rehabilitation units, and home care. The expanding role of total quality management (TQM) is also presented.
  • Article
    Full-text available
    This study evaluates the accuracy of costs derived from the ratio of costs to charges (RCCs), using costs based on relative value units (RVUs) as the "gold standard." We found that RCC-calculated costs were not a good basis for determining the costs of individual patients. However, when examining average costs per diagnosis-related group (DRG), RCCs performed better. For almost 70% of the DRGs, average RCC-calculated costs were within 10% of average RVU-calculated costs. RCCs were even more reliable for comparing the relative cost of patients in a DRG in one hospital to the average cost of patients in that DRG in a group of hospitals. Charges, or an overall hospital RCC (as opposed to the departmental RCCs we used in most of our analyses), were not a good basis for determining relative hospital costs.
  • This paper explains practical approaches for collecting inpatient cost data for cost-of-illness and cost-effectiveness analyses. The economic definition of cost of an item is the value of the resources that are consumed in its production. Cost analysis should collect the resources hypothesized to be affected by the illness or intervention. The dollar value of these resources can also be estimated. Diagnosis-related group (DRG) reimbursements are not helpful when all study patients have the same DRG or when no DRG exists (e.g., nosocomial infection). Hospital charges are not a good surrogate for costs. Hence, data needed include resources used, charges, and cost-to-charge ratios, so that cost can be estimated. Resources used can be obtained from hospital information systems. For some resource use (e.g., physician services, pharmacy, and intravenous fluids), charges or cost-to-charge ratios may not be available, and an external standard may be needed to estimate the dollar value. For many types of resources, hospital financial systems provide both charges and cost-to-charge ratios. This yields an estimate of average cost (total cost divided by patient days) when marginal cost (change in variable cost per day of patient stay) is a better estimate of the value of the resources consumed. However, cost-to-charge ratios remain the only practical way of estimating cost in many circumstances and are commonly used in economic studies. Cost-of-illness estimates vary among the various nonrandomized study designs used. "Real-world" randomized trials are potentially useful to obtain advantages of randomization but avoid the protocol-induced biases of traditional double-blind controlled trials.
  • Article
    Correcting the decrease in oxygen delivery from anemia using allogeneic RBC transfusions has been hypothesized to help with increased oxygen demands during weaning from mechanical ventilation. However, it is also possible that transfusions hinder the process because RBCs may not be able to adequately increase oxygen delivery. In this study, we determined whether a liberal RBC transfusion strategy improved outcomes related to mechanical ventilation. Seven hundred thirteen patients receiving mechanical ventilation, representing a subgroup of patients from a larger trial, were randomized to either a restrictive transfusion strategy, receiving allogeneic RBC transfusions at a hemoglobin concentration of 7.0 g/dL (and maintained between 7.0 g/dL and to 9.0 g/dL), or to a liberal transfusion strategy, receiving RBCs at 10.0 g/dL (and maintained between 10.0 g/dL and 12.0 g/dL). The larger trial was designed to evaluate transfusion practice rather than weaning per se. Baseline characteristics in the restrictive-strategy group (n = 357) and the liberal-strategy group (n = 356) were comparable. The average durations of mechanical ventilation were 8.3 +/- 8.1 days and 8.3 +/- 8.1 days (95% confidence interval [CI] around difference, - 0.79 to 1.68; p = 0.48), while ventilator-free days were 17.5 +/- 10.9 days and 16.1 +/- 11.4 days (95% CI around difference, - 3.07 to 0.21; p = 0.09) in the restrictive-strategy group vs the liberal-strategy group, respectively. Eighty-two percent of the patients in the restrictive-strategy group were considered successfully weaned and extubated for at least 24 h, compared to 78% for the liberal-strategy group (p = 0.19). The relative risk (RR) of extubation success in the restrictive-strategy group compared to the liberal-strategy group, adjusted for the confounding effects of age, APACHE (acute physiology and chronic health evaluation) II score, and comorbid illness, was 1.07 (95% CI, 0.96 to 1.26; p = 0.43). The adjusted RR of extubation success associated with restrictive transfusion in the 219 patients who received mechanical ventilation for > 7 days was 1.1 (95% CI, 0.84 to 1.45; p = 0.47). In this study, there was no evidence that a liberal RBC transfusion strategy decreased the duration of mechanical ventilation in a heterogeneous population of critically ill patients.
  • Article
    Intensive care patients require therapy that can vary considerably in type, duration and cost, so making it extremely difficult to predict patient resource use. Few studies measure actual costs; usually average daily costs are calculated and these do not reflect the variation in resource use between individual patients. The aim of this study was to analyse a data set of 193 critically ill adult patients to look for associations between routinely collected descriptive data and patient-specific costs. Regression analysis was used to explore any relationships between average daily patient-specific costs and the following variables: duration of intensive care unit stay, Acute Physiology and Chronic Health Evaluation II scores in the first 24 h, gender, age, mechanical ventilation at any point during the stay, postoperative status, emergency admission and mortality. Overall, this analysis explained 33.6% of the variation in average daily costs. The additional costs of an extra day of care, mechanical ventilation, an extra point on the Acute Physiology and Chronic Health Evaluation II score, and survival were obtained.
  • Article
    Full-text available
    The outcome of patients receiving mechanical ventilation for particular indications has been studied, but the outcome in a large number of unselected, heterogeneous patients has not been reported. To determine the survival of patients receiving mechanical ventilation and the relative importance of factors influencing survival. Prospective cohort of consecutive adult patients admitted to 361 intensive care units who received mechanical ventilation for more than 12 hours between March 1, 1998, and March 31, 1998. Data were collected on each patient at initiation of mechanical ventilation and daily throughout the course of mechanical ventilation for up to 28 days. All-cause mortality during intensive care unit stay. Of the 15 757 patients admitted, a total of 5183 (33%) received mechanical ventilation for a mean (SD) duration of 5.9 (7.2) days. The mean (SD) length of stay in the intensive care unit was 11.2 (13.7) days. Overall mortality rate in the intensive care unit was 30.7% (1590 patients) for the entire population, 52% (120) in patients who received ventilation because of acute respiratory distress syndrome, and 22% (115) in patients who received ventilation for an exacerbation of chronic obstructive pulmonary disease. Survival of unselected patients receiving mechanical ventilation for more than 12 hours was 69%. The main conditions independently associated with increased mortality were (1) factors present at the start of mechanical ventilation (odds ratio [OR], 2.98; 95% confidence interval [CI], 2.44-3.63; P<.001 for coma), (2) factors related to patient management (OR, 3.67; 95% CI, 2.02-6.66; P<.001 for plateau airway pressure >35 cm H(2)O), and (3) developments occurring over the course of mechanical ventilation (OR, 8.71; 95% CI, 5.44-13.94; P<.001 for ratio of PaO(2) to fraction of inspired oxygen <100). Survival among mechanically ventilated patients depends not only on the factors present at the start of mechanical ventilation, but also on the development of complications and patient management in the intensive care unit.
  • Article
    In patients undergoing open-heart surgery, allogeneic blood transfusion (ABT) may be related to an enhanced inflammatory response and impaired pulmonary function, resulting in a need for prolonged mechanical ventilation. Transfused red blood cell (RBC) supernatant, platelet supernatant or plasma components, may exercise varying effects on pulmonary function, because these fluids differ in their content of soluble biological-response modifiers. The records of 416 patients undergoing coronary artery bypass graft operations at the Massachusetts General Hospital were reviewed. Possible predictors and the number of days of postoperative ventilation, as well as the number of all transfused blood components, were recorded. The association between mechanical ventilation past the day of operation and the volume of transfused RBC supernatant, platelet supernatant, or plasma components, was calculated by logistic regression analyses. The volume of each transfused fluid differed (P < 0.0001) among patients ventilated for 0, 1, 2, 3, or > or = 4 days after the day of the operation. After adjusting for the effects of confounding factors, the volume of administered RBC supernatant was associated (P = 0.0312) with the likelihood of postoperative ventilation past the day of operation, but the volume of platelet supernatant, plasma components, or total transfused fluid was not (P = 0.1528, P = 0.1847, and P = 0.0504, respectively). These results are congruent with the hypotheses that ABT may impair postoperative pulmonary function and that any such adverse effect of ABT is probably mediated by the supernatant fluid of stored RBCs. Both hypotheses should be examined further, in future studies of the outcomes of ABT.
  • Article
    Critical care providers are under increasing pressure to be attentive to cost concerns. The ICU consumes a significant amount of resources and, as such, is a frequently identified target of efforts to limit escalating healthcare costs. Attempts to reduce costs need not progress in a haphazard fashion. Rather, they can proceed in a logical, systematic manner with the assistance of formal economic studies. Cost-effectiveness analysis is one tool for these projects-it allows physicians to compare the financial consequences of different approaches to resource allocation. ICU physicians, therefore, must become familiar with the basic concepts that underlie cost-effectiveness analysis. Cost-effectiveness analyses that address many different aspects of critical care delivery are now commonly found in the critical care literature. With a framework for evaluating these studies, clinicians can better apply their findings to their own institutions.
  • Article
    Length of stay data are increasingly used to monitor ICU economic performance. How such material is presented greatly affects its utility. To develop a weighted length of stay index and to estimate expected length of stay. To assess alternative ways to summarize weighted length of stay to evaluate ICU economic performance. Retrospective database study. Data for 751 ICU patients in 1998 at two hospitals used to develop weighted length of stay index. Data on 42,237 patients from 72 ICUs used as the basis of economic performance evaluation. Difference between actual and expected weighted length of stay, where expected weighted length of stay is based on patient clinical characteristics. Length of stay statistically explains approximately 85 to 90% of interpatient variation in hospital costs. The first ICU day is approximately four times as expensive, and other ICU days approximately 2.5 times as expensive, as non-ICU hospital days. In a regression model for weighted length of stay, patient clinical characteristics explain 26% of variation. ICU economic performance can be measured by excess weighted length of stay of a "typical" patient or by occurrence of long excess weighted lengths of stay. Although different summary measures of performance are highly correlated, choice of measure affects relative ranking of some ICUs' performance. Providers of statistical data on ICU economic performance should adjust length of stay for patient characteristics and provide multiple summary measures of the statistical distribution, including measures that address both the typical patient and outliers.
  • Article
    To determine the attributable cost of ventilator-associated pneumonia from a hospital-based cost perspective, after adjusting for potential confounders. Patients admitted between January 19, 1998, and December 31, 1999, were followed prospectively for the occurrence of ventilator-associated pneumonia. Hospital costs were defined by using the hospital cost accounting database. The medical and surgical intensive care units at a suburban, tertiary care hospital. Patients requiring >24 hrs of mechanical ventilation. None. We measured occurrence of ventilator-associated pneumonia, in-hospital mortality rate, total intensive care unit (ICU) and hospital lengths of stay (LOS), and total hospital cost per patient. Ventilator-associated pneumonia occurred in 127 of 819 patients (15.5%). Compared with uninfected, ventilated patients, patients with ventilator-associated pneumonia had a higher Acute Physiology and Chronic Health Evaluation II score on admission (p <.001) and were more likely to require multiple intubations (p <.001), hemodialysis (p <.001), tracheostomy (p <.001), central venous catheters (p <.001), and corticosteroids (p <.001). Patients with ventilator-associated pneumonia were more likely to be bacteremic during their ICU stay (36 [28%] vs. 22 [3%]; p <.001). Patients with ventilator-associated pneumonia had significantly higher unadjusted ICU LOS (26 vs. 4 days; p <.001), hospital LOS (38 vs. 13 days; p <.001), mortality rate (64 [50%] vs. 237 [34%]; p <.001), and hospital costs (70,568 dollars vs. 21,620 dollars, p <.001). Multiple linear regression, controlling for other factors that may affect costs, estimated the attributable cost of ventilator-associated pneumonia to be 11,897 dollars (95% confidence interval = 5,265 dollars-26,214 dollars; p <.001). Patients with ventilator-associated pneumonia had significantly longer ICU and hospital LOS, with higher crude hospital cost and mortality rate compared with uninfected patients. After we adjusted for underlying severity of illness, the attributable cost of ventilator-associated pneumonia was approximately 11,897 dollars.
  • Article
    Full-text available
    We forecast a slowdown in national health spending growth in 2002 and 2003, reflecting slower projected Medicare and private personal health spending growth. These factors outweigh higher projected Medicaid spending growth, caused by weak labor markets, and an expectation of continued high private health insurance premium inflation related to the underwriting cycle. Over the entire projection period, national health spending growth is still expected to outpace economic growth. The result is that the health share of gross domestic product is projected to increase from 14.1 percent in 2001 to 17.7 percent in 2012.
  • Article
    A life-threatening attack of asthma that leads to intensive care unit (ICU) admission, intubation, or both identifies patients at high risk of subsequent morbidity and mortality and represents a major cost burden. To assess the rates, characteristics, and costs of ICU admissions and intubations among asthma-related hospitalizations. This analysis was performed using a database of 215 hospitals representing more than 3 million annual inpatient visits. Asthma-related hospital admissions were identified by a primary diagnosis code for asthma during 2000. Logistic regression was used to estimate the odds ratios (ORs) for predictors of ICU admission, intubation, and in-hospital mortality. Ordinary least squares regression was used to estimate adjusted mean costs and length of stay. Of 29,430 admissions with a primary diagnosis of asthma, 10.1% were admitted to the ICU and 2.1% were intubated. The risk of in-hospital death was significantly greater in patients who were intubated but not admitted to the ICU (OR, 96.20; 95% confidence interval [CI], 50.24-184.20), those who were admitted to the ICU and intubated (OR, 62.69; 95% CI, 38.17-102.96), and patients with more severe comorbidities (OR, 1.53; 95% CI, 1.38-1.70). On average, intubated patients stayed in the hospital 4.5 days longer and incurred more than $11,000 in additional costs; patients admitted to the ICU stayed 1 day longer and accounted for $3,000 in additional costs vs standard admissions. The inpatient mortality, morbidity, and cost burden of life-threatening asthma in the United States is considerable. This study characterizes patients with asthma at risk of ICU admissions and intubations. Appropriate recognition and treatment are needed to prevent these severe and potentially life-threatening events.