Cost accounting of adult intensive care: methods and human and capital inputs.

OBJECTIVE: To cost adult intensive care by determining inputs to production, resource consumption per patient, and total cost per intensive care unit (ICU) stay. DESIGN: Prospective cost-accounting analysis of each patient stay in the ICU, over a 1-yr period. SETTING: An 11-bed, medical/surgical adult ICU, in a 932-bad urban teaching hospital. PATIENTS: All patients' admissions to an adult ICU over a 1-yr period, excluding those patients admitted solely for repeat hemodialysis. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Demographic information was collected, including age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) II score, primary reason for ICU admission, operative (elective and emergency) and nonoperative status, ICU length of stay, and ICU outcome. Direct patient care costs were accounted to individual patients whose care generated those costs, and indirect patient care costs were averaged over all patients in the ICU on a daily basis. Costs were collected for human (nursing, medical, professional, and support staff) and capital (laboratory, diagnostic imaging, supplies, drugs, and equipment) resources. Cost information was available on 690 patients (43% female, 57% male). Cost/day/patient was $1,508 +/- 475 (1992 Canadian dollars) and the average cost per ICU stay was $7,520 +/- 11,606. Median cost/stay for all patients was $2,600. Cost per ICU stay was < $5,000 in 68% of patients, with an ICU survival rate of 85%. High cost was not a marker for poor survival. There was no relationship between age and cost categories. Across most diagnoses, cost/ day/patient was remarkably constant, approximating $1,500/day/ patient at existing labor rates. CONCLUSIONS: In order to develop strategies aimed at cost containment, it is first necessary to undertake a thorough examination of cost drivers. This detailed cost-accounting study determined inputs to production, resources consumed by individual patients, and costs incurred during ICU stay.

Quality of life measures before and one year after admission to an intensive care unit.

OBJECTIVE: To assess outcome of patients admitted to an intensive care unit (ICU), using a prospective 1-yr follow-up, with special emphasis on various quality of life measures before and after admission to the ICU. DESIGN: Prospective comparison of quality of life before and 1 yr after admission to the ICU. SETTING: Eleven-bed adult medical/surgical ICU. PATIENTS: All patients admitted to the ICU over a 1-yr period were eligible for inclusion in this study. Repeat admissions were enrolled only on first admission. Patients < 17 yrs of age and those patients who died within 24 hrs of admission were excluded. INTERVENTIONS: Quality of life measures were collected before and 6 and 12 months after ICU admission. MEASUREMENTS AND MAIN RESULTS: The following data were collected: duration of ICU and hospital stay; ICU, hospital, 6- and 12-month mortality; quality of life (level of activity, activities of daily living, perceived health, support, and outlook on life) and place of residence at baseline and 12 months after ICU admission. There were 504 patients who met the study criteria; age 55 +/- 20 yrs (median 59), 229 female and 275 male. Mean ICU length of stay was 4.3 +/- 7.4 days. Hospital length of stay was 31 +/- 41 days. Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 14 +/- 7. Cumulative mortality: ICU 5.4%, hospital 13.5%, 6 month 20.6%, and 12 month 25%. One year quality of life questionnaires were completed for 293 patients. Relative to baseline, there was a decrease in the level of activity and activities of daily living at 12 months (p < .01). Perceived health status increased over the year for patients > or = 75 yrs of age (p < .01). There was no difference in the level of support from family or friends, or outlook on life, at 12 months. At 1 yr, 262 (89%) patients were living at home. CONCLUSION: Patients admitted to intensive care tend to have a decrease in the level of activity and activities of daily living 1 yr after their ICU stay, although in the very elderly, perceived health status increases. As well, the majority (89%) of patients return home.

A comparison of intensive care unit utilization in Alberta and western Massachusetts.

OBJECTIVE: To analyze differences in intensive care unit (ICU) utilization between a Canadian province and a U.S. area. DESIGN: Retrospective data analysis of hospital discharge data and existing data from an international study of severity of illness in ICU patients. SETTING: Administrative data for the province of Alberta and the four counties of western Massachusetts for the years 1990 to 1991 were used. Detailed data on consecutive ICU admissions from two Alberta hospitals, one western Massachusetts hospital, and 24 other U.S. hospitals for 3 months in 1991 were used. MEASUREMENTS AND MAIN RESULTS: ICU use and hospital mortality rates were compared for 50,030 hospital admissions divided into 11 patient groups. ICU days per million population were two to three times as great in western Massachusetts as in Alberta. The primary reason was higher ICU incidence (percent of hospitalized patients treated in the ICU) rather than a difference in hospital admission rate or length of ICU stay. ICU incidence in western Massachusetts was significantly higher in ten of 11 patient groups--for the coronary bypass surgery group, there was no difference. The hospital mortality rate in western Massachusetts was similar to, or higher than, the mortality rate in Alberta. In Alberta, a much higher proportion of ICU patients received mechanical ventilation. For elective surgery patients, the ICU severity of illness was lower in western Massachusetts and in other U.S. hospitals than in Alberta. CONCLUSIONS: Western Massachusetts hospitalized patients are more likely to be treated in an ICU than are similar patients in Alberta. There is no evidence that the greater ICU utilization in western Massachusetts led to a lower hospital mortality rate.

Cost containment: the Americas. Canada.

Resources allocated for health care in Canada are about to be decreased. In recent years, the Canadian healthcare system has been consuming a progressively greater share of the country's gross domestic product. Due to recession, less revenue is available for health care. The need to contain and limit national healthcare spending has begun to affect resource allocation in Canadian ICUs. Increasing efficiency and reducing inappropriate use may not be enough to contain costs. More difficult decisions need to be made.

One-year outcome of elderly and young patients admitted to intensive care units.

OBJECTIVE: To compare the outcome of patients over and under age 65 admitted to two intensive care units (ICUs). DESIGN: Prospective, two-center study. Convenience sample of all admissions to two adult ICUs for a 1-yr period, with a 1-yr follow-up. SETTING: Adult multidisciplinary closed ICUs. PATIENTS: All patients (n = 1,040) admitted to two ICUs during a 1-yr period were entered into the study, except patients with self-induced poisoning. Of these patients, 145 patients were lost to follow-up. INTERVENTIONS: Admission statistics on all patients included demographic, case mix, and severity data. Variables associated with intensive care unit outcomes at discharge (length of stay, mortality) and at 1 yr from admission (mortality, functional capacity, health attitudes) were analyzed. Vital status was confirmed from both Alberta Vital Statistics and Alberta Health. Follow-up interviews were conducted with all available survivors. RESULTS: The elderly group (> 65 yrs) comprised 46% of patients studied. Both age groups (> 65 yrs and < 65 yrs) had comparable demographics and illness severity measures. Although ICU and 1-yr mortality rates differed between groups (16% of > 65 yrs vs. 12.9% of < 65 yrs ICU mortality and 49% of > 65 yrs vs. 31% of < 65 yrs 1-yr mortality), age was not a major contributor to the variance in outcome. At 1 yr, 65% of patients admitted to the study were alive. Follow-up interviews were conducted with 75% of survivors. Assessment of activities of daily living showed that the elderly patients were similar to younger patients. The elderly demonstrated more positive health attitudes than younger survivors. Functional capacity was significantly associated with health attitudes of younger patients, but not for older survivors. CONCLUSIONS: Age does not have an important impact on outcome from critical illness, which is most strongly predicted by severity of illness, length of stay, prior ICU admission and respiratory failure. Satisfaction with personal health should not be inferred from the functional status of elderly survivors of intensive care.

Comparison of PT and aPTT values drawn by venipuncture and arterial line using three discard volumes.

BACKGROUND: Blood samples obtained through heparinized arterial catheters are used routinely for a variety of laboratory tests. Accuracy of coagulation studies performed from samples obtained in this fashion continues to be questioned, particularly in regard to the minimum discard volume necessary to clear the catheter of heparinized solution. OBJECTIVE: To examine differences between prothrombin time and activated partial thromboplastin time values obtained from blood drawn by venipuncture and from an indwelling intra-arterial line using three discard volumes. METHODS: Prothrombin time and activated partial thromboplastin time samples were drawn by venipuncture from 41 critically ill adult patients. Simultaneously, three consecutive blood samples of 2.3 mL were drawn from the arterial line after an initial discard volume of 3 mL (discard volumes of 3.0, 5.3 and 7.6 mL). RESULTS: Significant differences were found between arterial and venous prothrombin time values for the 3-mL discard volume group, as well as between arterial and venous activated partial thromboplastin time values for all three discard volume groups (paired t-test, Bonferroni correction). CONCLUSION: We recommend that when drawing prothrombin time and activated partial thromboplastin time samples from an arterial line, a 5.3-mL discard volume be used.

Isoflurane therapy for status asthmaticus in children and adults.

Two adults and two children with life-threatening asthma refractory to maximal standard therapy were treated with the inhalational anesthetic agent isoflurane. In each case, the temporal response to the initiation of therapy was striking. All patients survived and none experienced adverse reactions attributable to the drug. Rapid therapeutic benefit, minimal side effects, absence of cumulative toxicity, and ease of administration are factors supporting the use of isoflurane for patients with severe asthma.

Spironolactone-induced agranulocytosis.

Agranulocytosis associated with spironolactone administration is described in a 57-year-old man. Four days after initiation of spironolactone, leukocyte counts decreased from 8.2 to 2.3 X 10(9)/L with 6% neutrophils. Spironolactone, domperidone, and prochlorperazine were discontinued. Domperidone and prochlorperazine were reintroduced and there was concomitant improvement of the leukocyte and neutrophil counts. Substitution of triamterene for spironolactone was not associated with recurrent leukopenia. The potential association of spironolactone with granulocytopenia warrants increased awareness of this rare but serious adverse drug reaction.

A randomized clinical trial comparing ranitidine and antacids in critically ill patients.

In a randomized trial of gastric pH control for stress ulcer prophylaxis, 200 mg/day ranitidine iv was compared to antacids in 86 patients admitted to an ICU. Six (15%) patients receiving ranitidine and six (13%) given antacids failed to maintain greater than 50% of the hourly gastric pH measurements at or above 4. Increasing the ranitidine dosage to 300 mg/day did not provide additional control. One patient in the antacid group developed an overt upper GI bleed secondary to endoscopically proven erosive disease. We conclude that iv ranitidine in a dosage of 200 mg/day is as effective as antacids in reducing gastric acidity and preventing stress ulcer disease in critically ill patients.

Ruthenium-red-stained polyanionic fixed charges in peritoneal microvessels.

This study shows that the luminal surface of peritoneal microvascular endothelium, coated pits and coated vesicles are all negatively charged, unlike the limiting membrane of pinocytotic vesicles and transcellular channels. Our findings suggest that these cellular organelles have different functions as well as a different chemical composition. Anionic sites were observed along the subendothelial and subperithelial basal laminae of peritoneal capillaries and post capillary venules, respectively. Electric charge is a new parameter to be considered when analyzing transperitoneal transfer of charged macromolecules.

Noncardiogenic pulmonary edema during intrabiliary infusion of mono-octanoin.

Mono-octanoin (glycerol-1-mono-octanoate) is a medium-chain diglyceride used to dissolve gallstones. We describe a patient in whom noncardiogenic pulmonary edema developed during intrabiliary infusion of monooctanoin. The temporal sequence suggests that the drug infusion initiated the lung injury.

Cerebrospinal fluid myelin basic protein as a prognostic marker in patients with head injury.

Despite increasing interest in identifying biochemical and serologic markers to judge the severity of closed head injury in comatose patients, clinical variables remain the most readily available methods for assessing prognosis. In a series of 35 severely head-injured comatose patients, the cerebrospinal fluid (CSF) level of myelin basic protein (MBP) was analyzed by radioimmunoassay. MBP levels during the first week after injury were significantly correlated with the Glasgow outcome score at 7 days (p less than .005), 3 months (p less than .005), and 6 months (p less than .05) postinjury. Measurement of CSF MBP appears to be a useful laboratory adjunct to clinical assessment, for judging the outcome of severely head-injured patients.

The effect of vagal blockade on the variability of ventilation in the awake dog.

The present study examined the variability of breathing in five (5) awake tracheostomized dogs with the vagi intact and during complete vagal blockade produced by cooling exteriorized cervical vagal loops (VC). Breath by breath variations in both respiratory timing (assessed from the airflow signal) and the drive to the respiratory muscles (as assessed from the rate of inspiratory airflow (VI/TI) and occlusive pressure (P100) were examined. The degree of variability in the parameters characterizing breathing was evaluated from frequency distribution histograms and by calculation of the standard deviation. VC increased the mean values of VT, TI, TE, TI/TTOT, and decreased VT/TI and occlusion pressure, but had no consistent effect on the mean value of VE. The variability of VE, PACO2, VT, TI, TE, TI/TTOT was greater during VC in 4 of the 5 dogs. The increased variability of VE and PACO2 during VC appeared to be due to a poorer correlation between TI and TE. The present study suggests that vagal mechanoreceptors, presumably pulmonary stretch receptors, minimize breath by breath fluctuations in both the level and pattern of ventilation by controlling respiratory timing. An explanation, based on the model of inspiratory off-switching proposed by Beadley et al. (1975) is invoked.