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

BACKGROUND AND AIMS: The study evaluates the utility of therapeutic intervention scoring system (TISS-28) in quantifying the resource utilization, costs and predicting outcome of critically ill patients. MATERIALS AND METHODS: TISS-28 was prospectively applied to patients consecutively admitted to the intensive care units (ICU) of three public teaching hospitals and two private hospitals in Trinidad on a daily basis for a period of eight weeks. Demographic data, diagnoses on admission, nurse-patient ratio, ICU length of stay and hospital outcomes were recorded. Simplified acute physiology score (SAPS)-II was applied for all adult patients. Costs were calculated from data collected from the public hospitals in relation to TISS-28 score. RESULTS : TISS-28 scores of five hundred and ninety-five patient-days were analyzed. The median daily TISS-28 per patient was 27 [24.5, 30.6 quartiles (IQR)]; the median day-1 TISS-28 score was 29 (25, 33 IQR) and the median last day TISS-28 score was 25 (21, 30 IQR). The overall average TISS per nurse was 26.2 per day. The mean cost per patient per day was 414 US dollars. The discriminatory function of day-1 TISS-28 as a prognostic scoring system was less compared to SAPS II as shown by the area under the receiver operating characteristic curve (0.65 compared to 0.71). CONCLUSIONS: TISS-28 is useful for evaluating the resource utilization and costs and may not be useful as a prognostic scoring system.

Cost evaluation in the intensive care units of Trinidad applying the cost-blocks method - an international comparison.

This study evaluated the costs of intensive care in Trinidad applying the cost-blocks method. Data regarding demographics, severity of illness, therapeutic interventions and length of stay were prospectively recorded for 111 patients admitted to four intensive care units during a 3-month period. Annual costs, cost per admission, cost per patient-day and cost per therapeutic intervention score point were derived. The cost-block for staff, especially medical staff, was the largest proportion of the expenditure. Process of care and outcome were comparable, whereas costs were lower than the developed countries. The median cost per intensive care unit bed per year and cost per patient per day in Trinidad were 133,117 pounds and 366 pounds, respectively, in comparison with 265,163 pounds and 904 pounds in the UK. The cost-blocks method is a useful framework for evaluating the costs of intensive care and for comparing costs between countries.

Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Purpose: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. Materials and Methods: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. Results: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70 per cent and 64 per cent with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. Conclusions: Analytic hierarchy process is a very useful model to measure the global performance of an ICU.

Nosocomial infection in an Intensive Care Unit in a private hospital

The nosocomial infection rate in an Intensive care unit (ICU) of a private hospital was assessed during an 18-month survey. From 629 admissions to the ICU, 139 hospital-acquired infections were identified. The rate was 22.1 percent compared to the overall nosocomial infection rate of 15.3 percent for the entire hospital. In the ICU, the main infections occurred in the respiratory tract, 41 (29.5 percent), followed by surgical wounds, 35 (25.2 percent), urinary tract, 28 (20.1 percent) and the blood stream, 24 (17.3 percent). From 165 bacterial isolates, 80 percent of isolates were gram-negative rods, with P aeruginosa, 48 (36.6 percent), being the predominant gram-negative isolate followed by Klebsiella pneumoniae, 27 (20.6 percent), and Enterobacter sp, 22 (16.8 percent). The main gram-positive isolates were S aureus, 23 (41.8 percent), coagulase-negative Staphylococci, 17 (30.9 percent), and Enterococci, 11 (20.0 percent). Of the 23 S aureus strains, 15 (65.2 percent) were methicillin-resistant (MRSA), (8 MRSA were from surgical wounds, 5 from the respiratory tract and 2 from infected urine). Only 2 of the 17 (11.8 percent) coagulase-negative staphylococci were methicillin-resistant, and both were isolated from wounds. Resistance to ampicillin and augmentin (amoxicillin-clavulanic acid) was high, 81.9 percent and 55.4 percent, respectively. Gentamicin, azteronam, piperacillin-tazobactam showed resistance rates of less than 15 percent. Infection control measures aimed at reducing nosocomial infections at the hospital are often frustrated by apathy of hospital administrators who apparently are insensitive to the high nosocomial infection rate. Effort by the infection control team through seminars, lectures and newsletters have begun to show improvements in attitude and awareness of staff to infection control and preventative measures within the institution. (AU)

Trauma admissions to the Intensive Care Unit of the University Hospital of the West Indies, Kingston 7, Jamaica [abstract]

OBJECTIVE: Trauma is the single most common reason for admission to the surgical wards at the 500-bed University Hospital of the West Indies in Kingston, Jamaica. This study was undertaken to assess the impact of trauma on the Intensive Care Unit (ICU) in terms of time, resources, staffing and cost. It also assesses the pattern profile, frequency and outcome of trauma cases admitted to the multidisciplinary 8-bed ICU. METHODS: Records of all trauma patients admitted to the ICU over a period of a 5-year period between October 1995 and September 2000 were reviewed. Approval for this study was obtained from the institutional ethics committee. Data collected included age, gender, diagnosis, cause of trauma, referring specialities, duration of admission and outcome. RESULTS: During the study period 161 patients with severe trauma were admitted to the ICU, representing 12 percent and 16 percent of total and emergency ICU admission, respectively. There was a preponderance of men (M:F = 4:1), and they were generally younger than the average ICU patient (mean age 35 vs. 42 years). Trauma admission were almost exclusively emergencies (98 percent) and came mainly from the operating theatre/recovery room (67.3 percent) and Accident and Emergency (16.4 percent). The length of ICU stay of all trauma patients was a mean (SD) of 6.3 (8.4) days. More than one-half of the non-survivors (55 percent) died within 24 hours of ICU admission and 84 percent died by 7th ICU day. Road traffic accidents remain the leading cause of severe trauma (45 percent), but there was also a high prevalence of intentional and interpersonal violence (42 percent). CONCLUSION: Severe trauma in Jamaica is a major cause of hospitalization and intensive care utilization, and hence consumes a significant amount of already under-funded healthcare budget. In most instances it is preventable. Trauma prevention is therefore the most effective management. The need for a high dependency unit and expansion of the existing ICU is also underscored. (AU)

Coronary artery bypass graft outcome: the Trinidad and Tobago experience

The study is a retrospective review of the demographic, clinical, angiographic, and operative data of the first 205 consecutive CABG operations performed by Caribbean Heart Care at the Eric Williams Medical Sciences Complex (EWMSC), Trinidad and Tobago, between November 1993 and December 1997. The aim of the study was to determine the in hospital and intermediate term follow up results. The mean age of patients was 59 ñ 10 years and 78 percent male. Sixty-four percent were of East Indian descent, whereas, 16 percnt were of Africian descent. Forty-eight percent of the patients were hypertensive, 46 percent were diabetic, 33 percent had hyperlipidaemia, 20 percent had a recent history of cigarette smoking and 16 percent were obese. Sixty-five percent had a positive family history of ischaemic heart disease. The average time interval between angiography and surgery was 2.3 months. At the time of angiography, 63.5 percent of patients had Canadian Cardiac Society (CCS) class 3 or 4 angina. The mean ejection fraction was 61 ñ 15 percent. Wall motion abnormalities were seen in 67 pecent of patients. Significant stenoses of the left anterior descending artery, right circumflex artery, circumflex and ramus coronary arteries were present in 91 percent, 78 percent, 54 percent and 5 percent, respectively. Many patients (67 percent) had severe diffuse disease on angiography. The mean intensive care stay was 2.2 ñ 0.8 days. In hospital mortality was 3.9 percent (8/205). THe most frequent post operative complicaton was haemorrhage (2.6 percent). Acute renal failure occurred in 2.1 percent; pulmonary collapse, 1.6 percent; 1 percent and cardiac arrest , 1 percent. Both sternal wound infections and systemic sepsis occurred in 0.5 percent. Intermediate term follow-up data were obtained for 92 percent (189/205). The duration of follow-up ranged from 1 to 5 years (mean 3.7 years). During the follow up period, 7 patients (3.4 percent) died. Angina severity was reduced from a mean CCS score of 2.61 ñ 0.95 before CABG ot 1.22 ñ 0.55 at the time of follow up (p<0.0001). Overall 4-year mortality compared favourably with data from international studies. Among survivors, quality of life improved as evidenced by the reduction in the mean angina score.(Au)

Methicillin resistant Staphylococcus aureus

The prevalence of methicillin resistant Staphylococcus aureus (MRSA) at the General Hospital, Port-of-Spain, between June 1995 and May 1996 was determined. The MRSA prevalence rate was 4.6 percent of all S aureus isolates, with all but one nosocomially acquired. 15 isolates were associated with infections, and three were colonizing strains. 17 of the 18 patients with MRSA had received antibiotics previously, including 13 who had received multiple antibiotics. Skin and soft tissue were the sites of infection and colonization in 12 cases; and surgical wards and the Intensive Care Unit (ICU) accounted for 16 MRSA isolates. All isolates were sensitive to vancomycin and all but one were resistant to gentamicin. MRSA occurred sporadically in a wide distribution of wards and physicians' services, although the isolation of three strains from the ICU and three strains from a surgical ward were temporally related. Only one of two deaths was attributable to MRSA. Control of the spread of MRSA in this hospital must include the reinforcement of the appropriate use of antibiotics, hand washing and appropriate isolation of patients in the surgical and intensive care wards.(Au)

Stress among nurses working in intensive care units (ICUs) - Poster presentation

ICU nurses are subject to great stress in view of the serious nature of the patients and intensive monitoring and the shift work. We designed a study to assess the effect of some of these potential stressors: "working" or "nonworking origin", as well as to determine those working stimuli which produce anxiety. A study was done among 14 nurses (age 23 to 33, 1-7 years of experience) from different ICUs. Arterial blood pressure (ABP) and heart rate (HR) were measured twice daily in 8 different working days, along with body temperature (BT). Results of the survey were analyzed using Square Chi test (p=0.05) and the other variables through the Analysis of Variance test (p=0.001). The results of ABP, HR and BT showed no differences neither each day nor among the 8 different days. Only three stimuli of any origin showed significance: loss of interest to family activities or the job, the feeling of tension or anxiety, and non-serious condition of diseases. The most anxiogenic stimuli were scarcity of supplies and the shortage of qualified staff. These results agree with previous findings in relation with the low disturbing effects of working conditions in ICU and some non-labour conditions. The most anxiogenic stimuli were related to the responsibility and qualification of the surveyed nursing staff (AU)

Myocardial infarction in Antigua: 1990 to 1995

Between January 1990 and May 1995, 117 patients were admitted to the Intentsive Care at Holberton Hospital, Antigua, for chest pain due to suspected acute myocardial infarction. 39 (45 percent) of 86 patients whose records were available for retrospective review had confirmed (27 patients) or probable (12 patients) acute myocardial infarction. Risk factors identified among the patients included hypertension, diabetes, tobacco smoking, hypercholesterolaemia and obesity. On admission, 82 percent were Killip class I and 18 percent were Killip class II. Medications in the Intensive Care Unit included nitrates, aspirin, calcium and channel blockers, beta-adrenergic blockers, heparin and angiotensin converting enzyme inhibitors (21 percent). No thrombolytic agents were available. THe average hospital stay was 10 days and the in-hospital mortality rate was 13 percent. These data indicate that early mortality from acute myocardial infarction can be reduced in developing countries by early admission to an Intensive Care Unit and use of drugs known to be effective in its treatment.(AU)

Nosocomial infections in a thirteen-bed critical care unit in Matinique: epidemiology and cost analysis - abstract

The aim of our study was to analyse the problems caused by nosocomial infections (NI) in our intensive care unit (ICU). 239 patients admitted between January and June 1995 were included in the study. 33 episodes of nosocomial infection were diagnosed in 19 patients (7.9 percent). The overall incidence of NI was 13.9 percent. Lower respiratory tract infections were the most common (6.3 percent). Patients infected on admission to the ICU had more NI than other patients (odds ratio = 3.42, 95 percent confidence interval 3.28 - 4.52, p< 0.05). Gram negative bacteria were involved in 73.2 percent of NI. Acinetobacter baumanii and Peudomonas aeruginosa were responsible, respectively, for 22.4 percent and 25.4 percent of NI. The additional cost due to NI was 33 percent for laboratory investigations and 34 percent for antibiotics. After analysis of our results, our recommendations are a cautious use of antibiotics, more efficient diagnostic tools and particular care in preventing cross contamination of our mostly severely ill or infected patients. (AU)

Tetanus: a recurring intensive care problem

A fifteen-year retrospective study of 108 cases of tetanus admitted to the Intensive Care Unit (ICU) at the University Hospital of the West Indies is presented. Males predominated (70 percent), with peak incidence occurring amongst the young and the elderly. In 57 percent the disease was severe enough to require neuromuscular blockade and controlled ventilation. Respiratory complications occurred most commonly (80 percent), predominantly as a result of infection. Dysautonomia, exhibited by 55 percent of patients, presented the greatest difficulty in management. Mortality was high (20 percent), with sudden cardiac arrest being the most common cause of death. The average duration of stay in the ICU was long (27 days). As Jamaica is a Third World country with limited resources, the continued occurrence of this preventable disease represents a drain on existing intensive care funds. This must be brought to the attention of institutions responsible for planning health care programmes for developing countries (AU)

Suspected acute myocardial infarction: intravenous beta-blockade outside the coronary care unit: a pilot study

Shortage of Coronary Care Unit (CCU) beds prompted a study (I) to determine the number of patients with a suspected acute myocardial infarction (SAMI) who could not be placed in the CCU, but qualified for intravanous (IV) B-Blocker therapy, and (II) to assess the safety of such therapy in a general medical ward. During a six-month period, 34 patients with chest pain and E.C.G. changes of SAMI could not be placed in the CCU. Criteria for exclusion from B-Blocker therapy were the presence of >= 1 of the following: (1) age > 70 years, (2) Systolic B.P. < 100 mmHg, (3) Heart rate < 60 /min., (4) Cardiac failure, (5) Heart block, (6) Poor peripheral circulation, (7) Asthma or chronic bronchitis, and (8) Prior therapy with B-Blocker or calcium antagonists. 15 (44 percent) patients were excluded from therapy based on the above criteria. 19 (56 percent) received 5-10 mg atenolol IV within 3-10 hours of onset of chest pain and atenolol 100 mg daily was started immediately and continued indefinitely. 12 of these patients had an anterior wall, and 3 an inferior wall infarction. 3 developed congestive cardiac failure and none required anti-arrhythmic therapy. There were 2 deaths - 1 from ventricular asystole, and the other from cardiogenic shock 8 and 12 hours respectively after IV atenolol. While this small-scale study highlights the need for more CCU beds for optimum care, our results suggest that selected patients with SAMI managed in the general medical wards can still safely obtain the benefits of IV B-Blockade. (AU)

Ethical issues in intensive care: a look to the 90s - abstract

With the advent of Intensive Care Units has come the ability to offer life support technology to patients with failure of the vital systems, patients who would die without this type of support. Ethical decisions have now to be made as to the selection of patients who would have the optimum response to such technology. Such decisions are not easily made as the factors on which they are sometimes based are neither objective nor well-defined. These factors are not subject to patients pathology only, but als to the availability of the necessary equipment and personnel. Although such decisions have to be made in every country offering intensive care, they become more important in those countries with scarce resources, e.g., the West Indian Islands. In addition to the above issues, newer issues will be discussed, e.g., the impact of the AIDS patient on ICU personnel, "Living Wills", etc (AU)

Availability of suitable kidney transplant donors from an ICU population - abstract

In establishing a renal transplant service in the Bahamas, a review of the availability of suitable cadaveric organ donors in the Intensive Care Unit (ICU) was carried out over the period January, 1988 to October, 1988. Clinical criteria for suitable organ donation and brain deaths were applied to all patients who died in the ICU. Over the nine-month period, 351 patients were admitted to the ICU and 107 died; 8 of 107 deaths fulfilled the criteria for cadaveric organ donation. All suitable victims succumbed to head inury. The mean age was 27 years with 6 to 8 deaths occuring within 4 days of admission. Issues affecting donor procurement rate in major transplant centres are not applicable in the centralized stem under study where all patients requiring critical care are referred to the ICU. It is concluded that cadaveric organ donation alone is inadequate to fulfill the criteria for cadaveric organ donation. All suitable victims succumbed to head injury. The mean age was 27 years with 6 to 8 deaths occuring within 4 days of admission. Issues affecting donor procurement rate in major transplant centres are not applicable in the centralized stem under study where all patients requiring critical care are referred to the ICU. It is concluded that cadaveric organ donation alone is inadequate to fulfill the organ demand for renal transplantation. In the Bahamas a policy of using living related donor organs whenever possible is favoured. Casual observation of road traffic and ICU mortalities fosters an erroneous assumption of potential donor organs (AU)

Anaesthetics and intensive care 1948-1988 - abstract

This paper will review the development of the Department of Anaesthetics and Intensive Care at the U.H.W.I. and the growth of the specialty of anaesthesia between 1948 and 1988 (AU)

Infection in a multidisciplinary intensive care unit at the University Hospital of the West Indies

The records of 1,252 patients were reviewed to determine the incidence of infection, mortality and associated risk factors in our multi-disciplinary intensive care unit (MD-ICU) during the period 1977 to 1982. The infection rate and the mortality rate were 24 percent and 22 percent respectively. The mortality rate in the infected group was 25 percent. The infection rate was higher in the intra-abdominal and trauma group as compared to the cardio-thoracic group (P<0.05). The incidence of ICU-acquired respiratory tract infection (41 percent), wound infection (17 percent) and urinary tract infection (15 percent) was significantly different from non-ICU acquired infections (P<0.05). The commonest site of infection was the respiratory tract (37 percent). The incidence of infection was directly related to the duration of medical devices left in situ and the length of stay in the unit (more than seven days) (AU)