The use of intensive care unit severity scoring systems in reimbursement strategies.

In summary, there are several important aspects of the GCHQCP. First, it was not mandated by any government or agency. It is the result of a business initiative designed to reduce costs by rewarding quality outcomes and efficiency. Second, it is a collaborative effort involving hospitals, physicians, and business. This cooperation initially may have been induced by a potential threat of a loss of patients, but, nonetheless, it exists. Third, the first report includes no information about costs or charges. The GCHQCP wants the focus to be on quality of care, but, in addition, the businesses involved already know a great deal about what they are paying for health care. Future financial arrangements are much more important to those involved than the documentation of current practice. The GCHQCP has required tremendous energy and cooperation on the part of many individuals and institutions. Initiating and maintaining the project has required an unprecedented level of cooperation among groups that often have divergent interests, including business leaders, physicians, and hospital administrators. Nevertheless, the GCHQCP suggests that the monitoring of clinical outcomes using validated regression models to predict expected outcomes can assist community-sponsored programs in evaluating hospital performance in large health care systems. It is hoped that with such data, consensus can develop regarding the value of health care services to patients, payers, and providers in an arena of changing societal values and priorities regarding these services. Whatever the results of the initial release of information comparing hospitals, there are bound to be legitimate concerns regarding the methods of analysis selected. These concerns may focus on methodology, issues regarding the stratification of patient risk, or the ethical questions of what outcomes are desirable in certain subgroups of critically ill patients. If this project is successful, business, the health care community, and patient concerns will be taken into account and the evaluative process will evolve and improve. In a market-based strategy to reduce costs such as managed competition, there will be winners and losers. It is our job to develop ways to ensure that patients and those who practice quality medicine efficiently are winners.

Analysis of catecholamine and vasoactive peptide release in intracranial arterial venous malformations.

Craniotomy for resection of cerebral arterial venous malformation has been associated with postoperative hypertension, which necessitates administration of large doses of antihypertensive medications to control blood pressure. Controlling blood pressure is essential because hypertensive episodes can lead to postoperative cerebral hemorrhage with increases in morbidity and mortality. We measured vasoactive peptide and catecholamine release in 13 patients who underwent resection of an arterial venous malformation and in a control group of 6 patients who presented for clipping of unruptured cerebral aneurysms. Plasma renin activity, angiotensin I and II, vasopressin, aldosterone, epinephrine, and norepinephrine levels were measured intraoperatively and for 36 h postoperatively. Analysis of variance was used to assess sample and group effects. A significant interaction between sample and groups was found for norepinephrine (p < 0.001) and renin (p = 0.002). Our data suggest that elevated plasma renin and norepinephrine levels are in part responsible for postoperative hypertension in patients undergoing resection of arterial venous malformations. Blocking the release of these hormones may help control blood pressure after surgery for removal of arterial venous malformations.

Severity of illness: APACHE II analysis of an ICU population.

We reviewed the population of a surgical intensive care unit from July 1, 1987 to June 30, 1988, adjusting for severity of illness using the APACHE II system. Nineteen different departments admitted a total of 613 patients to the surgical intensive care unit. Predicted mortality was 22.9%; actual mortality was 15.7%. APACHE II generated reports which included analysis by age, mortality risk, department, primary physician, and diagnosis. We recommend reporting intensive care unit outcome by APACHE criteria to allow more meaningful comparisons of data and standardization of quality assurance programs. Finally, we present a critical review of the current APACHE II system and describe developments to be included in APACHE III.

Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small-bore nasoenteric feeding tubes.

OBJECTIVE: To demonstrate the efficacy and safety of an updated version of the nasal "bridle," which is used to prevent the accidental removal of small-bore nasoenteric feeding tubes. DESIGN: A descriptive study. SETTING: Surgical intensive care unit in a tertiary care hospital. PATIENTS: Twenty-six critically ill patients without nasotracheal tubes or facial trauma or fractures who received enteral nutrition and either had removed or were at risk for removing their properly positioned nasoenteric feeding tubes. INTERVENTIONS: A length of one-eighth inch (3.2 mm) umbilical tape is looped around the nasal septum and vomer by serially attaching the ends of the umbilical tape to a suction catheter, passing the catheter through the nostrils, into the oropharynx, and retrieving the ends from the oropharynx. The properly positioned umbilical tape loops into one nostril around the vomer, and out the other nostril. The feeding tube is then anchored to the umbilical tape with a central venous catheter fastener clamp. MEASUREMENTS AND RESULTS: Communicative patients denied discomfort, and there were no episodes of bleeding, infection, sinusitis, or nasal septal trauma caused by the umbilical tape bridle. Five patients had the bridle in place >30 days. There were only two cases in which the bridle failed to prevent removal of a feeding tube. One of these cases occurred because the fastener clamp anchor failed, but this patient had had the same bridle and feeding tube for 170 consecutive days. CONCLUSIONS: An umbilical tape bridle with a central venous catheter fastener clamp anchor is a safe and effective method to prevent the accidental removal of nasoenteric feeding tubes in critically ill patients. We recommend its use in confused or uncooperative patients, or when the risk of unintentional feeding tube removal is high.

Comparison study of intraosseous, central intravenous, and peripheral intravenous infusions of emergency drugs.

Intraosseous infusion of emergency drugs is a lifesaving alternative to intravenous administration when intravenous access cannot be rapidly established. We studied the comparative pharmacokinetics of the following six emergency drugs and solutions: epinephrine hydrochloride, 0.01 mg/kg; sodium bicarbonate, 1 mEq/kg; calcium chloride, 10 mg/kg; hydroxyethyl starch, 10 mL/kg; 50% dextrose in water, 250 mg/kg; and lidocaine hydrochloride, 1 mg/kg. Studies were conducted in normotensive, anesthetized dogs, with three animals studied with each of the drugs or solutions and each animal being treated with all three routes of administration (central intravenous, peripheral intravenous, and intraosseous) in randomized sequence. The effects of epinephrine were also assessed in a shock model. The intraosseous route of administration was comparable with the central and peripheral intravenous routes for all of the emergency drugs and solutions studied, with equivalent magnitudes of peak effect or drug level and equal or longer durations of action. Time to placement of the intraosseous needle varied from 15 seconds to 5 minutes, with a mean of 60 seconds. Time to placement of the needle varies with the skill and experience of the individual. With experience, all individuals could place the intraosseous needle in 60 seconds or less. The intraosseous route is comparable in effect to the central and peripheral intravenous routes of drug administration for epinephrine, sodium bicarbonate, hydroxyethyl starch, calcium chloride, 50% dextrose in water, and lidocaine and is a clinically feasible alternative when intravenous access will be critically delayed.