[Documentation of surgical performance--does more really help more? Comparison of the effects of maximum and limited documentation depth of clinical patient data on theoretical revenue volume of a surgical clinic after introduction of the DRG-based reimbursement system]. / Chirurgische Leistungsdokumentation--Hilft viel wirklich viel? Vergleich der Auswirkung von maximaler und geringer Dokumentationstiefe klinischer Patientendaten auf das theoretische Ertragsvolumen einer chirurgischen Klinik nach Einführung des DRG-basierten Entgeltsystems.

INTRODUCTION: The forthcoming introduction of a DRG-based account system in Germany aims at higher transparency and economic efficiency, particularly in the sector of in-patient health care. The availability of documentation of the highest quality, taking into account all potentially relevant diagnoses, appears to be the best method for achieving maximum revenue in individual surgical units. The aim of the study was to determine the relevance of various degrees of documentation depth on calculated DRG-based revenue. Furthermore, we evaluated whether improvements in the quality of documentation can be realized in current hospital organization. METHODS: In a prospective study, clinical data from 402 in-patients were collected and revenues were calculated based on the Australian-Refined DRG system. Various qualities of documentation were defined. In order to find the medical sectors most sensitive to "under-documentation", homogenous cases were classified into 23 treating groups, according to diagnosis. RESULTS: In 267 cases, maximum revenue was determined only by one main diagnosis, while better results could be achieved in 137 cases (34%) by extended documentation quality. Half of this gain could only be achieved by an independent medical documentation specialist. An upper limit of documentation intensity (number of diagnoses) could be defined. Maximum gain did not require maximum number of diagnoses. CONCLUSIONS: Documentation depth has an important influence on the calculated revenue of surgical therapy based on AR-DRG system. The quality and depth of the documentation is not, in itself, sufficient. In order to be really effective, it requires the highest degree of professionalism from hospital staff.

Predicting eventual success or failure to wean in patients receiving long-term mechanical ventilation.

PURPOSE: To determine if the ultimate ability of a long-term ventilated patient to wean can be predicted at the time of his or her admission to a long-term ventilator unit. DESIGN: Two-phased prospective study. SETTING: Long-term ventilator facility, university-affiliated. SUBJECTS: Adults ventilated for an average of 3 weeks, who did not have sepsis and who did not have chest tubes or progressive neurologic impairment. INTERVENTIONS: On admission to the long-term ventilator unit, historic factors, ventilator history, and the following laboratory and metabolic tests were obtained: electrolytes, serum calcium, magnesium, and phosphorus, WBC, hemoglobin, albumin, total protein, transferrin, oxygen consumption, carbon dioxide production, respiratory quotient, and dead space/tidal volume. The patients were then placed in a weaning protocol utilizing increasing duration of pressure support ventilation during the day with complete rest at night. Forty-two days after enrollment in the study, representing three times the duration of the weaning protocol, the patients who successfully weaned were compared to those who remained ventilator dependent (n = 20). Patients who died or were transferred to another institution were excluded from this phase of the study, because we were trying to develop parameters that would be predictive of successful weaning. A parameter was considered to be predictive, and retained for the scoring system, if it produced at most 15% false-positives and false-negatives. A score of 0 was then assigned to the threshold value that produced no false-positives; 2 to the threshold value that produced no false-negatives and 1 to the intermediate values. The scoring system was then applied to a new prospective group of patients (n = 72). MEASUREMENTS AND MAIN RESULTS: Of all the parameters evaluated, only the following satisfied the false-positive and false-negative requirements; static compliance, airway resistance, dead space to tidal volume ratio, PaCO2, and frequency/tidal volume. Applying these, in the scoring system, to the initial group of patients, demonstrated that a score greater than 3 was associated with failure to wean; a score less than 3 was associated with successful weaning, and a score of 3 was not predictive. Using these thresholds, the data were applied to the new prospective group of patients, which again demonstrated that a score of greater than 3 was associated with failure to wean in all cases. A score less than 3 was again associated with successful weaning but there were two false-positives. The sensitivity, specificity, and positive predictive and negative predictive values for the scoring system were 1.0, 0.91, 0.83, and 1.0, respectively. None of the individual parameters included in the scoring system demonstrated equivalent statistical results. All but two of the patients who died prior to finishing the weaning period had weaning scores, which suggested that they would not be successfully weaned. CONCLUSIONS: Parameters that are generally available, when combined into a scoring system, can predict at the time of admission to a long-term ventilator unit, in most cases, whether a patient will eventually wean. The scoring system resulted in no false-negatives and an acceptable number of false-positives. None of the individual parameters were as reliable as the scoring system as a whole.

Medical effectiveness of esophageal balloon pressure manometry in weaning patients from mechanical ventilation.

OBJECTIVE: To determine the efficacy of a new respiratory monitor, which uses esophageal balloons, in aiding clinicians attempting to wean patients from mechanical ventilation. DESIGN: Prospective study of patients who were deemed ready to be weaned after having required mechanical ventilation for a minimum of 3 days. Each of the patients served as his or her own control. SETTING: University medical intensive care unit. PATIENTS: The series consisted of 23 consecutive patients who were ready to wean from mechanical ventilation. INTERVENTIONS: Before the onset of the study, two weaning strategies were developed. One strategy involved using clinically available weaning parameters. The other strategy involved using esophageal balloon data that was recorded via a new respiratory monitor. Each of the weaning strategies resulted in the development of a scoring system that could be rigidly adhered to and which determined, without bias, to what extent the patient could be weaned each day. Rigid criteria were also developed to determine whether the weaning trial was successful or not. The two strategies were then compared to determine the ability of the strategy to shorten ventilatory time. MEASUREMENTS AND MAIN RESULTS: Each patient was evaluated daily by the two weaning protocols. At each weaning step, the two protocols were compared with respect to degree of aggressiveness and tolerance of the weaning maneuver by the patient. A protocol was judged superior if it resulted in more aggressive weaning without increased patient intolerance. The clinicians evaluating the patient with the clinical protocol could accelerate or retard the number of weaning steps by one step, based on the patient's clinical state and the clinician's experience. There was no such freedom in the esophageal protocol. The major finding was that in 40.5% of the instances, the protocol involving the esophageal balloon resulted in more aggressive weaning without patient intolerance. In 11.6% of the cases, the clinical protocol was more aggressive. Both protocols predicted the same number of weaning steps 39.8% of the time. In all these instances, the patient tolerated the weaning suggested. The use of data from the esophageal protocol resulted in weaning the patients 1.68 days faster than the use of data from the clinical protocol. CONCLUSIONS: The respiratory monitor, using esophageal balloon technology, is effective in that it can provide the clinician with data that can result in more aggressive weaning from mechanical ventilation without an increase in patient intolerance. The duration of mechanical ventilation can be shortened when these data are applied via a rigidly controlled weaning strategy.

The LBI-method for automated indexing of diagnoses by using SNOMED. Part 2. Evaluation.

We present a simple, formal, lexicon-based method for automated indexing of diagnoses based on the Systematized Nomenclature of Medicine (SNOMED), called LBI-method. Part 1 gave an introduction to the LBI-method and presented its realisation as application system SALBIDH. Part 2 presents the design and the results of an evaluation study to judge the quality of the LBI-method. In this evaluation study the quality of automated indexing as well as the quality of the retrieval of patient data by using automated indexed diagnoses was examined. The results show that the retrieval based on SNOMED indices is at least as good as the retrieval based on ICD classes despite a lot of indexing errors. From this we gather that our system is not yet good enough for immediate routine use but that an appropriate indexing quality and, as a result, a higher retrieval quality can be achieved after few improvements of the LBI-method, especially after revision of the lexicons.

The LBI-method for automated indexing of diagnoses by using SNOMED. Part 1. Design and realization.

We present a simple, formal, lexicon-based method for automated indexing of diagnoses based on the Systematized Nomenclature of Medicine (SNOMED II), called the LBI-method. Part 1 gives an introduction to the LBI-method and presents its realization as application system SALBIDH. The underlying model states that a diagnosis is represented by a set of indices of any nomenclature. The LBI-method is defined as a composition of functions, which in turn define the 3 steps of the LBI-method: preprocessing, morphological analysis, and semantic analysis. Part 2 will focus on the design and the results of an evaluation study to judge the quality of the LBI-method. In this evaluation study the quality of automated indexing was examined as well as the quality of the retrieval of patient data by using automated indexed diagnoses.

Relatively low proportion of dystrophin gene deletions in Israeli Duchenne and Becker muscular dystrophy patients.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are allelic disorders caused by mutations in the X-linked dystrophin gene. The most common mutations in western populations are deletions that are spread non-randomly throughout the gene. Molecular analysis of the dystrophin gene structure by hybridization of the full length cDNA to Southern blots and by PCR in 62 unrelated Israeli male DMD/BMD patients showed deletions in 23 (37%). This proportion is significantly lower than that found in European and North American populations (55-65%). Seventy-eight percent of the deletions were confined to exons 44-52, half of these to exons 44-45, and the remaining 22% to exons 1 and 19. There was no correlation between the size of the deletion and the severity of the disease. All the deletions causing frameshift resulted in the DMD phenotypes.

Analysis of indications for intensive care unit admission. Clinical efficacy assessment project: American College of Physicians.

OBJECTIVE: To formulate recommendations for the development of intensive care unit (ICU) admission policies. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to admission criteria for intensive care or coronary care units (CCUs). PATIENTS: Studies identifying patients least likely to benefit from ICU or CCU admission were analyzed. Patient populations of interest included adults (> or = 18 years of age) with medical conditions possibly requiring intensive care; trauma patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 970 articles identified as being pertinent to intensive care, only two case-control studies used the direct method of measuring the effect of ICU intervention on mortality. No studies were found that compared outcomes of low-risk patients treated in a CCU vs those treated in alternative hospital locations, and none identified patients with a very high probability of a bad outcome. CONCLUSIONS: The use of decision-making models for ICU and CCU admissions must be tested in prospective, randomized clinical trials. Critical care units and ICUs should be studied separately. Existing studies of early discharge from CCUs need to be summarized and evaluated. The triaging of ICU patients to alternative hospital locations needs to be evaluated, as do existing predictive models for early triage decision-making.

Analysis of indications for early discharge from the intensive care unit. Clinical efficacy assessment project: American College of Physicians.

OBJECTIVE: To formulate recommendations for the development of early intensive care unit (ICU) discharge criteria for low-risk monitor patients. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to ICU discharge criteria. PATIENTS: Studies identifying patients admitted to ICUs who could be characterized as low risk. Patient populations of interest included adults (> or = 18 years of age) with low-risk medical or mixed medical/surgical conditions; cardiac care unit and burn patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1,492 articles identified as being pertinent to ICU discharge, only 2 studies (by the same group of investigators) were found that distinguished low-risk populations among medical and mixed medical/surgical ICU patients. The physiologic component of the Acute Physiology and Chronic Health Evaluation (APACHE) was used in both of these studies to ascertain the degree of risk. No studies were found that compared outcomes of low-risk patients remaining in the ICU after 24 h with those transferred to other hospital locations. CONCLUSIONS: Objective methods (such as APACHE III) should be used to identify low-risk patients at 24 h post-ICU admission. A multicenter study should be conducted to compare outcomes on patients identified as low risk who are randomly assigned to alternative hospital locations for treatment versus those assigned to continued ICU treatment until routine ICU discharge. Mortality and quality of life data should be used as outcome measures (prior to ICU admission and 6 months post-ICU discharge).

Use of ultrahigh frequency ventilation in patients with ARDS. A preliminary report.

STUDY OBJECTIVE: Our objective was to compare the efficacy of ultrahigh frequency ventilation (UHFV) (frequencies > 3 Hz) with respect to oxygenation, airway pressures, and hemodynamic parameters in patients with adult respiratory distress syndrome (ARDS) who were not responding to conventional ventilation. DESIGN: We used a prospective, multicenter, nonrandomized study design in which each patient served as his own control. SETTING: Three university-affiliated, tertiary-care medical centers participated. PATIENTS: Persons aged 16 to 79 years old with ARDS and unresponsive to conventional ventilation, as defined by a Food and Drug Administration (FDA) approved protocol, were included. INTERVENTIONS: Ninety patients who were not responding to conventional ventilation were changed to UHFV using a microcomputer-controlled device. MEASUREMENTS AND RESULTS: The patient's blood gas, hemodynamic, and airway pressure variables were measured just before, and at 1 and 24 h after the switch to UHFV. We demonstrated clinically significant improvements in arterial oxygen tension (PaO2) and reductions in peak and mean inspiratory pressures. CONCLUSIONS: In a multicenter study, UHFV improved respiratory gas exchange and reduced airway pressure variables at both 1 h and 24 h after the onset of UHFV when compared with conventional ventilation just prior to the change and without hemodynamic deterioration, in patients with severe ARDS.

Techniques for weaning a patient from mechanical ventilation; when to begin, what method to use, and how to predict outcome.

A variety of methods have been employed to help wean patients from prolonged ventilatory support. Although synchronized intermittent mandatory ventilation is probably the most widely used, it has not been shown to be clearly superior to T piece or pressure support weaning. Regardless of the method you choose, begin weaning before the patient's lung function has returned to normal or baseline levels and end when the patient shows the minimum capacity necessary to sustain himself off the ventilator. The patient's response to the change in the level of ventilatory support governs the rapidity of weaning. The rapid shallow breathing index can be useful in predicting weaning outcome, as is the patient's ability to tolerate a weaning trial.

Validation of respiratory mechanics software in microprocessor-controlled ventilators.

BACKGROUND AND METHODS: Several microprocessor-controlled ventilators, available for clinical use, contain optional computer software programs capable of performing near-instantaneous determinations of airway resistance and lung compliance. This study was undertaken to determine the validity of the measurements for airway resistance and lung compliance obtained by the software packages on three microprocessor-controlled ventilators. Three ventilator models were studied. An artificial ventilator-patient circuit was constructed using a test lung and an endotracheal tube. Airway pressure and gas flow curves were recorded using conventional means. Static lung compliance and airway resistance were calculated using standard equations, while automated measurements were obtained from the ventilators. The following parameters were then varied to simulate a wide variety of clinical situations: tidal volume, peak inspiratory flow rate, respiratory rate, endotracheal tube, and test lung compliance. RESULTS: Automated measurements were highly correlated with values obtained manually (resistance: Puritan-Bennett 7200a r2 = .94, Bear 5 r2 = .98, Veolar r2 = .96; compliance: 7200a r2 = .93, Bear 5 r2 = .97, Veolar r2 = .97). Calculated limits of agreement between the two methods demonstrate that although not in absolute agreement, the software-determined values for airway resistance and lung compliance differed from the manually derived values in a ventilator-specific, predictable fashion. CONCLUSIONS: The correlation and agreement demonstrated between values of airway resistance and lung compliance measured by the respiratory mechanics software packages and those values derived manually suggest that these software packages may be useful for measuring trends, as well as responding to treatment in the clinical setting. These results apply only to the controlled, mechanical ventilation mode. Further studies are indicated to validate this software in patients capable of generating spontaneous breaths.

The technique of instituting mechanical ventilation. Patient preparation; endotracheal intubation; monitoring.

Potential indications for mechanical ventilation include hypoxemia unresponsive to oxygen administration, hypercapnia resulting in acidemia, and an unstable chest wall. For best results, carefully prepare the patient (both physically and emotionally) before instituting ventilation. Sedatives and local anesthesia can facilitate intubation; avoid paralytic agents unless you are experienced at intubation. The oral route is most commonly used. Once the patient circuit is attached to the endotracheal tube, reexamine the patient and double-check the inspiratory flow and I:E ratio; adjust the ventilator's settings as necessary. Monitor the patient frequently to ascertain the adequacy of alveolar ventilation and arterial oxygen.

A clinical librarian program in the intensive care unit.

OBJECTIVES: Clinical decision-making in the intensive care setting frequently requires the physician to obtain additional resource information. Physicians typically consult with colleagues, use personal medical books or files, or use library materials. Clinical librarians may also be used. This study evaluates the effectiveness of an ongoing clinical librarian program in the intensive care setting. DESIGN/SETTING: During a 3-month period, house officers in the medical and coronary ICUs in a major teaching hospital asked the clinical librarian 66 patient-care questions. Attached to the information selected by the clinical librarian was a questionnaire asking how the information was applied. MAIN RESULTS: There was an overall response rate of 65.1%. House officers indicated that the information: a) aided in diagnosis (37.2%), b) contributed to a better understanding of the therapy (51.2%), and c) resulted in improved patient management (30.2%). In some instances, the information was multibeneficial. The clinical librarian spent an average of 47 mins/question, and accumulated an average computer charge of $3.59. Personnel and on-line charges over the 3-month study period averaged $45/question. CONCLUSIONS: Clinical librarian programs may deliver patient-specific information in a timely, cost-effective manner. This information has an impact in the intensive care setting.

Beyond the basics: operating the new generation of ventilator. A look at the features and functions of these units.

Most modern ventilators have several key features in common: microprocessor control of operational and monitoring functions; electromechanical valves to control and adjust gas flow patterns; and extensive monitoring systems. In addition, these machines can provide a number of different modes of ventilation (including pressure support). Though not microprocessor-controlled, the Siemens Servo 900 series ventilators use feedback electronics to adjust inspiratory flow based on expiratory flow to meet preset volumes. In contrast, the Bennett 7200 units use microprocessor-regulated solenoid valves to deliver preset tidal volume. High-frequency ventilators deliver smaller tidal volumes at rates greater than 60 bpm.

Helium-oxygen mixtures in intubated patients with status asthmaticus and respiratory acidosis.

Seven patients with status asthmaticus intubated for respiratory failure who had elevated airway pressures and persistent respiratory acidosis were successfully ventilated using a mixture of 60 percent helium and 40 percent oxygen. All patients experienced a rapid reduction in airway pressures, CO2 retention, and resolution of acidosis while breathing a helium-oxygen mixture. There were no untoward effects. Helium-oxygen mixtures improve ventilation by reducing the Reynolds number and reducing density dependent resistance. Helium's beneficial effects are due to its high kinematic viscosity, high binary diffusion coefficient for CO2, and high diffusivity. Helium-oxygen mixtures should be considered for use in mechanically ventilated asthmatics with respiratory acidosis who fail conventional therapy.

A simple on-line information system for quality assessment.

Many aspects of medicine would be well served by a simple method to assess the outcome of care in specified groups of patients. This study examined charts of patients with stomach cancer on a surgical service. Two digits were added to the ICD-9 number in the routine discharge data; one for the nature and severity of case and the other for the outcome of care. The digits were designed for on-line registration at discharge. Information was also obtained on resource consumption in the various groups of patients. Most of the variables had to be evaluated implicitly as there were no explicit judgement criteria and few empiric data available for comparison. Implicit evaluation of the results was significant and prompted steps for improving care. With current systems, the information obtained from traditional hospital statistics is limited and partly misleading. By slight modification, however, hospital statistics may provide valuable information for assessing quality of care and resource allocation during hospitalization.

Detection of breast cancer by measuring areolar blood flow--a pilot study.

Regional blood flow in the areola was measured by using the non-invasive transient thermal clearance method in normal breasts and in breasts involved with cancer. Areolar blood flow (ABF) in normal breasts was almost constant for women in the age range 20-60y, but decreased at higher ages. ABF in breasts involved with cancer was higher than that in the contralateral breast, and higher than the average normal ABF in the corresponding age group. The effect was more prominent in the left breast. The transient thermal clearance method provides a potential non-invasive means for detection of breast cancer.

The use of helium-oxygen mixtures in the support of patients with status asthmaticus and respiratory acidosis.

Ten patients with status asthmaticus and respiratory or combined respiratory and metabolic acidosis were treated with a mixture of helium-oxygen (He-O2) in addition to the usual bronchodilator therapy and corticosteroids. A significant reversal of the acidosis was noted within the first 20 minutes, and no patient required subsequent intubation. The He-O2 mixture was started after the aerosolized and subcutaneous bronchodilators, but before intravenous corticosteroids and aminophylline had reached their peak effects. There were no untoward reactions and most of the patients sensed an immediate reduction in their dyspnea with the onset of He-O2 therapy. We conclude that He-O2 may be a useful adjunct to the usual medications employed in the treatment of status asthmaticus and may allow some patients to avoid intubation and mechanical ventilation.

Investigation of the significance of heavy metal contents of blackbird feathers.

The lead, cadmium and zinc in untreated blackbird (Turdus merula L.) feathers is predominantly of exogenous origin. The endogenous concentration is of minor importance. The degree of surface metal pollution depends on exposure time. The exogenous fraction of heavy metals cannot be completely removed by washing procedures. The difference between washed and unwashed feathers is demonstrated by SEM micrographs.