Monitoring costs in the ICU: a search for a pertinent methodology.

Attempts to determine costs in the intensive care unit (ICU) were not successful until now, as they failed to detect differences of costs between patients. The methodology and/or the instruments used might be at the origin of this failure. Based on the results of the European ICUs studies and on the descriptions of the activities of care in the ICU, we gathered and analysed the relevant literature concerning the monitoring of costs in the ICU. The aim was to formulate a methodology, from an economic perspective, in which future research may be framed. A bottom-up microcosting methodology will enable to distinguish costs between patients. The resulting information will at the same time support the decision-making of top management and be ready to include in the financial system of the hospital. Nursing staff explains about 30% of the total costs. This relation remains constant irrespective of the annual nurse/patient ratio. In contrast with other scoring instruments, the nursing activities score (NAS) covers all nursing activities. (1) NAS is to be chosen for quantifying nursing activities; (2) an instrument for measuring the physician's activities is not yet available; (3) because the nursing activities have a large impact on total costs, the standardisation of the processes of care (following the system approach) will contribute to manage costs, making also reproducible the issue of quality of care; (4) the quantification of the nursing activities may be the required (proxy) input for the automated bottom-up monitoring of costs in the ICU.

Evaluation of the antiviral response to zanamivir administered intravenously for treatment of critically ill patients with pandemic influenza A (H1N1) infection.

A retrospective nationwide study on the use of intravenous (IV) zanamivir in patients receiving intensive care who were pretreated with oseltamivir in the Netherlands was performed. In 6 of 13 patients with a sustained reduction of the viral load, the median time to start IV zanamivir was 9 days (range, 4-11 days) compared with 14 days (range, 6-21 days) in 7 patients without viral load reduction (P = .052). Viral load response did not influence mortality. We conclude that IV zanamivir as late add-on therapy has limited effectiveness. The effect of an immediate start with IV zanamivir monotherapy or in combination with other drugs need to be evaluated.

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients.

OBJECTIVE: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. DESIGN: A prospective observational multicenter study (EURICUS II) was carried out. SETTING: Fifty-five European ICUs. PATIENTS: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. RESULTS: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p<0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow, H=13.8554, insignificant); the area under ROC curve was 0.818. CONCLUSIONS: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes.

Use of selective digestive tract decontamination in European intensive cares: the ifs and whys.

BACKGROUND: Several studies have shown that the use of selective digestive tract decontamination (SDD) reduces mortality. However, fear for increasing multidrug resistance might prevent wide acceptance. A survey was performed among the units registered in the European Registry for Intensive Care (ERIC), in order to investigate the number of ICUs using SDD and the factors that prevented the use of SDD. METHODS: One invitation to the electronic survey was sent to each ERIC unit. The survey focused on department characteristics (intensive care type, local resistance levels), local treatment modalities (antibiotic stewardship) and doctors' opinions (collaborative issues concerning SDD). All ICU's in countries participating in the European Centre for Disease Prevention and Control resistance surveillance program were analysed. RESULTS: Seventeen percent of the ICUs registered in the ERIC database used SDD prophylaxis. Most of these ICUs were located in the Netherlands or Germany. ICUs using SDD were four times more likely to use antibiotic stewardship. Also larger ICUs were more likely to use SDD. On the contrary, resistance to antibiotics was not related to the use of SDD. Also the doctor's opinion that SDD is proven in cluster-randomized trials was not a determinant for not using SDD. CONCLUSION: SDD is used in a minority of the European ICUs registered in the ERIC database. Larger ICUs and ICUs with a prudent antibiotic policy were more likely to use SDD. Neither antibiotic resistance nor the cluster randomized study design were determinants of the non-use of SDD.

Nursing staff in intensive care in Europe: the mismatch between planning and practice.

OBJECTIVE: To test the use of a human resources-based classification of levels of care of ICUs; to evaluate the match between planned vs operative levels of care on a large sample of European ICUs. DESIGN: Analysis of the database of a multicentric, multinational, prospective cohort study, involving 89 ICUs from 13 European areas. SETTING: Database of EURICUS-I. METHODS: Provision of resources was measured as the number of nurses per ICU bed. Use of resources was measured by the daily use of a therapeutic index (nine equivalents of nursing manpower use score, NEMS) at patient level. Work utilization ratio (WUR) indicated the total number of NEMS points actually scored divided by the total possible NEMS score on each ICU. The planned level of care (LOC) or the mean number of patients to be assisted by one nurse (P/N ratio) made available to the unit was derived from the number of nurses and the number of beds in the ICU. The operative LOC or the actual mean number of patients who were assisted by one nurse (P/N ratio) was computed by dividing the number of NEMS points equivalent to the work of three nursing-shifts (46 points) by the mean daily NEMS score at ICU level. Severity of illness was evaluated by the new simplified acute physiology score. Kappa statistics, intraclass correlation coefficients, and interrater percentage of agreement were used to evaluate the reliability of the data collected for total NEMS score. Chi2 statistics and one-way analysis of variance were used when appropriate. MAIN RESULTS: Data of 16,047 patients (74,383 patient-days) admitted to the ICUs were analyzed. With an overall value of 26.5+/-9.3, the mean NEMS score at ICU level varied significantly among European areas. These differences were not explained by the severity of illness of the patients. The mean WUR was 0.73+/-0.29, presenting also significant differences among ICUs and European areas that were not explained by severity of illness. There was a mismatch between planned vs operative LOCs on 68 ICUs (76%); on 65 (73%), the operative LOC was lower than the planned LOC. This loss of resources concerned particularly the 61 ICUs planned to operate at LOC 3. CONCLUSIONS: The use of human resources-based classification of LOCs is an objective method for evaluation of the match between provision and use of resources in the ICU. This study has shown a large mismatch between planned and utilized LOC in a sample of 89 European ICUs. This mismatch, suggesting an important loss of invested resources, was more apparent in the ICUs that were planned to operate at a higher level of care.

Nine equivalents of nursing manpower use score (NEMS).

OBJECTIVES: To develop a simplified Therapeutic Intervention Scoring System (TISS) based on the TISS-28 items and to validate the new score in an independent database. DESIGN: Retrospective statistical analysis of a database and a prospective multicentre study. SETTING: Development in the database of the Foundation for Research on Intensive Care in Europe with external validation in 64 intensive care units (ICUs) of 11 European countries. MEASUREMENTS AND RESULTS: Development of NEMS on a random sample of TISS-28 items, cross validation on another random sample of TISS-28, and external validation of NEMS in comparison with TISS-28 scored by two independent raters on the day of the visit to the ICUs participating in an international study. Multivariable regression techniques, Pearson's correlation, and paired sample t-tests were used (significance at p < 0.05 level). Intraclass correlation, rate of agreement, and kappa statistics were used for interrater reliability tests. The TISS-28 items were reduced to NEMS (9 items) in a random sample of 2000 records; the means of the two scores were no different: TISS-28 26.23 +/- 10.38, NEMS 26.19 +/- 9.12, NS. Cross-validation in a random sample of 996 records; mean TISS-28 26.13 +/- 10.38, NEMS 26.17 +/- 9.38, NS; R2 = 0.76. External validation on 369 pairs of TISS-28 and NEMS has shown that the means of the two scores were no different: TISS-28 27.56 +/- 11.03, NEMS 27.02 +/- 8.98, NS; R2 = 0.59. Reliability tests have shown an "almost perfect" interrater correlation. Similar to studies correlating TISS with Simplified Acute Physiology Score (SAPS)-I and/or Acute Physiology and Chronic Health Evaluation II scores, the value of NEMS scored on the first day accounts for 30.4% of the variation of SAPS-II score. CONCLUSIONS: NEMS is a suitable therapeutic index to measure nursing workload at the ICU level. The use of NEMS is indicated for: (a) multicentre ICU studies; (b) management purposes in the general (macro) evaluation and comparison of workload at the ICU level; (c) the prediction of workload and planning of nursing staff allocation at the individual patient level.

Measuring quality of life with the sickness impact profile: a pilot study.

A pilot-study was done to investigate the applicability of the sickness impact profile (SIP) in ex-ICU patients. For this study 221 consecutively admitted patients were reviewed retrospectively after excluding children, deceased patients and readmissions. SIP was assessed in these patients by either interview or questionnaire. These were divided into three groups: i) Patients interviewed at home (n = 26). ii) Patients receiving the SIP-questionnaire by mail (n = 93). iii) As for group ii, but after receiving a telephone invitation to participate (n = 102). Highest mean SIP-score was found in group i (16.3). Groups ii and iii scored 10.2 and 7.9 respectively. Analysis of variance demonstrated overall SIP-scores of these groups to be significantly different. The response in group iii (77%) was significantly higher compared to group ii (56%). Data collection in Group i appeared to be most expensive costing $13.20 per patient, followed by group iii ($3.79) and group ii ($2.56). It is concluded that the self-administered SIP is suitable for measuring outcome in ICU-patients and is much cheaper than the direct interview technique. The 3 different approaches should be considered as independent methods of which individual results cannot be compared. The response can be improved significantly by calling the patients before sending the questionnaire.

Experimental validation of frequently-used echocardiographic right-ventricular impedance parameters.

BACKGROUND: Aim of the study was to validate commonly used bedside right-ventricular (RV) impedance parameters, which are utilized in determining heart-lung interactions during mechanical ventilation. METHODS: Fifteen pigs were equally assigned to either an open or a closed pericardium group. In all animals, an inflatable vascular occluder and a flow probe were placed around the main pulmonary artery, which allowed for a gradual increase in pulmonary vascular impedance with banding of the pulmonary artery. A median sternotomy was performed for the open pericardium group, and a lateral thoracotomy was performed for the closed pericardium group. RESULTS: In the open pericardium group, mean acceleration time (ACmean) and the slope of the pulmonary artery flow correlated significantly with Poiseuille resistance over the banding (r=0.67 and r=0.65, respectively). In the closed pericardium group, the ratio of the right to left ventricular area, eccentricity index, and tricuspid annular plane systolic excursion did not correlate with resistance over the banding, only the ACmean showed a significant correlation with resistance over the banding (r=0.88). CONCLUSION: ACmean is a reliable parameter of RV impedance that can be used to study the heart-lung interactions during mechanical ventilation.

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients

Objective: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. Design: A prospective observational multicenter study (EURICUS II) was carried out. Setting: Fifty-five European ICUs. Patients: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. Interventions: None. Main variables of interest: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. Results: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p: <0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow,H: =13.8554, insignificant); the area under ROC curve was 0.818. Conclusions: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes (AU)

Objetivo: Comprobar si el grado y duración de las alteraciones en las variables fisiológicas recogidas en la monitorización rutinaria en UCI durante el primer día de estancia, junto con pocos datos adicionales, proporcionan información similar a la obtenida con los sistemas tradicionales de predicción de mortalidad. Diseño: Estudio observacional, prospectivo y multicéntrico (EURICUS-II). Ámbito: 55 UCIs de Europa. Pacientes: 17.598 pacientes consecutivos, ingresados durante 10 meses. Intervenciones: ninguna. Variables de interés principales: se recogieron manualmente datos horarios sobre alteraciones o "eventos" en la presión arterial sistólica, frecuencia cardiaca y saturación de oxígeno, para construir un índice basado en estos eventos y un modelo de predicción de mortalidad. Resultados: El índice de eventos el primer día fue 6,37±10,47 puntos y se asoció significativamente con la mortalidad (p<0,001), con una capacidad de discriminación (área bajo la curva ROC) para la mortalidad de 0.666. Se construyó un segundo índice que incluye este índice de eventos en el primer día, la edad, procedencia del ingreso y puntuación de la Escala de Coma de Glasgow. Un modelo construido con este segundo índice más el diagnóstico fue validado mediante el método jackknife (Hosmer-Lemeshow, H=13.8554, no significativo), con un área bajo la curva ROC de 0,818. Conclusiones: Se puede construir un índice pronóstico con rendimiento similar al de los sistemas habituales a partir de los datos de monitorización de los pacientes en la UCI junto a escasas características del paciente. Nuestros resultados pueden servir de guía para la posible construcción automatizada de índices pronósticos (AU)

The open lung concept: effects on right ventricular afterload after cardiac surgery.

BACKGROUND: The open lung concept (OLC) is a method of ventilation intended to maintain end-expiratory lung volume by increased airway pressure. Since this could increase right ventricular afterload, we studied the effect of this method on right ventricular afterload in patients after cardiac surgery. METHODS: We studied 24 stable patients after coronary artery surgery and/or valve surgery with cardiopulmonary bypass. Patients were randomly assigned to OLC or conventional mechanical ventilation (CMV). In the OLC group, recruitment manoeuvres were applied until Pa(o(2))/FI(O(2)) was greater than 50 kPa (reflecting an open lung). This value was maintained by sufficient positive airway pressure. In the CMV group, volume-controlled ventilation was used with a PEEP of 5 cm H(2)O. Cardiac index, right ventricular preload, contractility and afterload were measured with a pulmonary artery thermodilution catheter during the 3-h observation period. Blood gases were monitored continuously. RESULTS: To achieve Pa(O(2))/Fl(O(2)) > 50 kPa, 5.3 (3) (mean, SD) recruitment attempts were performed with a peak pressure of 45.5 (2) cm H(2)O. To keep the lung open, PEEP of 17.0 (3) cm H(2)O was required. Compared with baseline, pulmonary vascular resistance and right ventricular ejection fraction did not change significantly during the observation period in either group. CONCLUSION: No evidence was found that ventilation according to the OLC affects right ventricular afterload.

Critical care medicine in the hospital: lessons from the EURICUS-studies

We have performed a retrospective analysis of the EURICUS-studies using their database at the Foundation for Research on Intensive Care in Europe (FRICE) and other related documents, among which the various reports produced to the European Union which granted the studies, with the following purposes: a) to select and describe the most relevant observational and experimental results of the EURICUS studies; b) to inventory the main obstacles to the appropriate organization of intensive care medicine in the Hospital and c) to highlight amid the acquired knowledge those subjects which could have a direct and primary impact for improving the organization and management of intensive care units (ICUs). The EURICUS-studies have shown a rather non-systematic variation on the variables of the organization and management, resulting in a significant waste of resources and in a generally perceived insufficient performance of ICUs in Europe. Three major roadblocks were found: a) the lack of a clear concept of Critical Care Medicine; b) the lack of defined objectives both regarding the planning of the facilities and the activities to be developed in the ICU and c) the lack of a purposeful organization and management of work in the ICU. The further development and integration of each ICU in the Hospital should consider the following: a) the system approach to the analysis and standardization of processes of care; b) the redefinition of all jobs in each ICU; c) the definition of patient/nurse ratios in each ICU and sibling departments and d) to professionalize the organization and management of the ICU

Hemos hecho un análisis retrospectivo de los estudios EURICUS, usando la base de datos de la Fundación para la Investigación en Medicina Intensiva en Europa (FRICE) y otros documentos relacionados, incluyendo los diferentes informes dirigidos a la Unión Europea, la cual financió los estudios, con los siguientes objetivos: a) seleccionar y describir los resultados más relevantes de los estudios tanto observacionales como experimentales EURICUS; b) hacer un inventario de los principales obstáculos a la organización óptima de la medicina intensiva en los hospitales y c) destacar los temas entre los conocimientos adquiridos que puedan tener un impacto directo y primario en la mejora de la organización y dirección de las Unidades de Cuidados Intensivos (UCI). Los estudios EURICUS han revelado una variación considerablemente no sistemática en las variables relacionadas con la organización y dirección, con el resultado de un malgasto importante de recursos y un rendimiento de las UCI en Europa que generalmente se considera insuficiente. Se encontraron tres obstáculos mayores: a) la falta de un concepto claro de la medicina intensiva; b) la falta de objetivos definidos, tanto en la planificación de las instalaciones como en las actividades a desarrollar en la UCI y c) la falta de una organización y dirección decisiva del trabajo en la UCI. En el desarrollo y la integración de la UCI en los hospitales se debería considerar cada uno de los siguientes: a) el abordaje sistemático integrado (system approach) al análisis y estandardización de los procesos médicos; b) la redefinición de todos los trabajos en la UCI; c) la definición de la ratio paciente/enfermera en cada UCI y departamentos relacionados y d) la profesionalización de la organización y dirección de la UCI