Utilization of coronary care units in Sweden

Coronary care unit usage has expanded rapidly in all high income countries with little attention to effectivity or cost. A study of six randomly chosen Swedish units showed that larger units in teaching hospitals had significantly lower age-adjusted mortality rates, higher proportions of myocardial infarction patients, and greater productivity and efficiency. Comparisons with a study from the United States showed better results in the Swedish hospital units according to all variables measured. Although proof of effectiveness of CCU's is lacking, their continued use is assured. A less than optimal solution is a rational distribution of units based upon epidemiologically determined need, while stressing good organization and efficiency.     

Intensive care units in the triage mode: an organizational perspective

Decisions to admit and discharge patients to and from the intensive care unit (ICU) when beds are scarce should be made in accordance with the triage principle--that is, allocate resources on the basis of the ability to benefit from intensive care. However, uncertainty over resource capacity and patient prognosis limits the ability of decision makers to use this prioritization principle and results in ICUs containing inappropriately placed patients who are denying or delaying care to patients who could benefit more. Using Jay Galbraith's "information processing" model, ICU admission and discharge decision making is described. Organizational strategies to reduce uncertainty and improve decision making are discussed, including strengthening the management role of the ICU physician director and employing prognostic instruments (e.g., mortality prediction models) to share and process information.     

Intensive care ventilators

This study presents ECRI's evaluation findings for four newly tested intensive care ventilators, as well as updated ratings for six previously evaluated models. Intensive care ventilators provide temporary support for critically ill patients who cannot breathe on their own or who require assistance to maintain adequate gas exchange in the lungs. Most of today's models offer a variety of capabilities to help clinicians tailor treatments to each patient, to alert users to potentially dangerous conditions, and to protect the patient when problems arise. We found that all the evaluated models can satisfactorily ventilate patients. However, not all the models would be an appropriate choice for the typical intensive care unit (ICU). Some of the units we tested lack capabilities that we desire for intensive care applications, and some include noteworthy deficiencies, particularly related to their alarm systems. In fact, we rate one unit Unacceptable because its alarm limits default to unsafe values. Of the remaining units, we rate five models Preferred because they offer the functionality to meet the needs of a broad range of ICU patients. Two additional units offer more limited capabilities, but they perform well and are inexpensive; these models, which we rate Acceptable, may be the best choice for some facilities. The final two units are Not Recommended for most new purchases because they lack features that aid in patient-ventilator synchrony; such features can improve patient comfort and thus are highly desirable. ECRI's recommended purchasing strategy, which is detailed in the Conclusions section, will help healthcare facilities select from among the evaluated models.     

Intensive care ventilators

Intensive care ventilators provide temporary ventilatory support to critically ill patients who cannot breathe on their own or who require assistance to maintain adequate ventilation. These ventilators offer a wide range of capabilities and can meet the needs of many types of patients. We last evaluated intensive care ventilators for adult use in our July-August 2000 issue. In the current Evaluation, we revisit the ratings of nine previously evaluated ventilators and describe our findings for one newly evaluated unit, the Siemens Servo-i. As ventilator technology has evolved, so have our ratings. Several units have added new features and capabilities since we last examined them. As a result, we have rated them higher in this study. Conversely, a few models have been given lower ratings because they haven't kept up with the advances in the technology; although they perform adequately, we can no longer recommend their purchase because better choices are available.     

Bronchoscopy in intensive care units

The authors report their 1535 urgent bronchoscopic examinations performed between 1998-2002. The examinations/interventions were requested mostly by surgical and internal medicine intensive care units. The main indications were: postoperative excretion removal, stump control, suspicion of fistula, foreign body, injury of a large bronchus, tracheal stenosis, specimen taking and bronchoscopic local drug treatment. The authors mention the most important contraindications for urgent bronchofiberscopy too: missing written consent of the patient (except the cases of unconsciousness), size discrepancy between the tool and tracheal lumen, and asthmatic attack. The authors also underline the emerging importance of both diagnostic and therapeutic bronchoscopy performed on emergency wards and intensive care units. They conclude: it's necessary for the anesthetists to get a basic level ability to work with bronchofiberscope and for pulmonologist-bronchologists to be experienced to answer the questions of other specialists.     

Relating personnel costs in special care units and in traditional care units to resident characteristics

BACKGROUND: There are over 16 000 nursing homes in the United States (US), among which approximately 70% of residents are cognitively impaired. Reflecting this, approximately 20% of US nursing homes maintain Special Dementia Care Units (SCUs). SCUs supposedly provide more staff time and more specialized staff assignments to residents than do traditional care units. AIMS OF THE STUDY: This paper addresses the issues of staff time and assignment: do the costs of personal care inputs differ according to whether they are provided by SCUs or in traditional care settings? Related to this, are differences associated with the different settings, or are they accounted for by resident characteristics within the settings? METHODS: Given the bias generally associated with collection of staff time data, the author developed (supported by the Health Care Financing Administration and the National Institute on Aging) and used in this study a barcode-based system ('InfoAide'). Using InfoAide, each provider automatically recorded task- and resident-specific time expenditure data which were subsequently monetized, using prevailing local wage rates. Individual resident personal characteristics and status data were provided by another simultaneous study of SCU impacts among the same residents. Regression analysis (MANCOVA for significantly correlated dependent variables) was used to examine the relationships between cost and SCU/traditional status, and individual resident characteristics, separately for each category of provider. RESULTS: Controlling for resident characteristics, the cost of aide care is significantly (positively) related (p <=0.01) to SCU status. Cognitive impairment, ADL impairment and being restrained are also related to higher aide care cost (p <=0.05, p <=0.01, and p <=0.05, respectively). The same is generally true of Speech Therapy, Social Service and care by licensed practical nurses, although the differences between SCU and traditional care units are essentially trivial - and there are no SCU/traditional care differences for registered nurses. DISCUSSION: SCU/traditional unit status, even when combined with the central resident covariates, explains very little variance in service costs, other than among nursing aides; in separate MR analyses in which monetized service time was the dependent variable, the cumulative adjusted R2 among aides was 0.37; for each of the other categories of service provider, the adjusted R2 was less than 0.10. There were differences (particularly in cognitive and ADL impairment) between SCU and non-SCU residents; these differences were related to differences in basic services which were, in turn, provided primarily by aides. The increased level of care provided in SCUs is attributable primarily to nursing aides. However, there is relatively little (albeit statistically significant) variation in more 'elective'services according to individual characteristics or to SCU versus traditional unit placement. This discussion is limited by the absence of analyses of possible interactions among variables, and by the cross-sectional nature of the data presented here. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This absence of a substantial relationship between SCU/traditional status suggests that dichotomization between SCU and traditional care is misplaced, and that more attention should perhaps be given to the targeting and tailoring of services related to individual gradations of impairment and need. IMPLICATIONS FOR HEALTH POLICY FORMULATIONS: A very considerable literature has developed recently pertaining to Special versus Traditional care for persons with dementing illness. These data suggest that this is not a fruitful distinction, and that more effort should be devoted to defining and quantifying the elements and quality of care provided to nursing home residents. IMPLICATIONS FOR FURTHER RESEARCH: Further research is needed into the components of optimal quality care for demented nursing home residents, and into the interaction among these components as they relate to resident outcomes.     

The shortened EMpowerment of PArents in THe Intensive Care 30 questionnaire adequately measured parent satisfaction in pediatric intensive care units

ObjectiveTo shorten and validate the EMpowerment of PArents in THe Intensive Care (EMPATHIC) questionnaire of optimal length to measure satisfaction of parents whose child has been admitted to pediatric intensive care units (PICUs).Study Design and SettingA total of 3,354 (55.4%) parents in eight PICUs completed the 65-item EMPATHIC questionnaire. Multiple regression analysis was applied to evaluate the statistical performances. The reduced domains were intercorrelated by the Pearson's product moment correlation coefficient. The robustness of the findings was evaluated by adjusted R² for internal cross-validations. Reliability was assessed by internal consistency.ResultsMultiple regression analysis based on statistical redundancy established the optimal length at 30 items over five different domains: information (5 items), care and cure (8 items), organization (5 items), parental participation (6 items), and professional attitude (6 items). The explained variances of the domains ranged from 85% to 93%. The domains of the full and optimal version showed strong correlations (r = 0.92–0.97). Cross-validation among eight centers and across time provided adjusted R² values on domain level between 85% and 95%. The reliability estimates of the domains, assessed by Cronbach's α, varied between 0.73 and 0.93.ConclusionBy statistically eliminating the redundant items, the EMPATHIC questionnaire could be reduced from 65 to 30 items.