Classification for coding procedures in the intensive care unit

BACKGROUND: There is no commonly accepted coding system for non-operative procedures in general, including intensive care unit (ICU) procedures. In order to create a classification of codes for ICU procedures, a system developed at the University Hospital of Bergen was evaluated in four Nordic countries. METHODS: Classification codes were constructed using seven main groups of related procedures that were given a letter from A to G. Within each group major procedures were given a number from 00 to 99, with the possibility of up to 10 subclassifications within each procedure. A simple questionnaire regarding the use of coding general ICU procedures and some specific procedures was sent to 171 ICUs in Sweden, Finland, Denmark, and Norway. They were also asked to give their comments on the new classification coding system, which was attached. RESULTS: One hundred and fifty-four questionnaires were returned (response rate 90%). Some or most of the ICU procedures were registered in the ICUs (82.2%). However 38% did not use any coding system and 24% used a specific internal system. The new classification coding system was well received, and was given a mean value of 7.5 using a VAS scale from 0 to 10 (best). Most ICUs would consider using this system if introduced at a national level. CONCLUSION: Most Nordic ICUs do register some or most of the procedures performed. Such procedures are however, registered in very different ways, using several different systems, and are often home-made. The new classification system of ICU procedures was well rated.     

Readmission to the intensive care unit: An indicator that reflects the potential risks of morbidity and mortality of surgical patients in the intensive care unit

Purpose  To investigate the characteristics and outcomes of surgical patients who were readmitted to the intensive care unit (ICU). Methods  The data were collected for all readmissions to the surgical ICUs in a tertiary hospital in the year 2003. Results  Of all the 945 ICU discharges, 110 patients (11.6%) were readmitted. They had a longer initial ICU stay (8.05 ± 7.17 vs 5.22 ± 4.95, P < 0.001) and were older and in a more severe condition than those not readmitted, but with a longer hospital stay and higher mortality rate (40% vs 3.6%, P < 0.001). A total of 26.4% of the readmission patients had an early readmission (<48 h), with a lower mortality rate than those with a late readmission (24.1% vs 45.7%, P = 0.049). A total of 46.4% of the patients were readmitted with the same diagnosis while the rest were readmitted with a new complication. Respiratory disease was the most common diagnosis for patients readmitted with a new complication (66.1%). The nonsurvivors had a significantly higher second Acute Physiology and Chronic Health Evaluation (APACHE II) score (22.1 ± 8.8 vs.14.6 ± 7.4, P < 0.001) and second Therapeutic Intervention Scoring System (TISS) score (30.1 ± 8.7 vs 24.7 ± 7.6, P = 0.001) and a longer stay in the first ICU admission (10.4 ± 9 days vs 6.4 ± 5 days, P = 0.010). A multivariate analysis showed that the first ICU length of stay and the APACHE II score at the time of readmission were the two risk factors for mortality. Conclusion  The mortality of surgical patients with ICU readmission was high with respiratory complications being the most important issue.     

Assessing critical care unit performance: a global measure using graphical analysis

Outcome measurement in critical care is difficult because of the wide variety of patients treated and the diverse therapeutic options and pathways available. Individual outcome measures for critical care are available but are naturally limited to only a single aspect of performance. Most importantly, better performance in one aspect of care may compromise the standard of care in another. A global measure of performance would be helpful. For the year 1999-2000, the five hospitals in the East Anglian Critical Care Network provided data on capacity, workload and performance. The data was transformed and displayed graphically on a radar chart so that the area of the polygon within the radar chart was proportional to each unit's overall performance. The results from the five hospitals suggest that there is little overall difference in the units' global performance but the graphical representation highlighted some individual deficiencies. Graphical analysis of complex processes such as critical care delivery may facilitate performance assessment, providing that the measures chosen, weightings assigned and scales used are standardised with care.     

超声心动图对重症监护室患者管理重要性的研究

目的 超声心动图对重症监护室(intensive care unit,ICU)患者的管理有着重要的作用,研究分析由具备基本心脏超声检查能力的ICU医师完成的超声检查对ICU患者管理的意义.方法 采用回顾性临床观察研究的方法,纳入并记录2009年8月～2010年5月本院ICU中行经胸超声心动图(trans-thoraci...     

Ultrasound-guided placement of midline catheters in the surgical intensive care unit: a cost-effective proposal for timely central line removal

Background

The early removal of central intravenous (IV) catheters, as a means of reducing the incidence of central line–associated blood stream infections (CLABSI), remains a major health care initiative. However, attaining IV access in the surgical intensive care unit (SICU) can be quite difficult. We report the success of a novel, resident-driven program for the placement of ultrasound-guided midline catheters in critically ill patients.

Materials and methods

A prospective pilot study of 31 subjects admitted to the SICU from June to December 2011 was performed. Intermediate-length (20 cm) midline catheters were placed by trained housestaff, under ultrasound guidance, into the basilic or cephalic veins. Procedural details including time to cannulation, complications, and costs were recorded.

Results

Successful placement was achieved in 96.8% (n = 30), with a mean follow-up of 9.8 ± 5.6 (range 2–21) days. An average of 1.3 ± 0.7 (range 1–4) attempts with a median of 13.0 ± 14.5 (range 0.5–68) minutes was required for successful venous cannulation. The most common site was the basilic vein (n = 23). Only minor complications were encountered; three catheters leaked at the insertion site and one patient developed phlebitis. No CLABSI occurred. The total procedure cost was $87 per catheter for the SICU team compared with $1500 per catheter when performed by an interventional radiologist. During the study period, a total of 283 central line days were avoided with an estimated cost savings of $13,614.

Conclusions

Ultrasound-guided midline catheters placed by the housestaff are a cost-effective alternative for patients in the SICU with difficult IV access. Successful placement can help facilitate early central line removal and thus may reduce CLABSI rates.     

The role of a critical care unit in an epidemic

The role of a critical care unit in life-threatening situations is well established. The management of 52 children with acute gastroenteritis and 22 children with acute paralytic poliomyelitis as part of recent epidemics is described. The solutions to the problems in the critical care management of these 74 victims (out of a total of 6197 patients admitted during the epidemics) are discussed.     

Albumin administration prevents the onset of pressure ulcers in intensive care unit patients

Pressure ulcers (PUs) are a common problem in critically ill patients admitted to the intensive care units (ICUs) and they account for more than 70% of patients with low serum albumin at admission. The aim of this study was to test the efficacy of intravenous administration of albumin in patients with low serum albumin < 3·3 g/dl. In a 1‐year period, a total of 73 patients were admitted to the ICU (males 45, 61·64% and females 28, 38·36%); of these, 21 patients were admitted with hypoalbuminaemia (serum albumin < 3·3 g/dl) and randomised into two groups: 11 patients were treated with 25 g intravenous albumin for the first 3 days within the first week of ICU stay (group A) and 10 patients did not receive albumin (group B). Three patients (27·27%) showed the onset of PUs in group A, whereas seven patients (70%) showed the onset of PUs within the first 7 days of stay in group B. Moreover, ulcers of group B were more severe than those of group A. This study shows that intravenous administration of albumin reduces the onset of PUs in patients admitted to the ICU and in some cases it also reduces the risk of progression to advanced stages of PUs.     

Trends in the use of renal replacement therapy modality in intensive care unit: a 7 year study

Abstract

Background: The use of renal replacement therapy (RRT) modality in the intensive care unit (ICU) depends primarily on provider preference and hospital resource. This study aims to describe the prevalence of RRT use and the trends in RRT modality use in the ICU over the past 7 years. Methods: All ICU admissions, including medical, cardiac, and surgical ICUs from 1 January 2007 to 31 December 2013, were included in this study. RRT use was defined as the use of intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) within a given ICU day. The RRT use was reported as the proportion of ICU days on each RRT modality divided by the total ICU days with RRT usage. Results: Over the course of this study (72,005 ICU admissions), 272,271 ICU days were generated. RRTs were used in 4110 ICU admissions (5.7%) and on 21,159 ICU days (7.8%). RRT use was 10,402 (49%) for IHD, and 10,954 (52%) for CRRT. The trend of IHD and CRRT use did not change from year 2007 to 2013. On ICU days with RRT, the choice of RRT modality was associated with the number of vasopressor use (p?<?0.001). CRRT was more preferred on the ICU days with the increasing number of vasopressor use. Conclusions: RRTs were used in about 6% of ICU admission. The use of IHD and CRRT was similar and did not change over 7 years. The choice of RRT modality mainly depended on the number of vasopressors used on ICU days with RRT.     

Classification of adverse events occurring in a surgical intensive care unit

INTRODUCTION: We aimed to describe the preventability and provider specificity of surgical intensive care unit (SICU) deaths and complications compared with those in a cohort of trauma patients. METHODS: Data were collected on all trauma and SICU admissions from July 1, 2001, to June 30, 2004, from administrative (Trauma Base and Project Impact) and morbidity databases. Services were protocol driven and staffed by in-house attendings. Performance improvement assessments were made by consensus. Deaths and complications were classified as preventable, potentially preventable, or nonpreventable, and provider-specific or not. Statistical significance was established at the P < .05 level. RESULTS: One hundred sixty-eight deaths (5.6% rate), 464 procedure-related, and 694 non-procedure-related complications were noted in 2969 SICU patients compared with 166 deaths (3.6% rate), 178 procedure-related, and 261 non-procedure-related complications in 4,655 trauma patients. Thirty-one percent of SICU deaths were preventable/potentially preventable compared with 14% of trauma deaths, but only 1.9% was attributable to the SICU provider. SICU complications were less frequently preventable/potentially preventable than in trauma patients (52% versus 61%) and less often provider-specific (5% versus 19%). CONCLUSIONS: SICU complications are deemed preventable less often than in trauma patients and, if so, infrequently incriminate the SICU provider. Preventable and potentially preventable SICU deaths are rarely attributed to SICU care. These data suggest that SICU performance improvement should focus on systems solutions and pre-SICU care.     

Hospital resource use and costs among abdominal aortic aneurysm repair patients admitted to the intensive care unit

BackgroundAbdominal aortic aneurysm (AAA) repair is associated with significant morbidity and mortality. As a result, many of these patients are monitored postoperatively in the intensive care unit (ICU). However, little is known about resource utilization and costs associated with ICU admission in this population. We sought to evaluate predictors of total costs among patients admitted to the ICU after repair of nonruptured or ruptured AAA.MethodsWe retrospectively analyzed prospectively collected data (2011-2016) of ICU patients admitted after AAA repair. The primary outcome was total hospital costs. We used elastic net regression to identify pre-ICU admission predictors of hospitalization costs separately for nonruptured and ruptured AAA patients.ResultsWe included 552 patients in the analysis. Of these, 440 (79.7%) were admitted after repair of nonruptured AAA, and 112 (20.3%) were admitted after repair of ruptured AAA. The mean age of patients with nonruptured AAA was 74 (standard deviation, 9) years, and the mean age of patients with ruptured AAA was 70 (standard deviation, 8) years. Median total hospital cost (in Canadian dollars) was $21,555 (interquartile range, $17,798-$27,294) for patients with nonruptured AAA and $33,709 (interquartile range, $23,173-$53,913) for patients with ruptured AAA. Among both nonruptured and ruptured AAA patients, increasing age, illness severity, use of endovascular repair, history of chronic obstructive pulmonary disease, and excessive blood loss (≥4000 mL) were associated with increased costs, whereas having an anesthesiologist with vascular subspecialty training was associated with lower costs.ConclusionsPatient-, procedure-, and clinician-specific variables are associated with costs in patients admitted to the ICU after repair of AAA. These factors may be considered future targets in initiatives to improve cost-effectiveness in this population.     

The impact of a high-dependency unit on the workload of an intensive care unit

While there has been recent support for high-dependency unit development, there are few data reporting the impact of such development on existing critical care facilities. Therefore the aim of this study was to examine the workload and capacity constraints of an adult general intensive care unit before and after the development of an adjacent high-dependency unit. Following the opening of the high-dependency unit, the total number of patients admitted increased by 49%. On the high-dependency unit, more elderly patients were admitted for longer and more frequently following midweek elective surgery. On the intensive care unit, patients' initial severity of illness was lower and their duration of admission decreased; fewer patients were admitted directly from the general wards. The financial benefits of high dependency care may be eroded by the increased use of the critical care services.     

新生儿重症监护病房重症脓毒症临床流行病学研究

目的 研究新生儿重症监护病房(SlCU)重症脓毒症临床流行病学特征.方法 回顾性调查2006年6月至2007年5月入住NICU患儿的病例资料,统计重症脓毒症的发生率、人口学特征、感染特点、病死率及死亡的危险因素等.结果 依据2005年颁布的国际儿科脓毒症诊断标准,本研究新生儿甭症脓毒症在NICU的发病率、病死率分别为19.8%(48/243)和45.8%(22/48),70.8%(34/48)系男性患儿;相对于其他危重病患儿,重症脓毒症病例的Apgar评分低、PRISM评分和病死率高.48名重症脓毒症患儿中,56.3%(27/48)有明确培养结果 ,大肠杆菌为最常检出的病原微生物;52.1%(25/48)患儿≥3个器官功能受损,最常见受累的是呼吸系统.重症脓毒症死亡危险因素的单因素分析发现PRISM评分高、功能障碍器官数目多、出现循环系统/血液系统/神经系统功能障碍的患儿死亡的相对危险度显著增加.结论 重症脓毒症是NICU中发生率高、病死率高的危重症,感染特征与国内外研究基本一致.多中心、大规模、不同年龄段的儿童承症脓毒症临床流行病学研究将有助于推动我国儿童脓毒症的规范诊治,提高新生儿危重病的治愈率.     

丙泊酚和咪唑安定用于ICU呼吸机治疗病人的镇静

目的 观察丙泊酚和咪唑安定对ICU呼吸机治疗病人的镇静效果，为危重病人镇静用药提供依据。方法 选拔在ICU呼吸机治疗的病人40例，随机分为两组，丙泊酚组21例，先静注丙泊酚1.5mg/kg镇静诱导，然后改用微量注射泵持续注射丙泊酚，根据Ramsay氏分级标准调整用量；咪唑安定组19例，先静注咪唑安定0.05mg/kg镇诱导，然后改用微量注射泵持续注射咪唑安定，根据不同镇静分级调整用量，分别记录Ramsay氏分级Ⅲ-Ⅵ级时的用药量及用药前后、苏醒时的心率、血压、脉搏血氧饱和度和停药后苏醒时间，停药后再入睡和恶心发生情况，结果 两组病人随镇静程度的加深而用药量增加，但呼吸、循环无明显抑制。丙泊酚组较咪唑安定组苏醒时间快，且苏醒后再入睡及出现恶心病人明显减少。结论 丙泊酚和咪唑安定都能达到ICU病人所需的镇静要求，丙泊酚苏醒快，且苏醒后再入睡和恶心的发生明显少于咪唑安定。     

Intensive care unit design and mortality in trauma patients

Background

The architecture of medical care facilities ca affect the safety of a patient, but it is unknown if the architecture affects outcomes. We hypothesized that patients in rooms who are more visible from the central nursing station would experience better outcomes than those patients in less visible rooms.

Materials and methods

A total of 773 patients admitted to the trauma intensive care service over a 12-mo period were retrospectively evaluated. Outcomes were hospital mortality and intensive care unit (ICU) length of stay (LOS). The unit is designed with a bank of high-visibility rooms (HVRs) directly across from the nursing station and two side sections of low-visibility rooms (LVRs). No formal triage occurs, but patients are prioritized to HVRs as available.

Results

Patients in the HVRs had a 16% mortality (52 of 320); meanwhile, the patients in the LVRs experienced an 11% mortality (49 of 448, P = 0.03). ICU mortality did not differ significantly when controlling for age, Charlson Comorbidity Index (CCI), Head Abbreviated Injury Score, and the Injury Severity Score (ISS) (P = 0.076). Age, CCI, Head Abbreviated Injury Score, and ISS did individually correlate with mortality (age: P = 0.0008; CCI: P = 0.017; and ISS: P < 0.0001). Visibility was not a predictor of ICU LOS or complications among survivors (mean ICU HVR LOS = 4.8 d; mean ICU LVR LOS = 4.7; P = 0.88, n = 661). Only ISS was a significant predictor of ICU LOS and complications (P < 0.0001).

Conclusions

Trauma patient room placement within the ICU does not relate to mortality rate significantly when corrected for patient acuity. Instead, variables such as age, ISS, and CCI are associated with mortality. A policy of placing more critically ill patients in HVRs may prevent increased mortality in high-acuity patients.     

非重症监护病房多重耐药菌感染来源及分布

目的:分析非重症监护病房(ICU)多重耐药菌(MDRO)感染来源及分布,为制定精准化MDRO防控措施提供依据。方法:选取南京医科大学第一附属医院2017年10月至2019年9月802例自非ICU科室MDRO感染者体内分离出的1116株MDRO菌株作为研究对象,依据来源将MDRO分为院外感染(外院转入、社区获得)和院内感染(本院转入、科室获得)两大类型共4个组别进行分析。结果:本院非ICU科室感染的MDRO以碳青霉烯类耐药肠杆菌科(CRE)(384/1116、34.41%)及耐甲氧西林金黄色葡萄球菌(MRSA)(331/1116、29.66%)为主;不同科室MDRO感染构成差异有统计学意义(χ^(2)=185.687、P<0.001),4种常见MDRO感染最多的科室为老年医学科(147/1116、13.17%)、神经外科(112/1116、10.04%)和康复医学科(95/1116、8.51%)。CRE、MRSA、碳青霉烯类耐药鲍曼不动杆菌(CRAB)和碳青霉烯类耐药铜绿假单胞菌(CRPA)检出率分别为10.69%(704/6584)、43.83%(554/1264)、33.72%(376/1115)和27.11%(475/1752),均显著低于全院科室CRE、MRSA、CRAB、CRPA的平均检出率[25.35%(3474/13704)、51.48%(1093/2123)、79.15%(4704/5943)和46.99%(2051/4365)],差异均有统计学意义(χ^(2)=584.309、15.583、960.632、203.726,P均<0.001);非ICU科室间以上4种MDRO检出率差异均有统计学意义(χ^(2)=190.766、97.642、75.078和69.515,P均<0.001)。MDRO感染部位主要为下呼吸道(540/1116、48.39%)、手术部位(132/1116、11.83%)和泌尿道(123/1116、11.02%)。院外感染者共641例(57.44%),包括外院转入(373/1116、33.42%)和社区获得(268/1116、24.01%);院内感染者475例(42.56%),包括本院转入(52/1116、4.66%)和科室获得(423/1116、37.90%)。结论:本院非ICU科室MDRO感染近2/3来源于院外输入和院内转入,需重视感染控制基本措施落实并通过信息系统早期识别,且各科室间MDRO感染来源及分布不同,应根据其特点制定针对性措施,实现精准化防控。     

Low serum albumin level as an independent risk factor for the onset of pressure ulcers in intensive care unit patients

Critically ill patients are at high risk of developing pressure ulcers (PUs) and patients who develop PUs remain significantly longer in the intensive care unit (ICU) with significantly increased morbidity and mortality. Therefore, the identification of patients at truly increased risk is important. The aim of this study was to examine the association of low serum albumin present at admission in ICU patients with the onset of PUs. We conducted a retrospective cohort study on 610 patients who were admitted to intensive care unit. Level of serum albumin and other biochemical indices, recorded at the time of admission, were collected. We collected information about PU occurrence after admission and conducted a statistical analysis with biomarkers at ICU admission and during hospital stay. The incidence of PU in the ICUs was 31% and about 70% of patients with PUs had hypoalbuminemia at admission. The lowest values of serum albumin in patients with PUs were directly proportional to the severity of ulcers. In this study, we found a close association between serum albumin and PUs. In fact serum albumin was negatively correlated with PU and may be considered one of the independent determinants of PU occurrence in patients admitted to ICUs.