An initial comparison of intensive care in Japan and the United States.

OBJECTIVE: The objective of this study was to compare the utilization of, and outcome from, critical care services in selected medical centers providing secondary and tertiary care in the United States and Japan. DESIGN: Prospective data collection on 1,292 patients from each of the participating Japanese study hospitals in 1987 to 1989 and compared with the 5,030 patients in the United States 1982 Acute Physiology and Chronic Health Evaluation (APACHE II) database used to develop the APACHE II equation. Detailed organizational characteristics of the participating ICUs and hospitals were also obtained. SETTING: Data collection took place in the ICUs of 13 U.S. hospitals and six Japanese hospitals. PATIENTS: Data were collected on consecutive, unselected patients from medical, surgical, and mixed medical/surgical critical care units, with a spectrum of medical and surgical diagnoses. MEASUREMENTS AND MAIN RESULTS: U.S. and Japanese ICUs have a similar array of diagnostic and therapeutic modalities. Only 2% (range 0.6 to 3.5) of beds in Japanese hospitals were designated to intensive care. The organization of the Japanese and U.S. ICUs varied by hospital. There were significantly fewer women admitted to Japanese ICUs and a substantially lower proportion of low-risk-of-death patients. Despite a rapidly aging population, there were relatively fewer elderly patients with chronic health ailments in the Japanese ICU population (8%) compared with the U.S. cohort (18%). CONCLUSIONS: In this sample of hospitals, similar high-technology critical care is available in the United States and Japan. Variations in utilization between the two countries represent differences in case mix and bed availability. The APACHE II equation stratified patients in the Japanese patient cohort across the full spectrum of increasing severity of illness.     

Improving family communications at the end of life: implications for length of stay in the intensive care unit and resource use.

BACKGROUND: Inadequate communication persists between healthcare professionals and patients and patients' families in intensive care units. Unwanted or ineffective treatments can occur when patients' goals of care are unknown or not honored, increasing costs and care. Having the primary physician provide medical information and then having a physician and clinical nurse specialist team improve opportunities for patients and their families to process that information could improve the situation. This model has not been tested for its effect on patients' outcomes and resource utilization. OBJECTIVES: To evaluate the effect of a communication team that included a physician and a clinical nurse specialist on length of stay and costs for patients near the end of life in the intensive care unit. METHODS: During a 1-year period, patients judged to be at high risk for death (N = 151) were divided into 2 groups: 43 patients who were cared for by the medical director teamed with a clinical nurse specialist and 108 patients who received standard care, provided by an attending physician. RESULTS: Compared with the control group, patients in the intervention group had significantly shorter stays in both the intensive care unit (6.1 vs 9.5 days) and the hospital (11.3 vs 16.4 days) and had lower fixed ($15,559 vs $24,080) and variable ($5087 vs $8035) costs. CONCLUSIONS: Use of a physician and a clinical nurse specialist focused on improving communication with patients and patients' families reduced lengths of stay and resource utilization.     

Assessing the effectiveness of critical pathways on reducing resource utilization in the surgical intensive care unit

OBJECTIVES: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU). DESIGN AND SETTING: Prospective cohort study in a university surgical ICU. PATIENTS: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time. MEASUREMENTS AND RESULTS: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year. CONCLUSIONS: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU.     

Do older internists use more hospital resources than younger internists for patients hospitalized with chest pain? A study of patients hospitalized in the coronary care and intermediate care units.

OBJECTIVES: Recent concern about escalating healthcare expenditures has prompted healthcare payers and hospitals to identify physicians whose hospital resource consumption exceeds expected norms. The goals of this study were to determine whether analyses of practice patterns in this manner may a) systematically identify older physicians as big resource "spenders," and b) provide misleading information caused by the failure to adjust utilization data for severity of illness. DESIGN: A prospective, observational study. SETTING: The coronary care and intermediate care unit in an 1,100-bed community hospital. PATIENTS: A total of 217 patients hospitalized for chest pain cared for by noncardiologists. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: On initial inspection, it appeared that the patients of older physicians had longer lengths of stay and greater charge expenditures than the patients of younger physicians. However, further evaluation demonstrated that older physicians cared for older (76 vs. 67 yrs old, p = .0001) and more severely ill patients (judged by risk of complications, risk of acute ischemic heart disease, and disease staging). Older physicians cared for more severely ill myocardial infarction patients than did younger physicians (Killip Classification 2.0 vs. 1.1, p less than .00003). After adjusting for severity of illness, there were fewer differences in hospital charges and consultant use between older and younger physicians, although the patients of older physicians remained hospitalized longer. CONCLUSIONS: There is little difference in resource utilization between patients cared for by older and younger internists after controlling for severity of illness. This investigation highlights the potential hazards of ignoring severity of illness when judging physician efficiency in the coronary care unit.     

Impact of a clinical pathway on the postoperative care of children undergoing surgical closure of atrial septal defects

The purpose of this study was to impact of a clinical pathway on the postoperative management of children undergoing surgical closure of atrial septal defects (ASDs). Three groups of children were studied: group 1 (14 patients), before introduction of an intensive care team, minimally invasive surgery, and the clinical pathway; group 2 (17 patients), after the introduction of the intensive care team and minimally invasive surgical techniques but before the pathway; and group 3 (30 patients), after implementation of the clinical pathway. Average hospital length of stay fell from 118.52 +/- 19.83 hours (4.9 +/- 0.83 days) in group 1 to 95.92 +/- 66.48 hours (3.99 +/-2.77 days) in group 2 and declined further to 54.29 +/- 20.17 hours (2.26 +/- 0.84 days) in group 3 (p <.05). There were statistically significant decreases in laboratory resource utilization (p <.05). The addition of a dedicated intensive care team and utilization of minimally invasive surgical techniques reduced mean length of stay (by 20%) and resource utilization (by 50%). However, only the implementation of the pathway provided the consistency necessary for maximal quality management, cost saving, and reduction in length of stay (additional 44% reduction in mean length of stay and 40% reduction in resource utilization). These results show the incremental advantage of implementing a defined clinical pathway for postoperative management of children with atrial septal defects.     

Analysis of healthcare resource utilization with intensive insulin therapy in critically ill patients

OBJECTIVE: To perform an analysis of healthcare resource utilization with intensive insulin therapy, which has recently been shown to reduce morbidity and mortality rates of mechanically ventilated critically ill patients in a surgical intensive care unit. Design: A post hoc cost analysis. SETTING: Surgical intensive care unit. PATIENTS: Patients were 1548 mechanically ventilated patients admitted to a surgical intensive care unit. INTERVENTIONS: A post hoc cost analysis was conducted based on data collected prospectively as part of a large randomized controlled trial. The analysis performed was a healthcare resource utilization analysis in which the cost of hospitalization in the intensive care unit was determined based on length of stay and the frequency of crucial cost-generating morbid events occurring in the intensive and conventional insulin treatment groups. Sensitivity analyses were performed to evaluate the robustness of the findings. Discounting of costs was not performed as treatment was limited to the intensive care stay and follow-up was not continued beyond hospitalization. MEASUREMENTS AND MAIN RESULTS: In the intensive treatment group, total treatment cost was 109,838 Euros (144 Euros per patient). In the conventional treatment group, total treatment cost was 56,359 Euros (72 Euros per patient). The excess cost of intensive insulin therapy was 72 Euros per patient. The total hospitalization cost in the intensive treatment group was 6,067,237 Euros (7931 Euros per patient) compared with 8,275,394 Euros (10,569 Euros per patient) in the conventional treatment group. The excess cost of intensive care unit hospitalization in the conventional vs. intensive treatment group was 2638 Euros per patient. These intensive care unit benefits were not offset by additional costs for care on regular wards. CONCLUSIONS: Intensive insulin therapy, which reduces morbidity and mortality rates of mechanically ventilated patients admitted to a surgical intensive care unit, is associated with substantial cost savings compared with conventional insulin therapy.     

Longitudinal changes in procalcitonin in a heterogeneous group of critically ill patients*

OBJECTIVE:: The utility of procalcitonin for the diagnosis of infection in the critical care setting has been extensively investigated with conflicting results. Herein, we report procalcitonin values relative to baseline patient characteristics, presence of shock, intensive care unit time course, infectious status, and Gram stain of infecting organism. DESIGN:: Prospective, multicenter, observational study of critically ill patients admitted to intensive care unit for >24 hrs. SETTING:: Three tertiary care intensive care units. PATIENTS:: All consenting patients admitted to three mixed medical-surgical intensive care units. Patients who had elective surgery, overdoses, and who were expected to stay <24 hrs were excluded. INTERVENTIONS:: Patients were followed prospectively to ascertain the presence of prevalent (present at admission) or incident (developed during admission) infections and clinical outcomes. Procalcitonin levels were measured daily for 10 days and were analyzed as a function of the underlying patient characteristics, presence of shock, time of infection, and pathogen isolated. MAIN RESULTS:: Five hundred ninety-eight patients were enrolled. Medical and surgical infected cohorts had similar baseline procalcitonin values (3.0 [0.7-15.3] vs. 3.7 [0.6-9.8], p = .68) and peak procalcitonin (4.5 [1.0-22.9] vs. 5.0 [0.9-16.0], p = .91). Infected patients were sicker than their noninfected counterparts (Acute Physiology and Chronic Health Evaluation II 22.9 vs. 19.3, p < .001); those with infection at admission had a trend toward higher peak procalcitonin values than did those whose infection developed in the intensive care unit (4.9 vs. 1.4, p = .06). The presence of shock was significantly associated with elevations in procalcitonin in cohorts who were and were not infected (both groups p < .003 on days 1-5). CONCLUSIONS:: Procalcitonin dynamics were similar between surgical and medical cohorts. Shock had an association with higher procalcitonin values independent of the presence of infection. Trends in differences in procalcitonin values were seen in patients who had incident vs. prevalent infections.     

Neurologic intensive care resource use after brain tumor surgery: an analysis of indications and alternative strategies

OBJECTIVE: Greater demand and limited resources for intensive care monitoring for patients with neurologic disease may change patterns of intensive care unit utilization. The necessity and duration of intensive care unit management for all neurosurgical patients after brain tumor resection are not clear. This study evaluates a) the preoperative and perioperative variables predictive of extended need for intensive care unit monitoring (>1 day); and b) the type and timing of intensive care unit resources in patients for whom less intensive postoperative monitoring may be feasible. DESIGN: Retrospective chart review. SETTING: A neurocritical care unit of a university teaching hospital. PATIENTS: Patients were 158 consecutive postoperative brain tumor resection patients admitted to a neurocritical care unit within a 1-yr period (1998-1999). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Twenty-three patients (15%) admitted to the neurocritical care unit for >24 hrs were compared with 135 (85%) patients admitted for <24 hrs. Predictors of >1-day stay in the neurocritical care unit in a logistic regression model were a tumor severity index comprising radiologic characteristics of tumor location, mass effect, and midline shift on the preoperative magnetic resonance imaging scan (odds ratio, 12.5; 95% confidence interval, 3.1-50.5); an intraoperative fluid score comprising estimated blood loss, total volume of crystalloid, and other colloid/hypertonic solutions administered (odds ratio, 1.8; 95% confidence interval, 1.2-2.6); and postoperative intubation (odds ratio, 67.5; 95% confidence interval, 6.5-702.0). Area under the receiver operating characteristic curve for the model of independent predictors for staying >1 day in the neurocritical care unit was 0.91. Neurocritical care unit resource use was reviewed in detail for 134 of 135 patients who stayed in the neurocritical care unit for <1 day. Sixty-five (49%) patients required no interventions beyond postanesthetic care and frequent neurologic exams. A total of 226 intensive care unit interventions were performed (mean +/- sd, 1.7 +/- 2.6) in 69 (51%) patients. Ninety (67%) patients had no further interventions after the first 4 hrs. Neurocritical care unit resource use beyond 4 hrs, largely consisting of intravenous analgesic use (72% of orders), was significantly associated with female gender, benign tumor on frozen section biopsy, and postoperative intubation (chi-square, p <.05). CONCLUSIONS: A small fraction of patients require prolonged intensive care unit stay after craniotomy for tumor resection. A patient's risk of prolonged stay can be well predicted by certain radiologic findings, large intraoperative blood loss, fluid requirements, and the decision to keep the patient intubated at the end of surgery. Of those patients requiring intensive care unit resources beyond the first 4 hrs, the interventions may not be critical in nature. A prospective outcome study is required to determine feasibility, cost, and outcome of patients cared for in extended recovery and then transferred to a skilled nursing ward.     

Supporting ward staff in acute care areas: expanding the service.

Critical care services face significant change over the next five years; pressure on intensive care unit beds continues to escalate. As a result of service demands, there are still an increasing number of highly dependent patients being cared for in general ward areas, placing increasing pressures on the multi-professional team. There is now national recognition of these changing service requirements and wide-ranging proposals for improving the continuity and quality of care provided for critically ill patients within the NHS. The role of Clinical Nurse Educator Critical Care within one acute Trust over an 18-month period is reflected on and current expansion of the service in light of these national initiatives is explored.     

Improving tracheostomy care for ward patients

The number of patients with a tracheostomy being cared for in the ward setting has increased recently as intensive care clinicians use this procedure to aid early weaning from mechanical ventilation. As a result, ward staff are providing the specialist care required by patients with a tracheostomy more frequently. This article describes how the outreach team and the critical care practice development nurse in one trust collaborated to identify, develop and implement strategies to ensure that patients with a tracheostomy in the ward setting would be cared for by an educated and supported team of nurses.     

Elevated red cell distribution width at initiation of critical care is associated with mortality in surgical intensive care unit patients

PurposeRecent evidence suggests that red cell distribution width (RDW) is associated with mortality in mixed cohorts of critically ill patients. Our goal was to investigate whether elevated RDW at initiation of critical care in the intensive care unit (ICU) is associated with 90-day mortality in surgical patients.MethodsWe performed a retrospective, single-center cohort study. Normal RDW was defined as 11.5%–14.5%. To investigate the association of admission RDW with 90-day mortality, we performed a logistic regression analysis, controlling for age, sex, race, body mass index, Nutrition Risk Screening 2002 score, Acute Physiology and Chronic Health Evaluation II score, hospital length of stay, as well as levels of creatinine, albumin, and mean corpuscular volume.Results500 patients comprised the analytic cohort; 47% patients had elevated RDW and overall 90-day mortality was 28%. Logistic regression analysis demonstrated that patients with elevated RDW had a greater than two-fold increased odds of mortality (OR 2.28: 95%CI 1.20–4.33) compared to patients with normal RDW.ConclusionsElevated RDW at initiation of care is associated with increased odds of 90-day mortality in surgical ICU patients. These data support the need for prospective studies to determine whether RDW can improve risk stratification in surgical ICU patients.     

Determinants of outcome for patients admitted to a long-term ventilator unit

BACKGROUND: This prospective cohort study was done to identify determinants of successful weaning from mechanical ventilation among patients admitted to the 10-bed long-term ventilator unit (LTVU) of a teaching hospital. METHODS: Prospective patient surveillance and data collection were done on 472 patients admitted to the LTVU over a 4-year period (January 1996 to December 1999). RESULTS: Multiple logistic regression analysis showed that the absence of home mechanical ventilation at the time of hospital admission, absence of intensive care unit (ICU) readmission, and admission to the LTVU from a nonmedical service were independently associated with successful weaning. No statistical difference between hospital survivors and nonsurvivors was associated with length of stay in the LTVU and length of stay in the hospital. CONCLUSIONS: Patients admitted to an LTVU require prolonged hospitalizations and intensive resource utilization. These data suggest that improved methods for identifying patients who are unlikely to benefit from prolonged mechanical ventilation may assist physicians in their discussions with patients and family members as they consider various treatment options.     

A Model for an Integrated Emergency Medicine/Trauma Service

Objective: To describe a model for an integrated multidisciplinary trauma service and to compare survival outcomes for patients resuscitated by either emergency medicine (EM) or surgical housestaff assigned to the trauma service.
Methods: A prospective observational study was performed using injured patients evaluated in the trauma room at Hartford Hospital from July 1 through December 31, 1995. Inclusion criteria included an ICD-9-CM code of 800 through 959.9 and any of the following: transfer from another hospital, admission to the intensive care unit, hospitalization for ±23 hours, survival probability of ±90%, or Abbreviated Injury Score of ±3. Patients were excluded for burns necessitating transfer to a burn unit for definitive care, and for missing data elements that prevented a patient from being analyzed by the TRISS method. Data elements included mechanism of injury, Injury Severity Score, Revised Trauma Score, probability of survival, age, gender, and whether an EM resident was team leader. Patients in the EM cohort (group 1) were compared with patients for whom a surgical resident was team leader (group 2) for all data elements and for hospital survival. TRISS analysis was performed to evaluate outcomes in comparison with national norms.
Results: After exclusions, 609 patients were left for analysis. There were 141 (30%) resuscitated with an EM resident as team leader. No significant difference was found for matched variables between the groups. Both groups had good comparability with the Major Trauma Outcome Study (MTOS) database baseline, with M scores of 0.949 and 0.942, respectively. Outcomes for both groups also compared favorably with the MTOS norm for survival, with Z scores of 2.38 and 2.35 for groups 1 and 2.
Conclusions: These results suggest that in this model of integrated EW trauma service, equivalent survival outcomes occur whether EM or surgery housestaff act as team leaders.     

Worst case: rethinking tertiary triage protocols in pandemics and other health emergencies

Demand for critical care resources could vastly outstrip supply in an influenza pandemic or other health emergency, which has led expert groups to propose altered standards for triage and resource allocation. A pilot study by Christian and colleagues applied the Ontario, Canada draft critical care triage protocol to an actual retrospective cohort of intensive care unit patients. The findings are troubling. Patients who would have been triaged to expectant and designated for withdrawal of intensive care unit care and ventilator support in fact had substantial survival rates. Triage officers often disagreed and lacked confidence in their categorization decisions. These findings suggest that rationing paradigms which include categorical exclusion criteria and withdrawal of lifesaving resources should be reconsidered, and public input sought on nonclinical aspects.     

Nurse-performed ultrasound assessment of gastric residual volume and enteral nasogastric tube placement in the general intensive care unit

ObjectiveUltrasonography is an essential imaging modality in the critical care population and has been increasingly utilized to check gastric residual volume . Various studies have shown that intensive care unit nurses untrained in ultrasound can easily be trained in its accurate interpretation. We prospectively analyzed nurse-performed repeated measurements of gastric residual volume and nasogastric tube positioning via an ultrasound technique in the intensive care unit.DesignThis was a single-center, cross-sectional prospective study. Four intensive care unit nurses, evenly divided into two groups (teams A and B), underwent four hours of formal ultrasound training by three critical care staff physicians. The trained nurses provided bedside ultrasound assessments of gastric residual volume and nasogastric tube positioning which were compared to a standard protocol of syringe aspiration.ResultsNinety patients were recruited to the study. Four measurements per patient were performed, for a total of 360 assessments. The ultrasound gastric residual volume assessments were correlated with the syringe aspiration protocol and demonstrated high Intraclass Correlation Coefficient rates of 0.814 (0.61–0.92) for team A and 0.85 (0.58–0.91) for team B. Nasogastric tube placement was successfully and independently verified by ultrasound in most of the critically ill patients (78% of team A and 70% of team B). The comparative ultrasound assessments of tube positioning demonstrated good correlation of 0.733 (0.51–0.88) between each team’s two independent observers.ConclusionOur study demonstrated a strong correlation between US utilization for assessment of gastric residual volume and nasogastric tube positioning and standard protocol methods, suggesting it is a safe, simple and effective practice for intensive care unit nurses.     

Pro/con clinical debate: Antibiotics are important in the management of patients with pancreatitis with evidence of pancreatic necrosis

Pancreatitis is not an infrequent diagnosis in patients admitted to the intensive care unit. Prolonged stays, intense resource utilization and high morbidity/mortality are commonplace in such patients. Management for the most part is supportive, with the surgical team keeping close watch to intervene as the need arises. Over the past few decades there has been considerable debate regarding the usefulness of systemic antibiotics to prevent infectious complications in patients with evidence of pancreatic necrosis. In the present article of Critical Care, two expert groups debate the two sides of this contentious antibiotic issue.     

Caring for the patient undergoing transsphenoidal surgery in the acute care setting: an alternative to critical care.

Patients undergoing transsphenoidal surgery have complex needs that require expert care and the coordination of a multidisciplinary team of healthcare professionals. In general, patients requiring this surgery are cared for in intensive care units. An innovative program at the University of Virginia, developed 11 years ago, enables these patients to be cared for on an acute care unit for the entirety of their hospitalization. The success of this program is evident in positive clinical and financial outcomes.     

Description of the "new" intensive care unit of the Valladolid Río Hortega Hospital

The unit described herein forms part of the Rio Hortega Hospital in Valladolid (Spain) and is situated on the third floor. The building houses several medical and surgical specialities and has been renovated several times; the latest renovations have involved technical and structural renovation of the Intensive Care Unit. The new intensive care unit was inaugurated in February 1998 due to new technical and medical requirements. The aim of improving medical care and the degree of satisfaction among patients and their families has been achieved and the work environment is more congenial and peaceful. The unit is composed of two areas: the multipurpose intensive care unit and the cardiology intensive care unit, edowed with the same monitoring system and apparatus specific to each. Moreover, the unit is composed of an administration area, storerooms and an area for common services (a room for the cleaning of material, waste disposal, lavatories, etc.). The medical team is composed of (a) medical staff-seven staff doctors and five residents; (b) nursing staff: 18 nurses and 13 nurse's aides in the multipurpose Intensive Care Unit; 13 nurses and 8 nurse's aides in the cardiology intensive care unit: one supervisor common to both units; administrative staff: one secretary; one security guard and one cleaner. The distribution of nursing work depends on workload reflected in the patient's daily chart, protocols, nursing care plans and follow-up sheets for the nursing team. Visiting hours are divided between the morning and afternoon and information is given to the patient's relatives by the doctor before the visit. The hospital has three catholic priests who periodically visit the patients. We also try to help when the patients profess other religious faith. The type of patients who are cared for in the unit as well as their distribution according to condition, severity, death, etc, is shown in figures: the data correspond to the period from January 1 1998 to August 1 1999.     

Myocardial infarction following coronary artery bypass graft surgery increases healthcare resource utilization

OBJECTIVE: To assess the health economic impact of perioperative myocardial infarction in a cohort of patients undergoing coronary artery bypass graft surgery. DESIGN: Retrospective cohort analysis using data from hospital bills and uniform billing forms. SETTING: A total of 147 geographically diverse hospitals in the United States. PATIENTS: The study population consisted of 2,102 coronary artery bypass graft surgery patients enrolled in the PRIMO-CABG trial at U.S. sites between January 2002 and February 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Resource utilization and costs during the index hospitalization and during a 6-month follow-up period were compared between patients who had a myocardial infarction by postoperative day 4 and those who did not. Linear regression was used to examine whether myocardial infarction by day 4 was associated with index hospitalization costs, after adjusting for baseline characteristics. Myocardial infarction occurred in 191 (9.1%) patients undergoing coronary artery bypass graft surgery. Myocardial infarction was associated with a doubling of intensive care unit time (3.5 days among patients with no myocardial infarction and 7.1 days among patients with myocardial infarction, p < .01) and a 48% increase in hospital length of stay. Myocardial infarction by day 4 was associated with a 43% increase in hospital costs, a 29% increase in physician service costs, a 41% increase in total costs during the index hospitalization, and a 38% increase in cumulative 6-month costs. After baseline adjustment, myocardial infarction continued to be associated with higher index hospitalization costs. CONCLUSIONS: Myocardial infarction following coronary artery bypass graft surgery was associated with a significant increase in intensive care unit time, hospital length of stay, and overall costs, which contributed to greater hospital and physician service costs. Healthcare resource utilization is increased in patients sustaining a myocardial infarction following coronary artery bypass graft surgery.     

Improving geriatric transitional care through inter-professional care teams

Objectives  The aim of this study was to examine the impact of the use of an inter-professional care team on patient length of stay and payer charges in a geriatric transitional care unit.
Methods  An analysis of de-identified administrative records for transitional care patients for the 12-month period (2003–2004) cared for by the inter-professional team ( n  = 163) and cared for by traditional single provider care model ( n  = 176) was carried out. We conducted logistic regression on length of stay and charges controlling for patient demographics and acuity levels.
Results  The inter-professional care team patients had significantly shorter lengths of stay, fewer patient days and lower total charges. Patient diagnosis and acuity were similar across groups.
Conclusion  This study provides empirical evidence of the impact of an inter-professional care model in providing cost-effective transitional care in a nursing home setting. Evidence of shorter lengths of stay, shorter patient days and lower charges suggests benefit in the development and financing of inter-professional care teams for transitional care services.