Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital

OBJECTIVE: To determine the attributable cost and length of stay of intensive care unit (ICU)-acquired, catheter-associated bloodstream infections from a hospital-based cost perspective, after adjusting for potential confounders. DESIGN: Patients admitted to the ICU between January 19, 1998, and July 31, 2000, were observed prospectively for the occurrence of catheter-associated bloodstream infections. Hospital costs were obtained from the hospital cost accounting database. SETTING: The medical and surgical ICUs at a 500-bed suburban, tertiary care hospital. PATIENTS: Patients requiring central venous catheterization while in the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We measured occurrence of catheter-associated bloodstream infection, in-hospital mortality rate, total ICU and hospital lengths of stay, and total hospital costs. Catheter-associated bloodstream infection occurred in 41 of 1,132 patients (3.6 cases per 1000 catheter days). Patients with catheter-associated bloodstream infection had significantly higher unadjusted ICU length of stay (median, 24 vs. 5 days; p < .001), hospital length of stay (median, 45 vs. 11 days; p < .001), mortality rate (21 [51%] vs. 301 [28%], p = .001), and total hospital costs (83,544 dollars vs. 23,803 dollars, p < .001). Controlling for other factors that may affect costs and lengths of stay, catheter-associated bloodstream infections resulted in an attributable cost of 11,971 dollars (95% confidence interval, 6,732 dollars-18,352 dollars), ICU length of stay of 2.41 days (95% confidence interval, 0.08-3.09 days), and hospital length of stay of 7.54 days (95% confidence interval, 3.99-11.09 days). CONCLUSIONS: Patients with catheter-associated bloodstream infection had significantly longer ICU and hospital lengths of stay, with higher unadjusted total mortality rate and hospital cost compared with uninfected patients. After adjusting for underlying severity of illness, the attributable cost of catheter-associated bloodstream infection was approximately 11,971 dollars.     

Effect of interhospital transfer on resource utilization and outcomes at a tertiary care referral center

OBJECTIVE: Mortality and length of stay are two outcome variables commonly used as benchmarks in rating the performance of medical centers. Acceptance of transfer patients has been shown to affect both outcomes and the costs of health care. Our objective was to compare observed and predicted lengths of stay, observed and predicted mortality, and resource consumption between patients directly admitted and those transferred to the intensive care unit (ICU) of a large academic medical center. DESIGN: Observational cohort study. SETTING: Mixed medical/surgical ICU of a university hospital. PATIENTS: A total of 4,569 consecutive patients admitted to a tertiary care ICU from April 1, 1997, to March 30, 2000. INTERVENTIONS: None. MEASUREMENTS: Acute Physiology and Chronic Health Evaluation (APACHE) III score, actual and predicted ICU and hospital lengths of stay, actual and predicted ICU and hospital mortality, and costs per admission. MAIN RESULTS: Crude comparison of directly admitted and transfer patients revealed that transfer patients had significantly higher APACHE III scores (mean, 60.5 vs. 49.7, p < .001), ICU mortality (14% vs. 8%, p < .001), and hospital mortality (22% vs. 14%, p < .001). Transfer patients also had longer ICU lengths of stay (mean, 6.0 vs. 3.8 days, p < .001) and hospital lengths of stay (mean, 20 vs. 15.9 days, p < .001). Stratified by disease severity using the APACHE III model, there was no difference in either ICU or hospital mortality between the two populations. However, in the transfer group with the lowest predicted mortality of 0-20%, ICU and hospital lengths of stay were significantly higher. In crude cost analysis, transfer patients' costs were $9,600 higher per ICU admission compared with nontransfer patients (95% confidence interval, $6,000-$13,400). Risk stratification revealed that the higher per-patient cost was entirely confined to the transfer patients with the lowest predicted mortality. CONCLUSIONS: Patients transferred to a tertiary care ICU are generally more severely ill and consume more resources. However, they have similar adjusted mortality outcomes when compared with directly admitted patients. The difference in resource consumption is mainly attributable to the group of patients in the lowest predicted risk bracket.     

Mortality and the increase in length of stay attributable to the acquisition of Acinetobacter in critically ill patients.

OBJECTIVE: To determine the impact of Acinetobacter baumannii (AB) acquisition in intensive care unit (ICU) patients on mortality and length of stay (LOS). DESIGN: Pairwise matched 1:1 case-control study. SETTING: Medical-surgical ICU in a tertiary health care institution. PATIENTS: During 16 months, all patients admitted to the ICU were eligible. Case patients were defined as every patient with an AB isolation 48 hrs after ICU admission. Control patients were retrospectively selected from ICU patients without any AB isolation, according to seven matching variables. MEASUREMENTS AND MAIN RESULTS: Attributable mortality and excess LOS in the ICU were measured. Eighty-seven patients were included, with 75 pairs successfully matched. Infection was defined in 48 patients (23 respiratory). The attributable mortality rate for AB acquisition was 30% (49% vs.19%) (95% confidence interval [CI] = 23%, 37%): 43% (CI = 34%, 52%) in patients with infection (58% vs.15%) and 53% (CI = 41%, 65%) in patients with respiratory infections (70% vs.17%). The estimated risk rates for death were 2.6 (CI = 1.6, 4.5; p < .001), 4.0 (CI = 1.9, 8.3; p < .001), and 4.0 (CI = 1.6, 10.2; p < .01), respectively. The attributable excess LOS was 13 days for both AB acquisition and infection (23 vs. 10 days; p < .001) and respiratory infections (23 vs. 10 days; p < .01). In noninfected patients, no significant excess of mortality was found (33% vs. 26%), but LOS increased in 15 days. CONCLUSION: AB acquisition involved an excess LOS in ICU patients and increased risk of death, but the latter could be found only in patients with proven infection.     

Linezolid for treatment of ventilator-associated pneumonia: a cost-effective alternative to vancomycin

OBJECTIVES: To determine the incremental cost-effectiveness of linezolid compared with vancomycin for treatment of ventilator-associated pneumonia due to Staphylococcus aureus. DESIGN: Decision model analysis of the cost and efficacy of linezolid vs. vancomycin for treatment of ventilator-associated pneumonia. The primary outcome was the incremental cost-effectiveness of linezolid in terms of cost per added quality-adjusted life-year gained. Other outcomes were the marginal costs per hospital survivor and per year of life saved generated by using linezolid. Model estimates were derived from prospective trials of linezolid for ventilator-associated pneumonia and from other studies describing the costs and outcomes for ventilator-associated pneumonia. SETTING AND PATIENTS: Hypothetical cohort of 1,000 patients diagnosed with ventilator-associated pneumonia. INTERVENTIONS: In the model, patients received either linezolid or vancomycin. MEASUREMENTS AND MAIN RESULTS: The incremental cost-effectiveness of linezolid was calculated as the additional quality-adjusted life-years resulting from therapy with linezolid divided by the sum of the incremental costs arising because of use of linezolid (e.g., higher direct costs for linezolid, costs per in-hospital care of survivors, and posthospitalization costs). Despite its higher cost, linezolid was cost-effective for treatment of ventilator-associated pneumonia. The cost per quality-adjusted life-year equals approximately 30,000 dollars. The model was moderately sensitive to the estimated efficacy of linezolid over vancomycin. Nonetheless, even with all inputs simultaneously skewed against, linezolid remains a cost-effective option (cost per quality-adjusted life-year approximately 100,000 dollars). Based on Monte Carlo simulation, the results of our analysis are robust across a range of model inputs and assumptions (95% confidence interval for cost per quality-adjusted life-year ranges from 23,637 dollars to 42,785 dollars). CONCLUSIONS: Linezolid is a cost-effective alternative to vancomycin for the treatment of ventilator-associated pneumonia.     

Multiple-drug-resistant bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease: Prevalence, risk factors, and outcome

OBJECTIVE: To determine prevalence, risk factors, and effect on outcome of multiple-drug-resistant (MDR) bacteria in patients with severe acute exacerbation of chronic obstructive pulmonary disease. DESIGN: Prospective, observational, cohort study. SETTING: Thirty-bed medical intensive care unit (ICU) in a university hospital. METHODS: All chronic obstructive pulmonary disease patients with acute exacerbation who required intubation and mechanical ventilation for >48 hrs were eligible during a 4-yr period. Patients with pneumonia or other causes of acute respiratory failure were not eligible. In all patients, quantitative tracheal aspirate was performed at ICU admission (positive at 10 colony-forming units [cfu]/mL). MDR bacteria were defined as methicillin-resistant Staphylococcus aureus, ceftazidime- or imipenem-resistant Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia, and extended-spectrum beta-lactamase-producing Gram-negative bacilli. All patients received empirical antibiotic treatment at ICU admission. Univariate and multivariate analyses were used to determine variables associated with MDR bacteria and variables associated with ICU mortality. RESULTS: A total of 857 patients were included, and 304 bacteria were isolated (>/=10 cfu/mL) in 260 patients (30%), including 75 MDR bacteria (24%) in 69 patients (8%). When patients with MDR bacteria were compared with patients without MDR bacteria, previous antimicrobial treatment (odds ratio [OR], 2.4; 95% confidence interval [95% CI], 1.2-4.7; p = .013) and previous intubation (OR, 31; 95% CI, 12-82; p < .001) were independently associated with MDR bacteria. When patients with bacteria other than MDR or patients with no bacteria were used as a reference group, these risk factors were still independently associated with MDR bacteria. Although ICU mortality rate was higher in patients with MDR bacteria than in patients without MDR bacteria (44% vs. 25%; p = .001; OR, 2.3; 95% CI, 1.4-3.8), MDR bacteria were not independently associated with ICU mortality. Inappropriate initial antibiotic treatment (88% vs. 5%; p = <.001; OR, 6.7; 95% CI, 3.8-12) and ventilator-associated pneumonia (23% vs. 5%; p = <.001; OR, 1.3; 95% CI, 1-1.8) rates were significantly higher in patients with MDR bacteria than in patients with bacteria other than MDR. Inappropriate initial antibiotic treatment was independently associated with increased ICU mortality (OR, 7.1; 95% CI, 1.9-30; p = .003). CONCLUSION: MDR bacteria are common in patients with acute exacerbation of chronic obstructive pulmonary disease requiring intubation and mechanical ventilation. Previous antimicrobial treatment and previous intubation are independent risk factors for MDR bacteria. Although MDR bacteria are not independently associated with ICU mortality, inappropriate initial antibiotic treatment is an independent risk factor for ICU mortality in these patients. Further studies are needed to determine whether broad-spectrum antibiotic treatment is cost-effective in these patients.     

The impact of adverse patient occurrences on hospital costs in the pediatric intensive care unit

OBJECTIVES: To study the influence of adverse patient occurrences defined as airway complication (AC), vascular complication (VC), and infectious complication (IC) on intensive care unit (ICU) costs and length of stay (LOS). DESIGN: Retrospective, cohort study SETTING: An urban, tertiary care children's hospital in Philadelphia, PA. PATIENTS: All children admitted to a multidisciplinary pediatric ICU during the fiscal year 1994. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Demographic data, diagnoses, Pediatric Risk of Mortality scores, LOS, and deaths were recorded. Hospital charges were converted into costs by using cost-to-charge ratios. There were 23 AC, 35 VC, and 40 IC events. Multiple regression in models adjusting for age, Pediatric Risk of Mortality score, mortality, chronic disease, and diagnosis by using AC, VC, and IC indicator variables was performed on the dependent variables of LOS and total costs. IC was associated with an increase in total costs of $50,361.89 (p < .001), an increased LOS of 15.6 days (p < .001), and no significant increase in daily costs. There were no significant increases in costs or LOS seen with the AC and VC variables. In a matched analysis, the total costs attributable to IC averaged $32,040 per patient. CONCLUSIONS: The occurrence of complications in the pediatric ICU is associated with meaningful increases in LOS and hospital costs. ICs are more important predictors of costs than ACs or VCs. Continuing efforts should be made to minimize adverse occurrences to improve patient care and reduce costs.     

Experience with a clinical guideline for the treatment of ventilator-associated pneumonia

OBJECTIVE: To evaluate a clinical guideline for the treatment of ventilator-associated pneumonia. DESIGN: Prospective before-and-after study design. SETTING: A medical intensive care unit from a university-affiliated, urban teaching hospital. PATIENTS: Between April 1999 and January 2000, 102 patients were prospectively evaluated. INTERVENTIONS: Prospective patient surveillance, data collection, and implementation of an antimicrobial guideline for the treatment of ventilator-associated pneumonia. MEASUREMENTS AND MAIN RESULTS: The main outcome evaluated was the initial administration of adequate antimicrobial treatment as determined by respiratory tract cultures. Secondary outcomes evaluated included the duration of antimicrobial treatment for ventilator-associated pneumonia, hospital mortality, intensive care unit and hospital lengths of stay, and the occurrence of a second episode of ventilator-associated pneumonia. Fifty consecutive patients with ventilator-associated pneumonia were evaluated in the before period and 52 consecutive patients with ventilator-associated pneumonia were evaluated in the after period. Severity of illness using Acute Physiology and Chronic Health Evaluation II (25.8 +/- 5.7 vs. 25.4 +/- 8.1, p =.798) and the clinical pulmonary infection scores (6.6 +/- 1.0 vs. 6.9 +/- 1.2, p =.105) were similar for patients during the two treatment periods. The initial administration of adequate antimicrobial treatment was statistically greater during the after period compared with the before period (94.2% vs. 48.0%, p <.001). The duration of antimicrobial treatment was statistically shorter during the after period compared with the before period (8.6 +/- 5.1 days vs. 14.8 +/- 8.1 days, p <.001). A second episode of ventilator-associated pneumonia occurred statistically less often among patients in the after period (7.7% vs. 24.0%, p =.030). CONCLUSIONS: The application of a clinical guideline for the treatment of ventilator-associated pneumonia can increase the initial administration of adequate antimicrobial treatment and decrease the overall duration of antibiotic treatment. These findings suggest that similar types of guidelines employing local microbiological data can be used to improve overall antibiotic utilization for the treatment of ventilator-associated pneumonia.     

Ventilator-associated pneumonia using a closed versus an open tracheal suction system

OBJECTIVE: The aim of this study was to analyze the prevalence of ventilator-associated pneumonia (VAP) using a closed-tracheal suction system vs. an open system. DESIGN: Prospective and randomized study, from October 1, 2002, to December 31, 2003. SETTING: A 24-bed medical-surgical intensive care unit in a 650-bed tertiary hospital. PATIENTS: Patients requiring mechanical ventilation for >24 hrs. INTERVENTIONS: Patients were randomized into two groups; one group was suctioned with the closed-tracheal suctioning system and another group with the open system. MEASUREMENTS: Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous. MAIN RESULTS: A total of 443 patients (210 with closed-tracheal suction system and 233 with the open system) were included. There were no significant differences between groups of patients in age, sex, diagnosis groups, mortality, number of aspirations per day, and Acute Physiology and Chronic Health Evaluation II score. No significant differences were found in either the percentage of patients who developed VAP (20.47% vs. 18.02%) or in the number of VAP cases per 1000 mechanical ventilation-days (17.59 vs. 15.84). There were also no differences in the VAP incidence by mechanical ventilation duration. At the same time, we did not find any differences in the incidence of exogenous VAP. Likewise, there were also no differences in the microorganisms responsible for pneumonia. Patient cost per day for the closed suction was more expensive than the open suction system (11.11 US dollars +/- 2.25 US dollars vs. 2.50 US dollars +/- 1.12 US dollars, p < .001). CONCLUSION: We conclude that in our study, the closed-tracheal suction system did not reduce VAP incidence, even for exogenous pneumonia.     

The impact of ventilator-associated pneumonia on the Canadian health care system

INTRODUCTION: Ventilator-associated pneumonia (VAP) is a cause of morbidity and mortality in critically ill patients. It is associated with increased health care costs and duration of mechanical ventilation. Using published data and information from public health care providers, we sought to determine the impact of VAP on the Canadian health care system. METHODS: Ventilator-associated pneumonia incidence, attributable mortality, and intensive care unit (ICU) utilization/resource data were obtained through Canadian published and institutional data. Ontario case cost methodology was used for the cost of a critical care bed which is CAN dollars 2396 per day, excluding treatment costs. Antibiotic acquisition costs for Ontario were used. Physician reimbursement rates were obtained from the provincial ministries of health. Ventilator-associated pneumonia data, ICU resource data, and costs were combined to determine the impact of VAP. RESULTS: For the Canadian health care system; ICU utilization is 217 episodes per 100000 population and 1150 days of mechanical ventilation per 100000. The incidence of VAP is 10.6 cases per 1000 ventilator days (95% CI, 5.1-16.1). Ventilator-associated pneumonia increases ICU length of stay 4.3 days (95% CI, 1.5-7.0 days) per episode. The attributable mortality of VAP is 5.8% (95% CI, -2.4 to 14). The number of cases of VAP is estimated to be approximately 4000 cases per year (95% CI, 1900-6100). This results in 230 deaths per year with the lower and upper confidence intervals ranging from 0 to 580. Ventilator-associated pneumonia accounts for approximately 17000 ICU days per year or around 2% of all ICU days in Canada. The cost to the health care system is CAN dollars 46 million (possible range, dollars 10 million to 82 million) per year. CONCLUSION: The impact of VAP on the Canadian health care system is considerable. Eradication of this preventable nosocomial infection would save lives and conserve scarce health care resources.     

Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit.

OBJECTIVE: To identify clinical predictors for tracheostomy among patients requiring mechanical ventilation in the intensive care unit (ICU) setting and to describe the outcomes of patients receiving a tracheostomy. DESIGN: Prospective cohort study. SETTING: Intensive care units of Barnes-Jewish Hospital, an urban teaching hospital. PATIENTS: 521 patients requiring mechanical ventilation in an ICU for >12 hours. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND MAIN RESULTS: The main variables studied were hospital mortality, duration of mechanical ventilation, length of stay in the ICU and the hospital, and acquired organ-system derangements. Fifty-one (9.8%) patients received a tracheostomy. The hospital mortality of patients with a tracheostomy was statistically less than the hospital mortality of patients not receiving a tracheostomy (13.7% vs. 26.4%; p = .048), despite having a similar severity of illness at the time of admission to the ICU (Acute Physiology and Chronic Health Evaluation [APACHE] II scores, 19.2 +/- 6.1 vs. 17.8 +/- 7.2; p = .173). Patients receiving a tracheostomy had significantly longer durations of mechanical ventilation (19.5 +/- 15.7 days vs. 4.1 +/- 5.3 days; p < .001) and hospitalization (30.9 +/- 18.1 days vs. 12.8 +/- 10.1 days; p < .001) compared with patients not receiving a tracheostomy. Similarly, the average duration of intensive care was significantly longer among the hospital nonsurvivors receiving a tracheostomy (n = 7) compared with the hospital nonsurvivors without a tracheostomy (n = 124; 30.9 +/- 16.3 days vs. 7.9 +/- 7.3 days; p < .001). Multiple logistic regression analysis demonstrated that the development of nosocomial pneumonia (adjusted odds ratio [AOR], 4.72; 95% confidence interval [CI], 3.24-6.87; p < .001), the administration of aerosol treatments (AOR, 3.00; 95% CI, 2.184.13; p < .001), having a witnessed aspiration event (AOR, 3.79; 95% CI, 2.30-6.24; p = .008), and requiring reintubation (AOR, 2.21; 95% CI, 1.54-3.18; p = .028) were variables independently associated with patients undergoing tracheostomy and receiving prolonged ventilatory support. Among the 44 survivors receiving a tracheostomy in the ICU, 38 (86.4%) were alive 30 days after hospital discharge and 31 (70.5%) were living at home. CONCLUSIONS: Despite having longer lengths of stay in the ICU and hospital, patients with respiratory failure who received a tracheostomy had favorable outcomes compared with patients who did not receive a tracheostomy. These data suggest that physicians are capable of selecting critically ill patients who most likely will benefit from placement of a tracheostomy. Additionally, specific clinical variables were identified as risk factors for prolonged ventilatory assistance and the need for tracheostomy.     

The distribution of costs of care in mechanically ventilated patients with chronic obstructive pulmonary disease

OBJECTIVES: To delineate the costs of care of patients with Chronic Obstructive Pulmonary Disease (COPD) and respiratory failure and to compare them with those of other mechanically ventilated patients. DESIGN: A post hoc analysis of a prospective investigation. SETTING: Medical and coronary intensive care units (ICUs) of an 804-bed, university-based hospital. PATIENTS: A total of 300 mechanically ventilated patients, 44 with COPD and 256 others, were included. MEASUREMENTS AND MAIN RESULTS: Despite similar lengths of ICU stay (9 days) and mechanical ventilation (5.5 days COPD vs. 5 days other, p = .11), ICU respiratory care costs for patients with COPD were $2,422 ($1,157-$6,110) [median U.S. dollars (interquartile range)] vs. $1,580 ($738-$3,322) for the others (p = .01). Ventilator costs for COPD patients were $1,795 ($943-$5,782) vs. $1,574 ($613-$3,112) (p = .12). Total hospitalization respiratory care costs for COPD patients were higher, $4,064 ($2,422-$9,572) vs. $2,342 ($1,186-$4,591), (p = .0001), and 74.4% of the median difference in cost between COPD patients and others was accounted for by spontaneous nebulizers (p = .001), metered dose inhalers (p = .01), and pulse oximetry (p = .02). By using multiple linear regression analyses, we found that COPD remained associated with higher respiratory costs (p<.05). Respiratory Care was the third largest category of hospital costs after beds (27%) and pharmacy expenses (25%), and it comprised approximately 14% of total cost. Total hospital costs were large for both groups, but did not differ between COPD and the others [$24,217 ($16,211-$58,834) vs. $27,672 ($15,692-$53,766), respectively (p = .96)]. Linear regression analyses showed that only Acute Lung Injury score was significantly related to total ICU and hospital costs of care (p<.05). CONCLUSIONS: Costs of ICU and non-ICU respiratory care for patients with COPD are higher than costs of care for other mechanically ventilated patients. Although the increased cost of bronchodilators and oximetry in these patients may serve as target areas for reductions in respiratory care costs, it may also be true that these modalities of therapy and management are necessary and need to be used with even greater intensity to achieve better outcomes. The predominant contributions of bed and pharmacy costs in all of our patients with respiratory failure support research efforts addressing these aspects of care.     

Direct costs of severe sepsis in three German intensive care units based on retrospective electronic patient record analysis of resource use

OBJECTIVE: To determine the direct costs of severe sepsis patients in German intensive care units (ICUs). DESIGN: Retrospective electronic data analysis. SETTING: Three adult intensive care units (surgical/medical) in three university hospitals in Germany. PATIENTS: 385 patients identified by standard definitions as suffering from severe sepsis. MEASUREMENTS AND RESULTS: A bottom-up approach was used to determine the direct ICU cost on actual resource use (medication, laboratory tests, microbiological analysis, disposables, and clinical procedures) for patients with severe sepsis. To determine the total direct costs, center-specific personnel and basic bed ("hotel") costs were added to total resources consumed. Average hospital mortality of severely septic patients was 42.6%. Mean ICU length of stay (LOS) was 16.6 days. Survivors stayed on average 4 days longer than nonsurvivors. The mean direct ICU costs of care were 23,297+/-18,631 euros per patient and 1,318 euros per day. In comparison, average daily charges being paid for an ICU patient by the health care system in Germany are 851 euros (based on official statistics). Nonsurvivors were more expensive than survivors in total direct costs (25,446 vs. 21,984 euros) and in per day direct cost (1,649 vs. 1,162 euros). Medication makes up the largest part of the direct costs, followed by expenses for personnel. CONCLUSIONS. Patients with severe sepsis have a high ICU mortality rate and long ICU LOS and are substantially expensive to treat. Nonsurviving septic patients are more costly than survivors despite shorter ICU LOS. This is due to higher medication costs indicating increased efforts to keep patients alive.     

Assessing predictive accuracy for outcomes of ventilator-associated events in an international cohort: the EUVAE study

Purpose

To analyze the impact on patient outcome of ventilator-associated events (VAEs) as defined by the Centers for Disease Control and Prevention (CDC) in 2008, 2013, and the correlation with ventilator-associated pneumonia (VAP) or tracheobronchitis (VAT).

Methods

This was a prospective, observational, multicenter, international study conducted at 13 intensive care units (ICUs); thirty consecutive adults mechanically ventilated for ≥?48 h per site were eligible, with daily follow-up being recorded in a collaborative web database; VAEs were assessed using the 2013 CDC classification and its 2015 update.

Results

A total of 2856 ventilator days in 244 patients were analyzed, identifying 33 VAP and 51 VAT episodes; 30-day ICU mortality was significantly higher (42.8 vs. 19.6%, p?<?0.007) in patients with VAP than in those with VAT. According to the 2013 CDC definitions, 117 VAEs were identified: 113 (96%) were infection-related ventilator-associated complication-plus (IVAC-plus), while possible ventilator-associated pneumonia (PVAP) was found in 64 (56.6%) of them. VAE increased the number of ventilator days and prolonged ICU and hospital LOS (by 5, 11, and 12 days, respectively), with a trend towards increased 30-day mortality (43 vs 28%, p?=?0.06). Most episodes (26, 55%) classified as IVAC-plus without PVAP criteria were due to atelectasis. PVAP significantly increased (p?<?0.05) ventilator days as well as ICU and hospital LOS (by 10.5, 14, and 13 days, respectively). Only 24 (72.7%) of VAP and 15 (29.4%) of VAT episodes met IVAC-plus criteria.

Conclusions

Respiratory infections (mainly VAT) were the most common complication. VAE algorithms only identified events with surrogates of severe oxygenation deterioration. As a consequence, IVAC definitions missed one fourth of the episodes of VAP and three fourths of the episodes of VAT. Identifying VAT (often missed by IVAC-plus criteria) is important, as VAP and VAT have different impacts on mortality.

     

Sex and age effects on outcomes of total hip arthroplasty after inpatient rehabilitation

OBJECTIVE: To retrospectively examine the effects of sex and age on the inpatient rehabilitation outcomes of patients after total hip arthroplasty (THA). DESIGN: Exploratory, retrospective study. SETTING: A university-affiliated rehabilitation hospital. PARTICIPANTS: Male and female THA patients (N=332) were stratified into age brackets (<65y, 65-84y, >or=85y). All patients completed interdisciplinary inpatient rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Length of stay (LOS), FIM instrument scores, FIM efficiency (FIM/LOS), hospital costs, and discharge disposition location were collected by chart review. RESULTS: Regardless of age, women had lower FIM scores at admission and discharge than men (P<.05). FIM efficiency was 22% to 53% lower for women in primary THA and 16% to 85% lower in revision THA than men (P=.001). Women accrued higher total hospital charges than men (13,099 dollars vs 11,141 dollars; P<.05), and were discharged home less frequently than men (84.4% vs 90.9%; P<.05). Admission FIM scores were 10.6% and 8.9% lower and discharge FIM scores were 7.3% and 9.2% lower in patients 85 years or older than those less than 65 or 65 to 84 years (P<.01). FIM efficiency was 25% to 38% higher in patients less than 85 years than those 85 years and older (P=.015), and 37% higher in men than women (P=.001). Patients 85 years and older were discharged less frequently to home than patients less than 85 years (P<.05). CONCLUSIONS: All patients made functional improvement after inpatient rehabilitation, but women and patients 85 years and older had longer LOS and lower FIM efficiency, incurred greater hospital charges, and were less likely to be discharged to home than men and younger counterparts.     

Four-factor prothrombin complex concentrate for the reversal of factor Xa inhibitors for traumatic intracranial hemorrhage

ObjectiveThe objective of this study was to determine the effectiveness and safety of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of factor Xa inhibitors in patients with traumatic intracranial hemorrhage (ICH).MethodsThis was a retrospective cohort study of patients taking factor Xa inhibitors with traumatic ICH between March 1, 2015 and August 31, 2017 at two trauma centers. The primary outcome was in-hospital mortality in patients who received 4F-PCC (4F-PCC group) compared to those who did not (no reversal group). Secondary outcomes included functional recovery, hospital and intensive care unit (ICU) length of stay (LOS), and thromboembolic complications.ResultsThere were 62 patients included in the study. Injury Severity Score (ISS) was significantly higher in the 4F-PCC group (17.6 vs. 12.1, p = 0.019). The 4F-PCC group had a significantly higher mortality (22.9% vs. 3.7%, p = 0.034) and longer ICU LOS (2.5 vs. 1.4 days, p = 0.0024). The no reversal group had a significantly higher incidence of ischemic stroke/transient ischemic attack (TIA) (0% vs. 14.8%, p = 0.019). After controlling for ISS, there was no significant difference in mortality (p = 0.20), ICU LOS (p = 0.64), or ischemic stroke/TIA (p = 0.94). There was no difference in hospital LOS, discharge disposition, final Activity Measure for Post Acute Care daily activity score, VTE, or MI.ConclusionPatients with a higher ISS received 4F-PCC preferentially, which led to an apparent mortality benefit the no reversal group. After adjusting for baseline differences between groups, there was no difference in mortality, functional recovery, hospital and ICU LOS, or thromboembolic complications.     

Effect of oropharyngeal decontamination by povidone-iodine on ventilator-associated pneumonia in patients with head trauma

OBJECTIVE: To evaluate the effect of a regular oropharyngeal application of povidone-iodine on the prevalence of ventilator-associated pneumonia in patients with severe head trauma. DESIGN: Prospective randomized study. SETTING: A surgical intensive care unit of a university hospital. INTERVENTIONS: Patients with severe head trauma (Glasgow Coma Score of < or =8) expected to need ventilation for > or =2 days were prospectively randomized into three groups: those receiving nasopharynx and oropharynx rinsing with 20 mL of a 10% povidone-iodine aqueous solution, reconstituted in a 60-mL solution with sterile water (povidone-iodine group); those receiving nasopharynx and oropharynx rinsing with 60 mL of saline solution (saline group); or those undergoing a standard regimen without any instillation but with aspiration of oropharyngeal secretions (control group). MEASUREMENTS AND MAIN RESULTS: The prevalence of ventilator-associated pneumonia was compared among the three groups. A total of 98 patients were analyzed (povidone-iodine group, n = 36; saline group, n = 31; and control group, n = 31). A total of 28 cases of ventilator-associated pneumonia were diagnosed. There was a significant decrease in the rate of ventilator-associated pneumonia in the povidone-iodine group when compared with the saline and control groups (3 of 36 patients [8%] vs. 12 of 31 patients [39%] and 13 of 31 patients [42%], respectively; p = .003 and .001, respectively). The length of stay and mortality in the surgical intensive care unit were not statistically different between the three groups. CONCLUSIONS: The regular administration of povidone-iodine may be an effective strategy for decreasing the prevalence of ventilator-associated pneumonia in patients with severe head trauma.     

Antipsychotic use and diagnosis of delirium in the intensive care unit

ABSTRACT: INTRODUCTION: Delirium is an independent risk factor for prolonged hospital length of stay (LOS) and increased mortality. Several antipsychotics have been studied for the treatment of intensive care unit (ICU) delirium that has led to a high variability in prescribing patterns for these medications. We hypothesize that in clinical practice the documentation of delirium is lower than the incidence of delirium reported in prospective clinical trials. The objective of this study was to document the incidence of delirium diagnosed in ICU patients and to describe the utilization of antipsychotics in the ICU. METHODS: This was a retrospective, observational, cohort study conducted at 71 United States academic medical centers that reported data to the University Health System Consortium Clinical Database/Resource Manager. It included all patients 18 years of age and older admitted to the hospital between 1 January 2010 and 30 June 2010 with at least one day in the ICU. RESULTS: Delirium was diagnosed in 6% (10,034 of 164,996) of hospitalizations with an ICU admission. Antipsychotics were administered to 11% (17,764 of 164,996) of patients. Of the antipsychotics studied, the most frequently used were haloperidol (62%; n = 10,958) and quetiapine (31%; n = 5,448). Delirium was associated with increased ICU LOS (5 vs. 3 days, P < 0.001) and hospital LOS (11 vs. 6 days, P < 0.001), but not in-hospital mortality (8% vs. 9%, P = 0.419). Antipsychotic exposure was associated with increased ICU LOS (8 vs. 3 days, P < 0.001), hospital LOS (14 vs. 5 days, P < 0.001) and mortality (12% vs. 8%, P < 0.001). Of patients with antipsychotic exposure in the ICU, absence of a documented mental disorder (32%, n = 5,760) was associated with increased ICU LOS (9 vs. 7 days, P < 0.001), hospital LOS (16 vs. 13 days, P < 0.001) and in-hospital mortality (19% vs. 9%, P < 0.001) compared to patients with a documented mental disorder (68%, n = 12,004). CONCLUSIONS: The incidence of documented delirium in ICU patients is lower than that documented in previous prospective studies with active screening. Antipsychotics are administered to 1 in every 10 ICU patients. When administration occurs in the absence of a documented mental disorder, antipsychotic use is associated with an even higher ICU and hospital LOS, as well as in-hospital mortality.     

Automatic control of tracheal tube cuff pressure in ventilated patients in semirecumbent position: a randomized trial

OBJECTIVE: The aspiration of subglottic secretions colonized by bacteria pooled around the tracheal tube cuff due to inadvertent deflation (<20 cm H2O) of the cuff plays a relevant role in the pathogenesis of ventilator-associated pneumonia. We assessed the efficacy of an automatic, validated device for the continuous regulation of tracheal tube cuff pressure in preventing ventilator-associated pneumonia. DESIGN: Prospective randomized controlled trial. SETTING: Respiratory intensive care unit and general medical intensive care unit. PATIENTS: One hundred and forty-two mechanically ventilated patients (age, 64 +/- 17 yrs; Acute Physiology and Chronic Health Evaluation II score, 18 +/- 6) without pneumonia or aspiration at admission. INTERVENTIONS: Within 24 hrs of intubation, patients were randomly allocated to undergo continuous regulation of the cuff pressure with the automatic device (n = 73) or routine care of the cuff pressure (control group, n = 69). Patients remained in a semirecumbent position in bed. MEASUREMENTS AND MAIN RESULTS: The primary end point variable was the incidence of ventilator-associated pneumonia. Main causes for intubation were decreased consciousness (43, 30%) and exacerbation of chronic respiratory diseases (38, 27%). Cuff pressure <20 cm H2O was more frequently observed in the control than the automatic group (45.3 vs. 0.7% determinations, p < .001). However, the rate of ventilator-associated pneumonia with clinical criteria (16, 22% vs. 20, 29%) and microbiological confirmation (11, 15% vs. 10, 15%), the distribution of early and late onset, the causative microorganisms, and intensive care unit (20, 27% vs. 16, 23%) and hospital mortality (30, 41% vs. 23, 33%) were similar for the automatic and control groups, respectively. CONCLUSIONS: Cuff pressure is better controlled with the automatic device. However, it did not result in additional benefits to the semirecumbent position in preventing ventilator-associated pneumonia.     

A new concept for DRG-based reimbursement of services in German intensive care units: results of a pilot study

Objective To evaluate LOS in developing a concept of borderline ICU LOS for a realistic reimbursement of intensive care.Design Retrospective analysis of LOS and cost data extracted from patients electronic records.Setting Surgical ICU of the University Hospital Göttingen, Germany.Patients and participants All adult ICU admissions with LOS >24 h over a 24-month period (1 January 2000 to 31 December 2001; n=1631.)Interventions None.Measurements and results Cluster analysis partitioned the ICU population into three homogenous groups based on ICU LOS and total direct costs: cluster 1 (n=1405; mean LOS=2.8; mean cost=€2399); cluster 2 (n=190; mean LOS=13.4; mean cost=€12,754); cluster 3 (n=36; mean LOS=34.9; mean cost=€34,173). Cost distribution between cluster 1 and clusters 2 and 3 combined was 48 vs 52%. Upper 95 percentile LOS of 6.7 allowed cluster 1 to be replaced by an LOS profile population of 7 days population (n=1355; 96% population and 91% total ICU cost overlap with cluster 1) representing 83% of total ICU population and 44% of total ICU costs. Stratification of >7 day population into LOS less than or >20 days (n=220; n=56) were further differentiated by mortality (11 vs 23%) and sepsis incidence (33 vs 79%).Conclusions It may be feasible to formulate a LOS-based reimbursement scheme for ICU services in Germany based on the selection of (appropriate) patients ICU LOS profiles.     

The German Validation Study of the Surgical Intensive Care Unit Optimal Mobility Score

PurposeImmobilization of critically ill patients leads to muscle weakness, which translates to increased costs of care and long-term functional disability. We tested the validity of a German Surgical Intensive Care Unit (ICU) Optimal Mobilization Score (SOMS) in 2 different cohorts (neurocritical and nonneurocritical care patients).Materials and MethodsPhysical therapists estimated the patients' mobilization capacity by using the German version of the SOMS the morning after admission. We tested the prognostic value of the prediction for ICU and hospital length of stay (LOS) as well as for mortality, and built a model to account for other known predictors of these outcomes in the 2 cohorts.ResultsA total of 128 patients were included in the analysis, 48 of these were neurocritical care patients. The SOMS predicted mortality and ICU and hospital LOS. Neurocritical care patients stayed significantly longer in the ICU (median 12 vs 4 days, P < .001) and in the hospital (25 vs 17 days, P = .02). The SOMS predicted ICU and hospital LOS. It predicted mortality only in nonneurocritical patients.ConclusionsThe German SOMS assessed by physical therapists on the day after ICU admission predicts ICU and hospital LOS, and mortality. Our data suggest that the association between early mobilization and mortality is more complex in neurocritical care patients.