Expansion of the medical intensive care unit: clinical consequences in a large urban hospital

We examined how a permanent expansion of the medical ICU (MICU) affected resource utilization and severity of illness for intensive care admissions within a 700-bed urban teaching hospital. On our 162-bed medical service, construction of a separate cardiac care unit and the expansion of the MICU increased the number of core intensive care beds by 100%. We prospectively analyzed noncardiology MICU admissions 2 months before, immediately after, and 4 months after MICU expansion. Although the volume of MICU patients increased by 51% after MICU expansion, the severity of illness as determined by the Acute Physiology and Chronic Health Evaluation (APACHE II) score and types of admission diagnoses remained the same. Moreover, there was no change in MICU occupancy and length of stay, hospital or MICU mortality, or MICU readmission rate. The increased MICU patient volume came from the ED, transfers from other hospitals, and from other ICUs within our hospital. In contrast, the volume and severity of illness of MICU transfers from the inpatient medical floor service were constant in all time periods. These results suggest that, while MICU expansion increased patient volume, physician utilization of the MICU resources was unchanged. Our physicians used high-intensity ICU beds in a consistent fashion in response to external factors, such as ED activity, intramural ICU transfers, and referrals from other hospitals.     

Using a severity of illness scoring system to assess intensive care unit admissions for diabetic ketoacidosis

OBJECTIVE: To determine the appropriateness of intensive care unit (ICU) admissions for patients with the diagnosis of diabetic ketoacidosis (DKA) at our institution. DESIGN: Retrospective chart review. SETTING: Tertiary care inner-city hospital. SUBJECTS: All subjects admitted to the medical intensive care unit (MICU) from September 1996 to June 1997 with a diagnosis of DKA were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A grading system for the severity of DKA (grades 0-IV) from a previously published work was modified. Admissions to the MICU that were deemed appropriate a priori included patients with grade III or IV DKA, patients with grade II DKA who were older than 65 yrs of age, or patients with special situations normally warranting intensive care. MAIN RESULTS: Sixty-seven cases of DKA were reviewed. Two thirds of the patients had type I diabetes mellitus, and approximately 50% were men. No deaths occurred. Forty-four patients (66%) met the a priori ICU admission criteria. The average hospital stay for all patients was 4.2 (+/-3.6) days. The mean ICU stay was significantly longer in those with DKA grade III or IV, although the total hospital stay did not differ by severity of illness score. CONCLUSIONS: One third of the patients admitted to our MICU to receive treatment for DKA did not warrant ICU treatment based on the admission criteria. These individuals had an approximate MICU length of stay of 1 day. A prospective study of the severity of illness score will be undertaken to evaluate the safety, validity, and potential resource savings of applying these DKA ICU admission criteria within our institution.     

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.     

Implications of DRG payments for medical intensive care

Patients in the most prevalent DRGs in a Medical Intensive Care Unit (MICU) were compared with their counterparts who received only routine hospital care on adjusted total hospital costs and length of stay. Costs for both groups were compared with estimated DRG payments under an all-payer system. For patients in three DRGs, measures of severity of illness were examined as predictors of costs. Significant differences between MICU and routine care patients were found in 10 of 13 DRGs studied; intensive care costs were substantially above overall payment rates. The severity of illness measures varied widely in their correlation with costs, depending on DRG and whether the patients were MICU or routine care. These apparent differences in accounting costs may result in hospital decisions to restrict the number of MICU beds. Severity of illness adjustments to DRGs might produce more equitable payments. The most useful measure of severity may differ, however, depending on DRG.     

Prior healthcare utilization as a predictor of survival for medical intensive care unit patients

OBJECTIVE: To determine whether measures of inpatient care utilization from the year preceding admission to a medical intensive care unit (MICU) improve physiology-based predictions of hospital and 1-yr survival. DESIGN: Inception cohort study with a validation cohort. SETTING: The MICU in university-affiliated Department of Veterans Affairs Medical Center. PATIENTS: A total of 1,200 consecutive patients admitted to the MICU. MEASUREMENTS AND MAIN RESULTS: Increased use of inpatient health care before MICU admission was associated with increased mortality. However, inpatient utilization data failed to improve physiology-based logistic models for hospital and 1-yr survival (p > .15 for improvement in the area under the receiver operating characteristic curve for both end points in the validation cohort), whereas physiologic data improved models derived from measures of inpatient care (p < .001 for both end points). Empirically derived inpatient care models used only information from the few days preceding MICU admission, despite the availability of a full year of data. CONCLUSIONS: Chronic illness, as gauged by a need for frequent inpatient care in the year before MICU admission, is not independently predictive of poor short- or long-term survival. Clinicians should not attempt to predict survival of prospective MICU patients by the extent of previous inpatient care.     

The impact of do-not-resuscitate order on triage decisions to a medical intensive care unit

Purpose

To determine whether the presence of a do-not-resuscitate (DNR) order impacts on triage decisions to a medical intensive care unit (MICU) of an academic medical center.

Methods

Data were collected on 179 patients in whom MICU consultation was sought and included demographic, clinical information, diagnoses, ICU admission decision, Acute Physiological and Chronic Health Evaluation II (APACHE II) score, and the presence of DNR order. Functional status was determined retrospectively using the Modified Rankin Score.

Results

The only factor that influenced MICU admission was the presence of DNR order at the time of MICU consultation (odds ratio, 0.25; 95% confidence interval, 0.09-0.71, P < .006). There was no difference between the age, APACHE II scores, or functional status between admitted or refused. Medical intensive care unit admission was associated with increased length of stay without difference in mortality.

Conclusion

The presence of a DNR order at the time of MICU consultation was significantly associated with the decision to refuse a patient to the MICU.     

Profile of medical ICU vs. ward patients in an acute care hospital

Demographic characteristics, severity of illness, resource utilization, and outcome were compared for 351 medical ICU (MICU) and 329 ward patients of a large, urban, tertiary care hospital. Patients were similar in age, race, sex, and insurance coverage. Both MICU and ward patients had similar health status distributions 3 to 6 months before hospitalization. Severity of illness, as measured by the Acute Physiology Score was significantly higher in the MICU patients, although there was considerable overlap in the distributions. Resource utilization, as measured by the Therapeutic Intervention Scoring System (TISS), was also significantly higher in the MICU; again, the distributions of the two groups overlapped, although mostly for low values of TISS. Of the MICU sample, 28% to 30% never required active therapeutic interventions; 11% of the ward sample received active treatment. The significant overlap between MICU and ward distributions of severity of illness and resource utilization has implications for admission and discharge policies.     

Predictive factors of death in primary lung cancer patients on admission to the intensive care unit

OBJECTIVE: To assess the lung cancer patient's prognosis in the intensive care unit with early predictive factors of death. DESIGN: Retrospective study from July 1986 to February 1996. SETTING: Medical intensive care unit at a university hospital. PATIENTS: Fifty-seven patients with primary lung cancer admitted to our medical intensive care unit (MICU). MEASUREMENTS AND RESULTS: Data collection included demographic data (age, sex, underlying diseases, MICU admitting diagnosis) and evaluation of tumor (pathologic subtypes, metastases, lung cancer staging, treatment options). Three indexes were calculated for each patient: Karnofsky performance status, Simplified Acute Physiology Score (SAPS) II, and multisystem organ failure score (ODIN score). Mortality was high in the MICU: 66% of patients died during their MICU stay, and hospital mortality reached 75%. In multivariate analysis, acute pulmonary disease and Karnofsky performance status < 70 were associated with a poor MICU and post-MICU prognosis. For the survivors, long-term survival after MICU discharge depended exclusively on the severity of the lung cancer. CONCLUSIONS: We confirmed the high mortality rate of lung cancer patients admitted to the MICU. Two predictive factors of death in MICU were identified: performance status < 70 and acute pulmonary disease.     

Update on digital image management and PACS

Information technology is becoming a vital component of all health care enterprises, from managed care services to large hospital networks, that provides the basis of electronic patient records and hospital-wide information. The rationale behind such systems is deceptively simple: physicians want to sit down at a single workstation and call up all information, both clinical data and medical images, concerning a given patient. Picture archiving and communication systems (PACS) are responsible for solving the problem of acquiring, transmitting, and displaying radiologic images. The major benefit of PACS resides in its ability to communicate images and reports to referring physicians in a timely and reliable fashion. With the changes in economics and the shift toward managed and capitated care, the teleradiology component of PACS is rapidly gaining momentum. In allowing remote coverage of multiple sites by the same radiologists and remote consultations and expert opinion, teleradiology is in many instances the only option to maintain economically viable radiologic settings. The technical evolution toward more integrated systems and the shift toward Web-based technology is rapidly merging the two concepts of PACS and teleradiology in global image management and communication systems.     

DR-PACS-RIS系统在批量胸部X线体检中的应用

目的探讨DR-PACS-RIS系统在胸部X线体检中的应用价值。方法对150112例胸部体检者的X线胸片资料进行分析,计算日体检工作量、人均体检时间、医师平均每例阅片时间以及存储成本情况。结果日均检查223例,平均每例体检耗时仅1.1分钟,摄片工作时间约4小时,医师平均阅片及报告时间约1分钟/例。日均图像存储成本约1元。工作站具有统计工作量及多种查询功能。结论在体检中心配备DR-PACS-RIS胸片体检系统切实可行,能够收到明显的正面效益。合理优化检查流程可以进一步提高收益。     

Dehydroepiandrosterone, dehydroepiandrosterone-sulfate, and cortisol concentrations in intensive care unit patients

STUDY OBJECTIVE: This purpose of this study was to determine whether severity of illness, as defined by the intensive care unit (ICU) admission APACHE II (updated Acute Physiology and Chronic Health Evaluation) score, is correlated with early morning cortisol, dehydroepiandrosterone (DHEA), and/or dehydroepiandrosterone-sulfate (DHEA-S) concentrations. DESIGN: Early morning concentrations of DHEA, DHEA-S, and cortisol were determined within 24 hrs of admission and compared with admission APACHE II scores. SETTING: Medical (MICU), neurologic (NICU), and surgical (SICU) intensive care units of the University of Pittsburgh Medical Center. PATIENTS: A total of 191 men and women ranging in age from 16 to 93 yrs. All had been admitted to an ICU. MEASUREMENTS AND MAIN RESULTS: Statistically significant correlations between APACHE II scores and cortisol were observed for women in the MICU and SICU (r = .68, p = .0001; r = .35 p = .017, respectively) and for men in the NICU (r = .55, p = .003) and the SICU (r = .29, p = .036). The correlations between APACHE II scores and DHEA concentration data were statistically significant for women in the MICU (r = .37, p = .047) and SICU (r = .43, p = .002), as was the correlation between APACHE II and DHEA-S concentrations among women in the SICU (r = .38, p = .008). Although not statistically significant, a similar relationship was observed in the smaller group of NICU women (r = .40, p = .099). Each correlation was essentially unchanged when adjusted for age. CONCLUSION: These data show a positive correlation between APACHE II and cortisol concentrations in all groups except the MICU men. Also evident is the positive correlation between APACHE II scores and DHEA and DHEA-S concentrations in women, but not in men.     

Developing a rapid diagnosis and treatment centre: estimating impact on hospital resources

Objectives: To determine the possible impact on hospital bed occupancy if a "rapid diagnosis and treatment centre" (RDTC) were operational; to determine the number of patients that such a unit should be able to accommodate to avoid delays in transfer to this unit.

Design: Retrospective review of accident and emergency (A&E) department notes from consecutive adults over a 16 day period.

Setting: City centre teaching hospital with 1330 beds and 105 000 A&E new attendees per annum.

Main outcome measures: Total number of bed days saved per annum (and daily average, assuming no variation by season or day of the week) and the expected occupancy of the RDTC according to the time of day.

Results: The expected daily bed saving was estimated to be 16. Average occupancy was expected to be between six and eight (with little diurnal variation) and a unit with 10 beds would be sufficiently large to avoid delays for 85% of patients transferred there from A&E.

Conclusions: On the basis of a "paper exercise" an RDTC would be expected to be beneficial in terms of bed utilisation; careful evaluation of the effects of such a unit in operation should be undertaken.

     

Outcome prediction for individual intensive care patients: Useful,misused, or abused?

Probabilities of hospital mortality provide meaningful information in many contexts, such as in discussions of patient prognosis by intensive care physicians, in patient stratification for analysis of clinical trial data by researchers, and in hospital reimbursement analysis by insurers. Use of probabilities as binary predictors based on a cut point can be misleading for making treatment decisions for individual patients, however, even when model performance is good overall. Alternative models for estimating severity of illness in intensive care unit (ICU) patients, while demonstrating good agreement for describing patients in the aggregate, are shown to differ considerably for individual patients. This suggests that identifying patients unlikely to benefit from ICU care by using models must be approached with considerable caution.     

Evaluation of a sonographic PACS in clinical practice: analysis of technical and analytical time savings.

The aim of this study was to generate quantitative data regarding technical and analytical time savings obtained by use of an ultrasonographic PACS. Data/time cards were recorded for each patient encountered in an outpatient diagnostic ultrasound facility for a 4 week period immediately before and a 1 year period after installation of a PACS environment. Use of a sonographic PACS resulted in a per case time savings of 293 s in the technical component and 51 to 63 s in the analytical component of an average ultrasonographic examination. We conclude that use of a PACS workstation has the potential to increase productivity for both the sonographer and the radiologist.     

Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients

OBJECTIVE: The purpose of this study was to examine the effect of proactive palliative care consultation on length of stay for high-risk patients in the medical intensive care unit (MICU). DESIGN: A prospective pre/post nonequivalent control group design was used for this performance improvement study. SETTING: Seventeen-bed adult MICU. PATIENTS: Of admissions to the MICU, 191 patients were identified as having a serious illness and at high risk of dying: 65 patients in the usual care phase and 126 patients in the proactive palliative care phase. To be included in the sample, a patient had to meet one of the following criteria: a) intensive care admission following a current hospital stay of >or=10 days; b) age >80 yrs in the presence of two or more life-threatening comorbidities (e.g., end-stage renal disease, severe congestive heart failure); c) diagnosis of an active stage IV malignancy; d) status post cardiac arrest; or e) diagnosis of an intracerebral hemorrhage requiring mechanical ventilation. INTERVENTIONS: Palliative care consultations. MEASUREMENTS AND MAIN RESULTS: Primary measures were patient lengths of stay a) for the entire hospitalization; b) in the MICU; and c) from MICU admission to hospital discharge. Secondary measures included mortality rates and discharge disposition. There were no significant differences between the usual care and proactive palliative care intervention groups in respect to age, gender, race, screening criteria, discharge disposition, or mortality. Patients in the proactive palliative care group had significantly shorter lengths of stay in the MICU (8.96 vs. 16.28 days, p = .0001). There were no differences between the two groups on total length of stay in the hospital or length of stay from MICU admission to hospital discharge. CONCLUSIONS: Proactive palliative care consultation was associated with a significantly shorter MICU length of stay in this high-risk group without any significant differences in mortality rates or discharge disposition.     

超声影像工作站在超声诊断中的应用价值

目的本文总结了超声影像工作站的具体使用方法,介绍了使用工作站的诸多优点,认为使用工作站可明显简化诊断步骤,节约候诊时间;有利于图文资料的保存和传输,促进会诊和教学;便于质量控制和标准化;作为医院为RIS、HIS和PACS的一个重要组成部分,超声影像工作站正发挥着其不可或缺的作用。     

Physician Risk Attitudes and Hospitalization of Infants with Bronchiolitis

Objectives: To determine whether the risk attitudes of pediatric emergency physicians are related to the likelihood that otherwise healthy infants with bronchiolitis will be admitted for inpatient care. Methods: Risk aversion and discomfort with diagnostic uncertainty were assessed among 46 pediatric emergency physicians from three hospitals participating in the Child Health Accountability Initiative. Study physicians managed 397 otherwise healthy infants ages 0 to 12 months presenting to their hospital emergency departments with bronchiolitis. Mean risk aversion and discomfort with diagnostic uncertainty scores were compared across physician gender, years of experience, and formal training in emergency medicine. Additional analyses based on infants as the analytic unit determined admission rates of physicians scoring high and low on risk attitude measures. This model was controlled for severity of illness. Results: Scores on measures of risk aversion and discomfort with uncertainty were similar for male and female physicians and for physicians who had completed pediatric emergency medicine fellowship training and those without such training. Risk aversion scores were significantly higher for physicians with 15 or more years of experience. Admission rates for infants with bronchiolitis were no higher among physicians scoring above the median on risk attitude measures. When adjusted for severity of illness, physicians' risk attitudes were not associated with admission rates. Conclusions: Recent growth in per‐capita admissions for bronchiolitis is not accounted for by physician intolerance for diagnostic uncertainty. Physician risk attitudes should be considered in the context of hospital admissions for other pediatric conditions with unclear prognoses.     

A quality improvement project to decrease emergency department and medical intensive care unit transfer times

ObjectiveTo reduce transfer time of critically ill patients from the emergency department (ED) to the medical intensive care unit (MICU).DesignA prospective, observational study assessing preimplementation and postimplementation of quality improvement interventions in a tertiary academic medical center.InterventionsA team of frontline health care professional including ED, MICU, and supporting services using the clinical microsystems approach mapped out existing practice patterns, determined causes for delays, and used the Plan-Do-Study-Act to test changes.Measurements and Main ResultsThe team identified multiple issues that contributed to delays. These included poor coordination between transport services, respiratory therapy, and nursing in transferring patients from the ED as well delays in identification and transfer of stable MICU patients. These interventions reduced transfer time from 4.2 (3.4-5.7) hours to 2.2 (1.4-3.1) hours (median [interquartile range]; P < .001). Hospital length of stay decreased from 9.9 ± 9 to 8.3 ± 7 days (P < .03).ConclusionA team made up of frontline health care professionals using a structured quality improvement process and implementing multifaceted, multistage interventions, reduced transfer delays, and length of stay. Added benefits included engagement among members of the 2 microsystems and a more cohesive approach to patient care.     

PACS和RIS系统集成实施和应用

目的 本通过对华东医院PACS系统和RIS系统集成运用中工作流程和数据流程的分析，提出了五种符合IHE工作流程环节的集成方法，并对其优缺点进行了讨论。方法 华东医院PACS建设遵从医学影像通讯标准(Digital Imaging Communication in Medicme，DICOM)，系统主要由图像采集网关、中心服务器、图像显示工作站(包括诊断工作站和浏览工作站)和图像备份工作站组成。RIS系统以WEB技术为基础，主要由RIS服务器、RIS登记工作站、RIS检查工作站和RIS报告工作站组成。两系统间的信息交换可采用五种不同的方法进行。结果 根据医院的实际情况，我们分别在PACS图像采集网关、中心服务器、RIS服务器和PACS诊断工作站上应用了这五种集成方法，并取得令人满意的效果。结论 在医院的具体应用中，参照IHE所提出的工作流和数据流要求，我们所提出的这五种集成方法有其灵活、快速、易用、适用面广的优点，也存在HL7接口实现不足的弱点。