Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

Introduction

The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit &; Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD).

Methods

The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.

Results

The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.

Conclusions

The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.     

Early indicators of prolonged intensive care unit stay: impact of illness severity,physician staffing,and pre-intensive care unit length of stay

OBJECTIVE: Scoring systems that predict mortality do not necessarily predict prolonged length of stay or costs in the intensive care unit (ICU). Knowledge of characteristics predicting prolonged ICU stay would be helpful, particularly if some factors could be modified. Such factors might include process of care, including active involvement of full-time ICU physicians and length of hospital stay before ICU admission. DESIGN: Demographic data, clinical diagnosis at ICU admission, Simplified Acute Physiology Score, and organizational characteristics were examined by logistic regression for their effect on ICU and hospital length of stay and weighted hospital days (WHD), a proxy for high cost of care. SETTING: A total of 34 ICUs at 27 hospitals participating in Project IMPACT during 1998. PATIENTS: A total of 10,900 critically ill medical, surgical, and trauma patients qualifying for Simplified Acute Physiology Score assessment. INTERVENTIONS: None. RESULTS: Overall, 9.8% of patients had excess WHD, but the percentage varied by diagnosis. Factors predicting high WHD include Simplified Acute Physiology Score survival probability, age of 40 to 80 yrs, presence of infection or mechanical ventilation 24 hrs after admission, male sex, emergency surgery, trauma, presence of critical care fellows, and prolonged pre-ICU hospital stay. Mechanical ventilation at 24 hrs predicts high WHD across diagnostic categories, with a relative risk of between 2.4 and 12.9. Factors protecting against high WHD include do-not-resuscitate order at admission, presence of coma 24 hrs after admission, and active involvement of full-time ICU physicians. CONCLUSIONS: Patients with high WHD, and thus high costs, can be identified early. Severity of illness only partially explains high WHD. Age is less important as a predictor of high WHD than presence of infection or ventilator dependency at 24 hrs. Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study.     

Case mix,outcome and length of stay for admissions to adult,general critical care units in England,Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

Introduction

The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD).

Methods

The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.

Results

The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.

Conclusions

The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.

     

Impact of an inpatient rehabilitation facility on functional outcome and length of stay of burn survivors

This study reviewed the use of an inpatient rehabilitation unit for burn survivors. We hypothesized that adult burn patients admitted earlier to inpatient rehabilitation have an equal or better functional outcome than those remaining in acute burn center for rehabilitation care. Functional Independence Measure (FIM) data were prospectively collected on our burn center admissions dating January 2002 to August 2003. National rehabilitation data were acquired from eRehabData and burn literature. A total of 217 adult patients survived until hospital discharge, with 21 (9.7%) discharged to inpatient rehabilitation (REHAB). REHAB had larger burn injuries, more inhalation injuries, higher incidence hand/foot burns, and longer length of stay (LOS). REHAB had lower FIM upon rehabilitation facility admission than national averages but greater FIM improvement during comparable rehabilitation LOS. Although our earlier rehabilitation admission strategy results in more frequent rehabilitation unit referrals, patients had shorter burn center LOS and greater FIM improvement compared with limited national burn patient functional outcome data currently available.     

Understanding your managed care practice: the critical role of case mix systems

Successful implementation of managed care programs requires an understanding of case mix and severity of illness. This article summarizes the state of the art for both inpatient and outpatient services.     

Impact of physical therapy weekend coverage on length of stay in an acute care community hospital

This study compares the length of hospital stay of a group of patients treated in a community hospital during a period of five-day-a-week physical therapy coverage with the length of stay of a similar patient group treated during a period of seven-day-a-week physical therapy coverage. Comparisons of length of stay were made between the two groups and between subgroups based on diagnosis (stroke or orthopedic disorder) and surgical versus nonsurgical status. Multiple regression analysis was used to control for other factors influencing length of hospital stay. The mean length of stay was shorter for the seven-day-a-week group, and in a few subgroups the difference in length of stay was statistically significant. The results of this study suggest that weekend physical therapy may help reduce length of hospital stay. This finding should interest individuals concerned with the cost-effective use of physical therapy, especially under hospital reimbursement systems such as the Medicare diagnosis-related group.     

Simple triage scoring system predicting death and the need for critical care resources for use during epidemics

OBJECTIVES: In the event of pandemic influenza, the number of critically ill victims will likely overwhelm critical care capacity. To date, no standardized method for allocating scarce resources when the number of patients in need far exceeds capacity exists. We sought to derive and validate such a triage scheme. DESIGN:: Retrospective analysis of prospectively collected data. SETTING: Emergency departments of two urban tertiary care hospitals. PATIENTS: Three separate cohorts of emergency department patients with suspected infection, comprising a total of 5,133 patients. INTERVENTIONS: None. MEASUREMENTS: A triage decision rule for use in an epidemic was developed using only those vital signs and patient characteristics that were readily available at initial presentation to the emergency department. The triage schema was derived from a cohort at center 1, validated on a second cohort from center 1, and then validated on a third cohort of patients from center 2. The primary outcome for the analysis was in-hospital mortality. Secondary outcomes were intensive care unit admission and use of mechanical ventilation. MAIN RESULTS: Multiple logistic regression demonstrated the following as independent predictors of death: a) age of >65 yrs, b) altered mental status, c) respiratory rate of >30 breaths/min, d) low oxygen saturation, and e) shock index of >1 (heart rate > blood pressure). This model had an area under the receiver operating characteristic curve of 0.80 in the derivation set and 0.74 and 0.76 in the validation sets. When converted to a simple rule assigning 1 point per covariate, the discrimination of the model remained essentially unchanged. The model was equally effective at predicting need for intensive care unit admission and mechanical ventilation. CONCLUSIONS: If, as expected, patient demand far exceeds the capability to provide critical care services in an epidemic, a fair and just system to allocate limited resources will be essential. The triage rule we have developed can serve as an initial guide for such a process.     

Impact of trauma activation on the ED length of stay for nontraumatic patients

Introduction

Trauma activation prioritizes hospital resources for the assessment and treatment of trauma patient over all patients in the emergency department (ED). We hypothesized that length of stay (LOS) is longer for nontrauma patients during a trauma activation.

Methods

A retrospective, case-control chart review was conducted in a level I trauma center. Cases consist of patients who present 1 hour before and after the presentation of the trauma activation. Controls were patients presenting to the ED during the same period exactly 1 week before and after the cases. Confounding variables measured included sex, age, arrivals, and census for the 3 areas.

Results

Two hundred ninety-four trauma events occurred from January 1 until September 30, 2009. A significant difference was found between LOS of patients seen during a trauma activation with an average increase of 10.7 minutes in LOS (P =.0082; 95% confidence interval [CI], 2.8-18.7). This difference is attributable to the middle acuity area of the ED, in which the average increase in LOS was 20.3 minutes (P = .0004; 95% CI, 9.1-31.5). Significant LOS difference was not found when a trauma activation had an LOS of less than 60 minutes (P = .30; 95% CI, −7.1-61.7 for trauma LOS <60 minutes vs P = .02; 95% CI, 1.6-18.0 for trauma LOS ≥60 minutes).

Conclusion

This retrospective case-control chart review identified an increase in ED LOS for patient presenting during trauma activations. Resource prioritization should be accounted for during times when these critical patients enter the ED.     

Regulating hospital use: length of stay, beds and whiteboards

This paper presents part of a larger study of contemporary nursing practice and the rationalisation of hospital length of stay. Informed by Michel Foucault's work on governmentality, length of hospital stay and the re-engineering of surgical services are examined, not in terms of numerical representations of hospital use, but as part of social and political processes through which certain concepts are made susceptible to measurement and practices are organised. Using data generated through fieldwork in a hospital surgical division this analysis offers understandings of how social practices around length of hospital stay are translated and how they pattern contemporary hospital nursing practice. Nursing practice is explored through the reconstitution of hospital beds and the demands of local administration of hospital length of stay.     

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital

ObjectiveDescribe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital.MethodsA retrospective longitudinal registry study based on all ED visits with adult patients during 2009–2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician’s ratios) were extracted from the hospital’s electronic health record. Non-parametric analyses were conducted.ResultsThe proportion of unstable patients (triage level 1–2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8–9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18–79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3–5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5–7.9) compared to 15.5 min/year (95% CI: 15.2–15.8) for those being admitted.ConclusionFewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.     

Validation of the criteria for early critical care resource use in assessing the effectiveness of field triage

Background

This study aimed to validate the criteria for early critical care resource (CCR) use as an outcome predictor for seriously injured patients triaged in the field by comparing the effectiveness of the criteria for early CCR use with that of criteria defined by an Injury Severity Score (ISS) > 15.

Relationship of illness severity and length of stay to functional outcomes in the pediatric intensive care unit: a multi-institutional study

OBJECTIVE: The purpose of this study was to establish relationships between illness severity, length of stay, and functional outcomes in the pediatric intensive care unit (PICU) by using multi-institutional data. We hypothesized that a positive relationship exists between functional outcome scores, severity of illness, and length of stay. DESIGN: The study used a prospective multicentered inception cohort design. SETTING: The study was conducted in 16 PICUs across the United States that were member institutions of the Pediatric Critical Care Study Group of the Society of Critical Care Medicine. PATIENTS: In total, 11,106 patients were assessed, representing all admissions to these intensive care units for 12 consecutive months. MEASUREMENTS: Functional outcomes were measured by the Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) scales. Both scales were assessed at baseline and discharge from the PICU. Delta scores were formed by subtracting baseline scores from discharge scores. Other measurements included admission Pediatric Risk of Mortality scores, age, operative status, length of stay in the PICU, and diagnoses. Interrater reliability was assessed by using a set of ten standardized cases on two occasions 6 months apart. MAIN RESULTS: Baseline, discharge, and delta POPC and PCPC outcome scores were associated with length of stay in the PICU and with predicted risk of mortality (p < .01). Incorporation of baseline functional status in multivariate length of stay analyses improved measured fit. Mild baseline cerebral deficits in children were associated with 18% longer PICU stays after controlling for other patient and institutional characteristics. Moderate and severe baseline deficits for both the POPC and PCPC score predict increased length of stay of between 30% and 40%. On the standardized cases, interrater consensus was achieved on 82% of scores with agreement to within one neighboring class for 99.7% of scores. CONCLUSIONS: These data establish current relationships for the POPC and PCPC outcome scales based on multi-institutional data. The reported relationships can be used as reference values for evaluating clinical programs or for clinical outcomes research.     

Factors influencing length of stay in the intensive care unit.

BACKGROUND: Long stays in the intensive care unit are associated with high costs and burdens on patients and patients' families and in turn affect society at large. Although factors that affect length of stay and outcomes of care in the intensive care unit have been studied extensively, the conclusions reached have not been reviewed to determine whether they reveal an organizational pattern that might be of practical use in reducing length of stay in the unit. OBJECTIVE: To identify and categorize the factors associated with prolonged stays in the intensive care unit and to describe briefly the nonmedical interventions to date designed to reduce length of stay. METHODS: Articles published between January 1990 and March 2005 in English-language journals indexed by MEDLINE were searched for studies on outcomes and costs of care in the intensive care unit and on care at the end of life. RESULTS: The emerging consensus is that length of stay in the intensive care unit is exacerbated by several increasingly discernible medical, social, psychological, and institutional factors. At the same time, several nonmedical, experimental interventions have been designed to reduce length of stay. CONCLUSIONS: Interventions involving palliative care, ethics consultations, and other methods to increase communication between healthcare personnel, patients, and patients' families may be helpful in decreasing length of stay in the intensive care unit. Further studies are needed to provide a strategy for targeting specific risk factors indicated by the literature review.