Variation in Utilization of Intensive Care for Pediatric Diabetic Ketoacidosis

2019 ◽  
Vol 35 (11) ◽  
pp. 1314-1322
Author(s):  
Arpita K. Vyas ◽  
Yiu Ming Chan ◽  
Lavi Oud
Keyword(s):  
Intensive Care ◽  
Length Of Stay ◽  
Intraclass Correlation ◽  
Admission Rate ◽  
Hospital Charges ◽  
Level Variation ◽  
Hospital Level ◽  
Total Hospital ◽  
Icu Admission ◽  
Admission Rates

Objective: To examine the hospital-level variation in intensive care unit (ICU) utilization and quantify the relative contribution of patient and hospital characteristics versus individual hospital factors to the variation in ICU admission rates among pediatric hospitalizations with diabetic ketoacidosis (DKA). Methods: The Texas Inpatient Public Use Data File was used to identify hospitalizations of state residents aged 1 month to 19 years with a primary diagnosis of DKA between 2005 and 2014. Multilevel, mixed-effects logistic regression modeling was performed to examine the association of patient- and hospital-level factors with ICU admission. Risk and reliability adjustment was then performed to assess hospital-level variation in ICU utilization. Intraclass correlation coefficient was used to quantify variation in use of ICU attributable to individual hospitals. The association between adjusted rates of ICU admission and total hospital charges and length of stay was examined using linear regression. Results: Of the 23 585 DKA hospitalizations, 14 638 (62.1%) were admitted to ICU. On multilevel analysis, the odds of ICU admission progressively decreased with rising volume of DKA hospitalizations (adjusted odds ratio: 0.08 [highest vs lowest quartile]; 95% confidence interval [CI]: 0.03-0.24). The crude median (interquartile range [IQR]; range) of ICU admissions across hospitals was 82.6% (73%-90%; 11.1%-100%). The median (IQR) risk- and reliability-adjusted ICU admission rate was 81.0% (73.0%-86.9%), ranging from 11.2% to 94%. Following risk and reliability adjustment, the intraclass correlation coefficient was 0.005 (95% CI: 0.004-0.006). For each 10% increase in adjusted ICU admission rate, total hospital charges rose by 7% (95% CI: 3%-11%). There was no association between ICU admission rates and hospital length of stay. Conclusion: Although high variation in ICU utilization was noted across hospitals among pediatric DKA hospitalizations, the proportion of variation attributable to individual hospitals was negligible, once adjusted for patient mix and hospital characteristics.

scholarly journals Neurological Critical Care Services’ Influence Following Large Hemispheric Infarction and Their Impact on Resource Utilization

2018 ◽  
Vol 4 (1) ◽  
pp. 5-11
Author(s):  
Syed Omar Shah ◽  
Yu Kan Au ◽  
Fred Rincon ◽  
Matthew Vibbert
Keyword(s):  
Mechanical Ventilation ◽  
Intensive Care ◽  
Length Of Stay ◽  
Resource Utilization ◽  
Hospital Length Of Stay ◽  
Hospital Charges ◽  
Residual Variance ◽  
Total Hospital ◽  
Over Time ◽  
Hemispheric Infarction

AbstractIntroduction:Acute ischemic stroke (AIS) is the fourth leading cause of death in the US. Numerous studies have demonstrated the use of comprehensive stroke units and neurological intensive care units (NICU) in improving outcomes after stroke. We hypothesized that an expanded neurocritical care (NCC) service would decrease resource utilization in patients with LHI.Methods:Retrospective data from consecutive admissions of large hemispheric infarction (LHI) patients requiring mechanical ventilation were acquired from the hospital medical records. Between 2011-2013, there were 187 consecutive patients admitted to the Jefferson Hospital for Neuroscience (Philadelphia, USA) with AIS and acute respiratory failure. Our intention was to determine the number of tracheostomies done over time. The primary outcome measure was the number of tracheostomies over time. Secondary outcomes were, ventilator-free days (Vfd), total hospital charges, intensive care unit length of stay (ICU-LOS), and total hospital length of stay (hospital-LOS), including ICU LOS. Hospital charges were log-transformed to meet assumptions of normality and homoscedasticity of residual variance terms. Generalized Linear Models were used and ORs and 95% CIs calculated. The significance level was set at α = 0.05.Results: Of the 73 patients included in this analysis, 33% required a tracheostomy. There was a decrease in the number of tracheostomies undertaken since 2011. (OR 0.8; 95% CI 0.6-0.9: p=0.02).Lower Vfd were seen in tracheostomized patients (OR 0.11; 95%CI 0.1-0.26: p<0.0001). The log-hospital charges decreased over time but not significantly (OR 0.9; 95%CI 0.78-1.07: p=0.2) and (OR 0.99; 95%CI 0.85-1.16: p=0.8) from 2012 to 2013 respectively.The ICU-LOS at 23 days vs 10 days (p=0.01) and hospital-LOS at 33 days vs 11 days (p=0.008) were higher in tracheostomized patients.Conclusion: The data suggest that in LHI-patients requiring mechanical ventilation, a dedicated NCC service reduces the overall need for tracheostomy, increases Vfd, and decreases ICU and hospital-LOS.

Abstract 345: Hospital Variation in Admission to Intensive Care Units for Patients with Acute Myocardial Infarction

2013 ◽  
Vol 6 (suppl_1) ◽  
Author(s):  
RuiJun Chen ◽  
Kelly M Strait ◽  
Kumar Dharmarajan ◽  
Shu-Xia Li ◽  
John Martin ◽  
...  
Keyword(s):  
Critical Care ◽  
Intensive Care ◽  
Statistical Significance ◽  
Treatment Strategies ◽  
Admission Rate ◽  
Icu Admission ◽  
Admission Rates ◽  
Hospital Variation ◽  
Pulmonary Artery Catheters ◽  
Life Threatening

Background: The intensive care unit (ICU) has been credited with reducing mortality for patients hospitalized with AMI in a past era when life-threatening post-infarction ventricular arrhythmias were more common. With the evolution in the clinical profile and treatment of AMI, the marginal benefit of ICU care for many patients is less clear. As a result, the use of ICU care for patients with AMI may vary substantially among institutions, creating implications for treatment strategies and patient outcomes. Methods: We identified 114,980 hospitalizations for AMI from 311 hospitals in the 2009-10 Premier database using ICD-9-CM codes. We excluded hospitals with <25 AMI admissions, patients <18 yrs, and transfers. Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. For each quartile, we calculated (1) usage rates of critical care therapies and (2) in-hospital risk-standardized mortality rates (RSMRs) among all patients admitted with AMI. Kruskal-Wallis and Cochran-Armitage Trend tests assessed for statistical significance. Results: ICU admission rates for AMI patients varied markedly among hospitals (median 48%, IQR 35%-61%, range 0%-98%, Figure). Hospitals admitting more AMI patients to the ICU (higher quartiles) were (1) more likely to use critical care therapies in AMI patients overall (mechanical ventilation [Q1 to Q4: 13% to 16%], vasopressors/inotropes [17% to 21%], intra-aortic balloon pumps [4% to 7%], and pulmonary artery catheters [4% to 5%]; p for trend<0.05 in all comparisons). However, (2) there was no association between the hospital ICU admission rate and overall RSMR for all AMI patients (6% all quartiles; p=0.7271, Figure). Conclusion: ICU admission rates for AMI vary substantially across hospitals with evidence of greater use of ICU therapies in high admitting hospitals but without evidence of lower overall mortality. There is a need for further research to determine the optimal use of ICU care for contemporary populations of patients with AMI.

scholarly journals Healthcare trajectories before and after critical illness: population-based insight on diverse patients clusters

2019 ◽  
Vol 9 (1) ◽  
Author(s):  
Youenn Jouan ◽  
Leslie Grammatico-Guillon ◽  
Noémie Teixera ◽  
Claire Hassen-Khodja ◽  
Christophe Gaborit ◽  
...  
Keyword(s):  
Septic Shock ◽  
Mechanical Ventilation ◽  
Intensive Care ◽  
Critical Illness ◽  
Length Of Stay ◽  
Population Based ◽  
Hospital Length Of Stay ◽  
Healthcare Use ◽  
Icu Admission ◽  
Icu Discharge

Abstract Background The post intensive care syndrome (PICS) gathers various disabilities, associated with a substantial healthcare use. However, patients’ comorbidities and active medical conditions prior to intensive care unit (ICU) admission may partly drive healthcare use after ICU discharge. To better understand retative contribution of critical illness and PICS—compared to pre-existing comorbidities—as potential determinant of post-critical illness healthcare use, we conducted a population-based evaluation of patients’ healthcare use trajectories. Results Using discharge databases in a 2.5-million-people region in France, we retrieved, over 3 years, all adult patients admitted in ICU for septic shock or acute respiratory distress syndrome (ARDS), intubated at least 5 days and discharged alive from hospital: 882 patients were included. Median duration of mechanical ventilation was 11 days (interquartile ranges [IQR] 8;20), mean SAPS2 was 49, and median hospital length of stay was 42 days (IQR 29;64). Healthcare use (days spent in healthcare facilities) was analyzed 2 years before and 2 years after ICU admission. Prior to ICU admission, we observed, at the scale of the whole study population, a progressive increase in healthcare use. Healthcare trajectories were then explored at individual level, and patients were assembled according to their individual pre-ICU healthcare use trajectory by clusterization with the K-Means method. Interestingly, this revealed diverse trajectories, identifying patients with elevated and increasing healthcare use (n = 126), and two main groups with low (n = 476) or no (n = 251) pre-ICU healthcare use. In ICU, however, SAPS2, duration of mechanical ventilation and length of stay were not different across the groups. Analysis of post-ICU healthcare trajectories for each group revealed that patients with low or no pre-ICU healthcare (which represented 83% of the population) switched to a persistent and elevated healthcare use during the 2 years post-ICU. Conclusion For 83% of ARDS/septic shock survivors, critical illness appears to have a pivotal role in healthcare trajectories, with a switch from a low and stable healthcare use prior to ICU to a sustained higher healthcare recourse 2 years after ICU discharge. This underpins the hypothesis of long-term critical illness and PICS-related quantifiable consequences in healthcare use, measurable at a population level.

scholarly journals 272 Morbid Obesity in Lower Limb Arthroplasty: Short Length of Stay and Favourable One-Year Outcomes

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
M Sharrock ◽  
A Nugur ◽  
S Hossain
Keyword(s):  
Morbid Obesity ◽  
Length Of Stay ◽  
Lower Limb ◽  
Average Length ◽  
Perioperative Complications ◽  
Joint Infection ◽  
Admission Rate ◽  
Tendon Injury ◽  
Morbidly Obese ◽  
Admission Rates

Abstract Introduction There are concerns that BMI is associated with a greater length of stay (LOS) and perioperative complications in lower limb arthroplasty. Method We analysed data from a six-month period to see if there was a correlation between BMI and LOS. We performed a subgroup analysis for patients with morbid obesity (BMI &gt;40). Results 285 TKRs and 195 THRs were analysed. For TKRs, the average length of stay was 2.7 days. There was no significant correlation between BMI and LOS (r=-0.0447, p = 0.2267). The morbidly obese category (n = 33) had the shortest LOS (2.5 days) compared to other BMI categories. 30-day readmission rate was 6%. 90-day re-admission rate was 12%. Six patients had minor wound issues requiring no intervention or antibiotics only. The was one prosthetic joint infection, one stitch abscess, one DVT and one patellar tendon injury. For THRs, the average LOS was 2.9 days. There was no significant correlation between BMI and LOS (r = 0.007, p = 0.4613). The morbid obese category (n = 9) had the shortest LOS (1.9 days) compared to other BMI categories. No patients were readmitted within 90 days or had documented complications. Conclusions Increased BMI is not associated with increased LOS. The morbidly obese had the shortest LOS, and commendable complication and re-admission rates.

scholarly journals Can dedicated emergency team and area for older people reduce the hospital admission rate? - An observational pre- and post-intervention study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jenny Liu ◽  
Therese Palmgren ◽  
Sari Ponzer ◽  
Italo Masiello ◽  
Nasim Farrokhnia
Keyword(s):  
Length Of Stay ◽  
Hospital Admission ◽  
Older Patients ◽  
Outcome Measure ◽  
Admission Rate ◽  
Intervention Period ◽  
Total Hospital ◽  
Hospital Admission Rate ◽  
Emergency Team ◽  
Interprofessional Team

Abstract Background Emergency department (ED) care of older patients is often complex. Geriatric ED guidelines can help to meet this challenge. However, training requirements, the use of time-consuming tools for comprehensive geriatric assessment (CGA), a lack of golden standard to identify the frail patients, and the weak evidence of positive outcomes of using CGA in EDs pose barriers to introduce the guidelines. Dedicating an interprofessional team of regular ED medical and nursing staff and an older-friendly ED area can be another approach. Previous studies of geriatrician-led CGA in EDs have reported a reduced hospital admission rate. The aim of this study was to investigate whether a dedicated interprofessional emergency team also can reduce the hospital admission rate without the resources required by the formal use of CGA. Methods An observational pre-post study at a large adult ED, where all patients 80 years or older arriving on weekdays in the intervention period from 2016.09.26 to 2016.11.28 and the corresponding weekdays in the previous year from 2015.09.28 to 2015.11.30 were included. In the intervention period, older patients either received care in the geriatric module by the dedicated team or in the regular team modules for patients of mixed ages. In 2015, all patients received care in regular team modules. The primary outcome measure was the total hospital admission rate and the ED length of stay was the secondary outcome measure. Results We included 2377 arrivals in the intervention period, when 26.7% (N = 634) received care in the geriatric module, and 2207 arrivals in the 2015 period. The total hospital admission rate was 61.7% (N = 1466/2377) in the intervention period compared to 64.8% (N = 1431/2207) in 2015 (p = 0.03). The difference was larger for patients treated in the geriatric module, 51.1% compared to 62.1% (95% CI: 56.3 to 68.0%) for patients who would have been eligible in 2015. The ED length of stay was longer in the intervention period. Conclusions An interprofessional team and area dedicated to older patients was associated to a lower hospital admission rate. Further studies are needed to confirm the results.

Clinical and Economic Impact of Methicillin-Resistant Staphylococcus aureus Colonization or Infection on Neonates in Intensive Care Units

2010 ◽  
Vol 31 (2) ◽  
pp. 177-182 ◽  
Author(s):  
Xiaoyan Song ◽  
Eli Perencevich ◽  
Joseph Campos ◽  
Billie L. Short ◽  
Nalini Singh
Keyword(s):  
Staphylococcus Aureus ◽  
Cohort Study ◽  
Intensive Care ◽  
Length Of Stay ◽  
Economic Impact ◽  
Mortality Risk ◽  
Hospital Charges ◽  
Methicillin Resistant ◽  
Control Subjects ◽  
Mrsa Colonization

Objective.The rising incidence and mortality of methicillin-resistant Staphylococcus aureus (MRSA) colonization or infection in children has become a great concern. This study aimed to determine the clinical and economic impact of MRSA colonization or infection on infants and to measure excess mortality, length of stay, and hospital charges attributable to MRSA.Design.This is a retrospective cohort study.Setting and Patients.The study included infants admitted to a level III-IV neonatal intensive care unit from September 1, 2004, through March 31, 2008.Methods.A time-dependent proportional hazard model was used to analyze the association between MRSA colonization or infection and mortality. The relationships between MRSA colonization or infection and length of stay and between MRSA colonization or infection and hospital charges were assessed using a matched cohort study design.Results.Of 2,280 infants, 191 (8.4%) had MRSA colonization or infection. Of 132 MRSA isolates with antibiotic susceptibility results, 106 were resistant to clindamycin and/or trimethoprim-sulfamethoxazole, thus representing a noncommunity phenotype. The mortality rate was 17.8% for patients with MRSA colonization or infection and 11.5% for control subjects. Neither MRSA colonization (hazard ratio [HR], 0.9 [95% confidence interval {CI}, 0.5-1.5]; P > .05) nor infection (HR, 1.2 [95% CI, 0.7-1.9]; P > .05) was associated with increased mortality risk. Infection caused by MRSA strains that were resistant to clindamycin and/or trimethoprim-sulfamethoxazole increased the mortality risk by 40% (HR, 1.4 [95% CI, 0.9-2.2]; P > .05), compared with the mortality risk of control subjects, but the increase was not statistically significant. MRSA infection independently increased length of stay by 40 days (95% CI, 34.2—45.6; P < .001) and was associated with an extra charge of $164,301 (95% CI, $158,712-$169,889; P < .001).Conclusions.MRSA colonization or infection in infants is associated with significant morbidity and financial burden but is not independently associated with increased mortality.

scholarly journals Obstetric Admissions into the Intensive Care Unit in a Sub-urban University Teaching Hospital

2012 ◽  
Vol 6 (2) ◽  
pp. 33-36
Author(s):  
AF Faponle ◽  
AT Adenekan
Keyword(s):  
Intensive Care ◽  
Post Partum ◽  
Small Population ◽  
University Teaching ◽  
Neurological Dysfunction ◽  
Admission Diagnosis ◽  
Medical Problems ◽  
Total Hospital ◽  
Icu Admission ◽  
Urban University

Aims: Intensive care medicine is relatively young in developing countries and there are few studies showing obstetric utilization of the facilities in Intensive Care Units (ICU) in many developing nations. We sought to determine the ICU utilization by obstetric patients in our hospital, assess the spectrum of diseases necessitating admissions, the intervention required and outcome of such admissions. Methods: A 5 year retrospective review of all obstetric admissions into the ICU from January 2003 to December 2007. Subjects were included if they were admitted during pregnancy up to 42 days post partum. Data obtained included demographics, obstetric history, pre-existing medical problems, admission diagnosis, indication for ICU admission, intervention in the ICU and outcome. Results: Obstetric cases accounted for 1.5 % of total admissions into the ICU. These also represented 0.2% of total hospital deliveries. All the patients were admitted post partum. Eclampsia was the commonest primary obstetric diagnosis (58.8%) with neurological dysfunction as the commonest indication for ICU admission. Mortality rate among admitted cases was 41.2%. Conclusions: Obstetric patients form a small population of a third world multi-disciplinary ICU but mortality among this group was high. It is recommended that large obstetric units should establish there own ICUs with standard facilities which will facilitate improved care of critically ill pregnant women and thereby improve the outcome. NJOG 2011 Nov-Dec; 6 (2): 33-36 DOI: http://dx.doi.org/10.3126/njog.v6i2.6754

scholarly journals Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock

2020 ◽  
Vol 21 (2) ◽  
pp. 348-352
Author(s):  
Shadi Lahham ◽  
Clifton Lee ◽  
Qumber Ali ◽  
John Moeller ◽  
Chanel Fischetti ◽  
...  
Keyword(s):  
Septic Shock ◽  
Severe Sepsis ◽  
Length Of Stay ◽  
Large Scale ◽  
Admission Rate ◽  
Hospital Length Of Stay ◽  
Point Of Care Ultrasound ◽  
Septic Cardiomyopathy ◽  
Icu Admission ◽  
Sepsis And Septic Shock

Introduction: Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. Methods: We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. Results: We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm-20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. Conclusion: Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.

scholarly journals Impact of a specialist service in the Emergency Department on admission, length of stay and readmission of patients presenting with falls, syncope and dizziness

QJM ◽  
2020 ◽  
Author(s):  
K Jusmanova ◽  
C Rice ◽  
R Bourke ◽  
A Lavan ◽  
C G McMahon ◽  
...  
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Admission Rate ◽  
Readmission Rates ◽  
Specialist Service ◽  
Admission Rates ◽  
Potential Benefits ◽  
Bed Days ◽  
The Mean ◽  
The Impact

Summary Background Up to half of patients presenting with falls, syncope or dizziness are admitted to hospital. Many are discharged without a clear diagnosis for their index episode, however, and therefore a relatively high risk of readmission. Aim To examine the impact of ED-FASS (Emergency Department Falls and Syncope Service) a dedicated specialist service embedded within an ED, seeing patients of all ages with falls, syncope and dizziness. Design Pre- and post-cohort study. Methods Admission rates, length of stay (LOS) and readmission at 3 months were examined for all patients presenting with a fall, syncope or dizziness from April to July 2018 (pre-ED-FASS) inclusive and compared to April to July 2019 inclusive (post-ED-FASS). Results There was a significantly lower admission rate for patients presenting in 2019 compared to 2018 [27% (453/1676) vs. 34% (548/1620); X2 = 18.0; P &lt; 0.001], with a 20% reduction in admissions. The mean LOS for patients admitted in 2018 was 20.7 [95% confidence interval (CI) 17.4–24.0] days compared to 18.2 (95% CI 14.6–21.9) days in 2019 (t = 0.98; P = 0.3294). This accounts for 11 344 bed days in the 2018 study period, and 8299 bed days used after ED-FASS. There was also a significant reduction in readmission rates within 3 months of index presentation, from 21% (109/1620) to 16% (68/1676) (X2 = 4.68; P = 0.030). Conclusion This study highlights the significant potential benefits of embedding dedicated multidisciplinary services at the hospital front door in terms of early specialist assessment and directing appropriate patients to effective ambulatory care pathways.

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