Carl A. Sirio

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

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

Identifying potentially ineffective care in a community hospital.

ObjectivesTo develop a formula to predict mortality for intensive care unit patients between day 5 in an intensive care unit and 100 days after hospital discharge from a community hospital. DesignRetrospective 1-yr derivation study with validation on a subsequent year’s intensive care unit population. SettingAn 850-bed, not-for-profit community hospital with three adult intensive care units, including medical-surgical, cardiac-medical, and cardiac-surgical units. PatientsThe development patient set included 4045 consecutive adult admissions to the intensive care unit between July 1995 and June 1996. The validation sample consisted of 4084 admissions between July 1996 and June 1997. ResultsDuring the first year, 100-day posthospital discharge mortality was predicted by the combination Acute Physiology and Chronic Health Evaluation (APACHE) III predicted mortality on day 5 of >0.92 or the product of day 1 and day 5 APACHE predicted mortality of >0.40, with an increase in the APACHE predicted mortality from day 1 to day 5 of >0.10. Specificity in the development cohort was 0.99, sensitivity was 0.30, and positive predictive value was 0.95. The second-year validation study demonstrated a specificity, sensitivity, and positive predictive value of 0.98, 0.29, and 0.91, respectively, when applying the model to the validation sample. ConclusionsBy using readily available APACHE III data, we were able to identify patients at high risk of dying between intensive care unit day 5 and 100 days after discharge. Although the low sensitivity limits the number of patients for whom death at 100 days is predicted, the high specificity and positive predictive value suggests this information may provide useful information for families and physicians. If these formulas can be validated in diverse institutional settings, decisions regarding short- and long-term outcomes may be improved by using objective survival predictions from two time points.

The expanding role of ICU medical directors: from patient management to unit management.

Over the past three decades the focus of physicians delivering intensive care has been on patient management whereas the management of critical care units has been done primarily by nurses. This article reviews existing literature and the arguments supporting a more active role for physicians in the management of critical care units.

Acuity of Illness and Risk Prediction in Critically I11 Adults: The APACHE III Intensive Care Unit Management System

Providing patients with state-of-the-art, quality care has been a hallmark of 20-century medicine. Critical care units developed as an extension of postoperative recovery rooms and with the dissemination of effective electronic electrocardiographic cardiac monitoring, external cardiac massage, and respiratory support. Intensive care units (ICUs) proliferated worldwide in an attempt to improve patient outcome and overall quality of care by concentrating technology in the hospital environment.