Carolyn E. Bekes

Guidelines on critical care services and personnel: Recommendations based on a system of categorization of three levels of care.

ObjectivesTo describe three levels of hospital-based critical care centers to optimally match services and personnel with community needs, and to recommend essential intensive care unit services and personnel for each critical care level. ParticipantsA multidisciplinary writing panel of professionals with expertise in the clinical practice of critical care medicine working under the direction of the American College of Critical Care Medicine (ACCM). Data Sources and SynthesisRelevant medical literature was accessed through a systematic Medline search and synthesized by the ACCM writing panel, a multidisciplinary group of critical care experts. Consensus for the final written document was reached through collaboration in meetings and through electronic communication modalities. Literature cited included previously written guidelines from the ACCM, published expert opinion and statements from official organizations, published review articles, and nonrandomized, historical cohort investigations. With this background, the ACCM writing panel described a three-tiered system of intensive care units determined by service-based criteria. ConclusionsGuidelines for optimal intensive care unit services and personnel for hospitals with varying resources will facilitate both local and regional delivery of consistent and excellent care to critically ill patients.

Prediction of survival of critically ill patients by admission comorbidity

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

Reimbursement for intensive care services under diagnosis-related groups.

Current governmental policy, in an effort to reduce the federal deficit, has switched to a prospective payment system for hospital care of Medicare patients based on Diagnosis-Related Groups (DRGs). In New Jersey, all hospital care is reimbursed using a DRG system. This study examines the relationship between charges and reimbursement in a university hospital ICU under a DRG system for the care of patients who consume a large amount of the ICU resources. For patients who were classified Class IV under the Therapeutic Intervention Scoring System, with the possible exception of open heart patients, the charges for care delivered exceeded income received, with a net revenue of -

Critical care medicine as a distinct product line with substantial financial profitability: The role of business planning

24,098 and an adjusted net revenue of -

Ethical issues in hospital medicine

5,057 for ICU Class IV patients (excluding open hearts). Thus, it appears that the care given to these patients may have resulted in a financial loss to the institution. If this were to continue, the financial impact might have a negative effect upon attempts to regionalize intensive care services.

Economics of critical care: Medicare part A versus part B payments

Objective:As academic health centers face increasing financial pressures, they have adopted a more businesslike approach to planning, particularly for discrete “product” or clinical service lines. Since critical care typically has been viewed as a service provided by a hospital, and not a product line, business plans have not historically been developed to expand and promote critical care. The major focus when examining the finances of critical care has been cost reduction, not business development. We hypothesized that a critical care business plan can be developed and analyzed like other more typical product lines and that such a critical care product line can be profitable for an institution. Design:In-depth analysis of critical care including business planning for critical care services. Setting:Regional academic health center in southern New Jersey. Subjects:None. Interventions:As part of an overall business planning process directed by the Board of Trustees, the critical care product line was identified by isolating revenue, expenses, and profitability associated with critical care patients. Measurements and Main Results:We were able to identify the major sources (“value chain”) of critical care patients: the emergency room, patients who are admitted for other problems but spend time in a critical care unit, and patients transferred to our intensive care units from other hospitals. The greatest opportunity to expand the product line comes from increasing the referrals from other hospitals.A methodology was developed to identify the revenue and expenses associated with critical care, based on the analysis of past experience. With this model, we were able to demonstrate a positive contribution margin of

The future of hospital economic health.

7 million per year related to patients transferred to the institution primarily for critical care services. This can be seen as the profit related to the product line segment of critical care. There was an additional positive contribution margin of

WILL INSTITUTION OF A POLICY REQUIRING ROUTINE PREOPERATIVE PULMONARY FUNCTION TESTS (PFT) IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING (CABG) CHANGE THE POST OPERATIVE OUTCOMES?: 9

5.8 million attributed to the critical care portion of the hospital stay of patients admitted primarily through other product lines or the emergency room. This can be seen as the profit related to the “hospital service” segment of critical care. This represented a total contribution margin of

The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients.

12.8 million, approximately 24% of the institution’s entire contribution margin. This information was subsequently used to develop strategic plans to promote this product line. Conclusions:We were able to define the critical care product line, and we were able to demonstrate profitability through an analysis of revenue and expenses related to critical care services. Our experience suggests that the concept of critical care as a product line, in addition to a hospital service, may lead to a useful analysis of this new discipline. This plan provided a rational foundation for development of the operating and capital budgets for the health system.

Are Two (Inexperienced) Heads Better Than One (Experienced) Head?: Averaging House Officers' Prognostic Judgments for Critically Ill Patients

The medical ethics of the new millennium will be fascinating and fast moving in our pluralistic Western society. This will be particularly true in ethics in the hospital setting and under hospitalist models. Ethical decisions are ubiquitous in medical practice, at the microlevel of the patient-physician relationship and at the macro-level of the allocation of resources and other ethical decisions. Hospitalists need to recognize that ethical issues are distinct from medical ones and need to utilize different techniques in their resolution. Ethics in the public sector, such as in hospitals and other health care organizations, cannot transcend politics completely, because the public sector is the political arena. For ethical guidelines to survive, however, they must be based not on political expediency but on sound ethical principles and reasoning. As the knowledge of medicine, technology, and science continues to grow, the challenges of regulation, policy, and ethical issues in the hospital setting and elsewhere in the health care system will occupy physicians for some time to come.