Gianni D’Egidio

The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation

Introduction: The intensive care unit (ICU) consumes 20% of hospital expenditures and 1% of gross domestic product. Many strategies have been attempted to reduce ICU costs. A systematic review was conducted to evaluate the effect of palliative care (PC) consultations in the ICU on length of stay (LOS) and costs. Methods: A literature search was performed using PubMed, MEDLINE, EMBASE, and the Cochrane Library. Randomized controlled trials (RCTs), prospective, and retrospective cohort studies looking at PC consultations in adult ICUs published between January 2000 and February 2016 were selected. Independent reviewers assessed the eligibility of studies, extracted data on ICU, hospital LOS, and mortality, and rated each study’s quality. The cost was derived from an existing model in the literature; the primary outcome was ICU LOS and the secondary outcomes were direct variable costs, mortality, and hospital LOS. Results: We reviewed 814 abstracts, but only 8 studies met inclusion criteria and were included. The patients with a PC consultation in the ICU, when compared to those who did not, showed a trend toward reduced LOS. This reduction was statistically significant in the higher quality studies. Mortality was similar in both groups. Palliative care consultations also lead to a reduction in costs in 5 of the 8 eligible trials. On average, ICU costs were USD7533 and USD6406 (control vs PC, P < .05) and hospital direct variable costs were USD9518 and USD8971 (P < .05) per admission. Due to interstudy heterogeneity, all outcomes were described narratively. Conclusion: This review demonstrates a trend that PC consultations reduce LOS and costs without impacting mortality. However, due to the small sample sizes and varying degrees of quality of evidence, many questions remain. A large multicenter RCT and formal economic evaluation would be needed for more definitive results.

Neuroscience Intermediate-Level Care Units Staffed by Intensivists: Clinical Outcomes and Cost Analysis

Introduction: With an aging population and increasing numbers of intensive care unit admissions, novel ways of providing quality care at reduced cost are required. Closed neurointensive care units improve outcomes for patients with critical neurological conditions, including decreased mortality and length of stay (LOS). Small studies have demonstrated the safety of intermediate-level units for selected patient populations. However, few studies analyze both cost and safety outcomes of these units. This retrospective study assessed clinical and cost-related outcomes in an intermediate-level neurosciences acute care unit (NACU) before and after the addition of an intensivist to the unit’s care team. Methods: Starting in October 2011, an intensivist-led model was adopted in a 16-bed NACU unit, including daytime coverage by a dedicated intensivist. Data were obtained from all patients admitted 1 year prior to and 2 years after this intervention. Primary outcomes were LOS and hospital costs. Safety outcomes included mortality and readmissions. Descriptive and analytic statistics were calculated. Individual and total patient costs were calculated based on per-day NACU and ward cost estimates and significance measured using bootstrapping. Results: A total of 2931 patients were included over the study period. Patients were on average 59.5 years and 53% male. The most common reasons for admission were central nervous system (CNS) tumor (27.6%), ischemic stroke (27%), and subarachnoid hemorrhage (11%). Following the introduction of an intensivist, there was a significant reduction in NACU and hospital LOS, by 1 day and 3 days, respectively. There were no differences in readmissions or mortality. Adding an intensivist produced an individual cost savings of US

Compartment Syndrome as a Result of Systemic Capillary Leak Syndrome

963 in NACU and US

556: CRITICAL CARE AT THE END OF LIFE

2687 per patient total hospital stay. Conclusion: An intensivist-led model of intermediate-level neurointensive care staffed by intensivists is safe, decreases LOS, and produces cost savings in a system increasingly strained to provide quality neurocritical care.

Why Process Quality Measures may be More Valuable than Outcome Measures in Critical Care Patients

Objective. To describe a single case of Systemic Capillary Leak Syndrome (SCLS) with a rare complication of compartment syndrome. Patient. Our patient is a 57-year-old male, referred to our hospital due to polycythemia (hemoglobin (Hgb) of 220 g/L), hypotension, acute renal failure, and bilateral calf pain. Measurements and Main Results. The patient required bilateral forearm, thigh, and calf fasciotomies during his ICU stay and continuous renal replacement therapy was instituted following onset of acute renal failure and oliguria. Ongoing hemodynamic (Norepinephrine and Milrinone infusion) and respiratory (ventilator) support in the ICU was provided until resolution of intravascular fluid extravasation. Conclusions. SCLS is an extremely rare disorder characterized by unexplained episodic capillary hyperpermeability, which causes shift of volume and protein from the intravascular space to the interstitial space. Patients present with significant hypotension, hemoconcentration, hypovolemia, and oliguria. Severe edema results from leakage of fluid and proteins into tissue. The most important part of treatment is maintaining stable hemodynamics, ruling out other causes of shock and diligent monitoring for complications. Awareness of the clinical syndrome with the rare complication of compartment syndrome may help guide investigations and diagnoses of these critically ill patients.

Do Flashing Red Lights Help Improve Hand Hygiene Compliance at the Front Entrance of a Large Hospital

Learning Objectives: Despite the high cost associated with ICU use at the endof-life, very little is known at a population level about the characteristics of users and their end-of-life experience. In this study, our goal was to characterize decedents who received intensive care near the end of life and examine their overall health care use prior to death. Methods: We conducted a retrospective cohort study examining health care use and cost incurred by decedents in their last 90 days of life. We captured all deaths in a 3-year period, from April 1, 2010 to March 31, 2013 in Ontario, Canada. Deaths were identified using the Ontario Registered Persons Database (RPDB). All records of health care use paid for by the provincial Ministry of Health and Long Term Care (MOHLTC) in the last year of life were also retrieved. Results: Overall, 264 754 individuals were included in the study, of which 18% used ICU in the last 90 days of life. 34.5% of these ICU users were greater than 80 years of age and 53.0% had greater than 5 chronic conditions. The average cost of stay for these decedents was

Cost analysis of the very elderly admitted to intensive care units

15, 511 to

Critical care at the end of life: a population-level cohort study of cost and outcomes

25,526 greater than those who were not admitted to ICU, across varying levels of comorbidity. These individuals also died more in hospital (88.7% vs 36.2%), were readmitted more (40.2% vs 16.9%), spent more time in acute care settings (18.7 days vs. 10.5 days) and had more aggressive care measures, such as CPR (11.5% vs 1.0%) and feeding tube insertions (4.2% vs 0.9%) performed. Conclusions: Contrary to the notion that older, frail and multi-morbid individuals close to death may be inappropriate for ICU care, we show – at a population level – that a significant proportion of those with ICU use close to death are actually older and multi-morbid. Not only does this incur significantly greater costs on already limited resources, but we also show that this leads to increased deaths in hospital and increased rates of aggressive care measures that are ultimately futile. More work needs to explore the appropriateness of ICU admission at the end of life, as determined by the patient’s wishes and their overall medical condition.

Guide to strategic planning in critical care medicine

Background ICU is an ideal target for quality of care evaluation and initiatives because of the associated morbidity, mortality and high resource utilization of the patient population. Quality measures can be separated into structure, process and outcome. There has been longstanding debate about the ideal quality measure. Findings Structure measures are typically most valuable when good quality of care is unlikely, as it will often help illustrate glaring deficiencies. Process measures attempt to assess healthcare provider’s compliance with practices that are associated with positive outcomes. Outcome quality measures assess whether healthcare goals were realized. These measures can range from mortality, cost of care and patient satisfaction. The advantage of process measures is that data can be collected relatively quickly. Outcome measures can be rare or difficult to track; this can make the data collection process difficult. Also a larger sample size may be necessary to capture the outcome measure. Process measures frequently do not require large sample sizes and therefore allow for a quicker feedback process. Process measures also reduce the need for adjusting for severity of illness and co-morbidities, which can be time consuming and labor intensive. Conclusion It is apparent that process quality measures are the most practical, impactful and logical option for critical care patients. Outcome measures do have value but can be difficult to interpret in the critical care setting due to the heterogeneity of patients, the multiple disciplines involved in care and measures can be subjective.

500: THE COST TO ACHIEVE FUNCTIONAL RECOVERY IN VERY ELDERLY PATIENTS ADMITTED TO INTENSIVE CARE UNITS

Hand hygiene is one of the most effective measures against the spread of infectious diseases. Compliance with hand hygiene among healthcare workers and visitors to the hospital varies but can be quite poor in some instances [1]. Hand hygiene upon first entering a health care institution has not been studied in detail and the few studies addressing it have indicated that compliance is quite poor [1,2].