Judith Hudson-Civetta

Maintaining quality of care while reducing charges in the ICU. Ten ways.

We believed that the dilemma of controlling costs yet maintaining quality of care might be approached in 10 ways designed to improve efficiency of care: principles of management, elimination of standing orders, classification of patients, written guidelines, mandatory communication, no repetitive orders, single order for single test, removal of monitoring catheters, constant administrative attention, and feedback. We monitored quality of care using the therapeutic intervention scoring system (TISS), mortality, utilization of bed days in the ICU, and the total hospitalization of 50 patients treated in April 1983 and, 8 months after the interventions, 50 patients treated in February 1984. There were no differences in the patient population, severity, outcome, or days. The total lab bills were

Risk and detection of pulmonary artery catheter-related infection in septic surgical patients

10,000 in 1983 and

Stab wounds to the back and flank in the hemodynamically stable patient: A decision algorithm based on contrast-enhanced computed tomography with colonic opacification

6300 in 1984 (p less than 0.01). The total number of tests decreased by 2803 (42%) from 6685 to 3882, or 56 per patient per admission. Calculated ICU laboratory charges per patient decreased

Titrating positive end-expiratory pressure therapy in patients with early, moderate arterial hypoxemia

3226 (53%) from

Re-engineering ventilatory support to decrease days and improve resource utilization.

6210 to

Preoperative intensive care unit consultations : accurate and effective

2894. In 1983, while patients spent 15% of their hospital days in the ICU, they accumulated 61% of their total laboratory charges. In 1984, ICU days were 19% and ICU laboratory charges were 46% of the total. If the decrease of

Strategies to prevent organ failure.

3226 per patient is extrapolated to a years population, this would decrease charges by over

EVALUATION OF APACHE II FOR “COST CONTAINMENT” AND “QUALITY ASSURANCE” IN SURGICAL PATIENTS

2,000,000 in one 12-bed surgical ICU.

Failure of Splanchnic Resuscitation in the Acutely Injured Trauma Patient Correlates With Multiple Organ System Failure and Length of Stay in the ICU

Specimen cultures were evaluated in 49 catheterized patients who had a known focus of infection (primarily intra-abdominal peritonitis). Bacteria were recovered from 2% of flush solutions, 14% of transducer domes, 18% of diaphragms, and 24% of cardiac output fluids; however, these bacteria were not found in cultures of the pulmonary artery (PA) catheter segments. The rates of positive PA catheter-aspirate cultures were 30.6% on day 1, 20.4% on day 2, and 32.7% on day 3 (not statistically different). PA catheter-aspirate cultures had a sensitivity of 5.7% and a positive predictive value of 30% for catheter-related infection, and 15% sensitivity and 40% positive predictive value for peripheral bacteremia. While 95% (55 of 58) of the catheter- aspirate cultures were false-positives, only 0.5% (3 of 588) were true-positives. Peripheral blood cultures were positive in 10% of the patients, but the catheter segments were sterile or grew different organisms. Arterial line cultures had zero sensitivity and predictive value to detect catheter-related infection, and 15% sensitivity and 40% predictive value to detect peripheral bacteremia. Thus, PA catheter-aspirate cultures, routine peripheral blood cultures, and arterial cultures cannot be recommended to detect PA catheter-related infection. Catheter-related infection confirmed by catheter-segment cultures was 10.2% when the PA catheters were removed after 73 ± 6.5 (SD) h. Bacteria from catheter- segment cultures corresponded to those from the primary infection site.

Evaluation of APACHE II for cost containment and quality assurance.

PURPOSE The authors wanted to determine whether contrast-enhanced computed tomography (CE-CT) with colonic opacification is an accurate tool to triage hemodynamically stable victims of stab wounds to the flank and back. PATIENTS AND METHODS One hundred forty-five consecutive patients were categorized as low-risk ( penetration superficial to the deep fascia) or high-risk (penetration beyond the deep fascia) based on CE-CT findings. RESULTS There were no significant differences in admission vital signs, Glasgow Coma Scale, or complete blood counts between low- and high-risk groups. None of the 92 low-risk patients required surgery or had sequelae. Six of the 53 high-risk patients underwent surgery, 2 based on initial CE-CT, 4 due to evolving clinical signs. The CE-CT correctly predicted surgical findings in all cases. CONCLUSIONS Hemodynamically stable patients with stab wounds to the back and/or flank can be successfully triaged based on CE-CT findings. Low-risk patients may be discharged immediately. High-risk patients may have a discharge decision implemented at 24 hours.