Michael G. Seneff

The impact of long-term acute-care facilities on the outcome and cost of care for patients undergoing prolonged mechanical ventilation.

Objectives: To compare the 6‐month mortality rate of chronically ventilated patients treated either exclusively in a traditional acute‐care hospital or transferred during hospitalization to a long‐term acute‐care facility. To analyze the hospital cost of care and estimate the amount of uncompensated care incurred by acute‐care hospitals under the Medicare prospective payment diagnostic related groups system. Design: Retrospective chart review and questionnaire. Setting: Fifty‐four acute‐care referral hospitals and 26 long‐term acute‐care institutions. Patients: A total of 432 ventilated patients selected from 3,266 patients referred but not transferred to a study long‐term acute‐care facility and 1,702 ventilated patients from 4,174 patients referred and then subsequently transferred to the long‐term acute‐care facility. Six‐month outcomes were determined for the subgroup of patients ≥65 yrs old (279 and 1,340 patients, respectively). Hospital charges were available for 192 of the 279 nontransferred patients who were ≥65 yrs old and 1,332 of the 1,340 transferred patients. Interventions: None. Measurements and Main Results: The 6‐month mortality rate was 67.4% for the 279 nontransferred patients and 67.2% for the 1,340 transferred patients. On multiple regression analysis, variables associated with the 6‐month mortality rate included initial admitting diagnosis, age, the acute physiology score, and presence of decubitus ulcer. After controlling for these variables, there was no significant difference in 6‐month mortality rate, but admission to the long‐term acute‐care facility was associated with a longer mean survival time. Average total hospital costs for the 192 nontransferred patients was

Development and Standardization of a Furosemide Stress Test to Predict the Severity of Acute Kidney Injury

78,474, and estimated Medicare reimbursement was

Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity

62,472, resulting in an average of

Use of femoral venous catheters in critically ill adults : prospective study

16,002 of uncompensated care per patient. Estimated costs for the long‐term acute‐care facility admissions were

Evaluating laboratory usage in the intensive care unit: patient and institutional characteristics that influence frequency of blood sampling.

56,825. Conclusions: Patients undergoing prolonged ventilation have high hospital and 6‐month mortality rates, and 6‐month outcomes are not significantly different for those transferred to long‐term acute‐care facilities. These patients generate high costs, and acute‐care hospitals are significantly underreimbursed by Medicare for these costs. Acute‐care hospitals can reduce the amount of uncompensated care by earlier transfer of appropriate patients to a long‐term acute‐care facility.

Predicting Patient Outcome from Intensive Care: A Guide to APACHE, MPM, SAPS, PRISM, and Other Prognostic Scoring Systems

IntroductionIn the setting of early acute kidney injury (AKI), no test has been shown to definitively predict the progression to more severe stages.MethodsWe investigated the ability of a furosemide stress test (FST) (one-time dose of 1.0 or 1.5 mg/kg depending on prior furosemide-exposure) to predict the development of AKIN Stage-III in 2 cohorts of critically ill subjects with early AKI. Cohort 1 was a retrospective cohort who received a FST in the setting of AKI in critically ill patients as part of Southern AKI Network. Cohort 2 was a prospective multicenter group of critically ill patients who received their FST in the setting of early AKI.ResultsWe studied 77 subjects; 23 from cohort 1 and 54 from cohort 2; 25 (32.4%) met the primary endpoint of progression to AKIN-III. Subjects with progressive AKI had significantly lower urine output following FST in each of the first 6 hours (p<0.001). The area under the receiver operator characteristic curves for the total urine output over the first 2 hours following FST to predict progression to AKIN-III was 0.87 (p = 0.001). The ideal-cutoff for predicting AKI progression during the first 2 hours following FST was a urine volume of less than 200mls(100ml/hr) with a sensitivity of 87.1% and specificity 84.1%.ConclusionsThe FST in subjects with early AKI serves as a novel assessment of tubular function with robust predictive capacity to identify those patients with severe and progressive AKI. Future studies to validate these findings are warranted.

Use of Haloperidol Infusions to Control Delirium in Critically Ill Adults

Clinicians have access to limited tools that predict which patients with early AKI will progress to more severe stages. In early AKI, urine output after a furosemide stress test (FST), which involves intravenous administration of furosemide (1.0 or 1.5 mg/kg), can predict the development of stage 3 AKI. We measured several AKI biomarkers in our previously published cohort of 77 patients with early AKI who received an FST and evaluated the ability of FST urine output and biomarkers to predict the development of stage 3 AKI (n=25 [32.5%]), receipt of RRT (n=11 [14.2%]), or inpatient mortality (n=16 [20.7%]). With an area under the curve (AUC)±SEM of 0.87±0.09 (P<0.0001), 2-hour urine output after FST was significantly better than each urinary biomarker tested in predicting progression to stage 3 (P<0.05). FST urine output was the only biomarker to significantly predict RRT (0.86±0.08; P=0.001). Regardless of the end point, combining FST urine output with individual biomarkers using logistic regression did not significantly improve risk stratification (ΔAUC, P>0.10 for all). When FST urine output was assessed in patients with increased biomarker levels, the AUC for progression to stage 3 improved to 0.90±0.06 and the AUC for receipt of RRT improved to 0.91±0.08. Overall, in the setting of early AKI, FST urine output outperformed biochemical biomarkers for prediction of progressive AKI, need for RRT, and inpatient mortality. Using a FST in patients with increased biomarker levels improves risk stratification, although further research is needed.

Off-Pump versus On-Pump Coronary Artery Bypass Grafting Outcomes Stratified by Preoperative Renal Function

ObjectiveTo determine the frequency of clinically important complications of femoral venous catheters. DesignProspective survey of major and minor complications. SettingA mixed medical/surgical ICU in a university hospital. PatientsOne hundred twenty-three patients admitted to the ICU who underwent femoral venous catheterization over a 2-yr period. Measurements and Main ResultsThere were 150 catheters inserted in 123 patients for a mean duration of 6.4 days. There were no major complications including catheter-related sepsis. Minor complications consisted of arterial puncture (9.3%), local bleeding (10%), and local inflammation (4.7%). Critical care fellows had a significantly lower rate (6%) of insertion complications than interns or medical students (16%). We did not specifically look at the frequency of deep venous thrombosis. ConclusionsFemoral venous catheterization offers an alternative site of insertion to the subclavian and jugular veins for central venous access in the critically ill. The occurrence rate of clinically important complications is acceptably low. (Crit Care Med 1991; 19:550)

Neurogenic Pulmonary Edema: Successful Treatment With IV Phentolamine

OBJECTIVES To develop a predictive equation to estimate the frequency of blood drawing for intensive care unit (ICU) laboratory tests and to evaluate variations in ICU blood sampling practices after adjusting for patient and institutional factors. DESIGN Prospective, inception, cohort study. SETTING Forty-two ICUs in 40 hospitals, including 20 teaching and 17 nonteaching ICUs. PATIENTS A consecutive sample of 17,440 ICU admissions, in which 14,043 blood samples were drawn for laboratory testing on ICU days 2 to 7. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient demographic, physiologic, and treatment data were obtained on ICU day 1; the type and number of blood samples for laboratory testing were recorded on ICU days 1 to 7. In the 42 ICUs, a mean of 16.2 blood samples were drawn for tests on ICU days 2 to 7, but varied between 23 samples in the teaching ICUs and 9.9 samples in nonteaching ICUs. Using only ICU day 1 patient data, we predicted the subsequent number of samples drawn on ICU day 2 (R2 = .26 across individual patients) and on ICU days 2 to 7 (R2 = .26 across individual patients). The most important determinants of the number of blood samples drawn on ICU days 2 to 7 were the ICU day 1 Acute Physiology Score and admission diagnosis. After controlling for patient variables, hospital teaching status, number of beds, and location in the East and South were significantly (p < .05) associated with increased blood sampling on ICU day 2 and on ICU days 2 to 7. More frequent use of an arterial cannula and mechanical ventilation were also associated with increased blood sampling on subsequent days. CONCLUSIONS The ability to adjust for patient and institutional variables and to predict the number of blood samples drawn for laboratory tests can allow ICUs to compare their practices with those of other units. When integrated into a continuous quality improvement process, this information can be used to identify and focus on opportunities for improving blood conservation and reducing excessive diagnostic testing.

Femoral-based central venous oxygen saturation is not a reliable substitute for subclavian/internal jugular-based central venous oxygen saturation in patients who are critically ill.

Accurate prognosis is critical to the practice and im provement of intensive care. Recently, a number of gen eral prognostic scoring systems have been developed and their primary goal is to predict patient outcomes. We describe the principles underlying these systems and the methods they use to create predictions. We also explain how predictions of patient outcomes can be used to improve the precision of clinical trials, to evalu ate hospital and intensive care unit use and outcome, and eventually to assist in clinical decision-making.