Michael R. Silver

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

Medical effectiveness of esophageal balloon pressure manometry in weaning patients from mechanical ventilation.

78,474, and estimated Medicare reimbursement was

Detection of postoperative respiratory failure: How predictive is the agency for healthcare research and quality's patient safety indicator?

62,472, resulting in an average of

Improving outcomes: focus on workplace issues.

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

Variation in academic medical centers' coding practices for postoperative respiratory complications: implications for the AHRQ postoperative respiratory failure Patient Safety Indicator.

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.

Intrinsic gating of inward rectifier in bovine pulmonary artery endothelial cells in the presence or absence of internal Mg2

OBJECTIVE To determine the efficacy of a new respiratory monitor, which uses esophageal balloons, in aiding clinicians attempting to wean patients from mechanical ventilation. DESIGN Prospective study of patients who were deemed ready to be weaned after having required mechanical ventilation for a minimum of 3 days. Each of the patients served as his or her own control. SETTING University medical intensive care unit. PATIENTS The series consisted of 23 consecutive patients who were ready to wean from mechanical ventilation. INTERVENTIONS Before the onset of the study, two weaning strategies were developed. One strategy involved using clinically available weaning parameters. The other strategy involved using esophageal balloon data that was recorded via a new respiratory monitor. Each of the weaning strategies resulted in the development of a scoring system that could be rigidly adhered to and which determined, without bias, to what extent the patient could be weaned each day. Rigid criteria were also developed to determine whether the weaning trial was successful or not. The two strategies were then compared to determine the ability of the strategy to shorten ventilatory time. MEASUREMENTS AND MAIN RESULTS Each patient was evaluated daily by the two weaning protocols. At each weaning step, the two protocols were compared with respect to degree of aggressiveness and tolerance of the weaning maneuver by the patient. A protocol was judged superior if it resulted in more aggressive weaning without increased patient intolerance. The clinicians evaluating the patient with the clinical protocol could accelerate or retard the number of weaning steps by one step, based on the patients clinical state and the clinicians experience. There was no such freedom in the esophageal protocol. The major finding was that in 40.5% of the instances, the protocol involving the esophageal balloon resulted in more aggressive weaning without patient intolerance. In 11.6% of the cases, the clinical protocol was more aggressive. Both protocols predicted the same number of weaning steps 39.8% of the time. In all these instances, the patient tolerated the weaning suggested. The use of data from the esophageal protocol resulted in weaning the patients 1.68 days faster than the use of data from the clinical protocol. CONCLUSIONS The respiratory monitor, using esophageal balloon technology, is effective in that it can provide the clinician with data that can result in more aggressive weaning from mechanical ventilation without an increase in patient intolerance. The duration of mechanical ventilation can be shortened when these data are applied via a rigidly controlled weaning strategy.

The noninvasive respiratory care unit. Patterns of use and financial implications.

BACKGROUND Patient Safety Indicator (PSI) 11, or postoperative respiratory failure, was developed by the US Agency for Healthcare Research and Quality to detect incident cases of respiratory failure after elective operations through use of ICD-9-CM diagnosis and procedure codes. We sought to determine the positive predictive value (PPV) of this indicator. STUDY DESIGN We conducted a retrospective cross-sectional study, sampling consecutive cases that met PSI 11 criteria from 18 geographically diverse academic medical centers on or before June 30, 2007. Trained abstractors from each center reviewed medical records using a standard instrument. We assessed the PPV of the indicator (with 95% CI adjusted for clustering within centers) and conducted descriptive analyses of the cases. RESULTS Of 609 cases that met PSI 11 criteria, 551 (90.5%; 95% CI, 86.5-94.4%) satisfied the technical criteria of the indicator and 507 (83.2%; 95% CI, 77.2-89.3%) represented true cases of postoperative respiratory failure from a clinical standpoint. The most frequent reasons for being falsely positive were nonelective hospitalization, prolonged intubation for airway protection, and insufficient evidence to support a diagnosis of acute respiratory failure. Fifty percent of true-positive cases involved substantial baseline comorbidities, and 23% resulted in death. CONCLUSIONS Although PSI 11 predicts true postoperative respiratory failure with relatively high frequency, the indicator does not limit detection to preventable cases. The PPV of PSI 11 might be increased by excluding cases with a principal diagnosis suggestive of a nonelective hospitalization and those with head or neck procedures. Removing the diagnosis code criterion from the indicator might also increase PPV, but would decrease the number of true positive cases detected by 20%.

Potassium currents in rat type II alveolar epithelial cells.

Purpose of reviewStaff satisfaction has not traditionally been included as an intensive care unit quality indicator. The process of providing intensive care may profoundly affect clinicians. Dysfunctional encounters with coworkers and ethical burdens may extract a considerable personal toll and affect work attitudes and performance. Recent findingsMounting evidence indicates that psychosocial tensions, burnout and ethical stress are common and serious problems in the intensive care unit. These experiences impact negatively on job satisfaction, turnover, workplace disruption and patient care. Addressing workplace issues will help improve quality of care. SummaryTwo common sources of staff dissatisfaction are examined. Improving staff satisfaction can improve unit performance, and serve to attract and retain quality clinicians.

Pulmonary Alveolar Proteinosis Causing Severe Hypoxemic Respiratory Failure Treated With Sequential Whole-Lung Lavage Utilizing Venovenous Extracorporeal Membrane Oxygenation: A Case Report and Review

Background:The Agency for Healthcare Research and Quality Patient Safety Indicator (PSI) 11 uses International Classification of Disease, 9th Clinical Modification diagnosis code 518.81 (“Acute respiratory failure”)—but not the closely related alternative, 518.5 (“Pulmonary insufficiency after trauma and surgery”)—to detect cases of postoperative respiratory failure. We sought to determine whether hospitals vary in the use of 518.81 versus 518.5 and whether such variation correlates with coder beliefs. Study Design:We conducted a cross-sectional analysis of administrative data from July 2009 through June 2010 for UHC (formerly University HealthSystem Consortium)-affiliated centers to assess the use of diagnosis codes 518.81 and 518.5 in PSI 11-eligible cases. We also surveyed coders at these centers to evaluate whether variation in the use of 518.81 versus 518.5 might be linked to coder beliefs. We asked survey respondents which diagnosis they would use for 2 ambiguous cases of postoperative pulmonary complications and how much they agreed with 6 statements about the coding process. Results:UHC-affiliated centers demonstrated wide variation in the use of 518.81 and 518.5, ranging from 0 to 26 cases and 0 to 56 cases/1000 PSI 11-eligible hospitalizations, respectively. Of 56 survey respondents, 64% chose 518.81 and 30% chose 518.5 for a clinical scenario involving postoperative respiratory failure, but these responses were not associated with actual coding of 518.81 or 518.5 at the center level. Sixty-two percent of respondents agreed that they are constrained by the words that physicians use. Their self-reported likelihood of querying physicians to clarify the diagnosis was significantly associated with coding of 518.5 at the center level. Conclusions:The extent to which diagnosis code 518.81 is used relative to 518.5 varies considerably across centers, based on local coding practice, the specific wording of physician documentation, and coder–physician communication. To standardize the coding of postoperative respiratory failure, the 518.81 and 518.5 codes have recently been revised to make the available options clearer and mutually exclusive, which may improve the capacity of PSI 11 to discriminate true differences in quality of care.