Ramesh Sachdeva

Resource consumption and the extent of futile care among patients in a pediatric intensive care unit setting

OBJECTIVES To estimate resource consumption and the extent of futile care among patients admitted to the pediatric intensive care unit (PICU). STUDY DESIGN A prospective cohort study of 353 consecutive admissions followed for 1334 patient-days during the PICU stay at the Texas Childrens Hospital in Houston, Texas. Participants were 353 children and adolescents who were hospitalized in the PICU during September and October 1993. Three broad operational definitions of futility were developed to capture the maximum extent of resource consumption related to medical futility. Definition 1 (imminent demise futility) was developed by an objective, validated, severity of illness measure (Pediatric Risk of Mortality Score) to identify patients with high mortality risks. Definition 2 (lethal condition futility) was used to identify patients in the PICU whose long-term survival was unlikely. Definition 3 (qualitative futility) was used to identify patients with high morbidity. Resource consumption was measured according to the number of patient-days in the PICU and the Therapeutic Intervention Scoring System. RESULTS Twenty-three (6.5%) patients representing 36 (2.7%) patient-days met at least one of the definitions of medical futility for some of the days when they were in the PICU. None of the patient-days that met any of the definitions of medical futility were associated with high resource consumption compared with non-futile care patient-days. CONCLUSIONS Despite our use of broad definitions of medical futility, relatively small amounts of resources were used in futile PICU care. This suggests that attempts to reduce resource consumption in the PICU by focusing on medical futility are unlikely to be successful.

Risk Factors Associated With Pressure Ulcers in the Pediatric Intensive Care Unit

OBJECTIVE To identify risk factors that are associated with the development of pressure ulcers in children admitted to the pediatric intensive care unit (PICU). DESIGN Case control study with no interventions held in a 30-bed PICU of Texas Childrens Hospital, Houston. SETTING AND SUBJECTS The study included 59 patients who developed pressure ulcers in the PICU and 59 patients who were critically ill who did not develop pressure ulcers during the same time period. INSTRUMENTS Risk assessment data collection tool and Braden scale. METHODS A comparison was done to identify risk factors between 2 groups of pediatric patients with and without pressure ulcers. A 45-indicator assessment tool was used. Physical assessment including staging of pressure ulcers was performed. RESULTS Risk factors associated with pressure ulcers include edema (P = .0016), length of stay > 96 hours (P = .001), increasing positive end expiratory pressure (P = .002), not turning the patient or use of a specialty bed in the turning mode (P = .0001), and weight loss (P < .0001). CONCLUSIONS The presence of edema, increasing length of stay, patients on increasing positive-end expiratory pressure, not turning the patient, use of a specialty bed in the turning mode, and weight loss are associated with the increased risk of development of pressure ulcers in patients in the PICU.

Development of a survey to measure parent satisfaction in a pediatric intensive care unit.

ObjectiveTo use classic survey methodology to develop a specific survey tool that can assess parent satisfaction with medical care in a pediatric intensive care setting. DesignApplication of survey design methodology to develop and analyze a parent satisfaction survey. SettingA pediatric intensive care unit (PICU) in a large teaching hospital. SubjectsSixty-six parents of children admitted to a PICU. ResultsA four-stage process of item selection, item reduction, pretesting, and test analysis was used to create a 23-item parent satisfaction survey that was statistically analyzed and developed specifically for the PICU setting. The survey tool was developed with the input of parents of children admitted to a PICU, and it was administered to parents in the PICU. The resultant survey was analyzed for validity and reliability. Both test-retest and internal consistency reliability were evaluated. This design yielded a survey with acceptable reliability, as demonstrated by a reliability coefficient of 0.8275. Test-retest reliability also showed good correlation of answers. Validity was partially established by including parents in the identification of survey topics. ConclusionsClassic survey design methodology was applied to develop a specific satisfaction survey in a pediatric inpatient setting. This stepwise method yielded a parent survey specific to one type of inpatient unit, and the resultant survey tool reliably measured levels of parent satisfaction with medical care in that area. This study demonstrates the feasibility of applying classic survey methodology to develop a statistically analyzed parent satisfaction survey for an inpatient setting.

Effects of availability of patient-related charges on practice patterns and cost containment in the pediatric intensive care unit

OBJECTIVE To investigate the effects of the availability of daily patient-related charges to healthcare providers on practice patterns and cost containment in the pediatric intensive care unit (ICU) setting. DESIGN Prospective, nonrandomized, controlled trial. SETTING Pediatric ICU. PATIENTS All patients admitted to the pediatric ICU during the study period. This number included a prospective control group (n=325) and an intervention group (n=273). These 598 patients spent 2,274 patient days in the pediatric ICU. INTERVENTIONS The daily itemized patient charges related to diagnostic studies ordered in the pediatric ICU were made available to healthcare providers during the intervention period of the study. MEASUREMENTS AND MAIN RESULTS Information was collected prospectively on patients in the control group before the intervention period. This information included data on demographics, daily severity of illness measures, daily resource consumption, intensity of nursing and medical interventions, and daily patient-related charges. Outcome information on survival and length of pediatric ICU stay was also collected. The same data were collected prospectively during the intervention period of the study. Measurements on quality assurance and morbidity were made to ensure that there was no compromise in patient care. There were no significant differences in patient demographics and diagnoses between the control and intervention groups. There was a reduction in the average daily laboratory (16.7%), radiology (9.1%) computerized axial tomography (8.5%), and pharmacy (25.1%) charges in the intervention group as compared with controls. The decreases in laboratory and pharmacy charges were statistically significant (p<.0001). The decreases in laboratory and pharmacy charges remained significant even after adjustment for severity of illness. CONCLUSIONS The availability of patient-related charges to healthcare providers can result in changes in practice patterns, producing a decrease of patient charges and an improvement in cost containment in the pediatric ICU.

Predicting duration of stay in a pediatric intensive care unit: A Markovian approach

Abstract Pediatric Risk of Mortality (PRISM) scores representing the intensity of illness are utilized to study the dynamics of the movement of patients in pediatric intensive care. The flow of patients is modeled as a discrete time Markov process. The course of treatment and length of stay in the intensive care is described as a sequence of ‘Low’, ‘Medium’ and ‘High’ severity of illness states rather than by a string of services and scores. The Markovian model well reproduces the shape of data and the strength of the methodology lies in its generalizability to settings where patient’s length of stay and utilization of resources is highly correlated.

Measuring the impact of new technology: an outcomes-based approach.

In the current era of decreasing resources, many healthcare organizations are under increasing pressure to evaluate new technology. Advances and innovations in healthcare technology are instrumental in reshaping the healthcare system and in impacting the practice of medicine, including critical care. Healthcare organizations are faced with the following four questions related to adopting a new technology: 1) Should the organization invest in this technology? 2) What are the associated benefits and risks of the capital investment? 3) What is the impact on patient outcomes as a result of adopting the technology? 4) What is the return on investment to the organization? These issues represent challenging areas for the researcher, clinician, manager, and policy maker. New techniques from the business and outcomes research arenas allow for the development of quantitative and qualitative models to facilitate answering these questions. By integrating business and clinical considerations, these models can impact policy at two levels: 1) by identifying optimal capital expenditure decisions for individual healthcare organizations, it can provide a significant competitive advantage for an organization; and 2) by identifying optimal health policies related to technology at a national and international health level, it can impact the healthcare systems and patient outcomes in a favorable manner.

Evaluation of a real-time blood glucose monitor in children with diabetic ketoacidosis

Use of a real-time bedside glucose monitor was analyzed during the course of management of diabetic ketoacidosis (DKA) in children. Simultaneous determinations of blood glucose were obtained, using three methods: bedside glucose meter (One Touch II), laboratory glucose analyzer (YSI 2300 STAT), and a real-time bedside glucose monitor (VIA 1-01G Blood Chemistry monitor). Study patients included seventeen patients < 18 years of age admitted to a Pediatric Intensive Care Unit, with blood samples obtained during treatment of DKA by continuous insulin infusion. Four patients did not complete the study. Three experienced temporary technical problems with the monitor, and four required repeat IV placement. Duration of monitor use ranged between 6 and 47 h (mean 24 +/- 4 h). Blood glucose values ranged between 2.6 and 22.5 mmol/l. Overall correlation of blood glucose values were as follows: 0.965, 0.965, 0.973, VIA 1-01G vs. One Touch II, VIA 1-01G vs. YSI 2300 STAT, and One Touch II vs. YSI 2300 STAT, respectively (all P-values < 0.0001). This real-time bedside glucose monitor is accurate at glucose values < 13.8 mmol/l, and reliable for rapid, repetitive analyses. Results indicate that blood glucose values obtained using this real-time monitor are comparable to those using standard methods of measurement, and that this device is clinically applicable for use in management of children with DKA.

Cost of nosocomial infections in the pediatric intensive care unit

Nosocomial infections are associated with increases in both duration of hospital stay and associated costs. These increases cause a significant problem in the pediatric intensive care unit, where the acuity of patients and cost of delivery of care are much higher than those of other areas in the hospital. Only a few studies provide detailed information of costs attributable to nosocomial infection in the pediatric intensive care unit. The purpose of this article is twofold: to provide a summary of some of the studies that have estimated costs associated with nosocomial infections and to provide an overview of the methodological issues that surround measuring charges and costs in any cost analysis, with particular reference to nosocomial infections in the pediatric intensive care unit.

Perioperative management of the pediatric transplant patient

With advances in surgical techniques, an increasing number of children are becoming transplant candidates. Pediatric critical care physicians may need to manage both transplant donors and recipients in the pediatric intensive care unit. Care of such patients needs to be performed aggressively with complete attention to details in order to obtain successful transplant outcomes. The postoperative management of the transplant recipient includes the basic intensive care monitoring and management of postoperative patients who are critically ill. Besides this, there are some unique features among these patients which may complicate the postoperative stay in the pediatric intensive care unit and these are discussed here. It is important to remember that the successful management of a transplant patient includes the pediatric critical care physician’s abilities of not only taking care of acute issues but also of coordinating care between subspecialists. The pediatric critical care physician must always continue to provide support to families of these transplant patients during their intensive care unit stay.