Cost of intensive care in a Norwegian University hospital 1997–1999

AIM: The present study was performed in order to document costs of intensive care in a Norwegian university hospital and to perform an average cost-effectiveness study using the expected remaining life-years in survivors after 18 months. MATERIALS AND METHODS: Patients admitted to the general intensive care unit (ICU) at Haukeland University Hospital from 1997 to 1999 were followed up to 18 months post ICU using data from the Norwegian Peoples' registry. Our ICU patients have a further mortality equal to the average population in Norway from that time. By creating an age-matched and sex-matched sample of the general Norwegian population equal to survivors 18 months after ICU treatment, we could find the expected further survival time for each ICU survivor. Direct and indirect ICU expenses in the study period were retrieved using a 'top-down' method. Outcome assessment was performed using the total ICU expenses in the period divided by the sum of the life expectancy (years) in survivors after 18 months. RESULTS: The total ICU costs (converted to 2001 values) were € 16,697,415, excluding the costs of radiology and the use of operating theatres, which were both impossible to retrieve. A total of 1051 patients were treated, of whom 60.9% survived up to 18 months. Further total life expectancies were 24,428 years. The average costs of an ICU day and stay per patient were € 2601 and € 14,223, respectively, and the average cost per year of survival per patient was € 684. DISCUSSION: The absolute costs were found to be higher than recent European ICU studies reporting on the cost of ICU treatment. However, the price of a further life-year in survivors was lower and was comparable with other medical treatment

Epidemiology of sepsis in Norway in 1999

INTRODUCTION: Sepsis and severe sepsis are asociated with high hospital mortality. Little is known about the occurrence of sepsis in general hospital populations. The goal of the present study was to reveal the epidemiology of sepsis in Norwegian hospitals over 1 year. METHODS: Patients admitted to all Norwegian hospitals during 1999 (n = 700,107) were analyzed by searching the database of the Norwegian Patient Registry for markers of sepsis, using International Classification of Diseases (ICD)-10 codes for sepsis and severe infections. In patients with such diagnoses, demographic data, hospital outcome data and ICD-10 codes for organ dysfunction were also retrieved. Sepsis was further classified as primary or secondary, and severe (sepsis with vital organ dysfunction) or nonsevere. The age-adjusted mortality rate, and the sepsis rates for all hospital admissions and in the Norwegian population were calculated. RESULTS: A total of 6665 patients were classified as having sepsis, and of these 2121 (31.8%) had severe sepsis. The most frequent failing organ system was the circulatory system, and 1562 had septic shock. Mortality increased from 7.1% (in those with no documented organ dysfunction) to 71.8% (in those with three or more organ dysfunctions). The mean mortality was 13.5%, and the mortality of severe sepsis was 27%. The incidence of sepsis was 9.5/1000 hospital admissions and 1.49/1000 inhabitants in 1999. CONCLUSION: Sepsis is not uncommon in Norwegian hospitals and is associated with high hospital mortality, which is similar to recent findings from the USA. Awareness of sepsis and its appropriate treatment is mandatory in Norway if we are to reduce mortality from sepsis by 25% in the next 5 years

Changes in health-related quality of life from 6 months to 2 years after discharge from intensive care

BACKGROUND: Intensive care patients have, both before and after the ICU stay, a health-related quality of life (HRQOL) that differs from that of the normal population. Studies have described changes in HRQOL in the period from before the ICU stay and up to 12 months after. The aim of this study was to investigate possible longitudinal changes in HRQOL in adult patients (>18 years) from 6 months to 2 years after discharge from a general, mixed intensive care unit (ICU) in a university hospital. METHODS: This is a prospective cohort study. Follow-up patients were found using the ICU database and the Peoples Registry. HRQOL was measured with the Short Form 36 (SF-36) questionnaire. Answers at 6 months and 2 years were compared for all patients, surgical and medical patients, and different admission cohorts. Differences are presented with 95% confidence intervals. The SF-36 data were scored according to designed equations. SPSS 11.0 was used to perform t-tests and Mann-Whitney tests. RESULTS: A total of 100 patients (26 medical and 74 surgical) answered the SF-36 after 6 months and again after 2 years. There was overall moderate improvement in 6 out of 8 dimensions of the SF-36, and the average increase in score was + 4.0 for all 8 dimensions. The changes for surgical and medical patients were similar. Neurological and respiratory patients reported increased average HRQOL scores, while cardiovascular patients did not. Patients with worsening of scores from 6 months to 2 years were insignificantly older than patients with improved scores (55.3 vs. 49.7 years), and both groups had comparable severity scores (simplified acute physiology score, SAPS II, 37.2 vs. 36.3) and length of ICU stay (2.7 vs. 3.2 days). The statistically significant changes in HRQOL (in the Role Physical and Social Functioning dimensions) were, due to sample size, barely clinically relevant. CONCLUSION: In a mixed ICU population we found moderate increases in HRQOL both for medical and surgical patients from 6 months to 2 years after ICU discharge, but the sample size is a limitation in this study

Errors in medicine: punishment versus learning medical adverse events revisited - expanding the frame

Purpose of review : Despite healthcare workers’ best intentions, some patients will suffer harm and even death during their journey through the healthcare system. This represents a major challenge, and many solutions have been proposed during the last decades. How to reduce risk and use adverse events for improvement? Recent findings: The concept of safety culture must be acknowledged and understood for moving from blame to learning. Procedural protocols and reports are only parts of the solution, and this overview paints a broader picture, referring to recent research on the nature of adverse events. The potential harm from advice based on faulty evidence represents a serious risk. Summary: Focus must shift from an individual perspective to the system, promoting learning rather than punishment and disciplinary sanctions, and the recent opioid epidemic is an example of bad guidelines.publishedVersio

Elderly Patients in the Intensive Care Unit

Very old intensive care unit (ICU) patients, aged ≥ 80 years, are by no mean newcomers, but during the last decades their impact on ICU admissions has grown in parallel with the increase in the number of elderly persons in the community. Hence, from being a “rarity,” they have now become common and constitute one of the largest subgroups within intensive care, and may easily be the largest group in 20 years and make up 30 to 40% of all ICU admissions. Obviously, they are not admitted because they are old but because they are with various diseases and problems like any other ICU patient. However, their age and the presence of common geriatric syndromes such as frailty, cognitive decline, reduced activity of daily life, and several comorbid conditions makes this group particularly challenging, with a high mortality rate. In this review, we will highlight aspects of current and future epidemiology and current knowledge on outcomes, and describe the effects of the aforementioned geriatric syndromes. The major challenge for the coming decades will be the question of whom to treat and the quest for better triage criteria not based on age alone. Challenges with the level of care during the ICU stay will also be discussed. A stronger relationship with geriatricians should be promoted to create a better and more holistic care and aftercare for survivors.acceptedVersio

Long-term survival and quality of life after intensive care for patients 80 years of age or older

Background: Comparison of survival and quality of life in a mixed ICU population of patients 80 years of age or older with a matched segment of the general population. Methods: We retrospectively analyzed survival of ICU patients ≥80 years admitted to the Haukeland University Hospital in 2000–2012. We prospectively used the EuroQol-5D to compare the health-related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1–13.8 years. Results: The included 395 patients (mean age 83.8 years, 61.0 % males) showed an overall survival of 75.9 (ICU), 59.5 (hospital), and 42.0 % 1 year after the ICU. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL at follow-up between survivors (n = 58) and control subjects (n = 179) or between admission categories. Of the ICU non-survivors, 63.2 % died within 2 days after ICU admission (n = 60), and 68.3 % of these had life-sustaining treatment (LST) limitations. LST limitations were applied for 71.3 % (n = 114) of the hospital non-survivors (ICU 70.5 % (n = 67); post-ICU 72.3 % (n = 47)). Conclusions: Overall 1-year survival was 42.0 %. Survival rates beyond that were comparable to those of the general octogenarian population. Among survivors at follow-up, HRQOL was comparable to that of the age- and sex-matched general population. Patients admitted for planned surgery had better short- and long-term survival rates than those admitted for medical reasons or unplanned surgery for 3 years after ICU admittance. The majority of the ICU non-survivors died within 2 days, and most of these had LST limitation decisions

Cognitive function and health-related quality of life four years after cardiac arrest

Aim: Neuropsychological testing has uncovered cognitive impairment in cardiac arrest survivors with good neurologic outcome according to the cerebral performance categories. We investigated cognitive function and health-related quality of life four years after cardiac arrest. Methods: Thirty cardiac arrest survivors over the age of 18 in cerebral performance category 1 or 2 on hospital discharge completed the EQ-5D-5L and HADS questionnaires prior to cognitive testing using the Cambridge Neuropsychological Test Automated Battery. The results were compared with population norms. Results: Twenty-nine per cent of patients were cognitively impaired. The pattern of cognitive impairment reflects dysfunction in the medial temporal lobe, with impaired short-time memory and executive function slightly but distinctly affected. There was a significant reduction in quality of life on the EQ-VAS, but not on the EQ index. Conclusion: Cognitive impairment four years after cardiac arrest affected more than one quarter of the patients. Short-term memory was predominantly affected

Intensive care diaries reduce new onset post traumatic stress disorder following critical illness: a randomised, controlled trial

INTRODUCTION: Patients recovering from critical illness have been shown to be at risk of developing Post Traumatic Stress disorder (PTSD). This study was to evaluate whether a prospectively collected diary of a patient's intensive care unit (ICU) stay when used during convalescence following critical illness will reduce the development of new onset PTSD. METHODS: Intensive care patients with an ICU stay of more than 72 hours were recruited to a randomised controlled trial examining the effect of a diary outlining the details of the patients ICU stay on the development of acute PTSD. The intervention patients received their ICU diary at 1 month following critical care discharge and the final assessment of the development of acute PTSD was made at 3 months. RESULTS: 352 patients were randomised to the study at 1 month. The incidence of new cases of PTSD was reduced in the intervention group compared to the control patients (5% versus 13%, P = 0.02). CONCLUSIONS: The provision of an ICU diary is effective in aiding psychological recovery and reducing the incidence of new PTSD.RACHEL GROUP in addition to the authors: Denmark, Christensen D, Bogø I, Hansen R, Kjerrumgård H, Mathiasen L, Hyldested C, Toft C, Nordsjaelland Hospital; Bagger C, Larsen MB, Frank de Jong L, Odense University Hospital; Ågård AS, Knudsen K, Hinzel T, Århus University Hospital, Skejby; Italy, Scaramuzza A &amp; Bertacchini S, Ferrara; Norway, Schou Landmark J, Salomonsen A, Tøien K, Walther S, Oslo University Hospital Ulleval; Muri AK, Haukeland University Hospital; Portugal, Neutel E, Gomes E, Cardoso T, Ferreira R, Machado C, Santos C, Pinto S, Hospital Santo António - Centro Hospitalar do Porto, Amaro A, Morujão E, Jerónimo A, Rodrigues T, Carvalho F, Silva A, Morais A Hospital Pedro Hispano; Sweden, Löwenmark U, Etemad W, Rosell E, Sahgrenska University Hospital; Carlson U, Wirbrand Holmquist A, Kungälv Hospital; Åkerman E, Ersson A, Malmö University Hospital; UK, Tobin C, Whiston.</p