Accuracy of the discharge destination field in administrative data for identifying transfer to a long-term acute care hospital

<p>Abstract</p> <p>Background</p> <p>Long-term acute care hospitals (LTACs) provide specialized care for patients recovering from severe acute illness. In order to facilitate research into LTAC utilization and outcomes, we studied whether or not the discharge destination field in administrative data accurately identifies patients transferred to an LTAC following acute care hospitalization.</p> <p>Findings</p> <p>We used the 2006 hospitalization claims for United States Medicare beneficiaries to examine the performance characteristics of the discharge destination field in the administrative record, compared to the reference standard of directly observing LTAC transfers in the claims. We found that the discharge destination field was highly specific (99.7%, 95 percent CI: 99.7% - 99.8%) but modestly sensitive (77.3%, 95 percent CI: 77.0% - 77.6%), with corresponding low positive predictive value (72.6%, 95 percent CI: 72.3% - 72.9%) and high negative predictive value (99.8%, 95 percent CI: 99.8% - 99.8%). Sensitivity and specificity were similar when limiting the analysis to only intensive care unit patients and mechanically ventilated patients, two groups with higher rates of LTAC utilization. Performance characteristics were slightly better when limiting the analysis to Pennsylvania, a state with relatively high LTAC penetration.</p> <p>Conclusions</p> <p>The discharge destination field in administrative data can result in misclassification when used to identify patients transferred to long-term acute care hospitals. Directly observing transfers in the claims is the preferable method, although this approach is only feasible in identified data.</p

The risks and rewards of expanding ICU capacity

ICU capacity strain is associated with increased morbidity and lost hospital revenue, leading many hospitals to increase the number of ICU beds. However, this approach can lead to inefficiency and waste. A recent report in Critical Care highlights a different approach: creating new service lines for low-risk patients. In this case, the authors started a post-anesthesia care unit with an intensivist-led care team, resulting in lower hospital costs with no changes in ICU mortality. Although this type of change carries some risks, and will not work for every hospital, it is an example of the creative solutions hospitals must sometimes undertake to maintain the supply of critical care in response to a rising demand. © 2012 BioMed Central Ltd

Volume, outcome, and the organization of intensive care

Increasing evidence suggests that high case volume is associated with improved outcomes in the intensive care unit (ICU). Potential explanations for the volume–outcome relationship include selective referral, clinical experience and organizational factors common to high-volume ICUs. Distinguishing between these explanations has important health policy implications, because outcomes at low-volume ICUs could be improved either by exporting best practices found at high-volume centers or by regionalizing adult critical care – two very different care strategies. Future research efforts should be directed at better characterizing the process of care in high-volume ICUs and exploring the feasibility of creating a regionalized system of care

Under- and overnutrition and evidence of metabolic disease risk in rural black South African children and adolescents

Objectives: The objective was to determine the prevalence of under- and overnutrition, as well as evidence of metabolic disease risk in rural black South African children and adolescents.Design: A cross-sectional study was conducted.Setting: The setting was the Agincourt Health and Socio-demographic Surveillance System site, Mpumalanga province.Subjects: Six hundred children were randomly selected, of whom 588 were included in the analytical sample (mean age of 11.5 years, range of 7-15 years).Outcome measures: Outcome measures were anthropometric and blood pressure assessments, Tanner pubertal staging, as well as the determination of fasting serum lipid and glucose concentrations.Results: Using age and sex-specific World Health Organization 2007  growth references, the prevalence of stunting was determined to be 6.2% in the boys, and 2.7% in the girls, while 4.1% of the boys and 4.4% of the girls were underweight. Combined overweight and obesity prevalence was higher in the girls (13.5%) than in the boys (2.7%). Girls had significantly a higher body mass index and hip circumference than the boys in the early, mid and late pubertal stages. Pre-hypertension prevalence, using either systolic or diastolic blood pressure for sex, age and height, was 15% and 10% in the girls and boys, respectively. Furthermore, impaired fasting glucose (FG) (FG . 5.6 mmol/l) was detected in 5% of the children.  High-density lipoprotein cholesterol concentrations less than 1 mmol/l were observed in 0.7% of the boys and in 12% of the girls, which is indicative of cardiometabolic risk.Conclusion: Stunting levels were higher in the boys than in the girls in mid to late childhood in a rural setting in South Africa, while the girls had a higher prevalence of overweight and obesity than the boys.  Pre-hypertension prevalence in the boys and girls was high. Other  metabolic risk factors, i.e. impaired FG and lipids, were also seen in this population and were associated with adiposity. The study highlights the critical need for targeted health promotion interventions to optimise child health as part of a noncommunicable disease preventative strategy

New obstacles to improving the quality of end-of-life care in ICU

Background\ud Because of high mortality, end-of-life care is an important component of intensive care.\ud \ud Methods\ud Objective\ud To evaluate the effectiveness of a quality-improvement intervention to improve intensive care unit (ICU) end-of-life care.\ud \ud Design\ud Cluster-randomized trial of a multi-component educational intervention targeted at bedside ICU caregivers from 2004 to 2008.\ud \ud Setting\ud 12 community hospitals in Washington State, United States.\ud \ud Subjects\ud 2,318 patients dying in the ICU or within 30 hours of ICU discharge, as well as their families and the nurses participating in their care.\ud \ud Intervention\ud The intervention targeted clinicians with five components: clinician education, local champions, academic detailing, clinician feedback of quality data, and system supports.\ud \ud Outcomes\ud Quality of death and dying (QODD) and satisfaction surveys.\ud \ud Results\ud The primary outcome, family-QODD, showed no change with the intervention (P = 0.33). There was also no change in family satisfaction (P = 0.66) or nurse-QODD (P = 0.81). There was a non-significant increase in ICU days before death after the intervention (hazard ratio = 0.9; P = 0.07). Among patients undergoing withdrawal of mechanical ventilation, there was no change in time from admission to withdrawal (hazard ratio = 1.0; P = 0.81).\ud \ud Conclusions\ud A multifaceted quality improvement intervention was associated with no improvement in quality of dying among ICU decedents, as well as no reduction in resource utilization prior to the withdrawal of life sustaining measures

Beyond checklists: Using clinician prompts to achieve meaningful ICU quality improvement

Background\ud Checklists may reduce errors of omission for critically ill patients.\ud \ud Methods\ud Objective\ud To determine whether prompting to use a checklist improves process of care and clinical outcomes.\ud \ud Design\ud Prospective, concurrently-controlled cohort study with additional historical controls.\ud \ud Setting\ud Medical intensive Care Unit (MICU) of a tertiary care university hospital.\ud \ud Subjects\ud All patients admitted to either of two independent MICU teams.\ud \ud Intervention\ud Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. Pre-intervention patients received neither a checklist nor prompting.\ud \ud Outcomes\ud Primary outcome included differences between the prompted and control groups related to several key quality indicators being investigated- ventilator-free days, duration of empirical antibiotics, duration of central venous catheters, duration of foley urinary catheter, pharmacological deep vein thrombosis (DVT) prophylaxis per eligible days and, stress ulcer prophylaxis per eligible days. Secondary outcome included ICU mortality, hospital mortality, ICU length of stay and ventilator associated pneumonia.\ud \ud Results\ud One hundred and forty prompted group patients were compared with 125 concurrent control patients and 1283 pre-intervention patients. Compared with control patients, patients admitted to the service with prompting experienced increased ventilator-free days, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (adjusted odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 0.02). Checklist availability alone was not associated with reductions in mortality or length of staycompared with the pre-intervention patients.\ud \ud Conclusions\ud In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of substantial importance in the care of critically ill patients

Making the GRADE: How useful are the new Surviving Sepsis Campaign guidelines?

Background\ud Updated guidelines are needed to guide physicians to care for patients with severe sepsis on the basis of recent advances. Whether recommendations in the guidelines published previously were based on high-quality evidence or reflected preferences of care of a set of experts was unclear.\ud \ud Methods\ud Objective: The objective was to provide an update to the 'Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock’, last published in 2008. Design, setting, and subjects: A consensus committee of 68 international experts representing 30 international organizations was convened. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Intervention and outcomes: None\ud \ud Results\ud Key recommendations and suggestions in the guidelines included early quantitative resuscitation of patients with sepsis (1C); early initiation of antibiotics (1C); use of crystalloids in resuscitation (1B); use of norepinephrine as the first-choice vasopressor (1B); avoidance of intravenous steroids if hemodynamic stability can be achieved (2C); use of low tidal volumes, limited plateau pressures, and a conservative fluid strategy in acute respiratory distress syndrome (1A, 1B, and 1B); and minimizing continuous intravenous sedation (1B).\ud \ud Conclusions\ud Although a number of recommendations were based on low-quality evidence, strong agreement existed among international experts regarding many level 1 recommendations as the best care for patients with sepsis. These recommendations are the foundation of improved outcomes for these patients. Using GRADE for severe sepsis guidelines will help physicians to care for these patients and provide more transparency regarding areas where additional evidence and individualized patient care are needed

Does space make waste? The influence of ICU bed capacity on admission decisions

Background: Intensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few empiric data on whether the availability of ICU beds influences triage and processes of care for hospitalized patients who develop sudden clinical deterioration.Methods: Results: The cohort consisted of 3,494 patients. Reduced ICU bed availability was associated with a decreased likelihood of ICU admission within 2 hours of MET activation (P = 0.03) and with an increased likelihood of change in patient goals of care (P <0.01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% confidence interval (CI), -5.1% to57.3%) less likely to be admitted to the ICU and were 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than two ICU beds were available. However, hospital mortality did not vary significantly by ICU bed availability (P = 0.82).Conclusions: For hospitalized patients with sudden clinical deterioration, ICU bed scarcity decreases the probability of ICU admission and increases the probability of initiating comfort measures on the ward but does not influence hospital mortality. © 2013 BioMed Central Ltd

First do no harm: Surrogate endpoints and the lesson of β-agonists in acute lung injury

EXPANDED ABSTRACT: CITATION: Matthay MA, Brower RG, Carson S, Douglas IS, Eisner M, Hite D, Holets S, Kallet RH, Liu KD, MacIntyre N, Moss M, Schoenfeld D, Steingrub J, Thompson BT: Randomized, placebo-controlled clinical trial of an aerosolized β-agonist for treatment of acute lung injury. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Am J Respir Crit Care Med 2011, 184:561-568. BACKGROUND: β(2)-Adrenergic receptor agonists accelerate resolution of pulmonary edema in experimental and clinical studies of acute lung injury (ALI). METHODS: Objective: To determine whether an aerosolized β(2)-agonist would improve clinical outcomes in patients with ALI. Design: Multi-center, phase III randomized, placebo-controlled clinical trial. Setting: 33 hospitals participating National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Subjects: Patients who were intubated and receiving mechanical ventilation, had bilateral infiltrates consistent with edema on frontal chest radiograph, had a ratio of PaO(2 )to FIO(2 )(fraction of inspired oxygen) of 300 or less, and not had clinical evidence of left atrial hypertension. A maximum enrolment of 1,000 patients was planned. Intervention: Patients were randomized to receive aerosolized albuterol (5 mg) or saline placebo every 4 hours for up to 10 days. Outcomes: The primary outcome variable was ventilator-free days (VFD). Secondary outcome measures included mortality before hospital discharge on day 60 and day 90, the number of intensive care unit (ICU)-free days and the number of organ failure-free days. RESULTS: There were 282 patients enrolled before the trial was stopped for futility after the second interim analysis. The VFDs difference with albuterol treatment was unfavourable by -2.2 days, well past the futility boundary of -0.4 VFDs. VFDs were not significantly different between the albuterol and placebo groups (means of 14.4 and 16.6 days, respectively; 95% confidence interval for the difference, -4.7 to 0.3 days; P = 0.087). Rates of death before hospital discharge and the number of organ failure-free days were also not significantly different between the two groups. The number of ICU-free days was lower in the albuterol group in comparison with the placebo group (means of 13.5 and 16.2 days respectively; 95% confidence intervals for the mean difference, -4.9 to -0.4 days; P = 0.023). Overall, heart rates were significantly higher in the albuterol group by approximately 5 beats/minute in the first 2 days after randomization (P < 0.05), but rates of new onset atrial fibrillation (10% in both groups) and other cardiac dysrhythmias were not significantly different. CONCLUSIONS: These results suggest that aerosolized albuterol does not improve clinical outcomes in ALI patients. Routine use of β(2 )agonist therapy in mechanically ventilated ALI patients cannot be recommended