Articles: critical-care.
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Critical care medicine · Jul 1989
Cost and survival results of critical care regionalization for Medicare patients.
A ground-based mobile ICU, two medical evacuation helicopters, and a specially equipped fixed wing aircraft were utilized by a critical care transport team, staffed by a critical care physician, ICU nurse, critical care technologist, and respiratory therapist to facilitate regionalization of critical care services from small community hospitals to a central tertiary care facility. Survival, length of stay, age, actual hospital cost, and reimbursement were evaluated retrospectively for 81 Medicare patients transported by the team to a tertiary care facility during a 33-month period. ⋯ Average hospital cost per patient was $36,059.00, average Medicare reimbursement was $13,802.00, and average hospital loss was $22,256.00. We show that regionalization to tertiary care facilities can facilitate access to critical care technology, but the Medicare reimbursement system of diagnosis-related groups makes this concept financially prohibitive for the tertiary care hospital.
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The decision for timing of tracheostomy remains controversial. The relative complication rates in two retrospective series, in which 79 and 150 critically ill patients were examined, respectively, showed increased incidence of late complications with tracheostomy and led Petty's group to conclude "The value of tracheotomy when an artificial airway is required for periods as long as 3 weeks is not supported by data obtained in this study."
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Thirteen critically ill patients received flumazenil after multiple doses, or an infusion, of midazolam was used as part of a sedation regimen to facilitate intensive care. All patients remained excessively sedated after the midazolam was stopped for 6 hours or longer. ⋯ The dose of flumazenil required each hour was less than estimated previously; this indicates that it may be subjected to similar alterations of elimination as those described for midazolam. Flumazenil appears to be a useful drug for the reversal of prolonged benzodiazepine sedation but repeated bolus doses or an infusion are needed if significant accumulation of benzodiazepines has occurred.
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A method of quality assurance for a surgical intensive care unit is described. A system outcome score is devised, incorporating only easily obtained objective components that reflect the likelihood of death. Through the use of a derived outcome index, the actual mortality rate is compared with the predicted mortality rate as a method of monitoring the quality of care provided. Subroutines exist to identify errors in data entry, to detect malicious interference in patient care, to add nonscoring components for the purposes of clinical studies, and to facilitate retrieval of a concise summary of the major events during the stay of every patient admitted to the intensive care unit.