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Biomedical subjects

D Teres

Publications and source records attributed to D Teres.

At least 19 recordsLinked to original sources
PubMed1992

Resource utilization among intensive care patients. Managed care vs traditional insurance.

BACKGROUND: There is considerable evidence that members of managed care organizations use fewer hospital resources than patients covered by traditional health insurance. While intensive care might seem to be an unlikely setting for such differences to exist, the relationship between health coverage and use of intensive care has not been examined. METHODS: We conducted a cross-sectional analysis of consecutive intensive care unit admissions at a regional tertiary care teaching hospital. Patients in managed care plans (n = 159) and with traditional insurance (n = 389) were compared with respect to length of stay, hospital charges, charges for specific services, and use of mechanical ventilation. The analysis controlled for severity of illness, as measured by the Mortality Probability Model, case mix, and mortality. The whole sample as well as subsamples representing medical, emergency surgery, and elective surgery patients were examined. RESULTS: The managed care group, on average, had short stays (both hospital and intensive care unit), lower charges, and less use of mechanical ventilation than the traditionally insured group. Average differences of about 30% to 40% were observed. The finding held for the whole sample as well as the medical and emergency surgery subsamples. The differences were more pronounced in the patients with lowest severity of illness. CONCLUSION: Even in a setting where there would appear to be relatively little room for discretion in treatment decisions, incentives associated with type of health insurance seemed to affect resource use.

Cost Control↗
PubMed1991

Therapeutic impact of pulmonary artery catheterization in a medical/surgical ICU.

The objective of this study was to determine the following: (1) if standard clinical evaluation is sufficient to provide an accurate estimate of hemodynamic status of unstable ICU patients; (2) the impact of pulmonary artery catheterization (PAC) on diagnosis and treatment plan; and (3) whether therapy provided after PAC was appropriate as judged by an expert panel of senior ICU physicians. A descriptive analysis of utilization of pulmonary artery catheters in a medical/surgical ICU population was performed in a university-affiliated hospital (24-bed medical/surgical ICU). The subjects included 154 medical/surgical patients judged by ICU residents and attendings to require PAC. All 154 patients underwent PAC with four patients having more than one catheterization. Prior to insertion of the catheter, a questionnaire was completed by medical/surgical residents and attendings indicating reasons for PAC insertion and estimate of hemodynamics. Following PAC, residents/attendings indicated their evaluation of hemodynamics and planned therapy. An expert panel rated performance of the house staff regarding treatment plan on a scale of 1 to 5 (5 indicating optimal therapy). The overall proportion correct classification for pulmonary artery wedge pressure (PAWP), CO, and systemic vascular resistance (SVR) were 47 percent, 51 percent, and 36 percent, respectively. In 45 percent of PAC, information obtained resulted in a major change in therapy. Major change in therapy occurred more often when prediction of PAWP by residents proved inaccurate. The expert panel judged appropriate scores of 3, 4 and 5 in 84 percent of the cases. Prediction of hemodynamics in ICU patients by clinical evaluation alone is inaccurate and unreliable. There is a positive correlation between inaccurate prediction of hemodynamics and major therapeutic changes after PAC. Most resident/attending performance was judged appropriate. Results of this study suggest that PAC was instrumental to the management scheme in many patients unresponsive to initial therapy. However, a subset of ICU patients were judged to have been managed favorably, yet had treatment based on inaccurate hemodynamic assessment.

Cardiac Output↗
PubMed1990

Clinical assessment of hemodynamic values in two surgical intensive care units. Effects on therapy.

A prospective study of 126 surgical patients from two institutions was undertaken to assess the impact of pulmonary artery catheterization in surgical intensive care units. Before catheterization, surgical residents were asked to predict pulmonary artery wedge pressure, cardiac output, systemic vascular resistance, and plan of therapy. After catheterization, each chart was reviewed by a panel of intensive care specialists and a general surgeon. Correct classification for the hemodynamic variables ranged from 47% to 55%. Catheterization results prompted a major change in therapy in 50% of patients. The data suggest that hemodynamic variables obtained from pulmonary artery catheterization improve the accuracy of bedside evaluation and lead to alteration in therapy, particularly in patients whose pulmonary artery wedge pressure predictions were poor.

Adolescent↗
PubMed1990

Timing of intensive care unit admission in relation to ICU outcome.

This study assessed the relationship between admission time (from hospital admission to ICU admission) and mortality predicted by the Mortality Prediction Model (MPM), actual mortality, and resource use. All admissions, except elective surgery patients, to the general medical/surgical ICU of a tertiary care hospital during a 24-month period were studied (n = 1,889). Patients admitted to the ICU within 1 day of hospital admission had lower predicted and actual mortality, and used fewer resources than patients admitted later. Predicted mortality was higher than actual mortality for patients admitted to the ICU early and was lower than actual mortality for later ICU admissions. Transfers had higher predicted and actual mortality, and used more resources than nontransfer patients. Time from hospital admission to ICU admission can be a potentially useful variable in models of ICU outcome.

Adult↗
PubMed1990

Explaining variability of cost using a severity-of-illness measure for ICU patients.

Factors related to hospital resource use by intensive care unit (ICU) patients, including severity of illness at admission and intensity of therapy during the first 24 ICU hours were explored in this study. Analysis was based on 2,749 patients admitted to the general medical-surgical ICU at Baystate Medical Center, Springfield, Massachusetts, between February 1, 1983 and January 10, 1985. Resource use was indexed by hospital length of stay (LOS) adjusted for differences between ICU and other hospital days. Severity of illness was measured by the Mortality Prediction Model (MPM0), a validated predictor of outcome but not previously used to analyze resource consumption. Intensity of therapy was measured using the Therapeutic Intervention Scoring System (TISS). The 10% of patients with longest ICU stays were significantly different from the other 90% with respect to previous ICU use, MPM probability, and TISS score. Variability in resource use was analyzed using four diagnosis-related groups (DRGs) accounting for large numbers of ICU patients. The relationship between severity of illness and resource was nonlinear: as severity increased from low levels, resource use increased at a decreasing rate, reached a plateau, and eventually declined. Within each DRG, MPM0 explained a statistically significant percentage of the variability in resource use.

Costs and Cost Analysis↗
PubMed1990

Nursing perception of the availability of the intensive care unit medical director for triage and conflict resolution.

The Joint Commission on the Accreditation of Healthcare Organizations and the Society of Critical Care Medicine call on the physician medical director of the intensive care unit (ICU) to play an important role in admission and discharge decision-making. To assess nursing perception of the medical director's involvement in this decision-making, we analyzed data from a questionnaire administered at an annual ICU management conference to ICU nursing supervisors representing 101 hospitals and 137 ICUs. We asked nurses if the medical director or his or her designee (excluding residents) was available at night for triage, admission decision-making, and conflict resolution. In 21% (29) of the ICUs, nurses perceived no medical director at all. In the 54 ICUs with full-time medical directors, nurses in approximately 30% of the units said that there was no nighttime availability of the medical director or designee. The data suggest that many ICUs lack physician leadership in ICU management and resource allocation.

Conflict, Psychological↗
PubMed1989

Intensive care unit patient follow-up. Mortality, functional status, and return to work at six months.

Six months after hospital discharge, we followed up 1545 patients who had received care in the general medical-surgical intensive care unit (ICU) of a tertiary care hospital. Vital status could not be ascertained for 200 of these patients. Of the 1345 former ICU patients for whom a determination of vital status could be made, 1261 (94%) were alive and 84 (6%) had died. Of those known to be living, 887 (70%) responded to a questionnaire regarding employment, functional, and social status. A large proportion of survivors less than 40 years of age had returned to work. Younger patients admitted to the hospital for elective surgery reported as much compromise of physical and psychological activity as did older patients admitted for emergency reasons. Older survivors reported an increase of interaction with family members and a decrease of social interaction with those other than family.

Adult↗
PubMed1989

Outbreak of nosocomial Flavobacterium meningosepticum respiratory infections associated with use of aerosolized polymyxin B.

Flavobacterium meningosepticum is an uncommon cause of adult nosocomial infection. On a medical/surgical intensive care unit we recently encountered an adult outbreak of respiratory colonization and infection caused by this organism, which was associated with the prophylactic use of aerosolized polymyxin B that had been used in an attempt to abort an outbreak of infection caused by highly resistant strains of Pseudomonas aeruginosa. Twenty isolates (95% from respiratory secretions) of F. meningosepticum from nine persons were identified during a 2 1/2-month period. No environmental source has been identified to date. Pneumonia developed in five patients, and two deaths associated with this organism occurred. All isolates were sensitive to ciprofloxacin; none were sensitive to other antibiotics tested, including third-generation cephalosporins, aminoglycosides, erythromycin, trimethoprim-sulfamethoxazole, antipseudomonal penicillins, aztreonam, and imipenem/cilastatin. Two patients with nosocomial pneumonia were successfully treated with oral ciprofloxacin. F. meningosepticum may emerge as an important pathogen if prophylactic use of polymyxin B becomes more widespread. Ciprofloxacin may become the agent of choice for treatment of this organism.

Administration, Inhalation↗
PubMed1988

Refining intensive care unit outcome prediction by using changing probabilities of mortality.

Estimating prognosis is potentially useful as a measure of ICU performance and as a guide for the clinical care of individual patients. In this study, mortality prediction models (MPMs) for patients in an adult general medical-surgical ICU were derived from data gathered at ICU admission and after 24 and 48 h of ICU care. A predictive model was developed which incorporated a sequence of probabilities collected over time in the ICU. The results of this study suggest that using serial observations may enhance substantially the usefulness of the MPM as a vehicle for helping families anticipate the patients' likely outcome.

Humans↗
PubMed1988

Amniotic fluid embolism associated with castor oil ingestion.

We report a case of an amniotic fluid embolism (AFE) causing a cardiorespiratory arrest associated temporally with ingestion of castor oil in a full-term normal pregnancy. Risk factors usually associated with AFE were not found in this patient.

Adult↗
PubMed1988

Prospective study of clinical bleeding in intensive care unit patients.

We investigated prospectively clinical bleeding in 1,328 consecutive patients admitted to a medical/surgical ICU over 1 yr. One hundred thirty-eight (10.4%) patients bled after ICU admission, and an additional 388 (29.2%) bled coincident with admission. The upper GI tract was the site of bleeding in 34.8% of patients whose bleeds commenced in the ICU, and accounted for 22% of total sites. Patients with clinical bleeding after ICU admission had a significantly (p less than .001) higher likelihood of death than those who did not bleed, and those with multiple bleeding sites had a higher mortality (54.9%) than those with single sites (31%) (p less than .006). Multiple logistic regression analyses revealed that risk ratios (RR) for bleeding after ICU admission were mechanical ventilation (RR = 1.82), nutritional failure (RR = 3.45), acute renal failure (RR = 3.36), antiulcer medication (RR = 3.36), and anticoagulants (RR = 4.19). No antibiotics could be specifically incriminated. This study defines the scope, characteristics, and importance of bleeding in ICU patients and establishes risk factors.

Aged↗
PubMed1987

Compartment syndrome in a patient monitored with an automated blood pressure cuff.

Noninvasive blood pressure monitoring may be hazardous in patients with seizures or movement disorders. We report on a patient with hyperactivity and tremor in whom a compartment syndrome was apparently induced by an automated blood pressure cuff. As the patient moved, the device seems to have continued to cycle in an attempt to obtain a stable baseline reading. Pressure tubing to the self-inflating bladder on such devices should be disconnected between readings in situations where frequent, easy observation is not possible.

Adult↗
PubMed1987

Oliguria from high intra-abdominal pressure secondary to ovarian mass.

Oliguria in association with elevated intra-abdominal pressure developed in a patient with an ovarian mass. Operative decompression of the abdomen reversed the oliguric state. Clinically, laparotomy may be indicated in the presence of decreasing urinary output and elevated intra-abdominal pressure.

Abdomen↗