The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient

Vasilevskis, Eduard E.; Chandrasekhar, Rameela; Holtze, Colin; Graves, John A.; Speroff, Theodore; Girard, Timothy D.; Patel, Mayur B.; Hughes, Christopher; Cao, Aize; Pandharipande, Pratik P.; Ely, E. Wesley

doi:10.1097/mlr.0000000000000975

Cited by 114 publications

(93 citation statements)

References 46 publications

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“…Complete or partial disorientation at the time of admission of the elderly person was also associated with a higher expenditure on hospitalizations. This finding corroborates the results obtained by Vasilevskis et al 32 , which identified, from a prospective cohort study, that disorientation is directly associated with the increase in expenses related to ICU admissions. The importance of the variable for the phenomenon studied is also confirmed by some of the main instruments used to assess the prognosis of an intensive care stay, such as the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Logistic Organ Dysfunction System (LODS), which use the variable as a criterion in their scores 33 .…”

Section: Discussionsupporting

confidence: 93%

Gasto de internação de idosos em unidades de terapia intensiva nos hospitais privados de uma capital do nordeste brasileiro

Bonfada

Barbosa

Lima

et al. 2020

Rev. bras. geriatr. gerontol.

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Resumo Objetivo: Analisar a associação entre variáveis demográficas, de morbidade e relativas às condições da hospitalização com os gastos decorrentes da internação de idosos em unidades de terapia intensiva (UTI) de hospitais privados em uma capital do nordeste brasileiro. Método: Trata-se de um estudo epidemiológico, analítico e do tipo seccional, com abordagem quantitativa, no qual foram coletados dados referentes a 312 internações de idosos em UTI de todos os hospitais privados de Natal (RN), Brasil. A variável dependente foi o custo de internação e as variáveis independentes relacionadas à caracterização dos indivíduos quanto ao perfil sociodemográfico, ao quadro mórbido e às características da internação. Os dados foram analisados por meio de estatística descritiva, teste qui-quadrado, teste t e regressão logística múltipla com as razões de prevalência (RP). Resultados: O custo médio por internação foi de R$ 4.266,05±3.322,50 para o grupo de baixo custo e R$ 39.753,162 ± 4.929,12 para o grupo alto custo. Constatou-se que a hospitalização decorrente de agravos clínicos (RP=1,81; IC95%=1,06-3,09) e respiratórios (RP=2,48; IC95%=1,48-5,24), a necessidade de ventilação mecânica (RP=2,33; IC95%=1,43-3,78) e a desorientação completa ou parcial no momento da admissão (RP=1,81; IC95%=1,15-2,84) estiveram associadas ao maior gasto nas internações no modelo estatístico múltiplo. Conclusão: Esses achados trazem evidências de que a implantação de ações capazes de promover melhores condições de saúde para os idosos, por meio da criação de protocolos e linhas de cuidado, especificamente criados para esse público, podem ser relevantes na redução dos gastos decorrentes da internação de idosos em terapia intensiva. Analyze the association between demographic variables, morbidity and relative to the conditions of hospitalization with the expenses resulting from the admission of elderly people in intensive care units (ICU) of private hospitals in a capital of northeastern Brazil. Method: This is an epidemiological, analytical and sectional study, with a quantitative approach, in which data were collected regarding 312 hospitalizations of elderly people in the ICU of all private hospitals in Natal (RN), Brazil. The dependent variable was the cost of hospitalization and the independent variables related to the characterization of individuals in terms of socio-demographic profile, morbid condition and characteristics of hospitalization. Data were analyzed using descriptive statistics, Chi-square test, t test and multiple logistic regression with prevalence ratios (PR). Results: The average cost per hospitalization was R$ 4.266,05±3.322,50 for the low cost group and R$ 39.753,162±4.929,12 for the high cost group. It was found that hospitalization due to clinical (PR=1,81; 95%CI=1,06-3,09) and respiratory conditions (PR=2,48; 95CI%=1,48-5,24), the need for mechanical ventilation (PR=2,33; 95%CI=1,43-3,78) and complete or partial disorientation at the time of admission (PR=1,81; 95%CI=1,15-2,84) were associated with higher expenditure on hospitalizations in the multiple statistical model. Conclusion: The knowledge produced by the study may serve as a subsidy for the implementation of actions capable of promoting better health conditions for the elderly, reducing expenses related to their hospitalization in highly specialized sectors. In addition, the research raises evidence that the construction of protocols and lines of care guiding the work process in the intensive care sector, specifically created for the elderly, may be relevant in reducing the expenses resulting from hospitalization of the elderly.

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Section: Discussionsupporting

confidence: 93%

Gasto de internação de idosos em unidades de terapia intensiva nos hospitais privados de uma capital do nordeste brasileiro

Bonfada

Barbosa

Lima

et al. 2020

Rev. bras. geriatr. gerontol.

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“…The main finding of this study was that the use of hydromorphone was associated with more days alive and DFCF while on ECMO support, with more time free of coma and with ~75% less narcotic exposure when compared with fentanyl. These findings are relevant to patient‐centered outcomes because the development of delirium in critically ill patients is associated with higher mortality, increased time on mechanical ventilation, increased length of stay, and higher costs 17‐24 …”

Section: Discussionmentioning

confidence: 99%

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

et al. 2020

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INTRODUCTION Data comparing sedatives in patients receiving extracorporeal membrane oxygenation (ECMO) are sparse. However, it is known that the ECMO circuit alters the pharmacokinetic properties of medications via drug sequestration of lipophilic agents and increased volume of distribution. OBJECTIVES This study evaluated the difference in days alive without delirium or coma and the sedative requirements in patients receiving fentanyl versus hydromorphone in ECMO patients. METHODS This single-center retrospective observational study evaluated adults receiving ECMO for more than 48 hours and continuous infusion of either fentanyl or hydromorphone for at least 6 hours. Of 148 patients evaluated, 88 received fentanyl and 60 received hydromorphone continuous infusion sedation. Outcomes included delirium-free and coma-free (DFCF) days, narcotic use, and sedative use. MAIN RESULTS There was an increase in the number of DFCF days in the hydromorphone group at day 7 (p=0.07) and day 14 (p=0.08) and a significant reduction in daily fentanyl equivalent exposure. Propensity score matching yielded 54 matched pairs. An 11.1% increase was observed in the proportion of ECMO days alive without delirium or coma in the hydromorphone group at 7 days (53.2% vs 42.1%, p=0.006). Patients in the hydromorphone group received significantly fewer narcotics with a median of 555 µg (interquartile range [IQR] 287-905 µg) of fentanyl equivalents per day compared with 2291 µg (IQR 1053-4023 µg) in the fentanyl group (p<0.005). CONCLUSION The use of hydromorphone-based sedation in ECMO patients resulted in more days alive without delirium or coma while significantly reducing narcotic requirements. KEY WORDS acute respiratory distress syndrome, extracorporeal membrane oxygenation, intensive care, sedation, delirium.

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“…Historically, delirium rates among mechanically ventilated ICU populations were consistently 70-75%, and the duration of delirium has consistently proven an independent predictor of longer lengths of stay, higher mortality, greater cost of care, and alarming rates of acquired dementia that lasts years following illness [70][71][72][73]. Given these facts, it is important to carry into the pandemic the knowledge that delirium in mechanically ventilated patients can be reduced dramatically to 50% using a culture of lighter sedation and mobilization via the implementation of the safety bundle called the ABC-DEFs promoted by the Society of Critical Care Medicine (SCCM) in their ICU Liberation Collaborative [37,38].…”

Section: Covid-19: Icu Delirium Management-potential Problems and Solmentioning

confidence: 99%

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

et al. 2020

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The novel coronavirus, SARS-CoV-2-causing Coronavirus Disease 19 , emerged as a public health threat in December 2019 and was declared a pandemic by the World Health Organization in March 2020. Delirium, a dangerous untoward prognostic development, serves as a barometer of systemic injury in critical illness. The early reports of 25% encephalopathy from China are likely a gross underestimation, which we know occurs whenever delirium is not monitored with a valid tool. Indeed, patients with COVID-19 are at accelerated risk for delirium due to at least seven factors including (1) direct central nervous system (CNS) invasion, (2) induction of CNS inflammatory mediators, (3) secondary effect of other organ system failure, (4) effect of sedative strategies, (5) prolonged mechanical ventilation time, (6) immobilization, and (7) other needed but unfortunate environmental factors including social isolation and quarantine without family. Given early insights into the pathobiology of the virus, as well as the emerging interventions utilized to treat the critically ill patients, delirium prevention and management will prove exceedingly challenging, especially in the intensive care unit (ICU). The main focus during the COVID-19 pandemic lies within organizational issues, i.e., lack of ventilators, shortage of personal protection equipment, resource allocation, prioritization of limited mechanical ventilation options, and end-of-life care. However, the standard of care for ICU patients, including delirium management, must remain the highest quality possible with an eye towards long-term survival and minimization of issues related to post-intensive care syndrome (PICS). This article discusses how ICU professionals (e.g., physicians, nurses, physiotherapists, pharmacologists) can use our knowledge and resources to limit the burden of delirium on patients by reducing modifiable risk factors despite the imposed heavy workload and difficult clinical challenges posed by the pandemic.

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The Cost of ICU Delirium and Coma in the Intensive Care Unit Patient

Abstract: Delirium is associated with substantial costs after accounting for time-varying illness severity and could be 20% higher (∼$22,500) if not for its association with early ICU mortality.

Cited by 114 publications

References 46 publications

Gasto de internação de idosos em unidades de terapia intensiva nos hospitais privados de uma capital do nordeste brasileiro

Gasto de internação de idosos em unidades de terapia intensiva nos hospitais privados de uma capital do nordeste brasileiro

Comparison of Hydromorphone versus Fentanyl‐based Sedation in Extracorporeal Membrane Oxygenation: A Propensity‐Matched Analysis

COVID-19: ICU delirium management during SARS-CoV-2 pandemic

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