Utilization of Intensive Care Unit Resources

Heidi E Lilja
1
, Ari Leppäniemi
2
, Esko Kemppainen
2
1
Bernard O'Brien Institute of Microsurgery. Melbourne, Australia.
2
Department of
Gastroenterological and General Surgery, Meilahti Hospital, University of Helsinki.
Helsinki, Finland
ABSTRACT
Context Severe acute pancreatitis is a
common abdominal emergency; it is a
potentially fulminant disease with no specific
treatment. The incidence of severe acute
pancreatitis is increasing, but the overall
population mortality rate has remained
unchanged as the case fatality rate has
decreased over time. The hospital mortality
rate of patients with severe acute pancreatitis
has dropped to 20% even in the most severe
forms of the disease. The prolonged course of
severe acute pancreatitis, associated with
multi-organ failure and other complications,
is a considerable strain on intensive care unit
(ICU) resources.
Objective To analyze the extent of ICU
resources consumed by the severe acute
pancreatitis patient group as well as the
expenses of the treatment and differences in
the costs of survivors versus patients who die
after a prolonged stay in the ICU.
Design Retrospective study.
Participants All patients with severe acute
pancreatitis treated in the general ICU of
Helsinki University Hospital from 1995 to
2005 (245 patients; 169 (69.0%) with alcohol-
induced severe acute pancreatitis).
Results The mean length of the ICU stay was
17.4 days and severe acute pancreatitis
patients constituted 17.0% of all ICU days.
The mean hospital cost per patient was 86,856
Euros. The overall mortality rate was 26.1%
and the hospital costs of the non-survivors
seemed to be higher (although not
significantly) than that of the survivors.
Conclusions Optimal early care in order to
decrease the onset of organ dysfunctions and
better prognostic models to identify non-
surviving severe acute pancreatitis patients
earlier could lead to considerable savings in
the overall use of ICU resources.
INTRODUCTION
Severe acute pancreatitis, a disease with high
mortality, is associated with multi-organ
failure and the development of local
pancreatic complications such as abscesses,
infected necrosis and the formation of
pseudocysts. Patients with severe acute
pancreatitis and its associated complications
form a great challenge to the health care
system necessitating admission to a high
dependency or intensive care unit (ICU),
often for a prolonged period associated with a
significant strain on resources.
The incidence of severe acute pancreatitis is
increasing in many countries, mostly
explained by higher alcohol consumption, as
alcohol is a major contributor to the disease
[1]. The incidence of acute pancreatitis varies
between 5 and 80 per 100,000 people, with
the highest incidence seen in the United States

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and Finland [2]. About 30% of acute
pancreatitis cases are severe. The mortality
rate of these patients has been in the range of
30-50% and a mean hospital length of stay of
greater than one month, attesting to the
severity of pancreatitis at this end of the
spectrum [3].
Today, the hospital mortality rate of patients
with severe acute pancreatitis has dropped to
about 20% even in the most severe forms of
the disease [4]. In a review article based on 18
reported population-based studies of the first
attack of acute pancreatitis, the case-fatality
rate has decreased over time (1966-2005) [1].
Because of the prolonged course of severe
acute pancreatitis, however, the strain of this
patient group on ICU resources is
considerable. Thus, efforts to decrease the
incidence of severe acute pancreatitis, the
development of better prognostic models and
more effective treatment might not result only
in a better outcome for the patient, but also
produce enormous savings in health care
expenses.
Although ICU patients comprise a small
proportion of the total patients in the hospital,
they account for a significant amount of
hospital resources. In a cost-conscious
society, it is necessary to address the overall
performance of ICUs. This study was
designed to analyze the patients with severe
acute pancreatitis treated in the ICU of
Helsinki University Central Hospital, Finland.
More specifically, the aim of this study was to
analyze how much of ICU resources are used
by this particular patient group. In addition,
we analyzed the expenses of treating severe
acute pancreatitis in the ICU and whether
there was a difference in the costs of
survivors versus patients who die after
prolonged stay in the ICU.
METHODS
In this retrospective study, we analyzed the
hospital records of all patients with severe
acute pancreatitis treated in the general ICU
in Helsinki University Central Hospital from
1995 to 2005.
Patients
During the 11-year period, a total of 245
patients with severe acute pancreatitis were
treated in the ICU. The diagnosis of
pancreatitis was based on diagnostic and
prognostic laboratory tests including a CT
scan in all patients. The indication for ICU
treatment was severe acute pancreatitis with
organ dysfunction. Epidemiological data, the
criteria for severe acute pancreatitis and the
definitions of organ dysfunctions used at our
hospital have been published previously [5,
6]. A total of 92 patients (37.6%) in this group
were treated in the ICU after 2002, and they
constituted the population used for the
analyses of the treatment expenses because
the Euro has been the currency in Finland
since 2002.
Of the 245 patients included, 210 (85.7%)
were male. The mean age of the patients was
47±12 years. The majority of the cases were
alcohol-induced (169; 69.0%).
Cost Analysis
In general, the costs of patient care can be
divided into hospital costs (direct and indirect
costs) and community costs (loss of
productive work/sick leave, etc.). At Helsinki
University Central Hospital, the hospital cost
of a treatment period for every patient is
based on a standard daily cost (in the ward,
ICU, etc.) multiplied by the number of days in
the hospital with specific costs added for
operative and diagnostic (CT scan for
example) procedures and exceptionally
expensive medications. The daily cost in a
ward or ICU is based on the annual
calculation of the actual costs (direct and
overhead) of the service and includes
personnel costs, equipment, medication, etc.
For each Diagnosis-Related Group (DRG),
the mean hospital cost is calculated annually
based on the true calculated costs for that
group in the previous year reflecting the
utilization of resources spent for the care of
an individual patient. If the patient’s true
costs fall within 2 standard deviations (SD) of
the mean costs in that specific DRG-group,

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the mean cost will be used for the billing sent
to the home county of the patient. If the costs
are outside 2 SD, then the actual cost will be
used for billing.
The cost of one day in the ICU in Helsinki
University Central Hospital is 3,830 Euros per
patient. Personnel costs constitute about 47%
of the total cost, medicine and related medical
consumables 25%, and laboratory tests and
radiological examinations 4%. The remaining
24% of the cost consists of administrative and
infrastructure costs and included building
maintenance, information technology,
insurance and capital interest costs.
STATISTICS
Mean, standard deviation (SD), and
frequencies were used as descriptive statistics.
A comparison of continuous variables was
performed with an unpaired Student’s t test
with statistical significance at the two-tailed
0.05 level. Statistical analyses were carried
out using Microsoft Office Excel 2007 and
GraphPad Prism software (version 4.0; San
Diego, USA).
RESULTS
The total length of the ICU stay of patients
with severe acute pancreatitis was 4,438 days
constituting 17.0% of all ICU days. Their
mean±SD length of ICU stay was 17.5±15.6
days. Renal replacement therapy was required
in 99 (40.4%) cases of this patient group. The
mean±SD hospital cost per severe acute
pancreatitis patient was 86,856±79,896 Euros
(7,990,756 Euros for the 92 patients in the
period of time from 2002 to 2005).
Twenty patients (21.8%) underwent surgical
interventions in the period from 2002 to 2005;
the total cost of the surgical interventions was
approximately 12,500 Euros per patient (3.1%
of total ICU costs).
The overall mortality rate was 26.1% (64
patients; 23 in the period of time from 2002 to
2005). The non-survivors consumed 29.5% of
the ICU days (1,310 days) and 28.3% of the
hospital costs (2,261,962 Euros for the 23 non
survivors in the period of time from 2002 to
2005) of all severe acute pancreatitis patients
treated in the ICU. Their mean hospital cost
per patient was about 15,000 Euros higher
than that of the survivors (98,346±99,596 vs.
83,026±71,267; P=0.424). In most of the non-
survivors, death occurred after a prolonged
stay in the ICU, even if this difference did not
reach statistical significance (20.5±20.9 vs.
16.5±13.1 days; P=0.074).
DISCUSSION
As suggested in this study, patients with
severe acute pancreatitis utilize a considerable
proportion of university hospital ICU
resources. They require highly demanding
continuous care, special equipment and
therapeutic interventions such as mechanical
ventilation, renal replacement therapy and
invasive monitoring, for example. However,
the majority of expenses are constituted by
personnel costs as they account for nearly half
of all expenses. The increased need and
utilization of resources in the ICU derives
from the high incidence of multiple organ
dysfunctions requiring complex monitoring
and care, particularly true in patients with
severe acute pancreatitis. All patients
included in this study were treated in the ICU
because of the dysfunction of one or more
organ systems. The mean SOFA (Sequential
Organ Failure Assessment) score of the
severe acute pancreatitis patient group in our
hospital at one week time point is
approximately 9, as has already been reported
by Halonen et al. [6]. Only a minority of the
costs in our study were due to surgical
intervention (3.1% of total ICU costs). As
pointed out by this study, the expenses of the
non-survivors are higher than survivors (about
15,000 Euros per patient, even if the
difference does not reach the significant
level). This is probably due to a longer ICU
stay among non-survivors.
Although the management of severe acute
pancreatitis is expensive, it is justified by the
excellent outcome in terms of quality of life
[3, 7]. Many different strategies could be
adopted in order to diminish this load and to
accomplish considerable savings in the
overall use of ICU resources. First of all,
efficient preventive strategies to reduce the
overall incidence of acute pancreatitis are

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needed. This is a continuing challenge as
alcohol consumption seems to be increasing.
For instance, the increase in alcohol
consumption in Finland was 11% between
2003 and 2006. This increase is partly
explained by reduced alcohol taxes. In
Finland, where alcohol is sold through a state-
run monopoly, alcohol taxes were cut by one-
third in March 2004. The trend is alarming,
since about 70% of pancreatitis patients in
Finland are alcohol-induced. As alcohol is a
major contributor to severe acute pancreatitis,
preventative intervention should be a major
concern.
Secondly, optimal early care of severe acute
pancreatitis in order to decrease the onset of
organ dysfunctions and other complications is
a key point. Evidence-based recommendat-
ions for the management of critically ill
patients with severe acute pancreatitis have
been addressed by an international consensus
conference [8]. In their statement, a total of
23 recommendations were developed to
provide guidance to critical care clinicians
when caring for a patient with severe acute
pancreatitis. Accordingly, a study by Mofidi
et al. suggested that patients with severe acute
pancreatitis can be managed according to the
revised guidelines of the British Society of
Gastroenterology resulting in a lower
mortality rate [4]. Most recently, a review
article by Besselink et al. updated the
treatment procedure of severe acute
pancreatitis and suggested that the timing of
intervention is becoming increasingly
important in severe acute pancreatitis
management [9]. Although no specific
treatment for severe acute pancreatitis exists,
replacing the massive fluid loss in the early
disease phase is critical and determines the
prognosis. Early enteral nutrition for the
treatment of severe acute pancreatitis has
been shown to be important [10, 11].
Antibiotic prophylaxis has been associated
with decreased mortality and infected
pancreatic necrosis in some studies [12].
However, a recent meta-analysis suggested
that prophylactic antibiotic administration is
not an appropriate treatment strategy in
patients with severe acute pancreatitis, and it
should be limited to patients with pancreatic
necrosis [13]. Therefore, further studies are
required in order to provide adequate data and
to define the role of antibiotic prophylaxis in
patients with severe acute pancreatitis [14].
Some of the severe acute pancreatitis patients
develop increased intra-abdominal pressure,
associated with the onset of early organ
failure, increased mortality and a long-term
stay in the ICU. Organ dysfunction may be
avoided, and patients potentially benefiting
from decompressive surgical operations may
be recognized by frequent measurements of
intra-abdominal pressure during intensive
care [15]. Subcutaneous anterior abdominal
fasciotomy is a promising novel surgical
technique for abdominal decompression [16].
In addition to decompressive laparotomy,
infected pancreatic necrosis, abscesses or
pseudocysts are other indications for open
surgery in severe acute pancreatitis [17]. Even
when indicated, surgery in severe acute
pancreatitis is frequently delayed or even
replaced by minimally invasive surgical
methods.
To better understand the pathophysiological
mechanisms involved in pancreatitis and its
related systemic inflammatory response, the
development of new treatment strategies
would help. For instance, progress in
understanding the role of cytokines could
provide opportunities to use immuno-
modulatory therapies to improve the outcome
in severe acute pancreatitis [18]. In the future,
enterally administered probiotics may also be
used as a prophylaxis for reducing the
incidence of infectious complications [9].
Thirdly, better prognostic models for
identifying non-surviving patients earlier
could lead to remarkable savings in ICU
resources. Both therapy-associated and
patient-related factors play a role in survival
in severe acute pancreatitis, but there are only
a few relevant methods for predicting fatal
outcome. Many different scoring systems for
the prediction of the prognosis of severe acute
pancreatitis have been suggested [19]. Scores
such as Ranson and Imrie can be used to
determine whether the clinical course is likely
to be severe, but these scoring systems are

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inaccurate indicators of mortality in severe
acute pancreatitis. In addition, most of the
scoring systems for the severity of acute
pancreatitis are complicated and consist of
multiple factors. For example, 14 variables
are required in APACHE II [20]. A simpler
predictive model by Halonen et al. based on
four variables (age, highest serum creatinine
value within 60-72 h from primary admission,
need for mechanical ventilation and chronic
health status) was suggested in order to reach
at least the same predictive performance as
APACHE II [21]. Most recently, Ueda et al.
suggested that a scoring system made up of
only three items (i.e., serum blood urea
nitrogen equal to or greater than 25 mg/dL,
serum lactate dehydrogenase equal to or
greater than 900 IU/L and contrast-enhanced
computed tomography findings of pancreatic
necrosis) could be simple and feasible for the
prediction of severe acute pancreatitis at
admission [22]. This novel scoring system
seems to be competitive if compared to
conventional scoring methods, but still more
effort is needed to be able to develop a more
accurate scoring system which could identify
fatal outcome in severe acute pancreatitis
patients at the early phase of the disease.
In addition to many different scoring systems
for the prediction of severe acute pancreatitis,
increased intra-abdominal pressure is also
suggested to be a potential prognostic factor.
Intra-abdominal pressure has been shown to
be associated with the onset of early organ
failure and is also reflected in increased
mortality and fewer ICU-free days in patients
with severe acute pancreatitis [15].
Accordingly, Rosas et al. suggested that intra-
abdominal pressure is a useful, inexpensive
and easy method of measuring the evolution
and complications of acute pancreatitis [23].
Efforts targeted at improving treatment
methods and developing consistent care for
severe acute pancreatitis could result in
savings in ICU resources and a decrease in
overall expenses. Still, more accurate
recommendations
concerning
the
management of patients with pancreatitis,
especially focused on critically ill severe
acute pancreatitis patients is needed. A
number of important questions which have
not been answered to date using an evidence-
based approach remains to be answered.
Thus, further research is needed in associated
relevant areas concerning the treatment and
prognosis of severe acute pancreatitis.
Received November 9
th
, 2007 - Accepted
January 15
th
, 2008
Keywords Health Care Costs; Hospital
Mortality; Intensive Care Units; Pancreatitis,
Acute Necrotizing
Abbreviations DRG: diagnosis-related group
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Heidi E Lilja
Bernard O'Brien Institute of Microsurgery
42 Fitzroy Street
Fitzroy, VIC 3065
Melbourne
Australia
Phone: +61-3.9288.4018
Fax: +61-3.9416.0926
E-mail: heidi.lilja@helsinki.fi
Document URL: http://www.joplink.net/prev/200803/17.html
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