14th Annual Congress ± Geneva, Switzerland ± 30 September±3 October 2001
HOME MADE COMPUTER-BASED SYSTEM TO IMPROVE ICU
OUTSOURCING AN ICU: A SUCCESSFUL EXPERIENCE
ADMINISTRATION AND CLINICAL EFFECTIVENESS
Souza PP. ICU, HospitalEspanholdo Rio de Janeiro, Rio de Janeiro, Brazil
Tagan DO, Penseyres T, Jaermann Y, Joseph A. Medicalintensive care unit, Riviera Hospital,
INTRODUCTION. Outsourcing an ICU is an very new option of management, considering the
high costs envolved in set up and management of one ICU plus the need of expertise. It could be
INTRODUCTION. The amount of datas to integrate in an ICU is considerable. Managing of
a choice if the hospitalowner don¢t have enough money or experience in the criticalcare ar-
daily informations has become a challenge (1). We present a computer system that reliably ac-
ea.There is a lot of potential benefits, but they still are not clear. We wish to show a model of
quires, stores and diplays basic information necessary for clinical effectiveness and to report ac-
outsourcing and the results of a successful pratical experience of seven years and around 4.000
METHODS. The system is made of five modules: a patient database (for administrative, medi-
METHODS. The period of the study was from December 1994 to March 2001 in the Hospital
cal and nursing data), an information module (to facilitate transmission of useful informations),
Espanhol in Rio de Janeiro, a 64 bed-hospital oriented to high level elective surgery, basically
a radiological module (for easy consultation of X-ray), a laboratory module (for consultation of
oncologic. We addopted the model of complete outsourcing, including all the process in the
lab results) and an archive module (for consultation of former records).
ICU. Then, it was included purchase or rent of medical equipment, all the salaries and taxes, ac-
quisition and sell of medical matherial and drugs, to make the bill and all other activities en-
RESULTS. The database was created with Filemaker pro. It allows gathering and analyse of da-
tas to report the activity of the unit (nurse workload score, medical procedures. . .) and patient
caracteristics (origin and destination, physiologic scores, diagnosis, mortality. . .). Every items
RESULTS. We have started 5 years ago, begining with 4 beds, followed by 8 and then 12 beds.
has been chosen with care. The information system has been created with HTML language
The results have been very good. This complete model, with all process, including pharmacy
with allows easy sharing of documents through the Intranet of the hospital. This module con-
and nurses, seem to us the best, although they have more complexity and need a high cost man-
tains useful informations for medical and nurse staff which are updated regularly: policies, pro-
agement, compared to other outsourcing models. The set up costs are also higher. During this
cedures, clinical guidelines, care plans, teaching program with slides when available, monthly
7 years, we have payed to the hospital 17% of our bill and we have had a liquid profit of 6%
electronic newspaper, virtual library with selection of useful articles, report of cases of inter-
CONCLUSION. Outsourcing is a good option to hospitals which don't know or don't want to
manage the risks of an ICU. The complete model is the best, considering major flexibitity
CONCLUSION. The coordinated system has been elaborated during the last four years. The
against high costs, giving better profits and payment of better salaries, although the risks of
database is easily modified according to the new exigencies of the hospital administration or
bad managementand bankrupt are bigger. The liquid profit for the ICU managerial group are
medical society. Guidelines are regularly updated. This computer based tool was immediately
around 6% and the hospitalreceive 17% of the billwithout any risk or cost.
well accepted and is a cohesion tool. We present this work to show that with the limited res-
sources of a non universitary hospitala motivated team may create a costumized toolwhich
REFERENCE. Berenson RA: Intensive care units (ICUs): clinical outcomes, costs and deci-
sion making. Health Technology Case Study 28, Prepared for the Office of Technology Assess-
REFERENCE. Human-computer interactions: can computers improve the way doctors work?
Garrard S. Schweiz Med Wochenschr 2000; 130: 1557±63.
POLYSOMNOGRAPHY: A DIAGNOSTIC TOOL FOR EVALUATING SLEEP
TREATMENT OF STEROID-INDUCED CHOLESTASIS WITH ALBUMIN
Schneider T, Deegener T, Burchardi H. Dept. Anaesthesiology, Emergency & Intensive Care
Bellmann R, Zoller H, Schwaighofer H, Vogel W, Wiedermann CJ, Joannidis M. Dpt. Internal
Medicine, University Hospital, Göttingen, Germany
Medicine, University of Innsbruck, Innsbruck, Austria
INTRODUCTION. Sleep disorders occur in intensive care therapy. Until now, monitoring and
INTRODUCTION. Hepatocellular cholestasis caused by anabolic steroids is well known and
assessment of the level of sleep and the quality of sedation are only performed either by clinical
difficult to treat . Albumin dialysis has been shown to improve the outcome in patients with
aspects or by sedation scores, such as RAMSAY score . More than 20 other scores have been
cholestatic liver failure caused by chronic liver disease . We report a 22 year old man who
developped  which shows that the best suitable evaluation tool is still missing. Polysomnogra-
was admitted with pruritus and jaundice in December 2000 for the first time. The patient was
phy  is the golden standard for evaluation of sleep which, however, was possible up to now
known to suffer from chronic hepatitis C for years, which had been treated unsuccessfully with
only in special sleep laboratories. The development of a computer based miniaturized sleep lab-
interferon A and ribavirin. Two weeks before the first admission he had taken anabolic steroids
oratory now enables studies in the intensive care unit (ICU). The aim of this study was to estab-
(silabolin and nandrolone) by i.m. injection for body building. The clinical examination reveal-
lish such a sleep laboratory in the ICU environment.
ed an impressive icterus and numerous scratch marks. Totalserum bilirubine was 10.8 mg/dlat
this time, the direct bilirubin 9.71 mg/dl. There was a slight increase of transaminases and alka-
METHODS. Six postoperative extubated patients (53 yrs, SD 11,5) were examined at night
line phosphatase, blood cell count and prothrombin time were normal. Liver biopsy showed a
(9h:12min, SD 2h:03min). Polysomnography and sleep analysis was performed according to
portocentral cholestasis with mild portal cell infiltration. Treatment with cetirizine, a histamine
internationalcriteria [2, 4]. A digital32-chanalpolysomnograph (MEPAL, MAP, Martinsried)
(H1) blocker, and naltrexon, an opioid antagonist, was not effective. Administration of phe-
nobarbital for enzyme induction failed to reduce hyperbilirubinemia and to ameliorate clinical
symptomes. Since itching and jaundice worsened and the bilirubin level rose to 30 mg/dl, the pa-
RESULTS. Application of the electrodes and the transition-resistances of the skin raised no
tient was re-admitted to hospitalin January 2001.
problem. Electric smog, produced by other ICU equipment (eg. monitors, respirators etc.), did
METHODS. The molecular adsorbent recirculating system (MARS) was connected with a
not produce artefacts. During the measurement interferences occured in the following situa-
hemofiltration device (Baxter BM 14 + BM 11). MARS contains a synthetic hydrophilic/hydro-
tions: (a) patients with qualitative disturbances of consciousness. (b) actions performed by doc-
phobic domain-presenting semipermeable membrane (pore size smaller than albumin size, 100-
tors or nurses. (c) considerable perspiration. All interferences were caused by loosening or re-
nm thick). The opposite side of this membrane is rinsed with ligandin-like proteins (albumin) as
moval of the electrodes. Hypnograms were prepared. Based on these, the following variables
molecular adsorbents that are regenerated online using a chromatography-like recycling system
were calculated: TST (total sleep time) 297 min ( 115 min), TIB (time in bed) 462 min
. Anticoagulation was performed by continuous infusion of heparin. Three MARS sessions
( 123 min), proportion of sleep stage 1 37,9% ( 15,9%), stage 2 49,4% ( 9,7%), stage
were run: 9 hours at day 1, 18 hours at day 2 and 24 hours at day 5. Laboratory values were cont-
SWS (slow-wave-sleep) 7,85% ( 11,1%) and proportion of REM-sleep 2,6% ( 5,0).
roled before, 6 hours after start and at the end of albumin dialysis.
RESULTS. The procedure was well tolerated by the patient. There were no haemodynamic
CONCLUSION. Based on our results, it is possible to establish polysomnography in the ICU
changes and no bleeding events. The patient¢s condition significantly improved from the first
and to achieve a valid diagnosis of sleep disorders. Polysomnography is not yet an instrument
session. The pruritus had nearly vanished after the third therapy. Total bilirubin declined from
for routine diagnostic, but can become a valuable sophisticated method of examination. Espe-
31.8 mg/dl (before MARS therapy) to 17.2 mg/dl (after the third albumin dialysis). Bile acid
cially educated staff is needed for its use. It could be shown that sleep disorders in intensive
(cholylglycin) concentration decreased from 2,814 mcg/dl to 828 mcg/dl. Six weeks later the pa-
care medicine are a relevant problem.
tient presented in a satisfying condition. The bilirubin level was 3.6 mg/dl at this time.
CONCLUSION. Symptoms of steroid-induced cholestasis can efficiently be treated by albumin
REFERENCES. 1. Jonghe B et al. Intensive Care Med, 2000; 26: 275±852. 2. Penzel T et al.
dialysis with the molecular adsorbent recirculating system (MARS). The therapy results in a
EEG EMG Z Elektroenzephalogr Elektromyogr Verwandte Geb 1993, 24: 65±70. 3. Ramsay
marked reduction of bilirubin and bile acids. In our patient the MARS treatment was well toler-
M et al. Br Med J 1974; 2: 656±94. 4.Rechtschaffen A, Kales A. Public Health Service, US Gov-
ated. Whether it has contributed to the recovery of excretory liver function is unknown.
ernment Printing Office, Washington DC, 1968, 1±56
REFERENCES. 1. Erlinger S. Drug-induced cholestasis (1997) J Hepatol 26 Suppl 1: 1±4. 2.
Stange J, Mitzner SR, Klammt S, Freytag J, Peszynski P, Loock J, Hickstein H, Korten G,
Schmidt R, HentschelJ, Schulz M, Lohr M, Liebe S, Schareck W, Hopt UT (2000) Liver sup-
port by extracorporeal blood purification: a clinical observation. Liver Transpl 6: 603±13.
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