CRITICAL CARE UPDATE 2017 Editors Subhash Todi MD MRCP Director Department ofCritical Care Advanced Medicare Research Institute Kolkata, West Bengal, India Atul PKulkarni MD FISCCM PGDHHM FICCM Professor and Head Department of Anesthesiology, Critical Care Medicine and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Kapil Zirpe MD FCCM F1CCM Director Neuro Trauma Unit Ruby Hall Clinic Pune, Maharashtra, India The Health Sciences Publisher New Delhi I London I Panama • j ~\ 'J~: Jaypee Brothers Medical Publishers (P) Ltd Headquarters Jaypee Brothers Medical publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: jaypee@jaypeebrothers.com Overseas Offices J.P Medical Ltd 83Victoria Street, London SW1 H OHW (UK) Phone: +44 203170 8910 Fax: +44 (0)20 3008 6180 Email: info@.ipmedpub.com Jaypee Brothers Medical publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 ~angladesh 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professional should besought Every effort has been made where necessary to contact holders ofcopyright to obtain permission to reproduce copyright material Ifany have been inadvertently overlooked, the publisher will bepleased to make the necessary arrangements atthefirst opportunity Inquiries for bulk salesmaybesolicited at: jaypee@jaypeebrothers.com Critical Care Update 2017 /Subhash Todi, Atul PKulkarni, Kapil Zirpe First Edition: 2017 • ISBN: 978-93-86261-15-1 Printed at Sanat Printers iI j- l~ Contributors EDITORS Subhash Todi MD MRCP Director Department of Critical Care Advanced Medicare Research Institute Kolkata, West Bengal, India Atul PKulkarniMD FISCCM PGDHHM Professor and Head Department of Anesthesiology, Critical Care Medicine and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Kapil Zirpe MD FCCM FICCM Director Neuro Trauma Unit Ruby Hall Clinic Pune, Maharashtra, India Rahul A Pandit MD FJFICM FCICM EDIC FCCP DA Director, Department of Intensive Care Fortis Hospital and Healthcare Mumbai, Maharashtra, India Pradeep Rangappa DNB FJFICM EDIC FClCM, P9DipECHO MBA FICCM PGDMLE Senior Specialist Department of Intensive Care Columbiaasia Referral Hospital Bangalore, Karnataka, India SECTION EDITORS Arvind KBaronia MD Professor and Head Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Rajesh Chawla MD FCCM FCCP Senior Consultant Department of Respiratory, Critical Care and Sleep Medicine Indraprastha Apollo Hospitals, New Delhi, India Shivakumar Slyer MD DNB EDIC Professor and Head Department of Critical Care Medicine Bharati Vidyapeeth Deemed University Medical College Pune, Maharashtra, India Dilip RKarnad MD FACP FRCP Consultant Department of Critical Care Jupiter Hospital Thane, Maharashtra, India Vijaya P Patil MD Professor, Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India BananiPoddarMDDNB Professor Department of Critical Care Medicine Sanjay Gandhi Postgraduate Institute of Medical Sciences Lucknow, Uttar Pradesh, India Ramakrishnan NAB (Int Med) AB (Crit Care) AB (Sleep Med) MMM FACP FCCP FCCMFICCM Senior Consultant Department of Critical Care and Sleep Medicine, Apollo Hospitals Chennai, Tamil Nadu,lndi: Jayant RShelgaonkar DA MD FRCA FICCM Associate Director Department of Critical Care Aditya Birla Memorial Hospital Pune, Mahrashtra, India Shrikanth Srinivasan MD DNB FNB EDIC Senior Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India KVinodanMD DA Head Department of Anesthesia and Critical Care Medical Trust Hospital Cochin, Kerala, India Critical Care Update 2017 ~ CONTRIBUTING AUTHORS Chu-Chu A MBBS Nikhill\l Balankhe MD Devawrat RBuche MD FNB Department of Anesthesia Kingston Hospital Kingston, United Kingdom Director Department of Critical Care Orange City Hospital and Research Institute Nagpur, Maharashtra, India Clinical Associate Department of Centre for Critical Care BLK Superspeciality Hospital New Delhi, India Ankur Agrawal MDDM DMFeilow Department of Pulmonary and Critical Care Medicine Post Graduate Institute of Medicine Sciences Rohtak, Haryana, India ~ "" ""'" Vignesh C MD FNB EDIC Susruta Bandyopadhyay MD Director Department of Critical Care AMRI Hospitals Kolkata, West Bengal, India Consultant Department of Critical Care Apollo Hospitals Chennai, Tamil Nadu, India Chandrashish Chakravarty MD Vandana Agarwal MD FRCA Rajan Barokar MD EDIC MNAMSEDIC Professor Department of Anesthesia, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Director and Consultant Aditya Hospital Critical Care and Emergency Centre Nagpur, Maharashtra, India Consultant Department of ICU Apollo Gleneagles Hospitals Kolkata, West Bengal, India Rinaldo Bellomo MD FRACP FClCM Matthew JChan BMedSci PGDipEcho FAHMS Research Fellow Department of Intensive Care Austin Health Heidelberg, Victoria, Australia Nayana SAmin MD Protessor Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Andrew CArgent MBBCh Mmed MD FCPeds DCH FRCPCH Professor and Medical Director PICU Department of Pediatric Intensive Care Red Cross War Memorial Children's Hospital and University of Cape Town Cape Town, South Africa • Professor Department of Intensive Care Medicine University of Melbourne Parkville, Victoria, Australia Dhruva Chaudhry MD DNB OM Vikas Bhagat MD DOMS FICCM FICP Senior Registrar Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Mahrashtra, India Senior Professor and Head Department of Pulmonary and Critical Care Medicine Post Graduate Institute of Medicine Sciences Rohtak, Haryana, India lata Bhattacharya MD Consultant Department of Critical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Gagan Brar MD FNB IDCC EDIC Pradip KBhattacharya MD FICCM Aakanksha Chawla MD FCCM FCCP Consultant Department of Critical Care and Emergency Services Narayana Health Bangalore, Karnataka, India FCCCM Senior Resident Department of Respiratory, Critical Care andSleep Medicine Indraprastha Apollo Hospitals New Delhi, India Mildhur Arora MD IDCCM Attending Consultant Department ofCritical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Director Emergency and Critical Care Services Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Vipal Chawla MD IDCCM Khusrav BBajan MD EDIC Consultant Depatement of Critical Care PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India vi Munish Chauhan MD FNB EDIC Senior Consultant Department of Anesthesiology and Critical Care JLN Cancer Hospital Bhopal, Madhya Pradesh, India Neeta Bose MD Associate Professor Department of Anesthesia GMERS Medical College Vadodara, Gujarat, India Associate Consultant Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India ," Contributors Maurizio Cecconi MD FRCA FFICM MD Supradip Ghosh Dip Intensive Care Sushma KGurav DNB IDCCM Consultant and Reader Department of Anesthesia and Intensive Care Medicine StGeorge's University Hospitals NHS Foundation Trust StGeorge's University of London London, United Kingdom Additional Director and Head Department ofCritical Care medicine Fortis Escorts Hospital Faridabad, Haryana, India Intensivist Neuro-trauma Unit Grant Medical Foundation Ruby Hall Clinic Pune, Maharashtra, India Ravi Varma Durai Pandian MD FNB EDIC Associate Consultant Department of Intensive Care Medicine Apollo Hospital Chennai, Tamil Nadu, India Raymond D MD DM EDIC Consultant Department of Critical Care Apollo Hospitals Chennai, Tamil Nadu, India Kanishka Davda DNB Fellow of National Board Department of Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India Palepu BGopal MD FRCA CCST FICCM FCCM Consultant and HOD Department of Critical Care Medicine Continental Hospitals Hyderabad, Telangana, India Prabhas PGiri MD MRCPCH Assistant Professor and In-Charge PICU Department of Pediatrics Institute of Child Health Kolkata, West Bengal, India Anish Gupta MD Fellow FNB Institute of Critical Care Medicine Max Super Speciality Hospital New Delhi, India Rahul BAmte MD IDCCM EDIC Consultant Department of Critical Care Medicine Yashoda Hospitals Hyderabad, Telangana, India Nimita Deora MSc Clinical Research Assistant Department of Anesthesiology and Critical Care Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Deepak Govil MD FCCM EDIC FICCM Sandeep Dewan DA DNB IDCCM James Hanison FRCA Consultant Department of Anesthesia and Intensive Care Medicine Manchester Royal Infirmary United Kingdom Ashit V Hegde MD MRCP Consultant Department of Medicine and Critical Care PD Hindula National Hospital Mumbai, Maharashtra, India Javed Ismail MD DM • • Consultant Department of Pediatrics Post Graduate Institute of Medical Education and Research Chandigarh, India Jose Chacko MD DA DNB EDIC Director Department of Critical Care Medicine Medanta-The Medicity Gurgaon,_ Haryana, India Consultant and Head Department of Critical Care and Emergency Services Narayana Health Bangalore, Karnataka, India Navya Guwalani PG Gaurav Jain MD PDCC Director and Head Department ofCritical Care Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India Clinical Reseacrh Officer Department of Anesthesiology and Critical Care Chirayu Medical College and Hospital Bhopal, Madhya Pradesh, India Assistant Professor Department of Anesthesiology Institute of Medical Sciences Banaras Hindu University Varanasi, Uttar Pradesh, India Jigeeshu VDivatia MD FCCM FISCCM Abhinav Gupta MD DNB FNB EDIC Professor and Head Department of Anesthesiology, Critical Care andPain Tata Memorial Hospital Mumbai, Maharashtra, India Additional Medical Superintendent and Head School of Medical Sciences and Research, Sharda Hospital Sharda University Greater Noida, Uttar Pradesh, India Subhal BDixit MD IDCCM FICCM FCCM ,Director Department of Intensive Care Sanjeevan Hospital and MJM Hospital Pune, Maharashtra, India Sachin Gupta MD IDCCM IFCCM EDIC Senior Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India Yash Javeri DAIDCCM Director Department ofCritical Care Medicine Apex Healthcare Consortium New Delhi, India Sameer AJog MD IDCCM EDIC Consultant Intensivist Department of Emergency Medicine and Critical Care Deenanath Mangeshkar Hospital Pune, Maharashtra, India vii Critical Care Update 2017 Deven Juneja DNB FNB EDIC FCCM Krishna PMulavisala MD FRCA Saumen Meur DCH MRCPCH FRCPCH CCT Principal Consultant Department of Critical Care Medicine Max Super Speciality Hospital New Delhi, India Consultant Department of Anesthesiology Global Hospitals Hyderabad, Telangana, India Consultant Pediatric Intensivist Department of Pediatric Cardiology BM Birla Heart Research Centre Kolkata, West Bengal, India Sunil Karanth MD FNB EDIC FCICM Rajesh Pande MD PDCC FICCM FCCM Sheila NMyatra MD FCCM FICCM Chairman, Consultant, and Head Department of Critical care services Manipal Health Enterprise (P) Ltd Bangalore, Karnataka, India Director BLK Center forCritical Care BLK Superspeciality Hospital New Delhi, India Professor Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, Idia Mohit Kharbanda MD IDCCM FNB Samidh BPatel MD Director Department of Critical Care Desun Hospital Kolkata, West Bengal, India In-Charge Department of Critical Care Manik Hospital and Research Center Aurangabad, Maharashtra, India Ruchira WKhasne DA DNB IDCCM Kinjal Patel MD EDAICEDIC Consultant Department of Critical Care Apollo Hospital Nashik, Maharashtra, India Clinical Assistant Department of Lab Medicine Hinduja Hospital and Medical Research Centre Mumbai, Maharashtra, India Khalid I Khatib MD Sweta Patel MD IDCCM Professor Department of Medicine Shrimati Kashibai Navale Medical College Pune, Maharashtra, India Consultant, Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India Harish M Maheshwarappa MD DNB Jagadeesh KN MBBS IDCCM DM EDIC Consultant, Medanta Institute of Critical Care and Anesthesia Medanta-The Medicity Gurgaon, Haryana, India Consultant and Head Department of Critical Care Medicine Yashoda Hospitals Secunderabad, Telangana, India Niranjan Kissoon FRCPC FAAP FACPE Arghya Majumdar MD DNB MR~P MCCMCPE Director and Head Department of Nephrology AMRI Hospitals Kolkata, West Bengal, India Professor Department of Pediatrics University of British Columbia and BC Children's Hospital British Columbia, Vancouver, Canada Rohit V Kodagali MD Medical Advisor Medical Department Boehringer Ingelheim Mumbai, Maharashtra, India • viii Amit M Narkhede MD DNB Senior Resident Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Prashant Nasa MD FNB EDIC ClC FCCP FICCM Specialist and Head Department of Critical Care Medicine NMC Speciality Hospital Dubai, United Arab Emirates Anand M Nikalje MD Medical Director and In-Charge Department of Medicine and Critical Care MIT Hospital and Research Institute Aurangabad, Maharashtra, India Odiraa ( Nwankwor MD MPH FAAP Consultant Department of Pediatrics Children's Regional Hospital atCooper University Hospital Camden, New Jersey, USA Consultant Department of Pediatrics Alfred I DuPont Hospital for Children Wilmington, Delaware, USA Mohan AMathew MD Director Department of Anesthesia and Critical Care Lakeshore Hospital Kochi, Kerala, India Divya Pal MD IDCCM Fellow (FNB) Critical Care Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India Yatin Mehta MD MNAMS FRCA FAMS Sadanand SKulkarni MD FIACTA FICCM FTEE Vice-President Department of Medical Affairs and Clinical Research Fresenius Kabi India Pvt Ltd Pune, Maharashtra, India Chairman Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India • JV Peter MD DNB MAMS FRACP FJFICM FClCM FICCM Professor and Head Medical Intensive Care Unit Christian Medical College Vellore, Tamil Nadu, India Contributors Natesh RPrabu MD DNB DM EDIC Sriram Sampath MD Manoj KSingh MD DNB FNB Specialist Registrar Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Maharashtra, India Professor and Director Department of Critical Care Medicine StJohn's Medical College and Hospital Bangalore, Karnataka, India Consultant Department of Critical Care Apollo Hospital International Ltd Ahmedabad, Gujarat, India Ramesh Venkataraman AB (1M) AB (CCM) Gauri Saroj MD IDCCM EDIC Senior Consultant Department of Critical Care Medicine Apollo Hospitals Chennai, Tamil Nadu, India Consultant Department of Critical Care Jupiter Hospital Thane, Maharashtra, India Suresh Ramasubban FACP FCCP AB Sanjith Saseedharan IDCCM EDIC Senior Consultant Department of Pulmonary and Critical Care Medicine Apollo Gleneagles Hospital Kolkata, West Bengal, India Head Department of Critical Care SL Raheja Hospital-AFortis Associate Mumbai, Maharashtra, India Banambar Ray MD FICCM Pratik Savaj DNB Omender Singh MD FCCM Director Institute of Critical Care Medicine Max-Super Speciality Hospital New Delhi, India Saswati Sinha MD IDCCM EDIC FNNCC DA FIMSA Chief Consultant Department of Critical Care and Anaesthesia' Apollo Hospitals Bhubaneswar, Odisha, India Fellow of National Board Department of Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mum,bai, Maharashtra, India Sumit Ray MD FICCM Mozammil Shafi MD FNB Senior Consultant and Vice-Chairperson Department of Critical Care and Emergency Medicine Sir Gangaram Hospital New Delhi, India Associate Consultant Institute of Critical Care and Anesthesiology Medanta-The Medicity Gurgaon, Haryana, India Camilla Rodrigues MD Prakash Shastri MD FRCA FICCM Consultant Department of Lab Medicine Hinduja Hospital and Medical Research Centre Mumbai,Maharashtra, India Senior Consultant and Vice-Chairman Department of Critical Care and Emergency Medicine SirGangaram Hospital New Delhi, India Samir Sahu MD FICCM Suhail SSiddiqui MD FCCM DM Director Department of Critical Care and Pulmonology AMRI Hospitals Bhubaneswar, Odisha, India Specialist Senior Resident Department of Anesthesiology, Critical Care and Pain Tata Memorial Hospital Mumbai, Mahrashtra, India Arijit Samanta DA MD FNB Dinesh KSingh MD FICCM FNB trainee Department of Critical Care and Emergency Medicine Sir Gangaram Hospital New Delhi, India Professor Department of Anesthesiology Institute of Medical Sciences Banaras Hindu University Varanasi, UttarPradesh, India Consultant Department of Critical Care AMRI Hospitals Kolkata, West Bengal, India Mehul KSolanki MD FNB Consultant Department of Critical Care BAPS Yogiji Maharaj Hospital Ahmedabad, Gujarat, India Rajeev Soman MD Consultant Department of Internal Medicine and Infectious Diseases PD Hinduja National Hospital and Medical Research Centre Mumbai, Maharashtra, India Peter ESpronk MD PhD EDIC FCCP Director Department of Intensive Care Medicine Gelre Hospitals Apeldoorn Apeldoorn, The Netherlands T Shyam Sunder MD PDCC FICCM Medical Director Thumbay Hospital Hyderabad, Telangana, India Nisha Tipparaju MBBS ICU Medical Officer Thumbay Hospital Hyderabad, Telangana, India Deeksha STomar DA IDCCM IFCCM Associate Consultant Department of Critical Care Medicine Medanta-The Medicity Gurgaon, Haryana, India ix Critical Care Update 2017 Younsuck Koh MD PhD FCCM Sushma Patil MD • Sharmili Sinha MD DNB EDIC Professor Department of Pulmonary and Critical Care Medicine Asan Medical Center University of Ulsan College of Medicine Songpa-gu, Seoul, Korea Consultant In-Charge Neuro Trauma Unit, Ruby Hall Clinic Pune, Maharashtra, India Senior Consultant Department of Critical Care Medicine Apollo Hospitals Bhubaneswar, Odisha, India Mahesh Nirmalan MD FRCA PhD FFICM Faculty of Biology, Medicine and Health Consultant, Intensive Care Medicine Manchester Royal Infirmary University of Manchester and Central Manchester Foundation Trust Manchester, United Kingdom Saroj KPattnaik DNB IDeCM Consultant, Department of Critical Care Medicine, Apollo Hospitals Bhubaneswar, Odisha, India Srinivas Samavedam MD FNB EDIC FRCP Head, Department of Critical Care Virinchi Hospitals Hyderabad, Telangana, India x EDIC Sunit CSinghi MD FlAP FAMS FISCCM Consultant Intensivist Department of Emergency Medicine and Critical Care Deenanath Mangeshkar Hospital Pune, Maharashtra, India FICCMFCCM • Head Department of Critical Care Niramaya Hospital Pune, Maharashtra, India DNBDMLE Swapnil RPatharekar MD IDCCM IFCCM Sunitha BVarghese DNB IDeCM EDIC Director-Principal Maharishi Markandeshwar Institute of Medical Sciences and Research Ambala, Haryana, India Ximena Watson MbCHb Department of Anesthesia Kingston Hospital Kingston, United Kingdom Preface Dear Friends It is indeed a proud moment for Indian Society of Critical Care Medicine (ISCCM) to launch the first Critical Care Update 2017 book during itsannual congress in Kochi Over theyears, attendance atISCCM congress has been increasing exponentially and ascientific congress book highlighting the key topics discussed inthecongress was long overdue This book has around 80 chapters authored by national and international faculty covering all the major topics which will be discussed during thecongress This update will highlight therecent advances made inthefieldofcritical care with special reference to its relevance and application in resource limited settings A special section on "Economics of ICU" is worth mentioning We sincerely hope this book will be useful bothfor young intensivists to promote analytical thinking, post graduates to keep abreast of recent advances, and also to senior clinicians The publication of thls book was possible only through ajoint effortfrom themembers of theeditorial board, authors, and the publisher We hope this book willcontinue to bepublished in thefuture congresses - Subhash Todi Atul PKulkarni Kapil Zirpe , I CHAPTER 76:Severity of Illness Scores and Their Role in Assessing Intensive Care UnitCosts However, this relation between acuity of illness to cost is not completely linear." In fact, the relationship between severity scores and ICU cost is quite complicated Breslow and Badawi used an electronic ICU databaseand found that severity score on admission correlates with length of stay (and therefore cost)." However, the correlation was stronger for survivors than nonsurvivors The authors suggestedthat sicker patients require longer time to recover and would consume more resources 10 On the other hand, nonsurvivors had a shorter lengthofstay Thus, ICUs with better outcomes (where severely ill patients have better survival rates than predicted by their severity score) would have higher costs per patient than an ICU where more severely ill patients died." This observation emphasizes the importance of not only calculating day-l severity score to describe the severity ofillness of patientsadmitted to an ICU, but alsothe need to calculate the standardized mortality ratio (ratio of observed mortality/predicted mortality) before makingcost comparisons Dickie et al in their study of 257 ICU patients from the United Kingdom demonstrated that TISS reliably measures the costin the overall ICU population," However, the relation of the TISS scoreto the individual patient cost was not very robust and the difference between the estimated cost and the actualcostdiffered byas much as ±65% Considering that activity scoresmaybea surrogate forvariable costsand notfor the fixed ICU costs, this observation is not surprising Moran et al studied daily TlSS and omega scores and correlated them with actualICU costs in 1,333 Australian ICU patients and found that omegascorewas more usefulthan TISS and that totalcostcouldbe predictedbyomegascore, APACHE III scoreon admission, and ICU lengthofstay 17 They concluded that a combination of severity scores and activity indices couldmoreaccurately predictindividual patient'sICU cost 17 Scores and Cost Analysis in Indian Intensive Care Units Use of Activity Scores in Cost Analysis Many activity scores have been used to estimate cost of intensive care.Activity scoreshave been more effective than severity scores in estimating ICU costS.8,23 The TISS system has been most extensively used for this purpose and was devised as a method to compare patient care quantitatively among patients in the intensive care unit andoriginaIIy consisted of 76 activities which were assigned scores." This was then simplified and the number of items were reduced from 76 to 28." This modified TISS systemhas been used in many countries and found to be a useful predictor of ICU costS.13-15Infactmanystudieshavebeen ableto estimatecost per TISS point which could be a more realistic indicator of the standardizedcostofintensive carein a health caresystem (Table 1).13-15,24-27 However, cost per TISS point should only be interpretedbytakinginto consideration severity of illness and standardizedmortality ratios TABLE Co~t per the Th~rape~tic Inter~ention Severity Score POint reported In various studies Authors Year of Country publication ! Moerer et al 24 , 2007 Cost per _ TI55 point ; Germany ~! CONCLUSION m . _ _._ ,_ , 3€ ~f~;;~il~~~r~;:z_~~=]~_E~_j i Dickie et al.26 c···_· ··_···_·_- _, _._ I Parikh et al : ~ 1998 "-~-'i'-~ 13 i 1998 IUnited Kingdom I £25 '-.-. -' - ".- , India !~90 _ -;_ . _ _- '-'- ,.-.-. _. ,.-.- ~. , - - - -····-r ,-, .- - : Hariharan et alP ! \ _- _ _._ -_.- :L Clermont et al 15 _" " -~~- • 1998 _-0.• ~ . -( United States L _ _ _ ._ _ TISS, Therapeutic Intervention Severity Score -_ ': : £13 _:_ - - - _I!~~!~~ - 1994 l Sweden : $54 ,., : - "-.-." .-.-." _ : Malstam et al.14 ~ , -. .- . - - .- i Trinidad and 2007 ~ 'T' '-'~ ' -,_ j ' $268 _.L _._ While a few studies have performed cost analysis in Indian ICUS,I3,28-30 several factors need to be considered before applying scoresto performcostcomparisons invariousICUs • The disparity of the health care system (rural vs urban divide with respect to the resources and expertise available) preventsdelivery ofa uniform standardofcare fora particularseverity ofillness • Amount of care may vary for the same illness based on the sizeofthe hospitaleven in largecities • Wide variability in the availability, quality and cost of equipment used for various treatments (e.g., ventilators, bedside monitors), pharmacy cost between hospitals, level oftraining, and expertise ofnursesmaysignificantly altertotal costand costper TISS point • The nurse patient ratio ranges from 1:2 to 1:4 in Indian ICUs, and manpower costs accounts for 25-50% of variable ICU costs • Finally, althoughseverity and activity scoresmay help in adjusting for some of these differences in levels of care in Indian ICUs, cost differences should also take into account survival rates in ICUs being studied since cost are higher in ICUs where very severely ill patients are treated and withbetter outcomes _ ; Useofscoresas asurrogate forICU costshave limitations and, bythemselves, havenot been foundtobe useful tocompletely predict variable costs per patient On the other hand, they could havean important rolein comparing health care costs in different health care systems or ICUs by standardizing for casemix, severity ofillness, quantityofcare, and outcomes This should be done in five stages: Are the patients admitted in the two ICUs comparable? Severity scores could be used to ensure that baseline severity ofillness in patientsin the two ICUs issimilar 459 SECTION 10:Economics of Intensive Care UnitCare Are the patterns or organ dysfunction similar? Organ dysfunction scores could be used to quantitate the number of organ systems affected and also the specific organsthatwill require support Are outcomesin bothICUs comparable? The standardized mortalityratios should be compared Although baseline severity ofillnessisthe same, highercostsinoneICUmay be due to lower mortality, which correlates with greater length ofICUstayand highercost Is the quantity of care provided in the two ·ICUs comparable? Use of activity scores will help in this comparison-totalTISS per patientor day-I TISS couldbe compared What is the cost per TISS point? Lower cost in one ICU could be because of lowerquantityof care, so that cost per TISS point maybe the samein bothICUs Conversely, lower cost per TISS point would mean more efficient delivery of intensive care, provided that all previous indicatorsare comparable Finally, while standardizing costsformaking, comparisons is only one aspect of health economics of intensive care However, it should not be seen independentof the primary, secondary, and tertiary healthcare system in the country or region This is especially important when making comparisons across completely diverse healthcare systems as ininternational or regional comparisons L~~~~~E~~~~ . _ _ _ _ _.o_. ~ ",_.~ Kahn JM Understanding economic outcomes in crttical care Curr Opin Crit Care 2006;12(5):399-404 Jayaraman R, Ramakrishnan N Cost ofintensive care inIndia Indian JCrtt Care Med.200B;12(2):55-61 Kapadia F, Kulkarni AP, Divatia Jv India: Where have we been? ICU resource allocation in the new mill~nnium: Will we say "No'? 1stedition Springer, New York; 2013 pp 33-8 Divatia JV, Amin PR, Ramakrishnan N, etal Intensive care in India: the Indian intensive care case mix and practice patterns study Indian J Crit Care Med 2016;20(4):216-25 Patel V, Parikh R, Nandraj S, Balasubramaniam P, et al Assuring health coverage for all in India Lancet 2015;3B6(1 0011 ):2422-35 Burchardi H, Jegers M, Goedee M, Leimis JU Benchmarking in the ICU: the measurement of costs and outcome to analyze efficiency and efficacy Evaluating Critical Care: Using Health Services Research to Improve Quality Springer-Verlag, Berlin; 2002 pp, 222-43 Understanding Costs and Cost-Effectiveness in Critical Care: Report from the Second Amertcan Thoracic Society Workshop on Outcomes Research Am J Respir Crit Care Med 2002;165(4):540-50 B Jegers M, Edbrooke DL, Hibbert CL, et al Definitions and methods of cost assessment: an intensivist's guide ESICM section on health research and outcome working group on cost effectiveness Intensive Care Med 2002;2B(6):6BO-5 Vincent JL, Moreno R Clinical review: Scoring systems in the critically ill Crit Care 2010;14(2):207 460 10 Breslow MJ, Badawi O Severity scnring in the critically ill: Part 2: Maximizing value from outcome prediction scoring systems Chest 2012;141 (2):51 B-27 11 Miranda DR, de Rijk A, Schaufeli W Simplified therapeutic intervention scortng system: The TISS 2B items-results from a multicenter study Crit Care Med 1996;24(1):64-73 12 AngusDC, Linde-Zwirble WT, Lidicker J, et al Epidemiology of severe sepsis in the Un~ed States: analysis ofincidence, outcome, and associated costs of care Crit Care Med 2001 ;29(7):1303-1 O 13 Parikh CR; Karnad DR Quality, cost, and outcome of intensive care in apublic hospital in Bombay, India Crit Care Med 1999;27(9):1754-9 14 Malstam J, Lind L Therapeutic intervention scoring system (TISS)-a method for measuring workload and calculating costs in the ICU Acta Anaesthesiol Scand 1992;36(B):75B-63 15 Clermont G, Angus DC, Linde-Zwirble WT, et al Measuring resource use in the ICU with computerized therapeutic intervention scoring system-based data Chest 199B;113(2):434-42 16 Sznajder M, Leleu G, Buonamico G, Auvert B, Aegerter P, Meriiere Y, et al Estimation of direct cost and resource allocation in intensive care: correlation with Omega system Intensive Care Med 199B;24(6):5B2-9 17 Moran J, Peisach A, Solomon P, et al Cost calculation and prediction in adult intensive care: a ground-Up utilization study Anaesth Intensive Care 2004;32(6):7B7-97 1B Carson SS, Bach PB The epidemiology and costs ofchronic crttical illness Crit Care Clinics 2002;1 B(3):461-76 19 Bertolini G, Confalonieri M, Rossi C, Rossi G, Simini B, Gorini M, et al Costs of the COPD Differences between intensive care unit and respiratory intermediate care unit Respir Med 2005;99(7):B94-900 20 Dahl 0,Wo~al GG, Breslow MJ, et al The high cost of low-acuity ICU outliers J Healthc Manag 2012;57(6):421-33 21 Berenson RA Intensive Care Units QCUs): Clinical Outcomes, Costs, and Decision-making (Health Technology Case Study 2B), prepared for the Office of Technology Assessment, U.S Congress, OTA-HCS-2B, Washington DC, November 19B4 22 Adrie C, Alberti C, Chaix-Couturier C, Azoulay E, et al Epidemiology and economic evaluation ofsevere sepsis in France: age, severity, infection site, and place of acquis~ion (commun~, hosp~l, or intensive care unit) as determir.ants ofwor1