The evolution of Australian intensive care and its related costs: A narrative review

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Review Paper

The evolution of Australian intensive care and its related costs: A narrative review Kelly Thompson RN, BN, MPH (Economic Evaluation) a,b,∗ Colman Taylor PhD (Dr.) a Kevin Forde M Comm (Hons) (A/Prof) b Naomi Hammond RN, BN, MN (Crit. Care), MPH a,c,d,e a

Critical Care & Trauma Division, The George Institute for Global Health, Sydney, Australia School of Public Health and Community Medicine, UNSW, Australia c Sydney Medical School, University of Sydney, Sydney, Australia d Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia e St. George Clinical School, University of New South Wales, Sydney, Australia b

article information Article history: Received 27 June 2016 Received in revised form 1 August 2017 Accepted 11 August 2017 Keywords: Intensive care History Cost Narrative synthesis Systematic review

a b s t r a c t Objective: To conduct a narrative review on the evolution of intensive care and the cost of intensive care services in Australia. Review method: A narrative review using a search of online medical databases and grey literature with keyword verification via Delphi-technique. Data sources: Using Medical Subject Headings and keywords (intensive care, critical care, mechanical ventilation, renal replacement therapy, extracorporeal membrane oxygenation, monitoring, staffing, cost, cost analysis) we searched MEDLINE, PubMed, CINAHL, Embase, Google and Google Scholar. Results: The search yielded 30 articles from which we provide a narrative synthesis on the evolving intensive care practice in relation to key service elements and therapies. For the review of costs, we found five relevant publications and noted significant variation in methods used to cost ICU. Notwithstanding the limitations of the methods used to cost all publications reported staffing as the primary cost driver, representing up to 71% of costs. Conclusion: Intensive care is a highly specialised medical field, which has developed rapidly and plays an increasingly important role in the provision of hospital care. Despite the increasing importance of the specialty and the known resource intensity there is a paucity of data on the cost of providing this service. In Australia, staffing costs consistently represent the majority of costs associated with operating an ICU. This finding should be interpreted cautiously given the variation of methods used to cost ICU services and the limited number of available studies. Developing standardised methods to consistently estimate ICU costs which can be incorporated in research into the cost-effectiveness of alternate practice is an important step to ensuring cost-effective care. © 2017 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Background Intensive care is a medical specialty dedicated to the management of patients with life-threatening illness.1 In 1961, the first two intensive care units (ICUs) opened in Australia. By 2007 there were 149 ICUs providing 1881 available beds, 1318 ventilator beds

∗ Corresponding author at: The George Institute for Global Health, Critical Care & Trauma Division, L3, 50 Bridge Street, Sydney, NSW 2000, Australia. E-mail address: [email protected] (K. Thompson).

and staffed by a total of 6578 full time registered nurses and 477 full time intensive care specialists.2 Intensive care is an integral component of modern healthcare3 providing advanced technologies which require the skills of highly specialised healthcare professionals.4 The demand for ICU services and the cost of providing these services has increased rapidly5 due to an ageing population and the introduction of new technologies which have enabled long-term multi-organ support.6,7 Epidemiological studies have shown that most hospital deaths occur in the ICU1 and that only a small proportion (4%) of patients admitted

http://dx.doi.org/10.1016/j.aucc.2017.08.004 1036-7314/© 2017 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Thompson K, et al. The evolution of Australian intensive care and its related costs: A narrative review. Aust Crit Care (2017), http://dx.doi.org/10.1016/j.aucc.2017.08.004

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have an advanced care directive in place.2 In light of this, research evaluating the cost and sustainability of intensive care is important. Our objective was to provide a narrative review of the literature to understand and describe the evolution of intensive care services from inception to present (1970s–2016) and the estimated costs of providing ICU services in Australia. We report on the development of key service elements (such as invasive therapies, monitoring, and staffing) that may have contributed to the increasing costs of providing intensive care services over time as well as the reported costs of providing ICU services in Australia. 2. Review method & data sources To identify articles that reported on the development of ICU in Australia we undertook a broad search of the literature via multiple online sources using Cochrane’s recommended guidelines for conducting narrative synthesis.8 MEDLINE, PubMed, CINAHL and Embase were searched using Medical Subject Headings (MeSH) including; Intensive Care, Critical Care, Australia and ‘History, 20th Century.’ We then consulted an informal Delphi panel of experienced ICU clinicians and academics to determine the main service elements of intensive care. This enabled us to develop specific keywords to separately insert into the original MeSH search string (excluding the Australia and/or History, 20th Century MeSH to increase yield of search). Our keywords included; mechanical ventilation; renal replacement therapy (RRT) and extracorporeal membrane oxygenation (ECMO); monitoring; nursing staff and medical staff. Titles and abstracts of articles were reviewed and included if they reported a comprehensive or historical perspective on the development of ICU in Australia (Fig. 1). To describe the actual costs of ICU services over time we undertook a separate search of both MEDLINE and the grey literature (Google and Google Scholar) to identify articles evaluating the cost of intensive care services and interventions using MeSH terms of; Intensive Care and/or Critical Care and ‘Australia’ with economic focussed MeSH terms; Costs and Cost Analysis. Finally, we reviewed the reference lists of relevant articles and the grey literature to find additional material not found through the other search methods. 3. Results Fig. 1 provides an overview of the search results on the evolution of intensive care with a total of 30 articles describing the development of intensive care considered relevant for discussion in this narrative review. From the included 30 articles on the evolution of intensive care, we describe modern intensive care services and the development over time of the key service elements (invasive therapies, monitoring and staffing) of ICUs in Australia. We also report a summary of the five from nine relevant costing studies, estimating the cost of receiving care in an Australian ICU and compare costs over time.

increased due to the establishment of multidisciplinary ICUs, the ability to obtain point-of-care pathology such as arterial blood gases, and rapidly advancing engineering technology.9 Developed in the 1950s, the first ventilators required patients to receive pharmacological paralysing and sedative agents to enable effective ventilation.10 Significant developments have occurred since this time including; the introduction of Positive End Expiratory Pressure (PEEP), the invention of pressure support ventilation in the 1980s which revolutionised ventilator weaning, and the introduction of safety alarms in the 1990s.9 Technological developments have made mechanical ventilators safe and sophisticated devices able to synchronise spontaneous patient breaths and mechanical breaths without the requirement for pharmacological intervention.9,11 Despite many advances in modern Australian ICU’s, less than half of all patients receive mechanical ventilation during their admission12 implying a trend away from mechanical ventilation as an absolute requirement for admission to the ICU. 3.1.2. Continuous renal replacement therapy Renal replacement therapy (RRT) was developed for patients with chronic renal failure but was adapted by the intensive care specialty in the 1970s to enable continuous RRT to be carried out on critically ill patients. With the early devices, complications were common due to the requirement for arterial puncture and adequate blood pressure to tolerate the therapy.13 In the 1980s, the invention of double lumen catheters enabled delivery of RRT via venepuncture and the introduction of peristaltic pumps enabled large volumes of blood to be removed, cleaned and replaced to the patient in a continuous cycle. Both advances significantly improved the safety of administering RRT in the ICU.13 In 2001, the incidence of severe acute renal failure requiring RRT in Australia and New Zealand was approximately 8 per 100,000 adults per year.14 Despite these technological advances to improve the efficacy of RRT delivery in ICU, the mortality and morbidity burden for patients that require RRT in the ICU remains high.13,14 3.1.3. Extracorporeal membrane oxygenation Extracorporeal membrane oxygenation (ECMO) evolved from the discipline of cardiac surgery in the 1950s and is considered the most invasive and resource intensive therapy available in modern intensive care.15 ECMO provides cardiac and/or pulmonary support as an alternative means of respiratory gas exchange to aid oxygenation and ventilation to allow severely injured lungs time to rest and heal.15,16 Use of ECMO in ICU was not widely adopted throughout the 1970s and 1980s due to mortality rates of greater than 90%.15 In the last two decades advances in technology to increase circuit life and the introduction of veno-venous ECMO have made delivery safer.15,17 Targeted research on the use of ECMO in ICU patients has demonstrated better chances of survival15 and in 2009 during the H1N1 epidemic ECMO was successfully used to prevent mortality in greater than 80% of cases.18 Despite improvements in safety and efficacy, ECMO is infrequently used, generally initiated as a rescue therapy and commenced on suitable candidates when all other therapeutic measures have been exhausted.15

3.1. Key ICU service elements Highly invasive therapies have enabled ICU clinicians to support physiological life in the absence of independently functioning vital organs. This may have considerable implications for the economics of care.1 This literature search and Delphi panel identified several therapies which are fundamental to supporting life in the ICU and potentially contribute to the increasing costs of ICU services. 3.1.1. Mechanical ventilation Positive pressure ventilation facilitated the development of the intensive care specialty.9 In the last 60 years, ventilator use has

3.1.4. Monitoring The availability of continuous physiological monitoring and patient observation by skilled nursing staff is a core capability provided in all ICUs.19 The first invasive monitoring devices available in ICU were central venous catheters (1960s) and pulmonary artery catheters (1970s).13 These devices stimulated the speciality by providing insight into haemodynamics at the bedside.13 Monitoring capabilities have continued to evolve since the beginnings of ICU with the College of Intensive Care Medicine (CICM) Minimum Standards for Intensive Care (2011) providing the best insight into current bedside monitoring requirements.19 Monitoring devices

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Fig. 1. Search methods and results—evolution of intensive care services. * All included relevant ‘nursing staff’ results were also previously identified in the initial broad MeSH search term results, where results are duplicated articles have only been accounted for once.

in modern ICUs use advanced technology capable of alerting the bedside nurse to any sudden alteration in the patient’s condition implying the importance of skilled personnel to continuously and simultaneously manage both patient and device. 3.2. Staffing

data, predictable workload, tradition, severity of illness and budget constraints.20 The ACCCN recommends a nurse to patient ratio of 1:1 for ICU patients and 1:2 for high dependency patients where illness severity is generally lower (Table 1).21 It is recommended that at least 50% of nursing staff are qualified critical care nurses21 and all nursing staff responsible for direct patient care must be registered nurses.21

3.2.1. Nursing staff Intensive care nurses require specialist knowledge, skills and training.9,20 Historically, ICU nurses were prohibited from performing interventions without an order from a qualified medical practitioner.9 However, Australian ICU nurses now have independent responsibilities20 including operation of invasive devices such as ECMO machines, mechanical ventilators and dialysis machines, along with the administration and titration of vasopressors and inotropes.14 Australian intensive care nurses are represented by the Australian College of Critical Care Nurses (ACCCN).21,22 Determination of staffing needs is based on professional standards, historical

3.2.2. Medical staff ICUs are staffed by medical specialists, termed ‘intensivists’, specifically trained to provide intensive care medicine. Intensive care specialist training was first formally provided in Australia in 1976. The role of the intensivist has evolved from the foundations of anaesthesiology, where the skills of resuscitation, emergency intubation and mechanical ventilation were well established.22,23 Modern Australian intensivists work in a ‘closed’ system, taking responsibility for the overall management, treatment, admission and discharge of patients with input from other specialties as required.22 Constant medical practitioner patient supervision is

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4 Table 1 CICM minimum ICU staffing requirements.a Level of ICU

Nurse to patient ratio

Medical staffing requirements

Level I

• 1:1 for ventilated patients • 1:2 for high dependency patients • Minimum 2 RNs at any time

• Medical directorb • 24/7 registered medical practitioner

Level II

• 1:1 for ventilated patients • 1:2 for high dependency patients • In-charge nurse + additional nursing staff • 1 FTE nurse educator per 50 nurses

• Medical director • FTE intensivists at least >50% FTE • 24/7 intensivist availability

Level III

• 1:1 for ventilated patients • 1:2 for high dependency patients • In-charge nurse + additional nursing staff • 1 FTE nurse educator per 50 nurses

• Full time medical director • 4 FTE intensivists • 2 for every 4 FTE staff at least >50% FTE • All intensivists must be fellows of the CICM • 24/7 intensivist availability • Experienced medical practitioner present/8–15 patients

a

RN denotes registered nurse, FTE denotes full time equivalent. Where medical directors for all unit levels must be a Fellow of The College of Intensive Care Medicine (CICM).

ogy, whereby all ICU resources were retrospectively identified and summed, then divided by the number of patient bed days.27 McKinley’s two-part critical care costing study was as a component of a National Service Weights Study, which collected data on 1600 patients from 44 ICU’s in 34 public, private and paediatric units.28,29 Data included demographic and physiological status, interventions received and the cost of the ICU stay. ICU costs were obtained for each day of stay and services costed included; staffing (nursing and allied health were costed by time spent per patient and medical time was estimated by expert group consensus), consumables such as drugs and medical/surgical supplies, equipment (including maintenance), sterilisation, depreciation, goods and services and overheads.28 The remaining two studies did not specify the costing methods used to estimate the cost of ICU services. Table 2 summarises the reported costs of a bed day in Australian ICUs between 1976 and 2010, with 2010 being the last found report of the cost of ICU services in Australia. Across all identified studies that report a breakdown of costing, staffing costs were reported as the most significant cost, representing 54% ($277AUD per day in 1976) to 71% ($4028AUD per day in 2010) of costs.26,27,30 The proportion of costs allocated to clinical support, defined as laboratory and pathology costs in two of three studies, increased from 2% in 197630 to 10% in 2003,27 though importantly the definition of clinical support was not defined in the report from 1976.28 The average length of stay remained relatively unchanged at 3.4–3.9 days.26,27 Between 1976 and 2003 equipment and consumables consistently accounted for approximately 20% of ICU costs.26,27,30 Notwithstanding the limitation of variability in methods used to cost services, the main cost components of intensive care identified in this narrative review were relatively consistent regardless of study methodology and can be summarised as; staffing (54–71%), equipment and consumables (16–22%) and clinical support (2–11%).

b

4. Discussion mandatory and in order to achieve this provisional fellows, trainees, registrars and residents assist in providing a continuous service (Table 1).22 In addition to providing continuous patient supervision the role of ICU nurses and doctors has extended beyond the physical location of the ICU.24 Medical Emergency Teams (MET), were first trialled in 1990 at Liverpool Hospital, Australia, involving the escalation of care to the intensive care team for a deteriorating ward patient.24 Further, intensive care transport systems have also been developed providing a seamless transition between hospitals and extending the reach of intensive care medicine to the pre-hospital setting.25 3.3. ICU costs The literature search on the cost of ICU in Australia returned five articles reporting the cost of ICU services, with significant variability in the methods used to cost services. The study by Moran et al. used a comprehensive combination of ground up costing methods from data collected in three South Australian ICUs including; use of daily activity scoring systems Therapeutic Intervention Scoring System (TISS) and Omega scores as well as using patient level data to determine the total cost of consumables including drugs, procedural costs, pathology and radiology interventions. Medical, nursing and physiotherapy staffing costs were allocated based on units of time spent with individual patients in accordance with wages for each staffing category. They accounted for overheads, and included readmissions within the study period.26 The study by Rechner and Lipman used ground-up methodol-

Intensive care is a highly specialised medical specialty where interventions are implemented and managed by trained intensivists and therapies are delivered and continuously monitored by highly skilled nursing staff.19 The ICU patient population has changed. Patients are increasingly older and more likely to have a pre-existing comorbidity, few have an advanced care directive in place on admission.2 Technology has advanced rapidly. Mechanical ventilation, RRT and ECMO are safer and can be implemented and closely managed via invasive monitoring systems capable of instantly notifying skilled ICU staff of any slight variation in a patient’s condition.14,20,22 Despite these advances the average length of ICU stay is unchanged at approximately 3.5 days.25,26,28 This may be due to greater variability in case-mix i.e. whilst new technologies enable ICU’s to prolong life for the sickest patients, this should be juxtaposed to other groups of ICU patients who require a short predefined period of intensive care such as patients undergoing cardiac surgery. The cost of providing ICU services is high, with the last estimate at $4028AUD per bed day in 2010 and costs have increased consistently at a rate higher than inflation. Despite significant limitations of our comparisons due to different methodologies used to cost ICU services, there does not appear to be a ‘gold standard’ approach to costing Australian ICU services. However, some common consistencies in methods and results were noted. Staffing is consistently reported as the most expensive ICU resource, at a maximum of 71% of total costs.26–28,30 ICU costing studies frequently report costs on a per diem or per episode basis but it is well known that the case-mix of ICU patients is diverse and resource use is greatly dependent on illness severity. A mechanism to cost ser-

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Table 2 Costs of ICU per day over time in Australia. Year Type of study

1976 Historical narrative, costing methods not stated. $277

1991 Multi centre ground up utilisation using TISS & OMEGA $1744b

1994 Multi centre National Service Weights Study

2003 Single centre top-down study

2009/2010 Government report, methods not stated

$1680

$2670

$4028

Medical and nursing staff costs Consumables Equipment Clinical support Miscellaneous Overheads

$197 $55 $10 $5 $10

$942 $278

54% 16%

Not reported

$193 $41 $295

11%a 2.5% 17%

$1835 $525 $54 $255

Adjusted for inflationc (Dec 2016) (AUD) Average length of stay (days)

$1761 3.4

$2942

$3694 3.69

Cost per bed day (AUD)

a b c

71% 20% 3.5% 2% 4%

$3202 3.9

69% 20% 2% 9.5%

Not reported

$4698

Additional 11% added to account for clinical support which was excluded from total cost. To convert the episode cost to a per diem cost the episode cost $AU6801 was divided by the average length of stay 3.9 days. Adjusted using Reserve Bank of Australia Inflation Calculator sourced from http://www.rba.gov.au/calculator/annualDecimal.html.

vices based on resource allocation would enable health economists to more robustly estimate and predict the costs of ICU services and would be relatively simple to implement in Australia where many ICUs already routinely report administrative health data. Costing ICU services modelled on resource allocation would also be of great benefit for research into the cost-effectiveness of alternate practice which would provide valuable information to healthcare decision makers and policy experts and is an increasingly important component of clinical research. To our knowledge, this narrative synthesis is the first of its kind to evaluate and summarise the development of the key elements of ICU including studies that have reported the costs of ICU practice in Australia. We present a broad review of the literature on the development of ICU and it’s key components to provide readers with a deeper understanding of changing ICU practices prior to reporting our cost findings. Due to the broad nature of the topic it is possible we did not find all relevant articles. Our search was not limited by year but we only searched published articles and only included articles in English, which is pragmatic in the Australian context. No hand-searching of journals or conference proceedings or contact with authors was made. We searched a variety of online databases, along with strengthening our search terms by using an informal Delphi panel of clinical experts to inform on key service aspects of intensive care. Importantly it should be noted that as the structure and services provided by ICUs changed significantly between 1976 and 2010, the costs reported in the included studies are not strictly comparable and some of the cost increases reported would be accommodating changes in the structure of ICUs over this period. Furthermore, as 2010 was the last timepoint at which we could find reported costs on ICU, these costs are likely to underestimate the cost of providing ICU services in 2016/2017.

4.1. Implications and future direction Intensive care is a high cost resource which consumes a significant proportion of hospital based healthcare spending. As such, a significant finding of this review is the limited evidence regarding the cost of ICU services in Australia and, more importantly, the significant variability in methods used to estimate ICU costs and resource allocation. As the population ages and rates of co-morbid chronic illness rise the demand for ICU services will increase. Developing standardised methods to estimate ICU costs in Australia which may be widely applied in healthcare policy and planning as well as in research into the cost-effectiveness of altering clinical practice is important to ensuring the sustainability of this important healthcare resource.

5. Conclusion Intensive care is a high cost healthcare resource in Australia with staffing consistently reported as the major cost driver. Developing methods to estimate costs of ICU services in Australia which can be used by researchers, healthcare decision makers and policy experts would provide further clarity on the cost and cost-effectiveness of this expensive but vital resource.

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