1.1 Scope of Review

The following review of the past work done in the area of intensive care unit (ICU) length of stay is divided into two parts. The first part covers the studies done on the PICU length of stay while the second part delves into the literature of ICU length of stay.

1.2 Studies of Length of Stay in Pediatric Intensive Care Unit

Ruttimann & Pollack (1996) investigated the relationship of length of pediatric intensive care unit (PICU) stay to severity of illness and other potentially relevant factors available within the first 24 hours after admission. A median and geometric mean length of PICU stay of 2.0 and 1.9 days respectively, and the upper 95th percentile at 12 days were found. To prevent undue influence of outliers, all patients staying longer than 12 days were considered long-stay patients (4.1% of the total sample) and were excluded from the model-building process. In the LOS prediction model, variables found to be significantly associated (p <0.05) with prolonged length of PICU stay included Pediatric Risk of Mortality (PRISM) score, 10 diagnostic groups, 3 preadmission factors (operative status, inpatient/outpatient, previous PICU admission), and first-day use of mechanical ventilation (Table 2.1).

Table 1.1: Log-logistic regression model for length of stay

Log partial likelihood = -5487.2; global chi-square value = 1601.9; df = 15; p <0.0001

CI, Confidence interval; CNS, Central nervous system

*LOS ratios computed relative to PRISM score = 0.

†LOS ratios computed for an interaction with PRISM score = 6.42 (sample average).

Source: Modified from Ruttimann & Pollack (1996).

In the same study, Ruttimann & Pollack (1996) noted the ratio of observed to predicted LOS varied among PICUs from 0.83 to 1.25. The PICU factors associated (p <0.05) with shorter (5% to 11%) LOS were presence of an intensivist, presence of residents, and coordination of care, whereas an increased ratio of PICU to hospital beds was associated with longer (p <0.05) LOS (Table 2.2). After adjusting to patient conditions, medical school affiliation, admission volume, number of pediatric hospital beds, and PICU mortality rates did not have statistically significant effect on LOS. The study proposed the use of predictors to adjust LOS in PICUs for patient-related risk factors at admission, and hence enabling the comparison of resource utilization among different institutions.

Table 1.2: Effect of PICU characteristics on length of stay

CI, Confidence interval.

*2 Ã- ln (likelihood ratio) test.

†LOS ratio and 95% CIs computed for and increase of PICU/hospital bed ratio by a factor of 2.

Source: Modified from Ruttimann & Pollack (1996).

Development of a new LOS prediction model was necessary due to the availability of a newly updated pediatric severity-of-illness assessment system, PRISM III-24 (Pediatric risk of mortality, version III, 24-hour assessment). Ruttimann et al. (1998) have then fitted a generalized linear regression model (inverse Gaussian) to the observed LOS data with the log link function. In the new LOS prediction model, variables found to be significantly associated (p <0.05) with prolonged length of PICU stay included PRISM III-24 score, 8 diagnostic groups, 3 preadmission factors (operative status, inpatient/outpatient, previous PICU admission), and first-day use of mechanical ventilation (Table 2.3).

Table 1.3: Generalized linear regression model (inverse Gaussian) for length of stay (n = 9558)

CNS, Central nervous system; CV, cardiovascular system.

°Effect of the variable after adjusting for the effects of all other variables in the model.

†Log-likelihood ratio compared with the chi-squared distribution with 1 degree of freedom.

‡See Fig.2 (pg 82, Ruttimann et al. 1998).

Model fit: Scaled deviance = 9558 (chi-square with 9543 degrees of freedom, p >0.45). Observed versus predicted length of stay, mean (± SEM) in: training sample (n = 9,558): 2.351(± 0.032) versus 2.360(± 0.011), p >0.64; test sample (n = 1,100): 2.461(± 0.069) versus 2.419(± 0.035), p >0.49.

Source: Modified from Ruttimann et al. (1998).

Ruttimann et al. (1998) have also assessed the PICU efficiency with the new LOS prediction model and validation of the assessment by an efficiency measure based on daily use of intensive care unit-specific therapies (based on the criterion whether on each day a patient used at least one therapy that is best delivered in the ICU). PICU efficiency was computed as either the ratio of the observed efficient days or the days accounted for by the predictor variables to the total care days, and the agreement was assessed by Spearman’s rank correlation analysis. PICU efficiency comparisons for both the predictor-based and therapy-based methods are nearly equivalent. Ruttimann and colleagues (1998) acknowledged the advantage of predictor-based efficiency as it can be computed from admission day data only.

It was of researchers’ utmost interest to study the extended LOSs as well. Long-stay patients (LSPs) in the PICU were later being examined by Marcin et al. (2001). As explained previously, LSPs were defined as patients having a length of stay greater than 95th percentile (>12 days). In the study, the clinical profiles and relative resource use of LSPs were determined and a prediction model was developed to identify LSPs for early quality and cost saving interventions. To create a predictive algorithm, logistic regression analysis was used to determine clinical characteristics, available within the first 24 hours after admission that were associated with LSPs. Marcin and colleagues (2001) noted that, “Long-stay patients in the PICU consume a disproportionate amount of health care resources and have higher mortality rates than short-stay patients.”

Multivariate analysis of the study identified predictive factors of long-stay as: age <12 months, previous ICU admission, emergency admission, no CPR before admission, admission from another ICU or intermediate care unit, chronic care requirements (total parenteral nutrition and tracheostomy), specific diagnoses (acquired cardiac disease, pneumonia, and other respiratory disorders), having never been discharged from the hospital, need for ventilatory support or an intracranial catheter, and a Pediatric Risk of Mortality III (PRISM III) score between 10 and 33 (Table 2.4). Marcin et al. (2001) concluded that LSPs have less favorable outcomes and use more resources than non-LSPs. The clinical profile of LSPs includes those who are younger and those that require chronic care devices. The predictive algorithm was expected to help in identifying patients at high risk of prolonged stays appropriate for specific interventions.

Table 1.4: Significant independent variables from the logistic regression analysis

CI, confidence interval; ICU, intensive care unit; CPR, Cardiopulmonary resuscitation; IMU, intermediate care unit; TPN, total parenteral nutrition; PRISM, Pediatric Risk of Mortality.

Source: Modified from Marcin et al. (2001).

In a case study carried out by Kapadia et al. (2000) in a children’s hospital in the Texas Medical Center in Houston, discrete time Markov processes was applied to study the course of stay in a PICU as the patients move back and forth between the severity of illness states. To study the dynamics of the movement of patients in PICU, PRISM scores representing the intensity of illness were utilized. The study modeled the flow of patients as a discrete time Markov process. Rather than describing by a string of services and scores, the course of treatment and length of stay in the intensive care was described as a sequence of ‘Low’, ‘Medium’ and ‘High’ severity of illness. The resulted Markovian model appeared to fit the data well. The models were expected to provide information of how the current severity of illness is likely to change over time and how long the child is likely to stay in the PICU. The use of a Markovian approach allowed estimation of the time spent by patients in different severity of illness states during the PICU stay, for the purposes of quality monitoring and resource allocation.

1.2 Studies of Length of Stay in Intensive Care Unit

According to Gruenberg et al. (2006), institutional, medical, social and psychological factors collectively affect the length of stay (LOS) in the intensive care unit (ICU). Institutional factors include geographic location, resources, organizational structure, and leadership. In term of medical factors, specific medical interventions, specific clinical laboratory values, and the type and severity of patients’ illnesses were found to be related to length of stay in the ICU. Social factors such as lack of quality communication between patients’ families and physicians or other healthcare personnel, and conflict between patients’ families and hospital staff have resulted in prolonged ICU and hospital stays. Anxiety and depression experienced by a patient’s family members are psychological characteristics that contribute to inadequate decision making and extended ICU stays.

In order to examine the impact of prolonged stay in the intensive care unit (ICU) on resource utilization, Arabi and colleagues (2002) carried out a prospective study to determine the influence of certain factors as possible predictors of prolonged stay in an adult medical/surgical ICU in a tertiary-care teaching hospital. Prolonged ICU stay was defined as length of stay >14 days. The data analyzed included the demographics and the clinical profile of each new admission. Besides, two means were used to assess severity of illness: the Acute Physiology and Chronic Health Evaluation (APACHE) II score (Knaus et al., 1985, as cited in Arabi et al., 2002) and the Simplified Acute Physiology Score (SAPS) II (Le Gall et al., 1993, as cited in Arabi et al., 2002).

The study has identified predictors found to be significantly associated with prolonged ICU stay: non-elective admissions, readmissions, respiratory or trauma-related reasons for admission, and first 24-hour evidence of infection, oliguria, coagulopathy, and the need for mechanical ventilation or vasopressor therapy had significant association with prolonged ICU stay (Table 2.5 & 2.6). It was also found that mean APACHE II and SAPS II were slightly higher in patients with prolonged stay. Arabi et al. (2002) concluded that patients with prolonged ICU stay form a small proportion of ICU patients, yet they consume a significant share of the ICU resources. Nevertheless, the outcome of this group of patients is comparable to that of shorter stay patients. The predictors identified in the study were expected to be used in targeting this group to improve resource utilization and efficiency of ICU care.

Table 1.5: Demographic and clinical profile of patients in the study group [all values shown are n (%), except where indicated otherwise]

NS, not significant.

¹Because of rounding, some of the percentages may not add up to 100% exactly.

Source: Modified from Arabi et al. (2002).

Table 1.6: Possible predictors for prolonged stay and the associated odds ratio

Research into North Africa, Egypt and Jordan provided several resources into the cultural background which includes religion and traditions, views of disabilities, and lack of health care. Discrimination of disabilities speaks loud and clear as to the need for change, training and resources in these areas.   There is need for training of special education teachers, licensing of teachers and Orientation and Mobility specialist, however there is not enough services and or individuals to provide services needed to meet the increasing population of disabilities.

According to Muyingi (2015), The African population is losing their identity and has over the last 5 centuries.  Their identity is based on truths and religious tradition passed down through generations.  This has been challenged with the influx of Western missionaries, and technologies.  African generations have passed on their beliefs that guide their social interaction, their cultural beliefs; their functional life is guided by this internal belief system that this writer referred to as African Traditional Religion (ATR).   ATR has been uprooted due to negative feedback from missionaries saying that it is based on which craft, magic, and sorcery.  This new influx of religion is based on Christianity and Islam.  In a case study by Haddad (2000) on 2 villages in Jordan, (an Islamic state), made up 2 religious’ groups: Christianity (includes Greek Orthodox, Roman Catholic and Greek Catholic), and Muslim showed the difference in how each group functioned.  Both groups refer to themselves as Jordanian Arabs, Jordanian Christian Arabs and/or Palestinians (based on where they were originated from). Some of the interesting traditions between the groups include the rules of how they dress and how they participated in marriage.   Christians based their guidelines on their church’s philosophy – some churches allowed women to wear shorts, and both men and women to participate in the use of alcohol.  A Christian man can marry a Muslim with the understanding that he must convert and follow the Mosque guidelines, whereas the Muslims are not allowed alcohol, Women were expected to cover their bodies and faces (with a veil), and a man would never marry a Christian Woman – it’s not allowed.  Each group stays within its own, however if someone needed help; the community comes together regardless of what they believe.

In the article by Haddad (2000), Families are responsible for the needs of their children until they reach an age of independence and can support themselves.  The government does not have funds to assist family with any medical needs.  Most individuals with disabilities do not have access to services through special education.  The attitudes towards disabilities are looked upon as shameful and embarrassing.  Due to attitudes, not only by the parents but the general society, these individuals are prevented from services and the families have a very hard time leading a normal life (Hadidi, 2015).   Individuals with disabilities are either institutionalized or hidden in homes (Hadidi 2015).

Services starting emerging from 1960 – 1990, initially only serving 4 main disability groups that included visual impairment, hearing impairment, intellectual and physical disabilities and these services were provided by private volunteers through ministries of social and/or charity work (Hadidi 2015).  Initially it was provided through social services not through special education.  In a study on kindergarten teacher beliefs, (Abu-Jaber, Al-Shawareb and Gheit, 2010) early childhood education is new to Jordanians. The minister of education, (in this report), placed a high priority on early education of children, age 2 – 8.  Areas included kindergarten, special needs and family along with licensing standards for teachers.  However, most of the kindergartens were privately owned, making it financially unreachable for poor families.   According to Wiener, Welsh & Blasch (2010, pp. 558-561) a few Kindergarten instructors in Jordan were trained in pre-cane skills, in order to provide training to children as they enter the school system.   They are working on integrating the skills in education and Orientation and Mobility is becoming a requirement in specific special educational environments. There have also been a few people in Egypt that have been trained by instructors from Jordon.  However, Egypt does not have a large training of O&M professionals and they are unable to provide services for the many families that live in poverty and the high percentages of blindness due to close interfamily relationships (Wiener, Welsh & Blasch, 2010, pp.558-561).

In a study by Gobrial (2012) in Egypt, on the rights of children with intellectual disabilities; most children with disabilities are discriminated, excluded and lack access to health care, education and the rights provided their peers.  This article points out that there was an increase in intellectual disabilities from 2002 through 2008; an increase of 6 million people diagnosed with intellectual disabilities.   Following a revolution in Egypt (in 2011), the people were more involved in requesting rights and needs.   The UN and the Ministry of Education claimed the need for human rights of children, and the Ministry of Education presented a resolution #154 for improvement in educational needs, however based on the survey questions provided, a high number of participants were unaware of the children’s rights, and indicated that the government disregarded rights of these children and did not do anything to provide protection to the children or their families (Gobrial 2012).   There is a high need for preventative procedures for blindness in Jordan.  In a study of 1400 plus individuals which included 424 cases under the age of 16 and 998 cases in adults were blind due to lack of care, medical follow up and genetic disorders.  This study showed blindness was due to multiple reasons with the top 3 areas for adults including Retinitis Pigmentosa, Diabetic retinopathy and Glaucoma and the top 3 areas for children included congenital globe malformations, retinopathy of prematurity and Retinal dystrophies (Baarah, Shatnawi & Khatatbeh – May 2018).

There is limited services, rehabilitation or resources available due to poverty, and the high need of services.   Most areas do not allow for independent travel and there are no white cane or traffic laws to provide protection.  (Wiener, Welsh, & Blasch, 2010, pp. 558-561).   There are not enough trained individuals to serve this population.  According to Abu-Jaber, Al-Shawareb and Gheit (April 2010), the minister of education is working with the Jordanian university to help with training and obtaining educators for children programs.   With the limited resources, and several barriers existing in Africa, the introduction and need of Orientation and mobility, exist, however the environment is not developed for independent travel in the areas of North Africa, Jordan and Egypt (Wiener, W. R., Welsh, R. L., & Blasch, B. B. 2010).

References

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