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Could Quality Standards be achieved by Social Security Foundation Price Policy ?

Could Quality Standards be achieved by Social Security Foundation Price Policy ?. Dr Zuhal Karakurt TRMH Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital , Respiratory Intensive Care Unit , Istanbul. I have no any conflicts of interest.

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Could Quality Standards be achieved by Social Security Foundation Price Policy ?

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  1. CouldQualityStandards be achievedbySocialSecurityFoundationPricePolicy? Dr Zuhal Karakurt TRMH SüreyyapaşaChestDiseasesandThoracicSurgeryTrainingandResearchHospital, RespiratoryIntensiveCareUnit, Istanbul

  2. I havenoanyconflicts of interest.

  3. TRMH SüreyyapaşaChestDiseasesandThoracicSurgeryTrainingandResearchHospital, RespiratoryIntensiveCareUnit, Istanbul • Level III ICU (AccordingtoMinistery of Healthlevel : From 2007 annualcontrols) • Total 22beds (4+4+6+6+1+1) • Twoisolationroomswithsinglebed • 28 invasive, 6 noninvasive, 1 transport ventilators • 24 invasivemonitors,1 ABG machine, 1 bronchoscope, ECHO, 1 dialysismachine • Number of specialists: 8 (govermentworker) • 5 specialistsforday time, 1 specialistfornightshift (For 24 hoursunderguidance of specialistfrom ICU team) • Number of nurses: 40 (govermentworker) • Cleaningworkers: 13 (salaryfromhospital) • Secretary: 2 (govermentworker 1, withcontract 1) 63 personsfor 22 beds Number of patients in 2011:932 IMV: 40%, NIMV 95% APACHE-II: 22 Meandays of stay: 7.1 days Mortality 19% (expected 42%)

  4. Ministery of Health ICU QualityStandards 18 February 2012 SaturdayOfficialJournalNumber: 28208 Statement FromMinistery of Health: STATEMENT CONCERNING THE CHANGE IN STATEMENT OF METHODS AND PRINCIPALS OF ICU PRACTICE ADMINISTRATION IN HOSPITALS ARTICLE 1 –Thethirdarticle of thestatement, published in officialjournal on date 20/7/2011 number 28000, concerningMethodsAndPrincipals Of ICU PracticeAdministrationInHospitalswaschanged as below.

  5. TheQualityStandards of IntensiveCareUnitsDeterminedbyMinistery of Health in Turkey • Thequalitystandards of IntensiveCareUnitschangesaccordingtolevel I, II, III status in ourcountry. • Thepatientswithnoninvasive/invasivemechanicalventilationneed at chestdiseasesward, in case of “respiratoryfailure-single organ failure” should be followed in at leastlevel II ICU. • Thepatientshould be followed in level III intensivecareunit in presence of severe sepsis-septicshock, in presence of morethanone organ failure.

  6. ICU LevelFeatures: PatientFeatures 18 February2012 SATURDAY OfficialJournalNumber: 28208, Statement : Additions 1 Level II Inadditiontolevel I and II patientcharacteristics; 1- Patientsrequiringqualified, longtermobservationandintervention, longterm life supportorpatientswithmultiorganfailure, 2- Patientswithinvasiveornoninvasivemechanicalventilationandrequiringadvancedrespiratorymonitorisation , 3- Diseaseswithprogression of chronic organ dysfunctionaffectingdailyactivities, 4- HELLP syndrome, acuteproblemsrequiringclosefollow-upandtreatmentlikesevere sepsis, septicshock, ARDS, severe preeclampsiaandeclampsia, 5- Bleedingthatcannot be controlledandrequiringmassivetransfusion, 3- Intoxicationsresulting in organ dysfunction, 4- Internalcomplicationsdevelopedaftersurgery, (coronarysyndromes, sepsis, renalorliverfailureetc) 5- Acuteproblems in systemicdiseasesconcerningmorethanone organ, 6- Patientsrequiringisolation in ICU, (resistantinfections, immunsuppressedpatients) 7- Severe centralnervoussystempathologyandsurgery, (bleedingoversinus, compressionfracture, severe cerebraledema, subarachnoidbleeding, diffuseaxonalinjury, spinalshock, cordedema) 8- PatientswithGlascow score 8 andbelow, 9- Patientswithcardiacsurgery, 10- Multi-traumapatients. Level III Inadditiontolevel I patientcharacteristics; 1- Qualified, detailedshorttermobservationandintervention(invasivemonitorisation) andpatientsrequiring life support , 2-Patientsdischargedfromlevel III ICU but not ableto be discharged at all, 3-Patientswithmedicalconditionsrequiringemergenttreatment of single organ failure (hemodialysis, hemofiltration, plasmapheresis, mechanicalventilation, etc), 5-Patientswith risk requiringintensepreparationandsupportbeforesurgery , 6-Uncorrectablephysiologicormetabolicdisorders, 7-Life threateningintoxicationsandbleeding, 8- Severe infections, (peritonitisetc.) 9- Neuromusculardiseasesrequiringrespiratorysupport, patientswithnoninvasivemechanicalventilationneed, 10- Life threateningcomplications of pregnancy, (preeclampsiaetc.) 11- Hemothorax, empyema, severe malnutrition, 12- CentralNervousSystempathologiesandsurgery. (minimal epidural, subduralhematoma, posterior fossa pathologies, cranialfractures, spinallomberdrainageetc)

  7. Features of ICU Levels: Healthcareto be administered 18 February 2012 SATURDAY OfficialJournalNumber : 28208, Statement : Additions 1 Level II Inadditiontolevel II; Advancedairwaymanagement, Percutenoussurgeryortracheotomy, Continousorintermittantapplication of hemodialysisorhemofiltration in ICU, Temporarypacemaker, Gastroesaphagealtube(Blackmooretube). Level III Orotrachealintubation, Thoracenthesis, Respiratorydrugapplication, Defibrillation, Evaluation of arterialbloodgases, Evaluation of ECG, Cardiopulmonaryresucitation. Internaljugulerveincatheterisationand/orsubclavienveincatheterisationand/orfemoralveincatheterisation, Insertion of hemodialysiscatheter , Arterialcatheterisation, Lumberpuncture, Insertion of feedingtube, Mechanicalventilation. (Invasiveornoninvasive).

  8. Features of ICU levels: Specialistandnurse 18 February 2012 SATURDAY OfficialJournalNumber : 28208, Statement : Additions 1 Level II Inadditiontolevel II; 1- Neurosurgent, 2- Neurologyspecialist, 3- Cardiologist, 4- ChestDiseasesspecialist, 5-Microbiologistorinfectiousdiseasesandclinicalmicrobiologyspecialist. 6-Forrequiredspecialities presence of specialiststo be contactedquickly.*; (Radiologist, orthopedistandtraumatologist , physicalmedicineandrehabilitationspecialist, ENT specialist, ophthalmologist, dermatologist). Forevery 2 bed at leastonenurse/healthcareworker at any time duringtheday Level III Inadditiontolevel I; 1 -Neurosurgent* 2- Neurologyspecialist*, 3- Cardiologist*, 4- ChestDiseasesspecialist,* 5- Microbiologistorinfectiousdiseasesandclinicalmicrobiologyspecialist.* • Forevery 3 bed at leastonenurse/healthcareworker at any time duringtheday *If not present in hospital, it is enoughforaboveto be present in vicinity of city in case of emergentconditionswhenrequired.

  9. ICU PhysicianandNurseEducation Specialist Nurse/HealthCareWorker Shouldhave ICU experienceandget a certificate. ICU nurseshould be permenantduringworkingperiod. • Afterresidency, requirement of 3 yeareducationforbecoming a subspecialist. • Inabsence of theseconditions, specialistshouldhavecompleted at least 3 monthtrainingandget a certificate at a traininghospital.

  10. Features of ICU Levels:MedicalEquipment 18 February 2012 SATURDAY OfficialJournalNumber : 28208, Statement : Additions 1 Level II At least 4 beds Forevery 6 bedsoneisolationroom Inadditiontolevel II; 1- Foreachbed a monitorableto do invasivehemodynamicmonitorisation, 2- Foreverybedoneventilator, 3-Blood, serum andpatientheatingsystems, 4- Feedingpump, 5- Bedscaleforweight Level III • At least 4 beds • Isolationroom is not obligatory Inadditiontolevel I;1- Foreachbedinvasivemonitorwithunichannelpressuremonitorisation, 2- Forevery 2 bedsoneventilator , (Ifbedcapacity is morethan 6, foreach 3 bedsoneventilator is required), 3- Portablex-ray machine(hospital), 4- Infusionpump, 5- Bloodgasmachine (can be closeto ICU), 6- Defibrillator in ICU, 7- Uninterruptedpowersupply, 8- USG machine(hospital).

  11. SSF LevelPricing Levels , in additiontothatpriceschange as theclinicalstatus of patientschange. Forpatientshospitalisedlessthanorequalto 3 days, firstdayprice is not paid, payment is as “otherdays”.

  12. TRMH SüreyyapaşaChestDiseasesandThoracicSurgeryTrainingandResearchHospital, RespiratoryIntensiveCareUnit, Istanbul • Level III ICU (AccordingtoMinistery of Healthlevel : From 2007 annualcontrols) • Total 22beds (4+4+6+6+1+1) • Twoisolationroomswithsinglebed • 28 invasive, 6 noninvasive, 1 transport ventilators • 24 invasivemonitors,1 ABG machine, 1 bronchoscope, ECHO, 1 dialysismachine • Number of specialists: 8 (govermentworker) • 5 specialistsforday time, 1 specialistfornightshift (For 24 hoursunderguidance of specialistfrom ICU team) • Number of nurses: 40 (govermentworker) • Cleaningworkers: 13 (salaryfromhospital) • Secretary: 2 (govermentworker 1, withcontract 1)

  13. ICU InfrastructureCost Level II Level III Allthesame as Level II and Hemodialysismachine: Isolationroom: Isolationroomwithnegativepressure: Singleroom : 150 000.00 Euro • Areaout of ICU:(Areaforpatientrelativesandinformation) • Floor-wall: • ICU beds: • ICU antidecubitusbed • Monitor (invasive): • Invasivemechanicalventilator:(withmonitorand NIV mode) Aseptisorandhepafilter

  14. ICU materialsupply, personnelsalarypayment: Ministery of Health/UnivercityandPrivateHospitals MH/UnivercityICUs PrivateHospitalICUs Privatehospital (PH)is responsible in supplyingmaterialfor ICU. PH givessalary of physiciansandnurses. Frequentchange of ICU physicianandnurses. Hospitalalsopaysconsultationandnightshiftphysicians. • MH supports ICU materialsupply. • MH paysphysicians’ andnurses’ salary. • Facilityforsupplyingexperiencedphysicinandnurse. • Physiciansgetpointsandmoneyfrom general paymentforconsultationandnightshift. 90% additionalpaymenttoreciept can be obtainedfrompatient’srelatives. (SSF March 2012)

  15. I Level of PatientandCost: II III Thecost of 16 day ICU stay of an intubated COPD patientwithsepticshock at university/trainingandresearchhospitallevel III ICU Costanalysis 14532.00 TL 13896.00 TL IMV NIMV + Nasal O2 12890.00 TL Shock +IMV IMV + NIMV O2 8038.00 TL ICU day 3 10 16 14

  16. November 2011 ICU Cost Süreyyapaşa TRH 22-bedRespiratory ICU: • November 2011: 87 patients (556 days of stay) • IMV: 37 patients (186 days) • NIMV: 63 patients (293 days) • Nasal O2 monitorisation, arrythmia, hearthfailure: 6 patients • APACHE II: 21.9 • Mortality: 16 patients ( 18.4%) • Dischargetohome: 25 patients • Meandays of stay: 6.4 days

  17. OurCenter: November 2011 ICU Cost November 2011 Expenses: • Treatment: 70.959.00 TL • Tests: 9.219.00 TL • Consumablematerial:44.703.00 TL • (Medicalmaterial, Electricity/water/food, phonecalls, gas) • Materialrepair:4.200.00 TL • Personnelsalary:85.600.00 TL • TOPLAM: 214.681.00 TL • Incomefrom SSF in November 2011 accordingtopatient’sclinicallevel: 313.464.00 TL 313.464.00 214.681.00 98.783.00 TL

  18. CouldQualityStandards be achievedbySocialSecurityFoundationPricePolicy? THE ACQUIRED QUALITY STANDARDS CAN PARTIALLY BE RESUMED. It is not possibleto ACQUIRE QUALITY STANDARDS.

  19. Discussion WHAT CAN BE DONE? • Is it knownthatthequalitystandardsaskedforbyMinistery of Healthcannot be fullfilledbySocialSecurityFoundationpayment ?(YES) • Ministery of HealthandMinistery of WorkandSocialSecurityshouldcooperateand plan theirexpectationsandpayment, respecticely. • It is not possibletogetpaymentwith SSF, as it is in ourcenter, ifthehospitalbudgetinveststoachieve ICU qualitystandards.

  20. CouldQualityStandards be achievedbySocialSecurityFoundationPricePolicy?: NO. SOLUTION?? Mysuggestion… • SSF pricing can be achievedacctolevel of ICU instead of patient’sclinicalcondition. • It is essentialtoestablishpalliativesupporttreatmentunitsforfollowup of patientswhoaretoobadtobenefitfrom ICU treatment(4b). • Forelderly (>80)-demantiaandnursinghomepatientsspecialunitsshould be establishedandregulationsshould be done forfollowup in them. • General practitioners, familypractitionersandemergencywardphysiciansshould be educatedabout ICU demandforpatients in terminal conditions. • Increase in number of level III ICUs: Malpractice??? • Ifregulationsare not takenaboutthisissue, problemswillarise. • Inourcountry, physiciansperceive ICU as a unitforfollowingpatientsbeforedeath. • Itshould be remindedto SSF thatforevery terminal patientwhodie, thepayment is as level III firstday.

  21. ICU Cost of ElderlyandNeurologicCarePatients Between 2008-2010 2029 patients in our ICU Specializedunitsshould be establishedforelderly-demantiaandpatientswithneurologicsequelawhoneedcare; healthpoliticsshould be formedtodecreasecost. An urgent plan should be made as thesepatientshave risk forrehospitilasationandthesepatientssurvive in ICU at a rate over 80%. TTS 2011, 14. AnnualCongress, posters

  22. Thanks • Dr Gökay Güngör • Dr Özlem Yazıcıoğlu Moçin • Dr Tutku Moralı • Nurse: Derya Şeker

  23. TEŞEKKÜRLER

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