15 Jan 10
Posted in Admission to ICU, Critical Care at 0:48 by Laci
By J-L Vincent, S Opal and J Marshall
Crit Care Med 2010;38:283-287
Severity scores such as Acute Physiology and Chronic Health Evaluation II have been advocated as entry criteria for clinical trials and in clinical decision-making. We present ten reasons why we believe this approach is not appropriate and may even be detrimental.
Data sources
Available relevant literature from authors’ personal databases and personal knowledge of past and future clinical trial development.
Data synthesis
Severity scores were not designed for use in individual patients or for therapeutic decision-making for specific interventions. Difficulties with the time window needed to calculate these scores and the need to administer therapies early further limit their use in this context. The complex nature of the scores makes it difficult to use them at the bedside and there is considerable interobserver variability in score calculation. Inclusion of chronic health and age points in severity scores may prevent younger, previously healthy patients, with similar acute physiological dysfunction and therefore total lower severity scores, from trial inclusion or from receiving therapies that may be beneficial.
Conclusions
We believe severity of illness scores are poor surrogates for risk stratification and should not be used as a criterion for patient enrollment into clinical trials or as the basis for individual treatment decisions.
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09 Aug 09
Posted in Admission to ICU at 16:33 by Laci
By T Iwashyna, A Kramer, J Kahn
Critical Care Medicine 2009;37:1545-1557
Although intensive care units (ICUs) with higher overall patient volume may achieve better outcomes than lower volume ICUs, there are few data on the effects of increasing patient loads on patients within the ICU.
Objectives
To examine the association of ICU occupancy with the patient outcomes within the same ICU.
Methods
We examined 200,499 patients in 108 ICUs using the Acute Physiology and Chronic Health Evaluation IV database in 2002-2005. Daily census on the day of admission was determined for each patient and defined in relation to the mean census. We used conditional logistic regression to compare inpatient outcomes of patients admitted on high census days to those admitted in the same ICU on low census days. We controlled for severity of illness at the patient level using data on clinical, demographic, and physiologic variables on admission to the ICU.
Measurements and main results
Patients admitted on high census days had the same odds of inpatient mortality or transfer to another hospital as patients admitted on average or on low census days. These findings were robust to multiple alternative definitions of day of admission census and were confirmed in several subgroup analyses.
Conclusions
The ICUs in this data are able to function as high reliability organizations. They are able to scale up their operations to meet the needs of a wide range of operating conditions while maintaining consistent patient mortality outcomes.
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07 Jul 09
Posted in Admission to ICU at 16:07 by Laci
By I Meynaar, J van der Spoel, J Rommes, M van Spreuwel-Verheijen, R Bosman and P Spronk
Critical Care 2009, 13:R84
Caring for the critically ill is a 24-hour-a-day responsibility, but not all resources and staff are available during off hours. We evaluated whether intensive care unit (ICU) admission during off hours affects hospital mortality.
Methods
This retrospective multicentre cohort study was carried out in three non-academic teaching hospitals in the Netherlands. All consecutive patients admitted to the three ICU’s between 2004 and 2007 were included in the study, except for patients who did not fulfil APACHE II criteria (readmissions, burns, cardiac surgery, younger than 16 years, length of stay less than 8 hours). Data were collected prospectively in the ICU databases. Hospital mortality was the primary endpoint of the study. Off hours was defined as the interval between 10 pm and 8 am during weekdays and between 6 pm and 9 am during weekends. Intensivists, with no responsibilities outside the ICU, were present in the ICU during daytime and available for either consultation or assistance on site during off hours. Residents were available 24 hours a day 7 days a week in two and fellows in one of the ICUs.
Results
A total of 6725 patients were included in the study, 4553 (67.7%) admitted during daytime and 2172 (32.3%) admitted during off hours. Baseline characteristics of patients admitted during daytime were significantly different from those of patients admitted during off hours. Hospital mortality was 767 (16.8%) in patients admitted during daytime and 469 (21.6%) in patients admitted during off hours (P<0.001, unadjusted odds ratio 1.36, 95%CI 1.20-1.55). Standardized mortality ratios were similar for patients admitted during off hours and patients admitted during daytime. In a logistic regression model APACHE II expected mortality, age and admission type were all significant confounders but off hours admission was not significantly associated with a higher mortality (P=0.121, adjusted odds ratio 1.125, 95%CI 0.969-1.306).
Conclusions
The increased mortality after ICU admission during off hours is explained by a higher illness severity in patients admitted during off hours.
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15 Jun 08
Posted in Admission to ICU at 10:11 by Laci
By M M Levy, J Rapoport, S Lemeshow, D B Chalfin, G Phillips and M Danis
Ann Int Med 2008;148:801-809
Critically ill patients admitted to intensive care units (ICUs) are thought to gain an added survival benefit from management by critical care physicians, but evidence of this benefit is scant.
Objective
To examine the association between hospital mortality in critically ill patients and management by critical care physicians.
Design
Retrospective analysis of a large, prospectively collected database of critically ill patients.
Setting
123 ICUs in 100 U.S. hospitals.
Patients
101 832 critically ill adults.
Measurements
Through use of a random-effects logistic regression, investigators compared hospital mortality between patients cared for entirely by critical care physicians and patients cared for entirely by non–critical care physicians. An expanded Simplified Acute Physiology Score was used to adjust for severity of illness, and a propensity score was used to adjust for differences in the probability of selective referral of patients to critical care physicians.
Results
Patients who received critical care management (CCM) were generally sicker, received more procedures, and had higher hospital mortality rates than those who did not receive CCM. After adjustment for severity of illness and propensity score, hospital mortality rates were higher for patients who received CCM than for those who did not. The difference in adjusted hospital mortality rates was less for patients who were sicker and who were predicted by propensity score to receive CCM.
Limitation
Residual confounders for illness severity and selection biases for CCM might exist that were inadequately assessed or recognized.
Conclusion
In a large sample of ICU patients in the United States, the odds of hospital mortality were higher for patients managed by critical care physicians than those who were not. Additional studies are needed to further evaluate these results and clarify the mechanisms by which they might occur.
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