23 Mar 12
Posted in Admission to ICU, Critical Care at 1:43 by Laci
By H T Stelfox,B R Hemmelgarn, S M Bagshaw, S Gao, C J Doig, C Nijssen-Jordan, B Manns
Arch Int Med 2012;172:467-474
Intensive care unit (ICU) beds, a scarce resource, may require prioritization of admissions when demand exceeds supply. We evaluated the effect of ICU bed availability on processes and outcomes of care for hospitalized patients with sudden clinical deterioration.
Methods
We identified consecutive hospitalized adults in Calgary, Alberta, Canada, with sudden clinical deterioration triggering medical emergency team activation between January 1, 2007, and December 31, 2009. We compared ICU admission rates (within 2 hours of medical emergency team activation), patient goals of care (resuscitative, medical, and comfort), and hospital mortality according to the number of ICU beds available (0, 1, 2, or >2), adjusting for patient, physician, and hospital characteristics (using data from clinical and administrative databases).
Results
The cohort consisted of 3494 patients. Reduced ICU bed availability was associated with a decreased likelihood of patient admission within 2 hours of medical emergency team activation (P = .03) and with an increased likelihood of change in patient goals of care (P < .01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% CI, –5.1% to 57.3%) less likely to be admitted to the ICU and 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than 2 ICU beds were available. Hospital mortality did not vary significantly by ICU bed availability (P = .82).
Conclusion
Among hospitalized patients with sudden clinical deterioration, we noted a significant association between the number of ICU beds available and ICU admission and patient goals of care but not hospital mortality.
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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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