07 Jul 09

Off hour admission to an intensivist-led ICU is not associated with increased mortality

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.

15 Jun 08

Association between critical care physician management and patient mortality in the intensive care unit

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.

01 Apr 08

The incidence of low venous oxygen saturation on admission to the intensive care unit

Posted in Admission to ICU, ScvO2, Sepsis at 19:23 by Laci

By PA van Beest, JJ Hofstra, MJ Schultz, EC Boerma, PE Spronk and MA Kuiper

Critical Care 2008, 12:R33

Low mixed or central venous saturation (S(c)vO2) can reveal global tissue hypoxia and therefore can predict poor prognosis in critically ill patients. Early goal directed therapy (EGDT), aiming at an ScvO2 ≥ 70%, has been shown to be a valuable strategy in patients with sepsis or septic shock and is incorporated in the Surviving Sepsis Campaign guidelines.

Methods
In this prospective observational multi-center study, we determined central venous pressure (CVP), hematocrit, pH, lactate and ScvO2 or SvO2 in a heterogeneous group of critically ill patients early after admission to the intensive care units (ICUs) in three Dutch hospitals.

Results
Data of 340 acutely admitted critically ill patients were collected. The mean SvO2 value was > 65% and the mean ScvO2 value was > 70%. With mean CVP of 10.3 ± 5.5 mmHg, lactate plasma levels of 3.6 ± 3.6 and acute physiology, age and chronic health evaluation (APACHE II) scores of 21.5 ± 8.3, the in-hospital mortality of the total heterogeneous population was 32.0%. A subgroup of septic patients (n = 125) showed a CVP of 9.8 ± 5.4 mmHg, mean ScvO2 values of 74.0 ± 10.2%, where only 1% in this subgroup revealed a ScvO2 value < 50%, and lactate plasma levels of 2.7 ± 2.2 mmol/l with APACHE II scores 20.9 ± 7.3. Hospital mortality of this subgroup was 26%.

Conclusion
The incidence of low ScvO2 values for acutely admitted critically ill patients is low in Dutch ICUs. This is especially true for patients with sepsis/septic shock.

06 Nov 07

Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS)

Posted in Admission to ICU, Critical Care, Mechanical ventilation at 19:05 by Laci

By M J Wildman, C Sanderson, J Groves, B C Reeves, J Ayres, D Harrison, D Young,  K Rowan

BMJ 2007;335:xxx-xxx

To determine whether clinicians’ prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.

Design
Prospective cohort study.

Setting
92 intensive care units and three respiratory high dependency units in the United Kingdom.

Participants
832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.

Main outcome measures
Outcome predicted by clinicians. Observed survival at 180 days.

Results
517 patients (62%) survived to 180 days. Clinicians’ prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.

Conclusions
Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians’ prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.

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