Consequences of discharges from intensive care at night

End-of-life decisions: a cohort study of the withdrawal of all active treatment in intensive care units in the United Kingdom

OBJECTIVE

To describe the epidemiology of active treatment withdrawal in a nationally representative cohort of intensive care units (ICUs) focusing on between-unit differences.

DESIGN AND SETTING

Cohort study in 127 adult general ICUs in England, Wales and Northern Ireland, 1995 to 2001.

PATIENTS

118,199 adult admissions to ICUs.

MEASUREMENTS AND RESULTS

The decision to withdraw all active treatment was made for 11,694 of 118,199 patients (9.9%). There were a total of 36,397 deaths (30.8%) before discharge from hospital, and 11,586 (31.8%) of these occurred after the decision to withdraw active treatment, with no change over time (p=0.54). Considerable variation existed between units regarding the percentage of ICU deaths that occurred after the decision to withdraw active treatment (1.7-96.1%). Median time to death after the decision to withdraw active treatment was 2.4 h; 8% survived more than 24 h. After multilevel modelling, the factors independently associated with the decision to withdraw active treatment were: older age, pre-existing severe medical conditions, emergency surgery or medical admission, cardiopulmonary resuscitation in the 24 h prior to admission, and ventilation or sedation/paralysis in the first 24 h after admission. Substantial between unit variability remained after accounting for case-mix differences in admissions.

CONCLUSIONS

Although we were unable to examine partial withdrawal or withholding of care in this study, we found that the withdrawal of all active treatment is widespread in ICUs in the United Kingdom. There was little change in this practice over the period examined. However, there was considerable variation by unit, even after accounting for patient factors and differences in size and type of ICU, suggesting improved guidelines may be useful to facilitate uniform decision making.

Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors

Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years. Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, p(m)), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and "limitation of medical treatment" orders. The outcome measures were patient status at hospital discharge and ICU readmission rate. Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II p(m) did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II p(m) (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward.

CONCLUSION

At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.

Post-ICU mortality in critically ill infected patients: an international study

OBJECTIVE

To determine the incidence and risk factors for post-ICU mortality in patients with infection.

DESIGN AND SETTING

International observational cohort study including 28 ICUs in eight countries.

PATIENTS

All 1,872 patients discharged alive from the ICU over a 1-year period were screened for infection at ICU admission and daily throughout the ICU stay. Outcomes at ICU and hospital discharge were recorded.

MEASUREMENTS AND RESULTS

Post-ICU death occurred in 195 (10.4%) patients and was associated in the multivariable analysis with age, chronic respiratory failure, immunosuppression, cirrhosis, Simplified Acute Physiology Score II on the first day with infection, and LOD score at ICU discharge. Post-ICU death was more common among medical patients and patients with hospital-acquired infection or microbiologically documented infection and was less common in patients with pneumonia.

CONCLUSIONS

Post-ICU death in patients with infection was within previously reported ranges in overall ICU populations. The main risk factors were patient and infection characteristics, severity at ICU admission, and persistent organ dysfunction at ICU discharge. Further interventions such as further ICU management, discharge to a step-down unit, or follow-up by intensivists on the ward should be evaluated in patients with a high risk of post-ICU mortality.

Winter excess mortality in intensive care in the UK: an analysis of outcome adjusted for patient case mix and unit workload

OBJECTIVE

To investigate whether mortality in UK intensive care units is higher in winter than in non-winter and to explore the importance of variations in case mix and increased pressure on ICUs.

DESIGN AND SETTING

Cohort study in 115 adult, general ICUs in England, Wales and Northern Ireland.

PATIENTS AND PARTICIPANTS

113,389 admissions from 1995 to 2000.

MEASUREMENTS AND RESULTS

Hospital mortality following admission to ICU was compared between winter (December-February) and non-winter (March-November). The causes of any observed differences were explored by adjusting for the case mix of admissions and the workload of the ICUs. Crude hospital mortality was higher in winter. After adjusting for case mix using the APACHE II mortality probability this effect was reduced but still significant. When additional factors reflecting case mix and workload were introduced into the model, the overall effect of winter admission was no longer significant. Factors reflecting both the case mix of the individual patient and of the patients in surrounding beds were found to be significantly associated with outcome. After adjustment for other factors, the occupancy of the unit (proportion of beds occupied) was not significantly associated with mortality.

CONCLUSIONS

The excess winter mortality observed in UK ICUs can be explained by variation in the case mix of admissions. Unit occupancy was not associated with mortality.

Rationing critical care beds: a systematic review

OBJECTIVE

Rationing critical care beds occurs daily in the hospital setting. The objective of this systematic review was to examine the impact of rationing intensive care unit beds on the process and outcomes of care.

DATA SOURCE

We searched MEDLINE (1966-2003), CINAHL (1982-2003), Ovid Healthstar (1975-2003), EMBASE (1980-2003), Scisearch (1980-2003), the Cochrane Library, PUBMED related articles, personal files, abstract proceedings, and reference lists.

STUDY SELECTION

We included studies of seriously ill patients considered for admission to an intensive care unit bed during periods of reduced availability. We had no restriction on study design. Studies were excluded if rationing was performed using a scoring system or protocol and if cost-effectiveness was the only outcome.

DATA EXTRACTION

In duplicate and independently, we performed data abstraction and quality assessment.

DATA SYNTHESIS

We included ten observational studies. Hospital mortality rate was increased in patients refused intensive care unit admission vs. those admitted (odds ratio, 3.04; 95% confidence interval, 1.49-6.17). Factors associated with both intensive care unit bed refusal and increased mortality rate were increased age, severity of illness, and medical diagnosis. When intensive care unit beds were reduced, admitted patients were sicker, were less often admitted primarily for monitoring, and had a shorter intensive care unit length of stay, without other observed adverse effects.

CONCLUSIONS

These studies suggest that patients who are perceived not to benefit from critical care are more often refused intensive care unit admission; refusal is associated with an increased risk of hospital death. During times of decreased critical bed availability, several factors, including age, illness severity, and medical diagnosis, are used to triage patients, although their relative importance is uncertain. Critical care bed rationing requires further investigation.

The longer patients are in hospital before Intensive Care admission the higher their mortality

OBJECTIVE

To explore the relationship between hospital mortality and time spent by patients on hospital wards before admission to the intensive care unit (ICU).

DESIGN

Observational study of prospectively collected data.

SETTING

Participating intensive care units within the North East Thames Regional Database.

PATIENTS AND PARTICIPANTS

Patients, 7,190, admitted to ICU from the hospital wards of 24 hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Of ICU admissions from the wards, 40.1% were in hospital for more than 3 days and 11.7% for more than 15 days. ICU patients who died in hospital were in-patients longer (p=0.001) before admission (median 3 days; interquartile range 1-9) than those discharged alive (median 2 days; interquartile range 1-5). Hospital mortality increased significantly (p<0.0001) in relation to time on hospital wards before ICU: 47.1% (standardised mortality ratio 1.09) for patients in hospital 0-3 days before ICU admission up to 67.2% (standardised mortality ratio 1.39) for patients on the wards for more than 15 days before ICU. Length of stay before ICU admission was an independent predictor of hospital mortality (odds ratio per day 1.019; 95% confidence interval 1.014-1.024). There were significant differences (p<0.001) in patient age, APACHE II score and predicted mortality in relation to time on wards before ICU admission.

CONCLUSIONS

Mortality was high among patients admitted from the wards to ICU; many were inpatients for days or weeks before admission. The longer these patients were in hospital before ICU admission, the higher their mortality. Patients with delayed admission differed in some respects compared to those admitted earlier.

Improving care of the critically ill: institutional and health-care system approaches

Institutional and health-care system approaches complement bedside strategies to improve care of the critically ill. Focusing on the USA and the UK, we discuss seven approaches: education (especially of non-clinical managers, policy-makers, and the public), organisational guidelines, performance reporting, financial and sociobehavioural incentives to health-care professionals and institutions, regulation, legal requirements, and health-care system reorganisation. No single action is likely to have sustained effect and we recommend a combination of approaches. Several recent initiatives that hold promise tie performance reporting to financial incentives. Though performance reporting has been hampered by concerns over cost and accuracy, it remains an essential component and we recommend continued effort in this area. We also recommend more public education and use of organisational guidelines, such as admission criteria and staffing levels in intensive care units. Even if these endeavours are successful, with rising demand for services and continuing pressure to control costs, optimum care of the critically ill will not be realised without a fundamental reorganisation of services. In both the USA and UK, we recommend exploration of regionalised care, akin to US state trauma systems, and greater use of physician-extenders, such as nurse practitioners, to provide enhanced access to specialist care for critical illness.

Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database

INTRODUCTION

The present paper describes the methods of data collection and validation employed in the Intensive Care National Audit & Research Centre Case Mix Programme (CMP), a national comparative audit of outcome for adult, critical care admissions. The paper also describes the case mix, outcome and activity of the admissions in the Case Mix Programme Database (CMPD).

METHODS

The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.

RESULTS

The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.

CONCLUSIONS

The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.

Challenges in the care of the acutely ill

Health care providers, hospital administrators, and politicians face competing challenges to reduce clinical errors, control expenditure, increase access and throughput, and improve quality of care. The safe management of the acutely ill inpatient presents particular difficulties. In the first of five Lancet articles on this topic we discuss patients' safety in the acute hospital. We also present a framework in which responsibility for improvement and better integration of care can be considered at the level of patient, local environment, hospital, and health care system; and the other four papers in the series will examine in greater detail methods for measuring, monitoring, and improving inpatient safety.

Hospital mortality associated with day and time of admission to intensive care units

OBJECTIVE

To investigate whether hospital mortality of patients was associated with the day of the week or time of admission to intensive care units (ICUs).

DESIGN

Cohort study.

SETTING

One hundred two adult, general (mixed medical/surgical) ICUs in England, Wales and Northern Ireland.

PATIENTS AND PARTICIPANTS

A total of 56,250 admissions from 1995 to 2000 that fit the inclusion criteria for calculation of the APACHE II probability of hospital mortality.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Crude and case mix adjusted hospital mortality were examined by day of the week and time of day of admission to ICU. Patients admitted on Saturday and Sunday had higher crude hospital mortality compared with admissions on Wednesday [Saturday crude odds ratio (OR) 1.41, 95% CI 1.32-1.52; Sunday OR 1.56, 1.45-1.68]. The association was still significant after adjustment using the UK APACHE II model (Saturday OR 1.16, 1.1.07-1.26; Sunday OR 1.24, 1.14-1.35) but not after adjustment using individual components of the APACHE II model (Saturday OR 1.03, 0.95-1.12; Sunday OR 1.09, 1.00-1.19). Night admissions were also associated with higher mortality compared with day both before and after adjustment for case mix using the UK APACHE II model (crude OR 1.43, 1.37-1.51; adjusted OR 1.16, 1.10-1.23) but not after adjustment using components of the APACHE II model (OR 1.02, 95% CI 0.96-1.09).

CONCLUSIONS

After appropriate adjustment for case mix, day of the week and time of day of admission of patients to ICU were not associated with significant differences in hospital mortality.

[Scoring systems in the intensive care unit]

Scoring systems represent classification systems or point systems which have been designed for making quantitative statements regarding the severity of a disease, its prognosis, and its course. Furthermore, scores may serve the purposes of assessing therapies, of quality control and of quality assurance, and of an economic evaluation of intensive care. Like all measuring methods, scores are susceptible to failures and systematic mistakes. The clinical user should be well aware of these limitations. Generally, one would recommend only using scores which have been rigorously tested for their reliability, validity, and practicability. These include, but are not limited to, the updated versions of the APACHE, the SAPS, and the MPM. Although great strides have been made concerning development, verification, and clinical applicability, scores still exhibit a level of uncertainty which precludes their use in individual patients. Frequently, it may be of benefit to combine the more general scores with one or several organ dysfunction scores to determine the extent of functional impairment of specific organs. If, however, well-trained medical personnel apply tried and tested scoring systems, intensive care units will definitely gain a lot from it.

Intensive care admission decisions for a patient with limited survival prospects: a questionnaire and database analysis

OBJECTIVE

To explore the concept of futility by asking clinicians for estimates of survival and admission decisions for an intensive care unit patient with little chance of survival, and to compare these estimates with results from an intensive care database.

DESIGN

Questionnaire based on the presenting features of a genuine patient. It asked for estimated hospital survival, decision on intensive care admission, resuscitation status and importance of family views. Analysis of a regional intensive care database.

SETTING

Physicians working in British intensive care units.

PARTICIPANTS

We received 169 replies, 146 from consultants.

MEASUREMENTS AND RESULTS

Median estimated hospital survival was 5%; 60% of consultants and 76% of trainees would have admitted the patient, with 9% and 14%, respectively, prepared to perform further cardiopulmonary resuscitation. Among those estimating survival probability as less than 1%, 17.2% would have admitted the patient. Family opinions were vital to 4.3% of respondents and unimportant to 9.8%. There were 251 patients in the database with similar physiological derangements. Their observed hospital mortality was 91%. At intensive care admission an admitting physician assessed 111 of these patients as 'expected to die'. Mortality in this group was 99.1% (one survivor).

CONCLUSIONS

Experienced intensivists did not agree on estimated survival. Even when estimates agreed, admission decisions varied. Database analysis suggested that clinical judgement is relevant when assessing the risk of dying. Lack of consensus on survival estimates and admission decisions suggests that it would be difficult to achieve agreement on appropriate use of intensive care resources and on what constitutes futile treatment.

Clinical review: Outreach - a strategy for improving the care of the acutely ill hospitalized patient

We examined the literature relating to the safe care of acutely ill hospitalized patients, and found that there are substantial opportunities for improvement. Recent research suggests substantial benefit may be obtained by systems of outreach care that facilitate better integration, co-ordination, collaboration and continuity of multidisciplinary care. Herein we review the various approaches that are being adopted, and suggest the need for continuing evaluation of these systems as they are introduced into different health care systems.

Priority setting in a hospital critical care unit: qualitative case study

OBJECTIVE

To describe priority setting for admissions in a hospital critical care unit and to evaluate it using the ethical framework of "accountability for reasonableness.

DESIGN

Qualitative case study and evaluation using the ethical framework of accountability for reasonableness.

SETTING

A medical/surgical intensive care unit in a large urban university-affiliated teaching hospital in Toronto, Canada.

PARTICIPANTS

Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a hospital committee that formulated an admissions policy.

INTERVENTIONS

Modified thematic analysis of documents, interviews with participants, and direct observation of critical care unit rounds. Evaluation using the four conditions of Daniels and Sabin's accountability for reasonableness: relevance, publicity, appeals/revisions, and enforcement.

MEASUREMENTS AND MAIN RESULTS

We examined key features and participants' views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both medical and nonmedical reasons are used, although the nonmedical reasons are less well documented and understood. Medical directors, who are the chief decision makers, differ in their reasoning. Admitting decisions and reasons are usually explained to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care admissions policy exists but is not used and is not known to all stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders.

CONCLUSION

We have described and evaluated admissions decision making in a hospital's critical care unit. The key lesson of our study is not only the specific findings obtained here but also how combining a case study approach with the ethical framework of "accountability for reasonableness" can be used to identify good practices and opportunities for improving the fairness of priority setting in intensive care.

Economic aspects of severe sepsis: a review of intensive care unit costs, cost of illness and cost effectiveness of therapy

Severe sepsis remains both an important clinical challenge and an economic burden in intensive care. An estimated 750,000 cases occur each year in the US alone (300 cases per 100,000 population). Lower numbers are estimated for most European countries (e.g. Germany and Austria: 54-116 cases per year per 100,000). Sepsis patients are generally treated in intensive care units (ICUs) where close supervision and intensive care treatment by a competent team with adequate equipment can be provided. Staffing costs represent from 40% to >60% of the total ICU budget. Because of the high proportion of fixed costs in ICU treatment, the total cost of ICU care is mainly dependent on the length of ICU stay (ICU-LOS). The average total cost per ICU day is estimated at approximately 1200 Euro for countries with a highly developed healthcare system (based on various studies conducted between 1989 and 2001 and converted at 2003 currency rates). Patients with infections and severe sepsis require a prolonged ICU-LOS, resulting in higher costs of treatment compared with other ICU patients. US cost-of-illness studies focusing on direct costs per sepsis patient have yielded estimates of 34,000 Euro, whereas European studies have given lower cost estimates, ranging from 23,000 Euro to 29,000 Euro. Direct costs, however, make up only about 20-30% of the cost of illness of severe sepsis. Indirect costs associated with severe sepsis account for 70-80% of costs and arise mainly from productivity losses due to mortality. Because of increasing healthcare cost pressures worldwide, economic issues have become important for the introduction of new innovations. This is evident when introducing new biotechnology products, such as drotrecogin-alpha (activated protein C), into specific therapy for severe sepsis. Data so far suggest that when drotrecogin-alpha treatment is targeted to those patients most likely to achieve the greatest benefit, the drug is cost effective by the standards of other well accepted life-saving interventions.

Volume of activity and occupancy rate in intensive care units. Association with mortality

OBJECTIVE

Mortality after many procedures is lower in centers where more procedures are done. It is controversial whether this is true for intensive care units, too. We examined the relationship between the volume of activity of intensive care units (ICUs) and mortality by a measure of risk-adjusted volume of activity specific for ICUs.

DESIGN

Prospective, multicenter, observational study.

SETTING

Eighty-nine ICUs in 12 European countries.

PATIENTS

During a 4-month study period, 12,615 patients were enrolled.

INTERVENTIONS

Demographic and clinical statistics, severity at admission and a score of nursing complexity and workload were collected.

RESULTS

Total volume of activity was defined as the number of patients admitted per bed per year, high-risk volume as the number of high-risk patients admitted per bed per year (selected combining of length of stay and severity of illness). A multi-step risk-adjustment process was planned. ICU volume corresponding both to overall [odds ratio (OR) 0.966] and 3,838 high-risk (OR 0.830) patients was negatively correlated with mortality. Relative mortality decreased by 3.4 and 17.0% for every five extra patients treated per bed per year in overall volume and high-risk volume, respectively. A direct relationship was found between mortality and the ICU occupancy rate (OR 1.324 and 1.351, respectively).

CONCLUSIONS

Intensive care patients, whatever their level of risk, are best treated where more high-risk patients are treated. Moreover, the higher the ICU occupancy rate, the higher is the mortality.

Directory of clinical databases: improving and promoting their use

BACKGROUND

The controversy surrounding the actual and potential use of clinical databases partly reflects the huge variation in their content and quality. In addition, use of existing clinical databases is severely limited by a lack of knowledge of their availability.

OBJECTIVES

To develop and test a standardised method for assessing the quality (completeness and accuracy) of clinical databases and to establish a web based directory of databases in the UK.

METHODS

An expert group was set up (1). to establish the criteria for inclusion of databases; (2). to develop a quality assessment instrument with high content validity, based on epidemiological theory; (3). to test empirically, modify, and retest the acceptability to database custodians, face validity and floor/ceiling effects; and (4). to design a website.

RESULTS

Criteria for inclusion of databases were the provision of individual level data; inclusion in the database defined by a common circumstance (e.g. condition, treatment), an administrative arrangement, or an adverse outcome; and inclusion of data from more than one provider. A quality assessment instrument consisting of 10 items (four on coverage, six on reliability and validity) was developed and shown to have good face and content validity, no floor/ceiling effects, and to be acceptable to database custodians. A website (www.docdat.org) was developed. Indications over the first 18 months (number of visitors to the site) are that it is increasingly popular. By November 2002 there were around 3500 hits a month.

CONCLUSIONS

A website now exists where visitors can identify clinical databases in the UK that may be suitable to meet their aims. It is planned both to develop a local version for use within a hospital and to encourage similar national systems in other countries.

The effects of ICU admission and discharge times on mortality in Finland

OBJECTIVE

Hospital mortality increases if acutely ill patients are admitted to hospitals on weekends as compared with weekdays. Night discharges may increase mortality in intensive care unit (ICU) patients but the effect of ICU admission time on mortality is not known. We studied the effects of ICU admission and discharge times on mortality and the time of death in critically ill patients.

DESIGN

Cohort study using a national ICU database.

SETTING

Eighteen ICUs in university and central hospitals in Finland.

PATIENTS

Consecutive series of all 23,134 emergency admissions in January 1998-June 2001.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We defined weekend (as opposed to weekday) from 1600 hours Friday to 2400 hours Sunday and "out-of-office" hours (as opposed to "office hours") from 1600 hours to 0800 hours. Mortality was adjusted for disease severity, intensity of care, and whether restrictions for future care were set. ICU-mortality was 10.9% and hospital mortality 20.7%. Adjusted ICU-mortality was higher for weekend as compared with weekday admissions [odds ratio (OR 1.20) 95% CI 1.01-1.43], but similar for "out-of-office" and "office hour" admissions (OR 0.98, 0.85-1.13). Adjusted risk of ICU death was higher during "out-of-office" hours as compared with office hours (OR 6.89, 5.96-7.96). The time of discharge from ICU to wards was not associated with further hospital mortality.

CONCLUSIONS

Weekend ICU admissions are associated with increased mortality, and patients in the ICU are at increased risk of dying in evenings and during nighttime. Our findings may have important implications for organization of ICU services.

Determinants of post-intensive care mortality in high-level treated critically ill patients

OBJECTIVE

To assess the predictive ability of preillness and illness variables, impact of care, and discharge variables on the post-intensive care mortality.

SETTING AND PATIENTS

5,805 patients treated with high intensity of care in 89 ICUs in 12 European countries (EURICUS-I study) surviving ICU stay.

METHODS

Case-mix was split in training sample (logistic regression model for post-ICU mortality: discrimination assessed by area under ROC curve) and in testing sample. Time to death was studied by Cox regression model validated with bootstrap sampling on the unsplit case-mix.

RESULTS

There were 5,805 high-intensity patients discharged to ward and 423 who died in hospital. Significant odds ratios were observed for source of admission, medical/surgical unscheduled admission, each year age, each SAPSII point, each consecutive day in high-intensity treatment, and each NEMS point on the last ICU day. Time to death in ward was significantly shortened by different source of admission; age over 78 years, medical/unscheduled surgical admission; SAPSII score without age, comorbidity and type of admission over 16 points; more than 2 days in high-intensity treatment; all days spent in high treatment; respiratory, cardiovascular, and renal support at discharge; and last ICU day NEMS higher than 27 points

CONCLUSIONS

Worse outcome is associated with the physiological reserve before admission in the ICU, type of illness, intensity of care required, and the clinical stability and/or the grade of nursing dependence at discharge.

Breaks in continuity of care and the rural senior transferred for medical care under regionalisation

Continuity of care, defined as the patient experiencing coherent care over time and place, is challenged when a rural senior with multiple medical problems is transferred to a regional hospital for acute care. From an illustrative case of an older patient with pneumonia and atrial fibrillation, we catalogue potential breaks in continuity of care. Optimal continuity of care is characterised not only by regular contact with the providers who establish collaboration with patients and their caregivers, but also by communication, co-ordination, contingency, convenience, and consistency. Because it is not possible to have the same providers continuously available (relational continuity), for continuity of care, there is a need for integrative system approaches, such as: (1) policy and standards, disease management programs, integrated clinical pathways (management continuity), (2) electronic health information systems and telecommunications technology (communication continuity). The evaluation of these approaches requires measures that account for the multi-faceted nature of continuity of care.

Epidemiology of severe sepsis occurring in the first 24 hrs in intensive care units in England, Wales, and Northern Ireland

OBJECTIVE

To investigate the numbers, clinical characteristics, resource use, and outcomes of admissions who met precise clinical and physiologic criteria for severe sepsis (as defined in the PROWESS trial) in the first 24 hrs in the intensive care unit.

DESIGN

Observational cohort study, with retrospective analysis of prospectively collected data.

SETTING

Ninety-one adult general intensive care units in England, Wales, and Northern Ireland between 1995 and 2000.

PATIENTS

Patients were 56,673 adult admissions.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We found that 27.1% of adult intensive care unit admissions met severe sepsis criteria in the first 24 hrs in the intensive care unit. Most were nonsurgical (67%), and the most common organ system dysfunctions were seen in the cardiovascular (88%) and respiratory (81%) systems. Modeling the data for England and Wales for 1997 suggested that 51 (95% confidence interval, 46-58) per 100,000 population per year were admitted to intensive care units and met severe sepsis criteria in the first 24 hrs.Of the intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, 35% died before intensive care unit discharge and 47% died during their hospital stay. Hospital mortality rate ranged from 17% in the 16-19 age group to 64% in those >85 yrs. In England and Wales in 1997, an estimated 24 (95% confidence interval, 21-28) per 100,000 population per year died after intensive care unit admissions with severe sepsis in the first 24 hrs. For intensive care unit admissions who met severe sepsis criteria in the first 24 hrs, median intensive care unit length of stay was 3.56 days (interquartile range, 1.50-9.32) and median hospital length of stay was 18 days (interquartile range, 8-36 days). These admissions used 45% of the intensive care unit and 33% of the hospital bed days used by all intensive care unit admissions.

CONCLUSIONS

Severe sepsis is common and presents a major challenge for clinicians, managers, and healthcare policymakers. Intensive care unit admissions meeting severe sepsis criteria have a high mortality rate and high resource use.

Out of our reach? Assessing the impact of introducing a critical care outreach service

An outreach service was introduced in three surgical wards and the surgical high dependency unit in a large teaching hospital. A modified early warning score and callout algorithm were used to facilitate referrals to the team. Changes in unplanned admission rate to intensive care, length of stay, mortality rate and number of re-admissions following the introduction of outreach were sought. Following the introduction of the outreach service the emergency admission rate to intensive care fell from 58% to 43% (p = 0.05). These emergency patients had shorter lengths of stay (4.8 days vs. 7.4 days) and had a lower mortality (28.6% vs. 23.5%, p = 0.05). The re-admission rate also fell from 5.1% to 3.3% (p = 0.05). The outreach service had a significant impact on critical care utilisation.

Seasonal bed closures in an intensive care unit: a qualitative study

OBJECTIVE

To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness.

DESIGN

A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness."

SETTING

An university-affiliated medical/surgical ICU in Eastern Canada.

PARTICIPANTS

ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives).

MAIN OUTCOME MEASURES

Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences.

RESULTS

Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement.

CONCLUSION

Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

External validation of the SAPS II, APACHE II and APACHE III prognostic models in South England: a multicentre study

OBJECTIVE

External validation of three prognostic models in adult intensive care patients in South England. DESIGN. Prospective cohort study.

SETTING

Seventeen intensive care units (ICU) in the South West Thames Region in South England.

PATIENTS AND PARTICIPANTS

Data of 16646 patients were analysed.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We compared directly the predictive accuracy of three prognostic models (SAPS II, APACHE II and III), using formal tests of calibration and discrimination. The external validation showed a similar pattern for all three models tested: good discrimination, but imperfect calibration. The areas under the receiver operating characteristics (ROC) curves, used to test discrimination, were 0.835 and 0.867 for APACHE II and III, and 0.852 for the SAPS II model. Model calibration was assessed by Lemeshow-Hosmer C-statistics and was Chi(2 )=232.1 for APACHE II, Chi(2 )=443.3 for APACHE III and Chi(2 )=287.5 for SAPS II.

CONCLUSIONS

Disparity in case mix, a higher prevalence of outcome events and important unmeasured patient mix factors are possible sources for the decay of the models' predictive accuracy in our population. The lack of generalisability of standard prognostic models requires their validation and re-calibration before they can be applied with confidence to new populations. Customisation of existing models may become an important strategy to obtain authentic information on disease severity, which is a prerequisite for reliably measuring and comparing the quality and cost of intensive care.

Determinants of postintensive care unit mortality: a prospective multicenter study

OBJECTIVE

Six to 25 percent of patients discharged alive from the intensive care unit (ICU) die before hospital discharge. Although this post-ICU mortality may indicate premature discharge from a full ICU or suboptimal management in the ICU or ward, another factor may be discharge from the ICU as part of a decision to limit treatment of hopelessly ill patients. We investigated determinants of post-ICU mortality, with special attention to this factor.

DESIGN

Prospective, multicenter, database study.

SETTING

Seven ICUs in or near Paris, France.

PATIENTS

A total of 1,385 patients who were discharged alive from an ICU after a stay of > or = 48 hrs; 150 (10.8%) died before hospital discharge. Decisions to withhold or withdraw life-sustaining treatments were implemented in the ICUs in 80 patients, including 47 (58.7%) who died before hospital discharge.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

In the univariate analysis, post-ICU mortality was associated with advanced age, poor chronic health status, severe comorbidities, severity and organ failure scores (Simplified Acute Physiology Score II, sepsis-related organ failure assessment, and Logistic Organ Dysfunction at admission and at ICU discharge), decisions to withhold or withdraw life-sustaining treatments, and Omega score (reflecting ICU resource utilization and length of ICU stay). Multivariate stepwise logistic regression identified five independent determinants of post-ICU mortality: McCabe class 1 (odds ratio, 0.388 [95% confidence interval, 0.26-0.58]), transfer from a ward (odds ratio, 1.89 [95% confidence interval, 1.27-2.80]), Simplified Acute Physiology Score II score at admission >36 (odds ratio, 1.57 [95% confidence interval, 1.6-2.33]), decisions to withhold or withdraw life-sustaining treatments (odds ratio, 9.64 [95% confidence interval, 5.75-16.6]), and worse sepsis-related organ failure assessment score at discharge (odds ratio, 1.11 [95% confidence interval, 1.03-1.18] per point).

CONCLUSIONS

More than 10% of ICU survivors died before hospital discharge. Determinants of post-ICU mortality included variables reflecting patient status before and during the ICU stay. However, the most powerful predictor of post-ICU mortality was the decision to withhold or withdraw life-sustaining treatments in the ICU, suggesting that the decision has been made not to use the unique services of the ICU for these patients.

Ambulatory care-sensitive conditions: clinical outcomes and impact on intensive care unit resource use

BACKGROUND

We identified risk factors and clinical outcomes associated with ambulatory care-sensitive conditions requiring intensive care unit (ICU) admission.

METHODS

This prospective cohort study included 4,144 patients admitted to the medical ICU of an urban teaching hospital during a 3-year period.

RESULTS

A total of 627 patients were classified as having ambulatory care-sensitive conditions (ie, potentially preventable ICU admissions). Black race, decreasing Acute Physiology and Chronic Health Evaluation II (APACHE II) score, younger age, female sex, and absence of immunodeficiency were independently associated with ambulatory care-sensitive conditions. Patients classified as having ambulatory care-sensitive conditions accounted for 2,006 ventilator days, 2,508 ICU days, and 5,392 hospital days. The hospital mortality rate was statistically lower for patients with ambulatory care-sensitive conditions than for patients without these conditions. Patients classified as having ambulatory care-sensitive conditions were also statistically more likely than other patients to lack health insurance and to sign out of the hospital against medical advice.

CONCLUSION

Patients with ambulatory care-sensitive conditions account for a substantial portion of all admissions to the intensive care unit. These data suggest that interventions aimed at preventing such admissions could improve ICU bed use.

Critically ill patients readmitted to intensive care units--lessons to learn?

OBJECTIVE

To evaluate risk factors in critically ill patients who were readmitted to an intensive care unit (ICU) during their hospital stay.

DESIGN

Prospective multicenter cohort study.

PATIENTS AND SETTING

A total of 15180 patients discharged from 30 medical, surgical and mixed ICUs in Austria over a 2-year period.

MEASUREMENTS AND RESULTS

The data analyzed included data on patients' clinical characteristics, Simplified Acute Physiology Score II (SAPS II), Logistic Organ Dysfunction system (LOD), Simplified Therapeutic Intervention Scoring System (TISS-28), length of ICU stay, ICU mortality and hospital mortality. Of the 15180 patients who survived the first ICU stay, 780 patients (5.1%) were readmitted. These patients had more than a fourfold risk of dying during their hospital stay (21.7 vs 5.2%, p<0.001). For mechanically ventilated patients, the time between extubation and discharge during the first ICU stay was significantly shorter for readmitted than for non-readmitted patients (median 1 vs 2 days, p<0.001). On the day of their first ICU discharge, readmitted patients were in greater need of organ support, with more patients still requiring ventilatory, cardiovascular and renal support than non-readmitted patients.

CONCLUSIONS

The results of this study provide evidence that there exists a group of patients at higher risk of readmission to the ICU. At the time of their first ICU discharge, these patients presented with residual organ dysfunctions, which were associated with an increased risk of being readmitted. Optimizing organ functions in these patients before discharge from the ICU could result in reduced readmission rates.

Leaving the intensive care unit: a phenomenological study of the patients’ experience

Discharge from intensive care (ICU), is said to pose difficulties for patients; a phenomenon referred to as "relocation stress". However, this phenomenon has not been fully examined, particularly from the critical care patients' perspective. This study, therefore, explored the lived experience of transfer from ICU to the ward. Phenomenology, based on the interpretative Heideggerian approach was used to guide the study. A purposive sample of six participants was selected. Open interviews were used to collect data. Participants were interviewed twice; once in ICU, prior to transfer, and once in the ward following transfer. The findings revealed that pre-transfer, participants were mainly accepting of their impending transfer. Participants discussed a desire for normality and identified that leaving the ICU staff was the most negative component of transfer. In the post-transfer period, findings revealed mixed feelings regarding the actual transfer. Participants were still suffering from physical complaints, which led to feelings of despondency. Differences between ICU and the ward were also highlighted. Finally, the enormity of the ICU experience appeared to have an impact post-transfer. The results of this study indicate that transfer from ICU can be problematic for some individuals. However, caution is required regarding the use of the nursing diagnosis of relocation stress without obtaining an individual perspective on experiences. Recommendations include the need for greater continuity of care for those recovering from critical illness.

Uncertainty and scoring systems

Estimating risks for individual patients facilitates communication with patients, relatives and colleagues, and determines whether further treatment is futile. The process of estimating risks involves mathematics (i.e. scoring systems) and human experience and expertise. Understanding how risks are estimated is important because prognostication is an integral part of any medical specialty. In the USA, such treatment limitation or withdrawal decisions were made on only 7% of all intensive care unit patients but this represented 47% of all deaths on such units. In the UK, data reported by the Intensive Care National Audit and Research Centre suggest that although treatment limitation decisions are made on only 11.8% of patients, this accounts for over 50% of deaths on intensive care. Scoring systems offer a useful adjunct in identifying futility but there are important inherent weaknesses that limit their performance. This review aims to discuss some of these limitations.

Influence of patient gender on admission to intensive care

STUDY OBJECTIVES

To compare the case mix and outcomes of male and female patients admitted to intensive care units for a wide range of conditions.

DESIGN

Cross sectional study of prospectively collected data.

SETTING

The Intensive Care National Audit and Research Centre, (ICNARC) Case Mix Programme.

PARTICIPANTS

46 587 admissions to 91 units across England, Wales, and Northern Ireland.

MAIN RESULTS

No gender differences were found in case mix on admission or in mortality for five conditions (cardiac arrhythmia, chronic obstructive airways disease, asthma, self poisoning, and seizures). There was some evidence of horizontal and vertical inequity for female patients with myocardial infarction and with neurological bleeding. Vertical equity was not achieved for male pneumonia and ventricular failure patients and for women with primary brain injury.

CONCLUSIONS

This study demonstrated, for the first time, possible inequitable use of intensive care for patients with certain conditions. This may be secondary to gender bias and can result in either over-treatment in the favoured group, or under-treatment in the neglected group. It would therefore be pertinent to re-examine these findings using other databases, and to further investigate the causative factors, including gender bias.

Patient volume, staffing, and workload in relation to risk-adjusted outcomes in a random stratified sample of UK neonatal intensive care units: a prospective evaluation

BACKGROUND

UK recommendations suggest that large neonatal intensive-care units (NICUs) have better outcomes than small units, although this suggestion remains unproven. We assessed whether patient volume, staffing levels, and workload are associated with risk-adjusted outcomes, and with costs or staff wellbeing.

METHODS

186 UK NICUs were stratified according to volume of patients, nursing provision, and neonatal consultant provision. Primary outcomes were hospital mortality, mortality or cerebral damage, and nosocomial bacteraemia. We studied 13515 infants of all birthweights consecutively admitted to 54 randomly selected NICUs. Multiple logistic regression analyses were done with every primary outcome as the dependent variable. Staff wellbeing and stress were assessed by anonymous mental health index (MHI)-5 questionnaires.

FINDINGS

Data were available for 13334 (99%) infants. High-volume NICUs treated the sickest infants and had highest crude mortality. Risk-adjusted mortality and mortality or cerebral damage were unrelated to patient volume or staffing provision; however, nosocomial bacteraemia was less frequent in NICUs with low neonatal consultant provision (odds ratio 0.65, 95% CI 0.43-0.98). Mortality was raised with increasing workload in all types of NICUs. Infants admitted at full capacity versus half capacity were about 50% more likely to die, but there was wide uncertainty around this estimate. Most staff had MHI-5 scores that suggested good mental health.

INTERPRETATION

The implications of this report for staffing policy, medicolegal risk management, and ethical practice remain to be tested. Centralisation of only the sickest infants could improve efficiency, provided that this does not create excessive workload for staff. Assessment of increased staffing levels that are closer to those in adult intensive care might be appropriate.

The pulmonary physician in critical care: towards comprehensive critical care?

This overview of intensive care medicine in Europe and the United States is an introduction to the review series on "The pulmonary physician in critical care" which starts in this issue of Thorax.

Cardiopulmonary resuscitation directives on admission to intensive-care unit: an international observational study

BACKGROUND

Resuscitation directives should be a sign of patient's preference. Our objective was to ascertain prevalence, predictors, and procurement pattern of cardiopulmonary resuscitation directives within 24 h of admission to the intensive-care unit (ICU).

METHODS

We enrolled 2916 patients aged 18 years and older from 15 ICUs in four countries, and recorded whether, when, and by whom their cardiopulmonary resuscitation directives were established. By polychotomous logistic regression we identified factors associated with a resuscitate or do-not-resuscitate directive.

FINDINGS

Of 2916 patients, 318 (11%; 95% CI 9.8-12.1) had an explicit resuscitation directive. In 159 (50%; 44.4-55.6) patients, the directive was do-not-resuscitate. Directives were established by residents for 145 (46%; 40.0-51.3) patients. Age strongly predicted do-not-resuscitate directives: for 50-64, 65-74, and 75 years and older, odds ratios were 3.4 (95% CI 1.6-7.3), 4.4 (2.2-9.2), and 8.8 (4.4-17.8), respectively. APACHE II scores greater than 20 predicted resuscitate and do-not-resuscitate directives in a similar way. An explicit directive was likely for patients admitted at night (odds ratio 1.4 [1.0-1.9] and 1.6 [1.2-2.3] for resuscitate and do-not-resuscitate, respectively) and during weekends (1.9 [1.3-2.7] and 2.2 [1.5-3.2], respectively). Inability to make a decision raised the likelihood of a do-not-resuscitate (3.7 [2.6-5.4]) than a resuscitate (1.7 [1.2-2.3]) directive (p=0.0005). Within Canada and the USA, cities differed strikingly, as did centres within cities.

INTERPRETATION

Cardiopulmonary resuscitation directives established within 24 h of admission to ICU are uncommon. As well as clinical factors, timing and location of admission might determine rate and nature of resuscitation directives.

New issues in severity scoring: interfacing the ICU and evaluating it

Since the development of the first general outcome prediction models, these instruments have been widely used in the intensive care unit (ICU), both for patient evaluation and for ICU evaluation. Since some of these uses have been serious questioned, we assisted in the last years to the exploration of alternative paths for increasing the predictive power of the models and to enhance their applicability and utility in the real world. Part of these efforts focused on the exploration of more meaningful outcomes (clinical and non-clinical) with a strong tonic into the relation between outcomes and resources use. Also, since it is now widely recognized that the ICU is not an island, but it is integrated in a continuum of care, more and more efforts are being made to optimize and evaluate the interface between the ICU and the hospital, both at ICU admission and at ICU discharge. The objective of this review is to present and discuss, to the clinician working in the ICU, these emerging issues.

Variation in intensive care unit outcomes: a search for the evidence on organizational factors

This study was undertaken to determine the extent of empirical evidence on the role of organizational factors in the critical care literature and to categorize these factors. Studies evaluating organizational factors were identified through electronic and hand searching of the critical care literature. Sixty-three publications relating to 54 different studies were identified. The studies were grouped into eight main categories: staffing, teamwork, volume and pressure of work, protocols, admission to intensive care, technology, structure, and error. Studies evaluating organizational factors exist in the critical care literature, and there is evidence that the number is increasing each year. Results indicate that organizational factors may have an impact on mortality after case mix adjustment. Some areas have been investigated more thoroughly than others and are ripe for systematic review. Variation in case mix adjusted hospital mortality after intensive care is an old theme. This study has shown that emerging data will help us understand mortality differences and deliver better outcomes for patients.

Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model

OBJECTIVE

To develop a predictive model to triage patients for discharge from intensive care units to reduce mortality after discharge.

DESIGN

Logistic regression analyses and modelling of data from patients who were discharged from intensive care units.

SETTING

Guy's hospital intensive care unit and 19 other UK intensive care units from 1989 to 1998.

PARTICIPANTS

5475 patients for the development of the model and 8449 for validation.

MAIN OUTCOME MEASURES

Mortality after discharge and power of triage model.

RESULTS

Mortality after discharge from intensive care was up to 12.4%. The triage model identified patients at risk from death on the ward with a sensitivity of 65.5% and specificity of 87.6%, and an area under the receiver operating curve of 0.86. Variables in the model were age, end stage disease, length of stay in unit, cardiothoracic surgery, and physiology. In the validation dataset the 34% of the patients identified as at risk had a discharge mortality of 25% compared with a 4% mortality among those not at risk.

CONCLUSIONS

The discharge mortality of at risk patients may be reduced by 39% if they remain in intensive care units for another 48 hours. The discharge triage model to identify patients at risk from too early and inappropriate discharge from intensive care may help doctors to make the difficult clinical decision of whom to discharge to make room for a patient requiring urgent admission to the unit. If confirmed, this study has implications on the provision of resources.