The variability of critical care bed numbers in Europe

The association between the patient and the physician genders and the likelihood of intensive care unit admission in hospital with restricted ICU bed capacity

BACKGROUND

Despite the evidence that the patient gender is an important component in the intensive care unit (ICU) admission decision, the role of physician gender and the interaction between the two remain unclear.

OBJECTIVE

To investigate the association of both the patient and the physician gender with ICU admission rate of critically ill emergency department (ED) medical patients in a hospital with restricted ICU bed capacity operates with 'closed door' policy.

METHODS

A retrospective population-based cohort analysis. We included patients above 18 admitted to an ED resuscitation room (RR) of a tertiary hospital during 2011-12. Data on medical, laboratory and clinical characteristics were obtained. We used an adjusted multivariable logistic regression to analyze the association between both the patient and the physician gender to the ICU admission decision.

RESULTS

We included 831 RR admissions, 388 (46.7%) were female patients and 188 (22.6%) were treated by a female physicians. In adjusted multivariable analysis (adjusted for age, diabetes, mode of hospital transportation, first pH and patients who were treated with definitive airway and vasso-pressors in the RR), female-female combination (patient-physician, respectively) showed the lowest likelihood to be admitted to ICU (adjusted OR: 0.21; 95% CI: 0.09-0.51) compared to male-male combination, in addition to a smaller decrease among female-male (adjusted OR: 0.53; 95% CI: 0.32-0.86) and male-female (adjusted OR: 0.43; 95% CI: 0.21-0.89) combinations.

CONCLUSION

We demonstrated the existence of the possible gender bias where female gender of the patient and treating physician diminish the likelihood of the restricted health resource use.

Impact on mortality of prompt admission to critical care for deteriorating ward patients: an instrumental variable analysis using critical care bed strain

PURPOSE

To estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients.

METHODS

We performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt admissions (within 4 h of assessment) were compared to a 'watchful waiting' cohort. We used critical care strain (bed occupancy) as a natural randomisation event that would predict prompt transfer to critical care. Strain was classified as low, medium or high (2+, 1 or 0 empty beds). This instrumental variable (IV) analysis was repeated for the subgroup of referrals with a recommendation for critical care once assessed. Risk-adjusted 90-day survival models were also constructed.

RESULTS

A total of 12,380 patients from 48 hospitals were available for analysis. There were 2411 (19%) prompt admissions (median delay 1 h, IQR 1-2) and 9969 (81%) controls; 1990 (20%) controls were admitted later (median delay 11 h, IQR 6-26). Prompt admissions were less frequent (p < 0.0001) as strain increased from low (22%), to medium (15%) to high (9%); the median delay to admission was 3, 4 and 5 h respectively. In the IV analysis, prompt admission reduced 90-day mortality by 7.4% (95% CI 1.7-18.5%, p = 0.117) overall, and 16.2% (95% CI 1.1-31.3%, p = 0.036) for those recommended for critical care. In the risk-adjust survival model, 90-day mortality was similar.

CONCLUSION

After allowing for unobserved prognostic differences between the groups, we find that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.

Indicators of intensive care unit capacity strain: a systematic review

BACKGROUND

Strained intensive care unit (ICU) capacity represents a fundamental supply-demand mismatch in ICU resources. Strain is likely to be influenced by a range of factors; however, there has been no systematic evaluation of the spectrum of measures that may indicate strain on ICU capacity.

METHODS

We performed a systematic review to identify indicators of strained capacity. A comprehensive peer-reviewed search of MEDLINE, EMBASE, CINAHL, Cochrane Library, and Web of Science Core Collection was performed along with selected grey literature sources. We included studies published in English after 1990. We included studies that: (1) focused on ICU settings; (2) included description of a quality or performance measure; and (3) described strained capacity. Retrieved studies were screened, selected and extracted in duplicate. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale (NOS). Analysis was descriptive.

RESULTS

Of 5297 studies identified in our search; 51 fulfilled eligibility. Most were cohort studies (n = 39; 76.5%), five (9.8%) were case-control, three (5.8%) were cross-sectional, two (3.9%) were modeling studies, one (2%) was a correlational study, and one (2%) was a quality improvement project. Most observational studies were high quality. Sixteen measures designed to indicate strain were identified 110 times, and classified as structure (n = 4, 25%), process (n = 7, 44%) and outcome (n = 5, 31%) indicators, respectively. The most commonly identified indicators of strain were ICU acuity (n = 21; 19.1% [process]), ICU readmission (n = 18; 16.4% [outcome]), after-hours discharge (n = 15; 13.6% [process]) and ICU census (n = 13; 11.8% [structure]). There was substantial heterogeneity in the operational definitions used to define strain indicators across studies.

CONCLUSIONS

We identified and characterized 16 indicators of strained ICU capacity across the spectrum of healthcare quality domains. Future work should aim to evaluate their implementation into practice and assess their value for evaluating strategies to mitigate strain.

SYSTEMATIC REVIEW REGISTRATION

This systematic review was registered at PROSPERO (March 27, 2015; CRD42015017931 ).

Intensive Care Unit Admission for Patients in the INTERACT2 ICH Blood Pressure Treatment Trial: Characteristics, Predictors, and Outcomes

BACKGROUND

Wide variation exists in criteria for accessing intensive care unit (ICU) facilities for managing patients with critical illnesses such as acute intracerebral hemorrhage (ICH). We aimed to determine the predictors of admission, length of stay, and outcome for ICU among participants of the main Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2).

METHODS

INTERACT2 was an international, open, blinded endpoint, randomized controlled trial of 2839 ICH patients (<6 h) and elevated systolic blood pressure (SBP) allocated to receive intensive (target SBP <140 mmHg within 1 h) or guideline-recommended (target SBP <180 mmHg) BP-lowering treatment. The primary outcome was death or major disability, defined by modified Rankin scale scores 3-6 at 90 days. Logistic regression and propensity score analyses were used to determine independent associations.

MAIN RESULTS

Predictors of ICU admission included younger age, recruitment in China, prior ischemic/undetermined stroke, high SBP, severe stroke [National Institute of Health stroke scale (NIHSS) score ≥15], large ICH volume (≥15 mL), intraventricular hemorrhage (IVH) extension, early neurological deterioration, intubation and surgery. Determinants of prolonged ICU stay (≥5 days) were prior antihypertensive use, NIHSS ≥15, large ICH volume, lobar ICH location, IVH, early neurological deterioration, intubation and surgery. ICU admission was associated with higher-risk major disability at 90-day assessment compared to those without ICU admission.

CONCLUSIONS

This study presents prognostic variables for ICU management and outcome of ICH patients included in a large international cohort. These data may assist in the selection and counseling of patients and families concerning ICU admission.

Epidemiology of healthcare-associated infections in Polish intensive care. A multicenter study based on active surveillance

AIM

The aim of this study was to evaluate the incidence of health care-associated infections (HAIs) in patients treated in Polish intensive care units (ICUs).

METHODS

This retrospective analysis was based on the results of active targeted surveillance, according to the recommendation of the ECDC (European Centre of Disease Control and Prevention, HAI-Net light protocol), conducted in 2013-2015 in seven ICUs for adults located in southern Poland (observational study).

RESULTS

The incidence of HAI was 22.6% and 28.7/1000 person-days (pds). The incidence of pneumonia (PN) was 8.0%, bloodstream infections (BSIs) 7.2% and urinary tract infections (UTIs) 3.7%. The incidence per 1000 pds was as follows: PN 10.2, BSIs 9.2 and UTIs 4.7. PN was the most common source of secondary bloodstream infection (45%); the second was UTIs (22%). Mortality (directly and indirectly) associated with HAI was 10.8% and was related to the presence of PN or primary BSIs. HAIs were usually (69.2%) caused by Gram-negative bacteria; Klebsiella spp. and nonfermenting Gram-negative rods demonstrated very high antibiotic resistance.

CONCLUSION

Despite the lack of widely implemented active targeted surveillance programmes and top-down incentives, it is possible to carry out effective surveillance of HAIs in ICUs in Poland. The results of this study are comparable with the ECDC data, but the results are alarmingly high in two fields: epidemiology of PN and BSIs and very high antibiotic resistance in Gram-negative rods, which indicate the need for intense control in this area and for further studies to clarify the source of the observed discrepancy.

Intensive care admission and hospital mortality in the elderly after non-cardiac surgery

OBJECTIVE

To assess whether patient age is independently associated to Intensive Care Unit (ICU) admission after non-cardiac surgery.

DESIGN

An observational cohort study of the Spanish subset of the European Surgical Outcome Study (EuSOS) was carried out.

SETTING

Hospitals of the public National Health Care System and private hospitals in Spain.

INTERVENTION

None.

PATIENTS AND METHODS

All patients over 16 years of age undergoing inpatient non-cardiac surgery in the participating hospitals during a 7-day period in the month of April 2011 were consecutively included.

MAIN VARIABLES OF INTEREST

ICU admission rate, factors associated with ICU admission and hospital mortality were assessed using logistic regression analysis and fractional polynomial regression.

RESULTS

Out of 5412 patients, 677 (12.5%) were admitted to the ICU after surgery. The adjusted odds ratio (95% confidence interval [CI]) for ICU admission was 1.1 (0.8-1.4) for patients aged 65-74 years, 0.7 (0.5-1) for patients aged 75-85 years, and 0.4 (0.2-0.8) for patients over 85 years, respectively. Age, ASA score, grade of surgery (minor, intermediate, major), urgent surgery, surgical specialty, laparoscopic surgery and metastatic disease were independent factors for ICU admission. Global risk-adjusted mortality was 1.4 (95% CI 0.9-2.2). The ASA score, urgent surgery, surgical specialty and diabetes were predictors of hospital mortality.

CONCLUSIONS

Elderly patients (over 80 years) appear less likely to be admitted to ICU after non-cardiac surgery in Spanish hospitals. There was no significant association between age and postoperative mortality in this cohort.

Intensive care decision-making: Identifying the challenges and generating solutions to improve inter-specialty referrals to critical care

Introduction

Decision-making regarding admission to UK intensive care units is challenging. Demand for beds exceeds capacity, yet the need to provide emergency cover creates pressure to build redundancy into the system. Guidelines to aid clinical decision-making are outdated, resulting in an over-reliance on professional judgement. Although clinicians are highly skilled, there is variability in intensive care unit decision-making, especially at the inter-specialty level wherein cognitive biases contribute to disagreement.

Method

This research is the first to explore intensive care unit referral and admission decision-making using the Critical Decision Method interviewing technique. We interviewed intensive care unit (n = 9) and non-intensive care unit (n = 6) consultants about a challenging referral they had dealt with in the past where there was disagreement about the patient's suitability for intensive care unit.

Results

We present: (i) a description of the referral pathway; (ii) challenges that appear to derail referrals (i.e. process issues, decision biases, inherent stressors, post-decision consequences) and (iii) potential solutions to improve this process.

Discussion

This research provides a foundation upon which interventions to improve inter-specialty decision-making can be based.

Workload and severity of illness of patients on intensive care units with available intermediate care units: a multicenter cohort study

BACKGROUND

Intermediate Care Units (IMCU) are established in many hospitals to better match the requirements of patient care with respect to their personnel, equipment and other resources. This should relieve Intensive Care Unit (ICU) capacities for more severely ill patients and reduce readmissions to ICU. This study was conducted to investigate the effects of IMCU use on ICU populations.

METHODS

This is a retrospective analysis of the German National Registry of Intensive Care from the years 2000 to 2010.

RESULTS

We included 39 ICUs with high and 11 ICUs with low IMCU use. Patients in ICUs with high IMCU use were younger (mean age [high vs. low]: 60.5 vs. 64.5 years, P<0.001), while the severity of illness was higher (percentage of ventilated patients during ICU stay [high vs. low ICMU use]: 67.2% vs. 40.2%, P<0.001; patients ventilated >24 hours: 22% vs. 18%, P<0.001; mean therapeutic intervention scoring system-28 (TISS-28) score: 25.7 vs. 23.3, P<0.001). Readmission rates to ICU did not differ between ICU groups ([high vs. low]: 4.5% vs. 4.4%, P=0.25). ICUs with high IMCU use discharged 90.3% of all patients who were discharged to the IMCU or general ward between the regular workday hours of 06:00 and 14:59, while ICUs with low IMCU use discharged 83.8% of all patients discharged to the general ward in the same time period.

CONCLUSIONS

The use of IMCUs influences resource utilization of ICUs. Severity of illness and workload was higher in ICUs with high IMCU and more scheduled discharges occurred during the main working hours while readmission rates were similar.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey

BACKGROUND

Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80.

METHODS

We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80.

RESULTS

We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions.

CONCLUSION

There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.

[Reimbursement of intensive care services in Austria : Use of the LKF system]

In Austria, the reimbursement of intensive care services is based on a Diagnosis-Related Groups (DRG) system which has been adapted to the Austrian framework conditions. Compared to Germany where economic considerations had led to personnel cuts, mandatory targets outlined in both the LKF ("Leistungsorientierte Krankenanstaltenfinanzierung", Performance-oriented Hospital Financing) and ÖSG ("Österreichischer Strukturplan Gesundheit", Austrian Health Care Structure Plan) plans ensure a high level of medical and intensive care. A clearly defined minimal nurse-to-bed ratio should ensure adequate care of critically ill patients. However, such a staffing ratio is still lacking for intensive care unit physicians. The following article is meant to outline the fundamental structures of the Austrian intensive care units and provide consideration about further optimization of intensive care medicine provided in Austria to ensure the high level of care in the future.

[Reimbursement of intensive care services in the German DRG system : Current problems and possible solutions]

The reimbursement of intensive care and nursing services in the German health system is based on the diagnosis-related groups (G-DRG) system. Due to the lack of a central hospital planning, the G‑DRG system has become the most important influence on the development of the German health system. Compared to other countries, intensive care in Germany is characterized by a high number of intensive care beds, a low nurse-to-patient ratio, no official definition of the level of care, and a minimal available data set from intensive care units (ICUs). Under the given circumstances, a shortage of qualified intensive care nurses and physicians is currently the largest threat for intensive care in Germany. To address these deficiencies, we suggest the following measures: (1) Integration of ICUs into the levels of care which are currently developed for emergency centers at hospitals. (2) Mandatory collection of structured data sets from all ICUs including quality criteria. (3) A reform of intensive care and nursing reimbursement under consideration of adequate staffing in the individual ICU. (4) Actions to improve ICU staffing and qualification.

Critical Care Resources in Guangdong Province of China: Three Surveys from 2005 to 2015

OBJECTIVES

Data about the critical care resources in China remain scarce. The purpose of this study was to investigate the variation and distribution of critical care resources in Guangdong province from 2005 to 2015.

DESIGN

Data in regard to critical care resources were collected through questionnaires and visits every 5 years from 2005.

SETTING

All hospitals in Guangdong province were screened and hospitals that provide critical care services were enrolled.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

One hundred eleven, 158, and 284 hospitals that provide critical care services were enrolled in the three consecutive surveys respectively. The number of ICUs, ICU beds, intensivists, and nurses increased to 324, 3,956, 2,470, and 7,695, respectively, by 2015. Adjusted by population, the number of ICU beds per 100,000 (100,000) population increased by 147.7% from 2005 to 2015, and the number of intensivists and nurses per 100,000 population increased by 35.3% and 55.1% from 2011 to 2015. However, the numbers in the Pearl River Delta, a richer area, were higher than those in the non-Pearl River Delta area (ICU beds: 4.64 vs 2.58; intensivists: 2.90 vs 1.61; nurses: 9.30 vs 4.71 in 2015). In terms of staff training, only 17.85% of intensivists and 14.29% of nurses have completed a formal accredited critical care training program by 2015.

CONCLUSIONS

Our study was the first one to investigate the trend and distribution of critical care resources in China. The quantity of ICU beds and staff has been increasing rapidly, but professional training for staff was inadequate. The distribution of critical care resources was unbalanced. Our study can be beneficial for healthcare policymaking and the allocation of critical care resources in Guangdong province and other provinces in China.

Impact of a National Controlled Donation After Circulatory Death (DCD) Program on Organ Donation in the United Kingdom: A 10-Year Study

Organ transplantation is the most successful treatment for some forms of organ failure, yet a lack of organs means many die on the waiting list. In the United Kingdom, the Organ Donation Taskforce was set up to identify barriers to organ donation and in 2008 released its first report (Organ Donation Taskforce Report; ODTR). This study assesses the success since the ODTR and examines the impact of the United Kingdom's controlled donation after circulatory death (DCD) program and the controversies surrounding it. There were 12 864 intended donation after brain death (DBD) or DCD donors from April 2004 to March 2014. When the 5 years preceding the ODTR was compared to the 5 years following, intended DCD donors increased 292% (1187 to 4652), and intended DBD donors increased 11% (3327 to 3698). Organs retrieved per intended DBD donor remained static (3.30 to 3.26), whereas there was a decrease in DCD (1.54 to 0.99) due to a large rise in donors who did not proceed to donation (325 to 2464). The majority of DCD donors who proceeded did so within 30 min from time of withdrawal. Our study suggests further work on converting eligible referrals to organ donation and exploring methods of converting DCD to DBD donors.

Intensive care admissions due to poisoning

BACKGROUND

Poisoning represents a significant part of admissions to intensive care units. The aim of this nationwide study was to describe recent national quality register data of demographics and mortality for these patients.

METHOD

A retrospective national observational study including all patients over 19 years admitted to an ICU in Sweden, between 1 January 2010 and 31 December 2011, with an ICD-10 code for poisoning. The data were collected from three national registers (The Swedish Intensive Care Register, The National Patient Register, and The Cause of Death Register).

RESULTS

The incidence of ICU-treated poisonings was 43/100,000. Twenty-one per cent (n = 8155) of all poisoned patients seeking medical care were admitted to the ICU. Their median age was 38 years (q1-q3: 26-51), as many men as women and 46.5% (n = 3790) had a previous registered poisoning. A mix of different substances was the most common type of suspected poisoning (29.7%, n = 2424). The in-hospital mortality was 1.9% and was correlated to invasive mechanical ventilation (OR 6.91 CI 95% 4.59-10.42), age > 40 (OR 4.54 CI 95% 2.86-7.21) and no previous hospitalisation for poisoning (OR 3.23 CI 95% 2.06-5.07). For 78.3% (n = 119) of the deceased patients, the fatal poisoning was their first diagnosed poisoning. The 30-day mortality was 2.7%, a majority died from poisoning (P < 0.01).

CONCLUSION

In Sweden, patients treated in the ICU due to poisoning represent a fifth of all poisoned patients seeking medical care. Older men with no previous poisoning were considered a high-risk group.

SNAP-2 EPICCS: the second Sprint National Anaesthesia Project-EPIdemiology of Critical Care after Surgery: protocol for an international observational cohort study

INTRODUCTION

The admission of high-risk patients to critical care after surgery is a recommended standard of care. Nevertheless, poor compliance against this recommendation has been repeatedly demonstrated in large epidemiological studies. It is unclear whether this is due to reasons of capacity, equipoise, poor quality clinical care or because hospitals are working creatively to create capacity for augmented care on normal surgical wards. The EPIdemiology of Critical Care after Surgery study aims to address these uncertainties.

METHODS AND ANALYSIS

One-week observational cohort study in the UK and Australasia. All patients undergoing inpatient (overnight stay) surgery will be included. All will have prospective data collection on risk factors, surgical procedure and postoperative outcomes including the primary outcome of morbidity (measured using the Postoperative Morbidity Survey on day 7 after surgery) and secondary outcomes including length of stay and mortality. Data will also be collected on critical care referral and admission, surgical cancellations and critical care occupancy. The epidemiology of patient characteristics, processes and outcomes will be described. Inferential techniques (multilevel multivariable regression, propensity score matching and instrumental variable analysis) will be used to evaluate the relationship between critical care admission and postoperative outcome.

ETHICS AND DISSEMINATION

The study has received ethical approval from the National Research Ethics Service in the UK and equivalent in Australasia. The collection of patient identifiable data without prior consent has been approved by the Confidentiality Advisory Group (England and Wales) and the Public Privacy and Patient Benefit Panel (Scotland). In these countries, patient identifiable data will be used to link prospectively collected data with national registers of death and inpatient administrative data. The study findings will be disseminated using a multimedia approach with the support of our lay collaborators, to patients, public, policy-makers, clinical and academic audiences.

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

BACKGROUND

Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease.

METHODS

We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis.

RESULTS

The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective.

CONCLUSIONS

On average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.

Differences in Impact of Definitional Elements on Mortality Precludes International Comparisons of Sepsis Epidemiology-A Cohort Study Illustrating the Need for Standardized Reporting

OBJECTIVES

Sepsis generates significant global acute illness burden. The international variations in sepsis epidemiology (illness burden) have implications for region specific health policy. We hypothesised that there have been changes over time in the sepsis definitional elements (infection and organ dysfunction), and these may have impacted on hospital mortality.

DESIGN

Cohort study.

SETTING

We evaluated a high quality, nationally representative, clinical ICU database including data from 181 adult ICUs in England.

PATIENTS

Nine hundred sixty-seven thousand five hundred thirty-two consecutive adult ICU admissions from January 2000 to December 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

To address the proposed hypothesis, we evaluated a high quality, nationally representative, clinical, ICU database of 967,532 consecutive admissions to 181 adult ICUs in England, from January 2000 to December 2012, to identify sepsis cases in a robust and reproducible way. Multinomial logistic regression was used to report unadjusted trends in sepsis definitional elements and in mortality risk categories based on organ dysfunction combinations. We generated logistic regression models and assessed statistical interactions with acute hospital mortality as outcome and cohort characteristics, sepsis definitional elements, and mortality risk categories as covariates. Finally, we calculated postestimation statistics to illustrate the magnitude of clinically meaningful improvements in sepsis outcomes over the study period. Over the study period, there were 248,864 sepsis admissions (25.7%). Sepsis mortality varied by infection sources (19.1% for genitourinary to 43.0% for respiratory; p < 0.001), by number of organ dysfunctions (18.5% for 1 to 69.9% for 5; p < 0.001), and organ dysfunction combinations (18.5% for risk category 1 to 58.0% for risk category 4). The rate of improvement in adjusted hospital mortality was significant (odds ratio, 0.939 [0.934-0.945] per year; p < 0.001), but showed different secular trends in improvement between infection sources.

CONCLUSIONS

Within a sepsis cohort, we illustrate case-mix heterogeneity using definitional elements (infection source and organ dysfunction). In the context of improving outcomes, we illustrate differential secular trends in impact of these variables on adjusted mortality and propose this as a valid reason for international variations in sepsis epidemiology. Our article highlights the need to determine standardized reporting elements for optimal comparisons of international sepsis epidemiology.

Structure, Organization, and Delivery of Critical Care in Asian ICUs

OBJECTIVES

Despite being the epicenter of recent pandemics, little is known about critical care in Asia. Our objective was to describe the structure, organization, and delivery in Asian ICUs.

DESIGN

A web-based survey with the following domains: hospital organizational characteristics, ICU organizational characteristics, staffing, procedures and therapies available in the ICU and written protocols and policies.

SETTING

ICUs from 20 Asian countries from April 2013 to January 2014. Countries were divided into low-, middle-, and high-income based on the 2011 World Bank Classification.

SUBJECTS

ICU directors or representatives.

MEASUREMENTS AND MAIN RESULTS

Of 672 representatives, 335 (50%) responded. The average number of hospital beds was 973 (SE of the mean [SEM], 271) with 9% (SEM, 3%) being ICU beds. In the index ICUs, the average number of beds was 21 (SEM, 3), of single rooms 8 (SEM, 2), of negative-pressure rooms 3 (SEM, 1), and of board-certified intensivists 7 (SEM, 3). Most ICUs (65%) functioned as closed units. The nurse-to-patient ratio was 1:1 or 1:2 in most ICUs (84%). On multivariable analysis, single rooms were less likely in low-income countries (p = 0.01) and nonreferral hospitals (p = 0.01); negative-pressure rooms were less likely in private hospitals (p = 0.03) and low-income countries (p = 0.005); 1:1 nurse-to-patient ratio was lower in private hospitals (p = 0.005); board-certified intensivists were less common in low-income countries (p < 0.0001) and closed ICUs were less likely in private (p = 0.02) and smaller hospitals (p < 0.001).

CONCLUSIONS

This survey highlights considerable variation in critical care structure, organization, and delivery in Asia, which was related to hospital funding source and size, and country income. The lack of single and negative-pressure rooms in many Asian ICUs should be addressed before any future pandemic of severe respiratory illness.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Professional nursing practice in critical units: assessment of work environment characteristics

Objective

assess the autonomy, control over environment, and organizational support of nurses' work process and the relationships between physicians and nurses in critical care units.

Method

cross-sectional study conducted with 162 nurses working in the intensive care units and emergency service of a university hospital. The workers' satisfaction with their work environment was assessed using Brazilian Nursing Work Index - Revised, translated and adapted for the Brazilian culture.

Results

average age was 31.6 ± 3.9 years; 80.2% were women; 68.5% Caucasians and 71.6% worked in intensive care units. The nurses considered autonomy (2.38 ± 0.64) and their relationship with physicians (2.24 ± 0.62) to be characteristics of the work environment that favored professional practice. Control over environment (2.78 ± 0.62) and organizational support (2.51 ± 0.54), however, were considered to be unfavorable. No statistically significant differences were found between the units based on the scores obtained by the professionals on the Brazilian Nursing Work Index - Revised.

Conclusion

autonomy, relationship between physicians and nurses, and organizational support were considered by the units to be characteristics that favored nurses' professional practices. On the other hand, control over environment and organizational support were considered unfavorable.

Barriers toward organ donation in a Danish University Hospital

BACKGROUND

In Denmark, organ donation-rates are below the average in the western countries. We investigated the donor potential and identified barriers toward organ donation in a Danish university hospital.

METHODS

All patients who died in Aalborg University Hospital in 2012 were retrospectively identified. Patients with a CT- or MRI-proven deadly brain-lesion were eligible for inclusion.

RESULTS

Eighty-five patients with deadly brain-lesions were included, and of these 47 patients died in the intensive care unit (ICU). Older age and diagnosis of brain-hemorrhage and infarction were associated with admission to general ward (GW). In 62.4% of the patients the potential of becoming a donor was not identified. No donations occurred from patients dying from intracerebral hemorrhage or brain-infarction although they represented 44.7% of the potential donors.

DISCUSSION

This study reveals a huge, unrecognized donation potential at our hospital. About 30% was lost because they were never admitted to the ICU. After primary admission to the ICU, 15.3% of the potential donors were lost because they were transferred to the GW. In patients who died in the ICU 17.6% of the patients were not evaluated as potential donors. The relatives refused donation in 17.6% of cases.

CONCLUSION

It would be possible to raise the donation rate considerably if patients with donation potential are intubated and admitted to the ICU. When active treatment is considered withdrawn, possibility of organ donation should be evaluated, and the next of kin be approached by experienced staff.

Identifying opportunities to increase organ donation after brain death. An observational study in Sweden 2009-2014

BACKGROUND

There is a wide gap between the number of organ donors and patients on waiting lists for transplantation. The purpose of this Swedish nationwide study of the critical pathway for organ donation after brain death (DBD) was to identify missed opportunities for organ donation.

METHODS

We performed a prospective, observational study of all ICU deaths in Sweden from Jan 1, 2009 to Dec 31, 2014. The protocol structure followed the critical pathway for organ donation, which was developed and tested during 2008. We analysed differences in donation incidences between healthcare providers (counties) and patient characteristics using descriptive statistics and logistic regression.

RESULTS

The number of DBD per million population (pmp) was 14.9, varying almost 10-fold from 4.3 to 40.6 DBD pmp between counties. Regional variation in DBD decreased when we assigned the donor to the place of residence (from 6.9 to 27.7 DBD pmp). Women were more likely to become donors compared to men [crude odds ratio (OR) 1.60, 95% confidence interval (CI) 1.38-1.85, P < 0.001]. The increased likelihood remained after adjusting for age, comorbidity, and main diagnostic categories (OR 1.49, 95% CI 1.25-1.77, P < 0.001). An end-of-life decision was found in 50.9% of possible organ donors.

CONCLUSIONS

Regional differences in DBD were considerable, and women were more likely to become donors than men. There is a need for increased awareness of the potential for organ donation as an integral part of end-of-life clinical care. In-depth analysis of these differences may reveal opportunities for action that could lead to increased DBD.

Mapping the Characteristics of Critical Care Facilities: Assessment, Distribution, and Level of Critical Care Facilities from Central India

Background

In low- and middle-income countries such as India, where health systems are weak, the number of available Critical Care Unit (Intensive Care Unit [ICU]) beds is expected to be low. There is no study from the Indian subcontinent that has reported the characteristics and distribution of existing ICUs. We performed this study to understand the characteristics and distribution of ICUs in Madhya Pradesh (MP) state of Central India. We also aimed to develop a consensus scoring system and internally validate it to define levels of care and to improve health system planning and to strengthen referral networks in the state.

Methods

We obtained a list of potential ICU facilities from various sources and then performed a cross-sectional survey by visiting each facility and determining characteristics for each facility. We collected variables with respect to infrastructure, human resources, equipment, support services, procedures performed, training courses conducted, and in-place policies or standard operating procedure documents.

Results

We identified a total of 123 ICUs in MP. Of 123 ICUs, 35 were level 1 facilities, 74 were level 2 facilities, and only 14 were level 3 facilities. Overall, there were 0.17 facilities per 100,000 population (95* confidence interval [CI] 0.14-0.20 per 100,000 populations). There were a total of 1816 ICU beds in the state, with an average of 2.5 beds per 100,000 population (95* CI 2.4-2.6 per 100,000 population). Of the total number of ICU beds, 250 are in level 1, 1141 are in level 2, and 425 are in level 3 facilities. This amounts to 0.34, 1.57, and 0.59 ICU beds per 100,000 population for levels 1, 2, and 3, respectively.

Conclusion

This study could just be an eye opener for our healthcare authorities at both state and national levels to estimate the proportion of ICU beds per lac population. Similar mapping of intensive care services from other States will generate national data that is hitherto unknown.

Multifactorial analysis of fatigue scale among nurses in Poland

Significant progress in the field of nursing has contributed to the widening of range of functions and professional duties of nurses. More frequent lack of nursing personnel has an impact on negative reception of work, it decreases sense of professional satisfaction and increases the level of burden and fatigue. Methods. The study applied the non-experimental method – a descriptive comparative study without a control group. The data was collected on the basis of Polish-language version of a Japanese questionnaire. In order to evaluate the level of physical fatigue the pedometer was used. Results.158 respondents of a group of 160 were included in the statistical analysis. The study group was internally diversified. The research project assessed the usefulness of the multifactorial analysis in evaluating the main components of nursing fatigue. Multifactorial analysis has shown that mental fatigue concentrated with changes in activeness, motivation and physical fatigue are strongly correlated with age, professional experience and education. Conclusion. Nursing is a profession of a special character and mission. Regardless of the place of work, nursing staff should be given the possibility of pursuing their profession under conditions ensuring the sense of security and protecting them from harmful effects on health.

Outcome of mechanically ventilated patients initially denied admission to an intensive care unit and subsequently admitted

The outcome of mechanically ventilated patients initially denied admission to an intensive care unit (ICU) and subsequently admitted is unclear. We compared outcomes of patients denied ICU admission and subsequently admitted, to those of patients admitted to the ICU and to patients refused ICU admission. The medical records of all the patients who were subjected to mechanical ventilation for at least 24h over a 4year period (2010-2014) were reviewed. Of 707 patients (757 admissions), 124 (18%) were initially denied ICU admission and subsequently admitted. Multivariate stepwise logistic regression analysis showed significant association with death of: age, length of stay, nursing home residency, duration of mechanical ventilation, previous admission with mechanical ventilation, cause for mechanical ventilation, rate of failed extubations, associated morbidity (previous cerebrovascular accident, dementia, chronic renal failure), and occurrence of nosocomial bacteremia. The odds for death among patients denied ICU admission and subsequently transferred to the ICU compared to patients admitted directly to the ICU was 3.6 (95% CI: 1.9-6.7) (P<0.0001). The odds for death among patients refused ICU admission compared to those who were initially denied and subsequently admitted were not statistically significant (OR=1.7, 95% CI: 0.8-3.8). In conclusion, patients denied ICU admission and subsequently admitted face a considerable risk of morbidity and mortality. Their odds of death are nearly three times those admitted directly to the ICU. Late admission to the ICU does not appear to provide benefit compared to patients who remain in general medicine wards.

The Danish Intensive Care Database

AIM OF DATABASE

The aim of this database is to improve the quality of care in Danish intensive care units (ICUs) by monitoring key domains of intensive care and to compare these with predefined standards.

STUDY POPULATION

The Danish Intensive Care Database (DID) was established in 2007 and includes virtually all ICU admissions in Denmark since 2005. The DID obtains data from the Danish National Registry of Patients, with complete follow-up through the Danish Civil Registration System.

MAIN VARIABLES

For each ICU admission, the DID includes data on the date and time of ICU admission, type of admission, organ supportive treatments, date and time of discharge, status at discharge, and mortality up to 90 days after admission. Descriptive variables include age, sex, Charlson comorbidity index score, and, since 2010, the Simplified Acute Physiology Score (SAPS) II. The variables are recorded with 90%-100% completeness in the recent years, except for SAPS II score, which is 73%-76% complete. The DID currently includes five quality indicators. Process indicators include out-of-hour discharge and transfer to other ICUs for capacity reasons. Outcome indicators include ICU readmission within 48 hours and standardized mortality ratios for death within 30 days after admission using case-mix adjustment (initially using age, sex, and comorbidity level, and, since 2013, using SAPS II) for all patients and for patients with septic shock.

DESCRIPTIVE DATA

The DID currently includes 335,564 ICU admissions during 2005-2015 (average 31,958 ICU admissions per year).

CONCLUSION

The DID provides a valuable data source for quality monitoring and improvement, as well as for research.

Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle

Implementation of a quality improvement bundle for peri-operative management of emergency laparotomy (ELPQuIC) improved mortality in a previous study. We used data from one site that participated in that study to examine whether it was associated with the cost of care. We collected data from 396 patients: 144 before, 144 during and 108 after implementation of the bundle. We estimated costs incurred using previously published methodology based on the time the patient spent in hospital, in the operating theatre and in critical care. Duration of stay in hospital and critical care did not differ between time periods, p = 0.14 and p = 0.28, respectively. The costs per patient and per survivor did not differ between the time periods, p = 0.87 and p = 0.17, respectively. Costs were similar for patients aged < 80 years vs. ≥ 80 years. Implementation of a quality improvement bundle for emergency laparotomy has the capacity to save lives without increasing hospital costs.

Organizational characteristics, outcomes, and resource use in 78 Brazilian intensive care units: the ORCHESTRA study

PURPOSE

Detailed information on organization and process of care in intensive care units (ICU) in emerging countries is scarce. Here, we investigated the impact of organizational factors on the outcomes and resource use in a large sample of Brazilian ICUs.

METHODS

Retrospective cohort study of 59,693 patients (medical admissions, 67 %) admitted to 78 ICUs during 2013. We retrieved patients' data from an ICU quality registry and surveyed ICUs regarding structure, organization, staffing patterns, and process of care. We used multilevel logistic regression analysis to identify factors associated with hospital mortality. Efficient resource use was assessed by estimating standardized resource use and mortality rates adjusted for the SAPS 3 score.

RESULTS

ICUs were mostly medical-surgical (79 %) and located at private hospitals (86 %). Median nurse to bed ratio was 0.20 (IQR, 0.15-0.28) and board-certified intensivists were present 24/7 in 16 (21 %) of ICUs. Multidisciplinary rounds occurred in 67 (86 %) and daily checklists were used in 36 (46 %) ICUs. Most frequent protocols focused on sepsis management and prevention of healthcare-associated infections. Hospital mortality was 14.4 %. In multivariable analysis, the number of protocols was the only organizational characteristic associated with mortality [odds ratio = 0.944 (95 % CI 0.904-0.987)]. The effects of protocols were consistent across subgroups including surgical and medical patients as well as the SAPS 3 tertiles. We also observed a significant trend toward efficient resource use as the number of protocols increased.

CONCLUSIONS

In emerging countries such as Brazil, organizational factors, including the implementation of protocols, are potential targets to improve patient outcomes and resource use in ICUs.

Characteristics of Intensive Care in Patients Hospitalized for Heart Failure in Europe

Patients hospitalized for acute heart failure (AHF) may clinically decompensate and experience life-threatening complications. Regional differences in intensive care unit (ICU) admission rates have been reported by European registries. Variations regarding ICU bed and facilities availability may contribute to these geographic differences. ICU triage decision requires cautious clinical judgment to balance between clinical benefit of ICU care and associated risk and cost. In Europe, despite large variations in treatment practices, in-hospital mortality of AHF patients managed in ICUs is similar, suggesting that high-risk characteristics of AHF patients admitted to ICUs, rather than geographic variation in intensity of therapies, may be the principal determinant of prognosis.

A Nationwide Census of ICU Capacity and Admissions in Mongolia

In Mongolia, a Central Asian lower-middle income country, intensive care medicine is an under-resourced and–developed medical specialty. The burden of critical illness and capacity of intensive care unit (ICU) services in the country is unknown. In this nationwide census, we collected data on adult and pediatric/neonatal ICU capacities and the number of ICU admissions in 2014. All hospitals registered to run an ICU service in Mongolia were surveyed. Data on the availability of an adult and/or pediatric/neonatal ICU service, the number of available ICU beds, the number of available functional mechanical ventilators, the number of patients admitted to the ICU, and the number of patients admitted to the study hospital were collected. In total, 70 ICUs with 349 ICU beds were counted in Mongolia (11.7 ICU beds/100,000 inhabitants; 1.7 ICU beds/100 hospital beds). Of these, 241 (69%) were adult and 108 (31%) pediatric/neonatal ICU beds. Functional mechanical ventilators were available for approximately half of the ICU beds (5.1 mechanical ventilators/100,000 inhabitants). While all provincial hospitals ran a pediatric/neonatal ICU, only dedicated pediatric hospitals in Ulaanbaatar did so. The number of adult and pediatric/neonatal ICU admissions varied between provinces. The number of adult ICU beds and adult ICU admissions per 100,000 inhabitants correlated (r = 0.5; p = 0.02), while the number of pediatric/neonatal ICU beds and pediatric/neonatal ICU admissions per 100,000 inhabitants did not (r = 0.25; p = 0.26). In conclusion, with 11.7 ICU beds per 100,000 inhabitants the ICU capacity in Mongolia is higher than in other low- and lower-middle-income countries. Substantial heterogeneities in the standardized ICU capacity and ICU admissions exist between Mongolian provinces. Functional mechanical ventilators are available for only half of the ICU beds. Pediatric/neonatal ICU beds make up one third of the national ICU capacity and appear to meet or even exceed the demand of pediatric/neonatal critical care.

Designing and conducting a cluster-randomized trial of ICU admission for the elderly patients: the ICE-CUB 2 study

Background

The benefit of ICU admission for elderly patients remains controversial. This report highlights the methodology, the feasibility of and the ethical and logistical constraints in designing and conducting a cluster-randomized trial of intensive care unit (ICU) admission for critically ill elderly patients.

Methods

We designed an interventional open-label cluster-randomized controlled trial in 24 centres in France. Clusters were healthcare centres with at least one emergency department (ED) and one ICU. Healthcare centres were randomly assigned either to recommend a systematic ICU admission (intervention group) or to follow standard practices regarding ICU admission (control group). Clusters were stratified by the number of ED annual visits (<44,616 or >44,616 visits), the presence or absence of a geriatric ward and the geographical area (Paris area vs other regions in France). All elderly patients (≥75 years of age) who got to the ED were assessed for eligibility. Patients were included if they had one of the pre-established critical conditions, a preserved functional status as assessed by an ADL scale ≥4 (0 = very dependent, 6 = independent), a preserved nutritional status (subjectively assessed by physicians) and without active cancer. Exclusion criteria were an ED stay >24 h, a secondary referral to the ED and refusal to participate. The primary outcome was the mortality at 6 months calculated at the individual patient level. Secondary outcomes were ICU and hospital mortality, as well as ADL scale and quality of life (as assessed by the SF-12 Health Survey) at 6 months.

Results

Between January 2012 and April 2015, 3036 patients were included in the trial, 1518 patients in 11 clusters allocated to intervention group and 1518 patients in 13 clusters allocated to standard care. There were 51 protocol violations.

Conclusions

The ICE-CUB 2 trial was deemed feasible and ethically acceptable. The ICE-CUB 2 trial will be the first cluster-randomized trial to assess the benefits of ICU admission for selected elderly patients on long-term mortality.

Trial registration Clinical trials.gov identifier: NCT01508819

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0161-5) contains supplementary material, which is available to authorized users.

Medical Emergency Team: How do we play when we stay? Characterization of MET actions at the scene

BACKGROUND

The creation, implementation and effectiveness of a medical emergency team (MET) in every hospital is encourage and supported by international bodies of quality certification. Issues such as what is the best composition of the team or the interventions performed by the MET at the scene and the immediate outcomes of the patients after MET intervention have not yet been sufficiently explored. The purpose of the study is to characterize MET actions at the scene and the immediate patient outcome.

METHODS

Retrospective cohort study, at a tertiary care, university-affiliated, 600-bed hospital, in the north of Portugal, over two years.

RESULTS

There were 511 MET activations: 389 (76%) were for inpatients. MET activation rate was 8.6/1,000 inpatients. The main criteria for activation were airway threatening in 143 (36.8%), concern of medical staff in 121 (31.1%) and decrease in GCS > 2 in 98 (25.2%) patients; MET calls for cardiac arrest occurred in 68 patients (17.5%). The median (IQR) time the team stayed at the scene was 35 (20-50) minutes. At the scene, the most frequent actions were related to airway and ventilation, namely oxygen administration in 145 (37.3%); in circulation, fluid were administered in 158 (40.6%); overall medication was administered in 185 (47.5%) patients. End-of-life decisions were part of the MET actions in 94 (24.1%) patients. At the end of MET intervention, 73 (18.7%) patients died at the scene, 190 (60.7%) stayed on the ward and the remaining 123 patients were transferred to an increased level of care. Crude hospital mortality rate was 4.1% in the 3 years previously to MET implementation and 3.6% in the following 3 years (p < 0.001).

DISCUSSION

During the study period, the rate of activation for medical inpatients was significantly higher than that for surgical inpatients. In our hospital, there is no 24/7 medical cover on the wards, with the exception of high-dependency and intensive care units; assuming that the number of unplanned admissions and chronic ill patients is greater in medical wards that could explain the difference found, which prompts the implementation of a 24/7 ward residence. The team stayed on site for half an hour and during that time most of the actions were simple and nurse-driven, but in one third of all activations medical actions were taken, and in a forth (24%) end-of-life decisions made, reinforcing the inclusion of a doctor in the MET. A significant decrease in overall hospital mortality rate was observed after the implementation of the MET.

CONCLUSIONS

The composition of our MET with an ICU doctor and nurse was reinforced by the need of medical actions in more than half of the situations (either clinical actions or end-of-life decisions). After MET implementation there was a significant decrease in hospital mortality. This study reinforces the benefit of implementing an ICU-MET team.

Influence of ICU-bed availability on ICU admission decisions

BACKGROUND

The potential influence of bed availability on triage to intensive care unit (ICU) admission is among the factors that may influence the ideal ratio of ICU beds to population: thus, high bed availability (HBA) may result in the admission of patients too well or too sick to benefit, whereas bed scarcity may result in refusal of patients likely to benefit from ICU admission.

METHODS

Characteristics and outcomes of patient admitted in four ICUs with usual HBA, defined by admission refusal rate less than 11 % because of bed unavailability, were compared to patients admitted in six ICUs with usual low bed availability (LBA), i.e., an admission refusal rate higher than 10 % during a 90-day period.

RESULTS

Over the 90 days, the mean number of days with no bed available was 30 ± 16 in HBA units versus 48 ± 21 in LBA units (p < 0.01). The proportion of admitted patients was significantly higher in the HBA (80.1 %; n = 659/823) than in the LBA units [61.6 %: n = 480/779; (p < 0.0001)]. The proportion of patients deemed too sick to benefit from admission was higher in LBA (9.0 %; n = 70) than in the HBA (6.3 %; n = 52) units (p < 0.05). The HBA group had a significantly greater proportion of patients younger than 40 years of age (22.5 %; n = 148 versus 14 %; n = 67 in LBA group; p < 0.001) and higher proportions of patients with either high or low simplified acute physiologic score II values.

CONCLUSIONS

Bed availability affected triage decisions. Units with HBA trend to admit patients too sick or too well to benefit.

Quality and performance measures of strain on intensive care capacity: a protocol for a systematic review

BACKGROUND

The matching of critical care service supply with demand is fundamental for the efficient delivery of advanced life support to patients in urgent need. Mismatch in this supply/demand relationship contributes to "intensive care unit (ICU) capacity strain," defined as a time-varying disruption in the ability of an ICU to provide well-timed and high-quality intensive care support to any and all patients who are or may become critically ill. ICU capacity strain leads to suboptimal quality of care and may directly contribute to heightened risk of adverse events, premature discharges, unplanned readmissions, and avoidable death. Unrelenting strain on ICU capacity contributes to inefficient health resource utilization and may negatively impact the satisfaction of patients, their families, and frontline providers. It is unknown how to optimally quantify the instantaneous and temporal "stress" an ICU experiences due to capacity strain.

METHODS

We will perform a systematic review to identify, appraise, and evaluate quality and performance measures of strain on ICU capacity and their association with relevant patient-centered, ICU-level, and health system-level outcomes. Electronic databases (i.e., MEDLINE, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, and the Agency of Healthcare Research and Quality (AHRQ) - National Quality Measures Clearinghouse (NQMC)) will be searched for original studies of measures of ICU capacity strain. Selected gray literature sources will be searched. Search themes will focus on intensive care, quality, operations management, and capacity. Analysis will be primarily narrative. Each identified measure will be defined, characterized, and evaluated using the criteria proposed by the US Strategic Framework Board for a National Quality Measurement and Reporting System (i.e., importance, scientific acceptability, usability, feasibility).

DISCUSSION

Our systematic review will comprehensively identify, define, and evaluate quality and performance measures of ICU capacity strain. This is a necessary step towards understanding the impact of capacity strain on quality and performance in intensive care and to develop innovative interventions aimed to improve efficiency, avoid waste, and better anticipate impending capacity shortfalls.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42015017931.

Geographical variation in use of intensive care: a nationwide study

PURPOSE

To examine whether there is geographical variation in the use of intensive care resources in Denmark concerning both intensive care unit (ICU) admission and use of specific interventions. Substantial variation in use of intensive care has been reported between countries and within the US, however, data on geographical variation in use within more homogenous tax-supported health care systems are sparse.

METHODS

We conducted a population-based cross-sectional study based on linkage of national medical registries including all Danish residents between 2008 and 2012 using population statistics from Statistics Denmark. Data on ICU admissions and interventions, including mechanical ventilation, noninvasive ventilation, acute renal replacement therapy, and treatment with inotropes/vasopressors, were obtained from the Danish Intensive Care Database. Data on patients' residence at the time of admission were obtained from the Danish National Registry of Patients.

RESULTS

The overall age- and gender standardized number of ICU patients per 1000 person-years for the 5-year period was 4.3 patients (95 % CI, 4.2; 4.3) ranging from 3.7 (95 % CI, 3.6; 3.7) to 5.1 patients per 1000 person-years (95 % CI, 5.0; 5.2) in the five regions of Denmark and from 2.8 (95 % CI, 2.8; 3.0) to 23.1 patients per 1000 person-years (95 % CI, 13.0; 33.1) in the 98 municipalities. The age-, gender-, and comorbidity standardized proportion of use of interventions among ICU patients also differed across regions and municipalities.

CONCLUSIONS

There was only minimal geographical variation in the use of intensive care admissions and interventions at the regional level in Denmark, but more pronounced variation at the municipality level.

In-hospital vs. 30-day mortality in the critically ill - a 2-year Swedish intensive care cohort analysis

BACKGROUND

Standardised mortality ratio (SMR) is a common quality indicator in critical care and is the ratio between observed mortality and expected mortality. Typically, in-hospital mortality is used to derive SMR, but the use of a time-fixed, more objective, end-point has been advocated. This study aimed to determine the relationship between in-hospital mortality and 30-day mortality on a comprehensive Swedish intensive care cohort.

METHODS

A retrospective study on patients >15 years old, from the Swedish Intensive Care Register (SIR), where intensive care unit (ICU) admissions in 2009-2010 were matched with the corresponding hospital admissions in the Swedish Hospital Discharge Register. Recalibrated SAPS (Simplified Acute Physiology Score) 3 models were developed to predict and compare in-hospital and 30-day mortality. SMR based on in-hospital mortality and on 30-day mortality were compared between ICUs and between groups with different case-mixes, discharge destinations and length of hospital stays.

RESULTS

Sixty-five ICUs with 48861 patients, of which 35610 were SAPS 3 scored, were included. Thirty-day mortality (17%) was higher than in-hospital mortality (14%). The SMR based on 30-day mortality and that based on in-hospital mortality differed significantly in 7/53 ICUs, for patients with sepsis, for elective surgery-admissions and in groups categorised according to discharge destination and hospital length of stay.

CONCLUSION

Choice of mortality end-point influences SMR. The extent of the influence depends on hospital-, ICU- and patient cohort characteristics as well as inter-hospital transfer rates, as all these factors influence the difference between SMR based on 30-day mortality and SMR based on in-hospital mortality.

The Surviving Sepsis Campaign bundles and outcome: results from the International Multicentre Prevalence Study on Sepsis (the IMPreSS study)

INTRODUCTION

Despite evidence demonstrating the value of performance initiatives, marked differences remain between hospitals in the delivery of care for patients with sepsis. The aims of this study were to improve our understanding of how compliance with the 3-h and 6-h Surviving Sepsis Campaign (SSC) bundles are used in different geographic areas, and how this relates to outcome.

METHODS

This was a global, prospective, observational, quality improvement study of compliance with the SSC bundles in patients with either severe sepsis or septic shock.

RESULTS

A total of 1794 patients from 62 countries were enrolled in the study with either severe sepsis or septic shock. Overall compliance with all the 3-h bundle metrics was 19%. This was associated with lower hospital mortality than non-compliance (20 vs. 31%, p < 0.001). Overall compliance with all the 6-h bundle metrics was 36%. This was associated with lower hospital mortality than non-compliance (22 vs. 32%, p < 0.001). After adjusting the crude mortality differences for ICU admission, sepsis status (severe sepsis or septic shock), location of diagnosis, APACHE II score and country, compliance remained independently associated with improvements in hospital mortality for both the 3-h bundle (OR = 0.64 (95% CI 0.47-0.87), p = 0.004)) and 6-h bundle (OR = 0.71 (95% CI 0.56-0.90), p = 0.005)).

DISCUSSION

Compliance with all of the evidence-based bundle metrics was not high. Patients whose care included compliance with all of these metrics had a 40% reduction in the odds of dying in hospital with the 3-h bundle and 36% for the 6-h bundle.