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Roston TM, Aghanya V, Savu A, Fordyce CB, Lawler PR, Jentzer J, Wong GC, Brunham LR, Senaratne J, van Diepen S, Kaul P. Premature Acute Myocardial Infarction Treated With Invasive Revascularization: Comparing STEMI With NSTEMI in a Population-Based Study of Young Patients. Can J Cardiol 2024:S0828-282X(24)00521-X. [PMID: 38992813 DOI: 10.1016/j.cjca.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 06/19/2024] [Accepted: 07/01/2024] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Acute myocardial infarction (AMI) usually presents in older populations, in which there are established demographic and outcome differences for ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). No similar comparisons for AMI in the young population exist. METHODS We compared all index NSTEMI and STEMI hospitalizations in young (18-45 years) patients who required revascularization in Alberta, Canada. Outcomes were survival to discharge, and a composite of heart failure hospitalization, cardiac arrest hospitalization, and all-cause mortality at 1 and 5 years. RESULTS There were 1679 patients included with an index AMI who required revascularization: 655 (39.0%) NSTEMI and 1024 (61.0%) STEMI. The population was disproportionately male (86%), particularly in STEMI patients (87.3%). Marked dyslipidemia (35%) and active smoking (42%) were common, with similar rates among groups. Percutaneous coronary intervention was used in 98.7% of STEMI and 91.5% of NSTEMI patients (P < 0.001), with the remainder who underwent surgical revascularization. The in-hospital mortality rate during index AMI was higher in STEMI compared with NSTEMI patients (1.7% vs 0%; P < 0.001). The rates of the composite outcome were similar for both groups at 1 and 5 years of follow-up in patients who survived to index hospital discharge. After adjusting for sex, age, heart failure and/or cardiac arrest at index AMI, outcomes remained similar among groups at 1 and 5 years. CONCLUSIONS In young patients with AMI, STEMI was a disproportionately male phenomenon and associated with higher mortality at index hospitalization. One-year and 5-year outcomes were similar among STEMI and NSTEMI patients in those discharged alive at index AMI. Smoking and dyslipidemia appear to be major risk factors in the young.
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Affiliation(s)
- Thomas M Roston
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Vivian Aghanya
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Anamaria Savu
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher B Fordyce
- Division of Cardiology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada, and McGill University Health Centre, Montreal, Quebec, Canada
| | - Jacob Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Graham C Wong
- Division of Cardiology, Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Liam R Brunham
- Centre for Heart Lung Innovation, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Janek Senaratne
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada; The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada; The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- The Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Koerber DM, Katz JN, Bohula E, Park JG, Dodson MW, Gerber DA, Hillerson D, Liu S, Pierce MJ, Prasad R, Rose SW, Sanchez PA, Shaw J, Wang J, Jentzer JC, Kristin Newby L, Daniels LB, Morrow DA, van Diepen S. Variation in risk-adjusted cardiac intensive care unit (CICU) length of stay and the association with in-hospital mortality: An analysis from the Critical Care Cardiology Trials Network (CCCTN) registry. Am Heart J 2024; 271:28-37. [PMID: 38369218 DOI: 10.1016/j.ahj.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND Previous studies have suggested that there is wide variability in cardiac intensive care unit (CICU) length of stay (LOS); however, these studies are limited by the absence of detailed risk assessment at the time of admission. Thus, we evaluated inter-hospital differences in CICU LOS, and the association between LOS and in-hospital mortality. METHODS Using data from the Critical Care Cardiology Trials Network (CCCTN) registry, we included 22,862 admissions between 2017 and 2022 from 35 primarily tertiary and quaternary CICUs that captured consecutive admissions in annual 2-month snapshots. The primary analysis compared inter-hospital differences in CICU LOS, as well as the association between CICU LOS and all-cause in-hospital mortality using a Fine and Gray competing risk model. RESULTS The overall median CICU LOS was 2.2 (1.1-4.8) days, and the median hospital LOS was 5.9 (2.8-12.3) days. Admissions in the longest tertile of LOS tended to be younger with higher rates of pre-existing comorbidities, and had higher Sequential Organ Failure Assessment (SOFA) scores, as well as higher rates of mechanical ventilation, intravenous vasopressor use, mechanical circulatory support, and renal replacement therapy. Unadjusted all-cause in-hospital mortality was 9.3%, 6.7%, and 13.4% in the lowest, intermediate, and highest CICU LOS tertiles. In a competing risk analysis, individual patient CICU LOS was correlated (r2 = 0.31) with a higher risk of 30-day in-hospital mortality. The relationship remained significant in admissions with heart failure, ST-elevation myocardial infarction and non-ST segment elevation myocardial infarction. CONCLUSIONS In a large registry of academic CICUs, we observed significant variation in CICU LOS and report that LOS is independently associated with all-cause in-hospital mortality. These findings could potentially be used to improve CICU resource utilization planning and refine risk prognostication in critically ill cardiovascular patients.
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Affiliation(s)
- Daniel M Koerber
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | | - Erin Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Mark W Dodson
- Department of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, UT
| | - Daniel A Gerber
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Dustin Hillerson
- Department of Medicine, Division of Cardiovascular Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, Manitoba, Canada
| | - Matthew J Pierce
- North Shore University Hospital, Northwell Health, Manhasset, NY, USA
| | | | - Scott W Rose
- Atrium Health Wake Forest Baptist, Winston-Salem, NC
| | - Pablo A Sanchez
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey Shaw
- Division of Cardiology, Department of Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, La Jolla, CA
| | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Nilsson T, Mokhtari A, Sandgren J, Lundager Forberg J, Olsson de Capretz P, Ekelund U. Complications in Emergency Department Patients with Acute Coronary Syndrome with Contemporary Care. Cardiology 2024:1-10. [PMID: 38599184 DOI: 10.1159/000538637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION With the implementation of early reperfusion therapy, the number of complications in patients with acute coronary syndrome (ACS) has diminished significantly. However, ACS patients are still routinely admitted to units with high-level monitoring such as the coronary or intensive care unit (CCU/ICU). The cost of these admissions is high and there is often a shortage of beds. The aim of this study was to analyze the complications in contemporary emergency department (ED) patients with ACS and to map patient management. METHODS This observational study was a secondary analysis of data collected in the ESC-TROP trial (NCT03421873) that included 26,545 consecutive chest pain patients ≥18 years at five Swedish EDs. Complications were defined as the following within 30 days: death, cardiac arrest, cardiogenic shock, pulmonary edema, severe ventricular arrhythmia, high-degree atrioventricular (AV) block that required a pacemaker, and mechanical complications such as papillary muscle rupture, cardiac tamponade, or ventricular septum defects (VSDs). Complications were identified via diagnosis and/or intervention codes in the database, and manual chart review was performed in cases with complications. RESULTS Of all 26,545 patients, 2,463 (9.3%) were diagnosed with ACS, and 151 of these (6.1%) suffered any complication within 30 days. Mean age was higher in patients with (79.2 years) than without (69.4 years) complications, and more were female (39.7% vs. 33.0%). Eighty-four (3.4% of all ACS patients) patients died, 33 (1.3%) had cardiac arrest, 22 (0.9%) respiratory failure, 13 (0.5%) high-degree AV block, 10 (0.4%) cardiogenic shock, 12 (0.5%) severe ventricular arrhythmia, and 2 each (<0.1%) had VSD or cardiac tamponade. Almost 30% of the complications were present already at the ED, and 40% of patients with complications were not admitted to the CCU/ICU. Only 80 (53%) of the patients with complications underwent coronary angiography and 62 (41%) were revascularized with percutaneous coronary intervention or coronary artery bypass grafting. CONCLUSION With current care, serious complications occurred in only 6 out of 100 ACS patients, and 2 of these complications were present already at the ED. Four out of 10 ACS patients with complications were not admitted to the CCU/ICU and about half did not undergo coronary angiography. Further research is needed to improve risk assessment in ED ACS patients, which may allow more effective use of cardiac monitoring and hospital resources.
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Affiliation(s)
- Tsvetelina Nilsson
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
| | - Arash Mokhtari
- Department of Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jenny Sandgren
- Clinical Studies Sweden, Forum South, Skåne University Hospital, Lund, Sweden
| | | | | | - Ulf Ekelund
- Department of Emergency Medicine, Skåne University Hospital, Lund University, Lund, Sweden
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van Diepen S, Zheng Y, Senaratne JM, Tyrrell BD, Das D, Thiele H, Henry TD, Bainey KR, Welsh RC. Reperfusion in Patients With ST-Segment-Elevation Myocardial Infarction With Cardiogenic Shock and Prolonged Interhospital Transport Times. Circ Cardiovasc Interv 2024; 17:e013415. [PMID: 38293830 DOI: 10.1161/circinterventions.123.013415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 11/09/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND In patients with ST-segment-elevation myocardial infarction complicated by cardiogenic shock, primary percutaneous coronary intervention (pPCI) is the preferred revascularization option. Little is known about the efficacy and safety of a pharmacoinvasive approach for patients with cardiogenic shock presenting to a non-PCI hospital with prolonged interhospital transport times. METHODS In a retrospective analysis of geographically extensive ST-segment-elevation myocardial infarction network (2006-2021), 426 patients with cardiogenic shock and ST-segment-elevation myocardial infarction presented to a non-PCI-capable hospital and underwent reperfusion therapy (53.8% pharmacoinvasive and 46.2% pPCI). The primary clinical outcome was a composite of in-hospital mortality, renal failure requiring dialysis, cardiac arrest, or mechanical circulatory support, and the primary safety outcome was major bleeding defined as an intracranial hemorrhage or bleeding that required transfusion was compared in an inverse probability weighted model. The electrocardiographic reperfusion outcome of interest was the worst residual ST-segment-elevation. RESULTS Patients with pharmacoinvasive treatment had longer median interhospital transport (3 hours versus 1 hour) and shorter median symptom-onset-to-reperfusion (125 minute-to-needle versus 419 minute-to-balloon) times. ST-segment resolution ≥50% on the postfibrinolysis ECG was 56.6%. Postcatheterization, worst lead residual ST-segment-elevation <1 mm (57.3% versus 46.3%; P=0.01) was higher in the pharmacoinvasive compared with the pPCI cohort, but no differences were observed in the worst lead ST-segment-elevation resolution ≥50% (77.4% versus 81.8%; P=0.57). The primary clinical end point was lower in the pharmacoinvasive cohort (35.2% versus 57.0%; inverse probability weighted odds ratio, 0.44 [95% CI, 0.26-0.72]; P<0.01) compared with patients who received pPCI. An interaction between interhospital transfer time and reperfusion strategy with all-cause mortality was observed, favoring a pharmacoinvasive approach with transfer times >60 minutes. The incidence of the primary safety outcome was 10.1% in the pharmacoinvasive arm versus 18.7% in pPCI (adjusted odds ratio, 0.41 [95% CI, 0.14-1.09]; P=0.08). CONCLUSIONS In patients with ST-segment-elevation myocardial infarction presenting with cardiogenic shock and prolonged interhospital transport times, a pharmacoinvasive approach was associated with improved electrocardiographic reperfusion and a lower rate of death, dialysis, or mechanical circulatory support without an increase in major bleeding.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Yinggan Zheng
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Janek M Senaratne
- Department of Critical Care (S.v.D., J.M.S.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | | | - Debraj Das
- CK Hui Heart Center, Edmonton, Alberta, Canada (B.D.T., D.D.)
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, University of Leipzig, Germany (H.T.)
| | - Timothy D Henry
- Carl and Edyth Lindner Research Center at the Christ Hospital, Cincinnati, OH (T.D.H.)
| | - Kevin R Bainey
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
| | - Robert C Welsh
- Division of Cardiology, Department of Medicine (S.v.D., J.M.S., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
- Canadian VIGOUR Center (S.v.D., Y.Z., K.R.B., R.C.W.), University of Alberta, Edmonton, Canada
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Donnelly S, Barnett CF, Bohula EA, Chaudhry SP, Chonde MD, Cooper HA, Daniels LB, Dodson MW, Gerber D, Goldfarb MJ, Guo J, Kontos MC, Liu S, Luk AC, Menon V, O'Brien CG, Papolos AI, Pisani BA, Potter BJ, Prasad R, Schnell G, Shah KS, Sridharan L, So DYF, Teuteberg JJ, Tymchak WJ, Zakaria S, Katz JN, Morrow DA, van Diepen S. Interhospital Variation in Admissions Managed With Critical Care Therapies or Invasive Hemodynamic Monitoring in Tertiary Cardiac Intensive Care Units: An Analysis From the Critical Care Cardiology Trials Network Registry. Circ Cardiovasc Qual Outcomes 2024; 17:e010092. [PMID: 38179787 DOI: 10.1161/circoutcomes.123.010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS The median age of the study population was 66 (56-77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%-87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST-elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.
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Affiliation(s)
- Sarah Donnelly
- Division of General Internal Medicine, Department of Medicine (S.D.), University of Alberta, Edmonton, Canada
| | - Christopher F Barnett
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
| | - Sunit-Preet Chaudhry
- Division of Cardiology, Ascension St. Vincent Heart Center, Indianapolis, IN (S.-P.C.)
| | - Meshe D Chonde
- Cedars-Sinai Smidt Heart Institute, Los Angeles, CA (M.D.C.)
| | - Howard A Cooper
- Westchester Medical Center and New York Medical College, Valhalla (H.A.C.)
| | - Lori B Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego, La Jolla (L.B.D.)
| | - Mark W Dodson
- Department of Medicine, Intermountain Medical Center, Murray, UT (M.W.D.)
| | - Daniel Gerber
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, CA (D.G.)
| | - Michael J Goldfarb
- Division of Cardiology, Jewish General Hospital, Montreal, QC, Canada (M.J.G)
| | - Jianping Guo
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
| | - Michael C Kontos
- Division of Cardiology, Virginia Commonwealth University, Richmond (M.C.K.)
| | - Shuangbo Liu
- Max Rady College of Medicine, St. Boniface Hospital, Winnipeg, MB, Canada (S.L.)
| | - Adriana C Luk
- Peter Munk Cardiac Centre at Toronto General Hospital, Division of Cardiology and Interdepartmental Division of Critical Care Medicine, University of Toronto, ON, Canada (A.C.L.)
| | - Venu Menon
- Cardiovascular Medicine, Cleveland Clinic Foundation, OH (V.M.)
| | - Connor G O'Brien
- Division of Cardiology, Department of Medicine, University of California, San Francisco (C.F.B., C.G.O.)
| | - Alexander I Papolos
- Division of Cardiology, Department of Critical Care, MedStar Washington Hospital Center, DC (A.I.P.)
| | | | - Brian J Potter
- Centre Hospitalier de l'Université de Montréal Research Center and Cardiovascular Center, QC, Canada (B.J.P.)
| | | | - Gregory Schnell
- Department of Cardiac Sciences, Libin Cardiovascular Institute of Alberta, University of Calgary, Canada (G.S.)
| | - Kevin S Shah
- University of Utah Health Sciences Center, Salt Lake City (K.S.S.)
| | | | - Derek Y F So
- University of Ottawa Heart Institute, ON, Canada (D.Y.F.S.)
| | | | - Wayne J Tymchak
- Department of Critical Care Medicine (W.J.T.), University of Alberta, Edmonton, Canada
- Division of Cardiology, Department of Medicine (W.J.T.), University of Alberta, Edmonton, Canada
| | - Sammy Zakaria
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (S.Z.)
| | | | - David A Morrow
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (E.A.B., J.G., D.A.M.)
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Akodad M, Meunier PA, Padovani C, Cayla G, Zitouni W, Macia JC, Robert P, Steinecker M, Roubille F, Leclercq F. Identification of Low- versus High-Risk Acute Coronary Syndrome for a Selective ECG Monitoring Strategy. J Clin Med 2023; 12:4604. [PMID: 37510718 PMCID: PMC10380550 DOI: 10.3390/jcm12144604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/13/2023] [Accepted: 07/09/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND While admission of patients with acute coronary syndromes (ACS) in cardiology intensive care unit (CICU) is usual, in-hospital major outcomes in lower risk patients may be evaluated after early coronary angiography according to the European guidelines. METHODS Consecutive ACS patients were prospectively included after coronary angiography evaluation within 24 h and percutaneous coronary intervention (PCI), when required. Patients were classified as high- or low-risk according to hemodynamics, rhythmic state, ischemic and bleeding risks. Major in-hospital outcomes were assessed. RESULTS From January to June 2021, 277 patients were enrolled (62.8% with ST-segment elevation myocardial infarction (STEMI) (n = 174); 37.2% with non-NSTEMI (NSTEMI) (n = 103). PCI was required for 260 patients (93.9%). Seventy-four patients (26.7%) were classified as low-risk (n = 47 NSTEMI; n= 27 STEMI) and 203 patients (73.3%) as high-risk of events. All patients were monitored in CICU. While 38 patients (18.7%) from the high-risk group reached the primary endpoint, mainly related to rhythmic or conduction disorder (n = 24, 11.8%) or unstable hemodynamics (n = 17; 8.4%), only 1 patient (1.3%) in the low-risk group had one major outcome (no fatal bleeding); p < 0.01. The negative predictive value of our patient stratification for the absence of major in-hospital outcome was 100% (CI95%: 100-100%) for STEMI and 97.9% [CI95%: 93.2-100%] for NSTEMI patients. CONCLUSIONS Stratification of ACS patients after early coronary angiography and most of the time PCI, identify a population with very low risk of in-hospital events (1/4 of all ACS and 1/2 of NSTEMI) who may probably not require ECG monitoring and/or CICU admission. (NCT04378504).
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Affiliation(s)
- Mariama Akodad
- South Paris Cardiovascular Institute, Jacques Cartie Hospital, 91300 Massy, France
| | - Pierre-Alain Meunier
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - Caroline Padovani
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - Guillaume Cayla
- Department of Cardiology, University Hospital of Nîmes, 30900 Nîmes, France
| | - Wassim Zitouni
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - Jean-Christophe Macia
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - Pierre Robert
- Department of Cardiology, University Hospital of Nîmes, 30900 Nîmes, France
| | - Matthieu Steinecker
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - François Roubille
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
| | - Florence Leclercq
- Department of Cardiology, University Hospital of Montpellier, 34295 Montpellier, France
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7
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Sinha SS, Bohula EA, Diepen SVAN, Leonardi S, Mebazaa A, Proudfoot AG, Sionis A, Chia YW, Zampieri FG, Lopes RD, Katz JN. The Intersection Between Heart Failure and Critical Care Cardiology: An International Perspective on Structure, Staffing, and Design Considerations. J Card Fail 2022; 28:1703-1716. [PMID: 35843489 DOI: 10.1016/j.cardfail.2022.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 06/16/2022] [Accepted: 06/24/2022] [Indexed: 10/17/2022]
Abstract
The overall patient population in contemporary cardiac intensive care units (CICUs) has only increased with respect to patient acuity, complexity, and illness severity. The current population has more cardiac and noncardiac comorbidities, a higher prevalence of multiorgan injury, and consumes more critical care resources than previously. Patients with heart failure (HF) now occupy a large portion of contemporary tertiary or quaternary care CICU beds around the world. In this review, we discuss the core issues that relate to the care of critically ill patients with HF, including global perspectives on the organization, designation, and collaboration of CICUs regionally and across institutions, as well as unique models for provisioning care for patients with HF within a health care setting. The latter includes a discussion of traditional and emerging models, specialized HF units, the makeup and implementation of multidisciplinary team-based decision-making, and cardiac critical care admission and triage practices. This article illustrates the ways in which critically ill patients with HF have helped to shape contemporary CICUs throughout the world and explores how these very patients will similarly help to inform the future maturation of these specialized critical care units. Finally, we will critically examine broad, contemporary, international models of HF and cardiac critical care delivery in North America, Europe, South America, and Asia, and conclude with opportunities for the further investigation and generation of evidence for care delivery.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, Virginia
| | - Erin A Bohula
- Levine Cardiac Intensive Care Unit, TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sean VAN Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sergio Leonardi
- Fondazione IRCCS Policlinico San Matteo, Pavia and University of Pavia, Pavia, Italy
| | - Alexandre Mebazaa
- Université de Paris, Inserm 942 MASCOT, APHP Hôpitaux Universitaires Saint-Louis-Lariboisière, Paris, France
| | - Alastair G Proudfoot
- Perioperative Medicine Department, Barts Heart Centre, St Bartholomew's Hospital, London, UK; Clinic For Anaesthesiology & Intensive Care, Charité-Universitätsmedizin Berlin corporate member of Freie Universität Berlin and Humboldt Univesität zu, Berlin, Germany
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Yew Woon Chia
- Cardiac Intensive Care Unit, Department of Cardiology, Tan Tock Seng Hospital, Singapore
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil Intensive Care Unit, Federal University of São Paulo, Brazil
| | - Renato D Lopes
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Brazilian Clinical Research Institute (BCRI), Sao Paulo, Brazil
| | - Jason N Katz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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8
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Amon J, Wong GC, Lee T, Singer J, Cairns J, Shavadia JS, Granger C, Gin K, Wang TY, van Diepen S, Fordyce CB. Incidence and Predictors of Adverse Events Among Initially Stable ST-Elevation Myocardial Infarction Patients Following Primary Percutaneous Coronary Intervention. J Am Heart Assoc 2022; 11:e025572. [PMID: 36056738 PMCID: PMC9496426 DOI: 10.1161/jaha.122.025572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Cardiac intensive care units were originally created in the prerevascularization era for the early recognition of ventricular arrhythmias following a myocardial infarction. Many patients with stable ST‐segment–elevation myocardial infarction (STEMI) are still routinely triaged to cardiac intensive care units after a primary percutaneous coronary intervention (pPCI), independent of clinical risk or the provision of critical care therapies. The aim of this study was to determine factors associated with in‐hospital adverse events in a hemodynamically stable, postreperfusion population of patients with STEMI. Methods and Results Between April 2012 and November 2019, 2101 consecutive patients with STEMI who received pPCI in the Vancouver Coastal Health Authority were evaluated. Patients were stratified into those with and without subsequent adverse events, which were defined as cardiogenic shock, in‐hospital cardiac arrest, stroke, re‐infarction, and death. Multivariable logistic regression models were used to determine predictors of adverse events. After excluding patients presenting with cardiac arrest, cardiogenic shock, or heart failure, the final analysis cohort comprised 1770 stable patients with STEMI who had received pPCI. A total of 94 (5.3%) patients developed at least one adverse event: cardiogenic shock 55 (3.1%), in‐hospital cardiac arrest 42 (2.4%), death 28 (1.6%), stroke 21 (1.2%), and re‐infarction 5 (0.3%). Univariable predictors of adverse events were older age, female sex, prior stroke, chronic kidney disease, and atrial fibrillation. There was no significant difference in reperfusion times between those with and without adverse events. Following multivariable adjustment, moderate to severe chronic kidney disease (creatinine clearance <44 mL/min; 13% of cohort) was associated with adverse events (odds ratio 2.24 [95% CI, 1.12–4.48]) independent of reperfusion time, age, sex, smoking status, hypertension, diabetes, and prior myocardial infarction/PCI/coronary artery bypass grafting. Conclusions Only 1 in 20 initially stable patients with STEMI receiving pPCI developed an in‐hospital adverse event. Moderate to severe chronic kidney disease independently predicted the risk of future adverse events. These results indicate that the majority of patients with STEMI who receive pPCI may not require routine admission to a cardiac intensive care unit following reperfusion.
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Affiliation(s)
- Jaihoon Amon
- Division of Cardiology University of Saskatchewan Saskatoon Saskatchewan Canada
| | - Graham C Wong
- Division of Cardiology University of British Columbia and Vancouver General Hospital Vancouver British Columbia Canada.,Centre for Cardiovascular Innovation University of British Columbia Vancouver British Columbia Canada
| | - Terry Lee
- Centre for Health Evaluation and Outcome Sciences Vancouver British Columbia Canada.,School of Population and Public Health University of British Columbia Vancouver British Columbia Canada
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences Vancouver British Columbia Canada.,School of Population and Public Health University of British Columbia Vancouver British Columbia Canada
| | - John Cairns
- Division of Cardiology University of British Columbia and Vancouver General Hospital Vancouver British Columbia Canada.,Centre for Cardiovascular Innovation University of British Columbia Vancouver British Columbia Canada
| | - Jay S Shavadia
- Division of Cardiology University of Saskatchewan Saskatoon Saskatchewan Canada
| | - Christopher Granger
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Kenneth Gin
- Division of Cardiology University of British Columbia and Vancouver General Hospital Vancouver British Columbia Canada.,Centre for Cardiovascular Innovation University of British Columbia Vancouver British Columbia Canada
| | - Tracy Y Wang
- Duke Clinical Research Institute Duke University School of Medicine Durham NC
| | - Sean van Diepen
- Division of Cardiology, Department of Medicine and Department of Critical Care Medicine University of Alberta Edmonton Alberta Canada
| | - Christopher B Fordyce
- Division of Cardiology University of British Columbia and Vancouver General Hospital Vancouver British Columbia Canada.,Centre for Cardiovascular Innovation University of British Columbia Vancouver British Columbia Canada.,Centre for Health Evaluation and Outcome Sciences Vancouver British Columbia Canada
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9
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Fagundes A, Berg DD, Park JG, Baird-Zars VM, Newby LK, Barsness GW, Miller PE, van Diepen S, Katz JN, Phreaner N, Roswell RO, Menon V, Daniels LB, Morrow DA, Bohula EA. Patients With Acute Coronary Syndromes Admitted to Contemporary Cardiac Intensive Care Units: Insights From the CCCTN Registry. Circ Cardiovasc Qual Outcomes 2022; 15:e008652. [DOI: 10.1161/circoutcomes.121.008652] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND:
With the improvement in outcomes for acute coronary syndrome (ACS), the practice of routine admission to cardiac intensive care units (CICUs) is evolving. We aimed to describe the epidemiology of patients with ACS admitted to contemporary CICUs.
METHODS:
Using the CCCTN (Critical Care Cardiology Trials Network) Registry for consecutive medical CICU admissions across 26 advanced CICUs in North America between 2017 and 2020, we identified patients with a primary diagnosis of ACS at CICU admission and compared patient characteristics, resource utilization, and outcomes to patients admitted with a non-ACS diagnosis and across sub-populations of patients with ACS, including by indication for CICU admission.
RESULTS:
Of 10 118 CICU admissions, 29.4% (n=2978) were for a primary diagnosis of ACS, with significant interhospital variability (range, 13.4%–56.6%). Compared with patients admitted with a diagnosis other than ACS, patients with ACS had fewer comorbidities, lower acute severity of illness with less utilization of advanced CICU therapies (41.3% versus 66.1%,
P
<0.0001), and lower CICU mortality (5.4% versus 9.9%,
P
<0.0001). Monitoring alone, without another CICU indication at the time of admission, was the most frequent admission indication in patients with ACS (53.8%); less common indications in patients with ACS included respiratory insufficiency, shock, or the need for vasoactive therapy. Of patients with ACS admitted for monitoring alone, 94.8% did not subsequently require advanced intensive care unit therapies and had a low CICU length of stay (1.5 days [0.9–2.4] versus 2.6 [1.4–5.1],
P
<0.0001) and CICU mortality (0.6% versus 11.0%,
P
<0.0001), compared with patients with ACS with an admission indication beyond monitoring.
CONCLUSIONS:
In a registry of tertiary care CICUs, ACS represent ≈1/3 of all admissions with significant variability across hospitals. More than half of the ACS admissions to the CICU were for routine monitoring alone, with a low rate of complications and mortality. This observation highlights an opportunity for prospective studies to refine triage strategies for lower risk patients with ACS.
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Affiliation(s)
- Antonio Fagundes
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - David D. Berg
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Jeong-Gun Park
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Vivian M. Baird-Zars
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - L. Kristin Newby
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | | | - P. Elliott Miller
- Department of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (P.E.M.)
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Jason N. Katz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (L.K.N., J.N.K)
| | - Nicholas Phreaner
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | | | | | - Lori B. Daniels
- Sulpizio Cardiovascular Center, University of California San Diego, La Jolla (N.P., L.B.D.)
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
| | - Erin A. Bohula
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham & Women’s Hospital, Boston MA (A.F., D.D.B., J.-G.P., V.M.B.-Z, D.A.M., E.A.B.)
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10
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van Diepen S, Coulson T, Wang X, Opgenorth D, Zuege DJ, Harris J, Agyemang M, Niven DJ, Bellomo R, Wright SE, Young PJ, Bagshaw SM. Efficacy and safety of proton pump inhibitors versus histamine-2 receptor blockers in the cardiac surgical population: insights from the PEPTIC trial. Eur J Cardiothorac Surg 2022; 62:6537079. [PMID: 35213716 PMCID: PMC9334785 DOI: 10.1093/ejcts/ezac124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/27/2022] [Accepted: 02/10/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The comparative effectiveness and safety of proton pump inhibitors (PPIs) versus histamine-2 receptor blockers for stress ulcer prophylaxis in the cardiac surgical intensive care unit population is uncertain. Although the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) trial reported a higher risk of mortality in the PPI arm with no difference in gastrointestinal bleeding, detailed information on surgical variables and clinically relevant surgical subgroups was not available. METHODS The analysis included all Canadian cardiac surgery patients enrolled in the PEPTIC trial. Data were electronically linked using unique patient identifiers to a clinical information system. Outcomes of interest included in-hospital mortality, gastrointestinal bleeding, Clostridium difficile infections, ventilator-associated conditions and length of stay. RESULTS We studied 823 (50.6%) randomized to PPIs and 805 (49.4%) to histamine-2-receptor blockers. In the intention-to-treat analysis, there were no differences in hospital mortality [PPI: 4.3% vs histamine-2 receptor blockers: 4.8%, adjusted odds ratio (aOR) 0.97, 95% confidence interval (CI) 0.55-1.70], gastrointestinal bleeding (3.9% vs 4.8%, aOR 1.09, 95% CI 0.66-1.81), C. difficile infections (0.9% vs 0.1%, aOR 0.18, 95% CI 0.02-1.59), ventilator-associated conditions (1.6% vs 1.7%, aOR 0.92, 95% CI 0.85-1.00) or median length of stay (9.2 vs 9.8 days, adjusted risk ratio 1.06, 85% CI 0.99-1.13). No significant treatment differences were observed among subgroups of interest or per-protocol populations. CONCLUSIONS In a secondary analysis of cardiac surgery patients enrolled in the PEPTIC trial in Canada, no differences in effectiveness or safety were observed between use of PPIs and histamine-2 receptor blockers for stress ulcer prophylaxis. CLINICAL TRIAL REGISTRATION NUMBER anzctr.org.au identifier: ACTRN12616000481471.
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Affiliation(s)
- Sean van Diepen
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada,Corresponding author. 2C2 Cardiology Walter MacKenzie Center, University of Alberta Hospital, 8440-11 St., Edmonton, AB T6G 2B7, Canada. Tel: +1-780-407-6948; fax: +1-780-407-7485; e-mail: (S. van Diepen)
| | - Tim Coulson
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia
| | - Xiaoming Wang
- Health Services Statistical and Analytic Methods, Alberta Health Services, Calgary, AB, Canada
| | - Dawn Opgenorth
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada
| | - Danny J Zuege
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
| | - Jo Harris
- eCritical Alberta, Alberta Health Services, Calgary, AB, Canada
| | - Malik Agyemang
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Alberta Health Services, Calgary, AB, Canada,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia,Data Analytics Research & Evaluation Centre, University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | | | - Paul J Young
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia,Medical Research Institute of New Zealand, Wellington, New Zealand,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta, and Alberta Health Services, Edmonton, AB, Canada,Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, AB, Canada
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11
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Association between intensive care unit utilization for patients with non-ST-segment elevation myocardial infarction and patient experience. Am Heart J 2021; 231:32-35. [PMID: 33045223 DOI: 10.1016/j.ahj.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/22/2020] [Indexed: 11/22/2022]
Abstract
Routine intensive care unit (ICU) utilization for patients with initially stable non-ST segment elevation myocardial infarction is not associated with improved short- or long-term patient outcomes; however, the association with patient experience has not been reported. Using Hospital Consumer Assessment of Healthcare Providers and Systems patient survey data linked to ICU use data from the National Cardiovascular Data Registry, we found no association between hospital-level ICU utilization and metrics of patient experience, including communication, staff responsiveness, and overall satisfaction.
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12
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Dahine J, Hébert PC, Ziegler D, Chenail N, Ferrari N, Hébert R. Practices in Triage and Transfer of Critically Ill Patients: A Qualitative Systematic Review of Selection Criteria. Crit Care Med 2020; 48:e1147-e1157. [PMID: 32858530 PMCID: PMC7493782 DOI: 10.1097/ccm.0000000000004624] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To identify and appraise articles describing criteria used to prioritize or withhold a critical care admission. DATA SOURCES PubMed, Embase, Medline, EBM Reviews, and CINAHL Complete databases. Gray literature searches and a manual review of references were also performed. Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed. STUDY SELECTION We sought all articles and abstracts of original research as well as local, provincial, or national policies on the topic of ICU resource allocation. We excluded studies whose population of interest was neonatal, pediatric, trauma, or noncritically ill. Screening of 6,633 citations was conducted. DATA EXTRACTION Triage and/or transport criteria were extracted, based on type of article, methodology, publication year, and country. An appraisal scale was developed to assess the quality of identified articles. We also developed a robustness score to further appraise the robustness of the evidence supporting each criterion. Finally, all criteria were extracted, evaluated, and grouped by theme. DATA SYNTHESIS One-hundred twenty-nine articles were included. These were mainly original research (34%), guidelines (26%), and reviews (21%). Among them, we identified 200 unique triage and transport criteria. Most articles highlighted an exclusion (71%) rather than a prioritization mechanism (17%). Very few articles pertained to transport of critically ill patients (4%). Criteria were classified in one of four emerging themes: patient, condition, physician, and context. The majority of criteria used were nonspecific. No study prospectively evaluated the implementation of its cited criteria. CONCLUSIONS This systematic review identified 200 criteria classified within four themes that may be included when devising triage programs including the coronavirus disease 2019 pandemic. We identified significant knowledge gaps where research would assist in improving existing triage criteria and guidelines, aiming to decrease arbitrary decisions and variability.
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Affiliation(s)
- Joseph Dahine
- Département de médecine spécialisée, Centre intégré de santé et services sociaux de Laval (CISSS de Laval), Hôpital Cité-de-la-Santé, Université de Montréal, Laval, QC, Canada
| | - Paul C. Hébert
- Département de médecine, Centre Hospitalier de l’Université de Montréal, Université de Montréal et Centre de Recherche, Montreal, QC, Canada
| | - Daniela Ziegler
- Bibliothèque, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | | | - Nicolay Ferrari
- Centre de recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada
| | - Réjean Hébert
- Department of Health Management, Evaluation and Policy, School of Public Health, Université de Montréal, Montreal, QC, Canada
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13
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Tateishi K, Nakagomi A, Saito Y, Kitahara H, Kanda M, Shiko Y, Kawasaki Y, Kuwabara H, Kobayashi Y, Inoue T. Feasibility of management of hemodynamically stable patients with acute myocardial infarction following primary percutaneous coronary intervention in the general ward settings. PLoS One 2020; 15:e0240364. [PMID: 33035270 PMCID: PMC7546471 DOI: 10.1371/journal.pone.0240364] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/24/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Although current guidelines recommend admission to the intensive/coronary care unit (ICU/CCU) for patients with ST-segment elevation myocardial infarction (MI), routine use of the CCU in uncomplicated patients with acute MI remains controversial. We aimed to evaluate the safety of management in the general ward (GW) of hemodynamically stable patients with acute MI after primary percutaneous coronary intervention (PCI). METHODS Using a large nationwide administrative database, a cohort of 19426 patients diagnosed with acute MI in 52 hospitals where a CCU was available were retrospectively analyzed. Patients with mechanical cardiac support and Killip classification 4, and those without primary PCI on admission were excluded. A total of 5736 patients were included and divided into the CCU (n = 3488) and GW (n = 2248) groups according to the type of hospitalization room after primary PCI. Propensity score matching was performed, and 1644 pairs were matched. The primary endpoint was in-hospital mortality at 30 days. RESULTS The CCU group had a higher rate of Killip classification 3 and ambulance use than the GW group. There was no significant difference in the incidence of in-hospital mortality within 30 days among the matched subjects. Multivariable Cox proportional hazard model analysis among unmatched patients supported the findings (hazard ratio 1.12, 95% confidence interval 0.66-1.91, p = 0.67). CONCLUSIONS The use of the GW was not associated with higher in-hospital mortality in hemodynamically stable patients with acute MI after primary PCI. It may be feasible for the selected patients to be directly admitted to the GW after primary PCI.
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Affiliation(s)
- Kazuya Tateishi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Atsushi Nakagomi
- Takemi Program in International Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Yuichi Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Masato Kanda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yohei Kawasaki
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hiroyo Kuwabara
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Takahiro Inoue
- Healthcare Management Research Center, Chiba University Hospital, Chiba, Japan
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14
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McIntyre WF, Liu S, Garber PJ. Impact of Routine 24 Hour Coronary Care Unit Stay in Stable Patients After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. Am J Cardiol 2020; 125:1770-1773. [PMID: 32307092 DOI: 10.1016/j.amjcard.2020.03.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/14/2020] [Accepted: 03/19/2020] [Indexed: 11/19/2022]
Abstract
With the routine use of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), the rate of short-term complications is low and the optimal length-of-stay in the coronary care unit (CCU) following reperfusion is unknown. We hypothesized that the rate of complications would not differ between two groups of stable patients admitted to the CCU following primary-PCI for STEMI: (1) those for whom a minimum 24-hour stay was enforced (≥24 hour Standard Stay) and (2) those with no minimum length-of-stay (Physician-guided Stay). Data were collected retrospectively. We performed a regression analysis to determine predictors of the primary endpoint (a composite of in-hospital death, re-infarction and/or re-intervention, heart failure requiring intravenous diuretics, cardiac arrest, central nervous system and/or peripheral embolization, bleeding requiring transfusion, arrhythmia resulting in initiation of a class I or III antiarrhythmic drug, initiation of assisted ventilation, requirement for vasopressors or inotropes, or transfer to intensive care). A total of 242 patients were included in the analysis. The rate of the primary endpoint was 8% in the physician-guided stay group and 16% in the standard ≥24 hour stay group (p = 0.06). The most common complication in both groups was heart failure requiring diuretics (42%), which was predicted by the left ventricular end diastolic pressure on catheterization (area under the Receiver-Operator Curve of 0.75). In conclusion, Patients who are stable following primary PCI for STEMI have a low rate of complications. Stable STEMI patients do not appear to benefit from a mandatory ≥24 hours stay in the CCU.
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Affiliation(s)
- William F McIntyre
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shuangbo Liu
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philip J Garber
- Cardiac Sciences Program, University of Manitoba, Winnipeg, Manitoba, Canada.
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15
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Guimarães PO, Sampaio MC, Malafaia FL, Lopes RD, Fanaroff AC, de Barros E Silva PGM, Dos Santos TM, Okada MY, Mouallem ARE, Diniz MDS, Custódio JV, Garcia JCT, Furlan V. Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction. Eur J Intern Med 2020; 76:58-63. [PMID: 32089424 DOI: 10.1016/j.ejim.2020.02.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/28/2020] [Accepted: 02/11/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI. METHODS We described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis. RESULTS Mean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47-0.63). CONCLUSIONS Complications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.
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Affiliation(s)
| | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University, Durham, NC, United States
| | - Alexander C Fanaroff
- Cardiovascular Outcomes, Quality and Evaluative Research Center, University of Pennsylvania, Philadelphia, PA, United States; Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia, PA, United States
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16
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Vallabhajosyula S, Vallabhajosyula S, Burstein B, Ternus BW, Sundaragiri PR, White RD, Barsness GW, Jentzer JC. Epidemiology of in-hospital cardiac arrest complicating non-ST-segment elevation myocardial infarction receiving early coronary angiography. Am Heart J 2020; 223:59-64. [PMID: 32163754 DOI: 10.1016/j.ahj.2020.01.016] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/19/2020] [Indexed: 12/25/2022]
Abstract
In the period between 2000 and 2014, 584,704 admissions with non-ST-segment elevation myocardial infarction that received early coronary angiography (day zero) were identified from the National Inpatient Sample. In-hospital cardiac arrest was noted in 4349 (0.8%), of which ~47% were from ventricular arrhythmias and ~90% of occurred within ≤4 days. Non-ST-segment elevation myocardial infarction admissions with in-hospital cardiac arrest had higher in-hospital mortality compared to those without (61% vs. 1.6%) with an unchanged temporal trend of in-hospital cardiac arrest rates (adjusted odds ratio 1.29 [95% confidence interval 0.73-2.28]) in 2014 compared to 2000).
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Affiliation(s)
- Saraschandra Vallabhajosyula
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN; Center for Clinical and Translational Science, Mayo Clinic Graduate School of Biomedical Sciences, Rochester, MN.
| | | | - Barry Burstein
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Bradley W Ternus
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Pranathi R Sundaragiri
- Division of Hospital Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Roger D White
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Cardiovascular Anesthesia, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Jacob C Jentzer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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17
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Fanaroff AC, Chen AY, van Diepen S, Peterson ED, Wang TY. Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2020; 9:e015179. [PMID: 32174210 PMCID: PMC7335514 DOI: 10.1161/jaha.119.015179] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hospitals in the United States vary in their use of intensive care units (ICUs) for hemodynamically stable patients with non–ST‐segment–elevation myocardial infarction (NSTEMI). The association between ICU use and long‐term outcomes after NSTEMI is unknown. Methods and Results Using data from the National Cardiovascular Data Registry linked to Medicare claims, we identified 65 256 NSTEMI patients aged ≥ 65 years without cardiogenic shock or cardiac arrest on presentation between 2011 and 2014. We compared 1‐year medication non‐adherence, cardiovascular readmission, and mortality across hospitals by ICU use using multivariable regression models. Among 520 hospitals, 154 (29.6%) were high ICU users (>70% of stable NSTEMI patients admitted to ICU), 270 (51.9%) were intermediate (30%–70%), and 196 (37.7%) were low (<30%). Compared with low ICU usage hospitals, no differences were observed in the risks of 1‐year medication non‐adherence (adjusted odds ratio 1.08, 95% CI, 0.97–1.21), mortality (adjusted hazard ratio 1.06, 95% CI, 0.98–1.15), and cardiovascular readmission (adjusted hazard ratio 0.99, 95% CI, 0.95–1.04) at high usage hospitals. Patients hospitalized at intermediate ICU usage hospitals had lower rates of evidence‐based therapy and diagnostic catheterization within 24 hours of hospital arrival, and higher risks of 1‐year mortality (adjusted hazard ratio 1.07, 95% CI, 1.02–1.12) and medication non‐adherence (adjusted odds ratio 1.09, 95% CI, 1.02–1.15) compared with low ICU usage hospitals. Conclusions Routine ICU use is unlikely to be beneficial for hemodynamically stable NSTEMI patients; medication adherence, long‐term mortality, and cardiovascular readmission did not differ for high ICU usage hospitals compared with hospitals with low ICU usage rates.
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Affiliation(s)
- Alexander C Fanaroff
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute of Health Economics, and Cardiovascular Medicine Division University of Pennsylvania Philadelphia PA
| | - Anita Y Chen
- Department of Biostatistics and Computations Biology University of Rochester NY
| | - Sean van Diepen
- Divisions of Critical Care and Cardiology University of Alberta, Edmonton Alberta Canada
| | - Eric D Peterson
- ivision of Cardiology and Duke Clinical Research Institute Duke University Durham NC
| | - Tracy Y Wang
- ivision of Cardiology and Duke Clinical Research Institute Duke University Durham NC
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Chou YS, Lin HY, Weng YM, Goh ZNL, Chien CY, Fan HJ, Li CH, Chen HY, Hsieh MS, Seak JCY, Seak CK, Seak CJ. Step-down units are cost-effective alternatives to coronary care units with non-inferior outcomes in the management of ST-elevation myocardial infarction patients after successful primary percutaneous coronary intervention. Intern Emerg Med 2020; 15:59-66. [PMID: 30706252 DOI: 10.1007/s11739-019-02037-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
Percutaneous coronary interventions (PCIs) within a door-to-balloon timing of 90 min have greatly decreased mortality and morbidity of ST-elevation myocardial infarction (STEMI) patients. Post-PCI, they are routinely transferred into the coronary care unit (CCU) regardless of the severity of their condition, resulting in frequent CCU overcrowding. This study assesses the feasibility of step-down units (SDUs) as an alternative to CCUs in the management of STEMI patients after successful PCI, to alleviate CCU overcrowding. Criteria of assessment include in-hospital complications, length of stay, cost-effectiveness, and patient outcomes up to a year after discharge from hospital. A retrospective case-control study was done using data of 294 adult STEMI patients admitted to the emergency departments of two training and research hospitals and successfully underwent primary PCI from 1 January 2014 to 31 December 2015. Patients were followed up for a year post-discharge. Student t test and χ2 test were done as univariate analysis to check for statistical significance of p < 0.05. Further regression analysis was done with respect to primary outcomes to adjust for major confounders. Patients managed in the SDU incurred significantly lower inpatient costs (p = 0.0003). No significant differences were found between the CCU and SDU patients in terms of patient characteristics, PCI characteristics, in-hospital complications, length of stay, and patient outcomes up to a year after discharge. The SDU is a viable cost-effective option for managing STEMI patients after successful primary PCI to avoid CCU overcrowding, with non-inferior patient outcomes as compared to the CCU.
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Affiliation(s)
- Yu-Shao Chou
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsin-Yueh Lin
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ming Weng
- Division of Prehospital Care, Department of Emergency Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | | | - Cheng-Yu Chien
- Department of Emergency Medicine, Ton-Yen General Hospital, Zhubei, Hsinchu County, Taiwan
| | - Hsuan-Jui Fan
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Huang Li
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hsien-Yi Chen
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan
| | | | - Chen-Ken Seak
- Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Chen-June Seak
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, No. 5, Fusing St., Guei-shan Township, Taoyuan, 333, Taiwan, ROC.
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan.
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19
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van Diepen S, Katz JN, Morrow DA. Will Cardiac Intensive Care Unit Admissions Warrant Appropriate Use Criteria in the Future? Circulation 2019; 140:267-269. [PMID: 31329487 DOI: 10.1161/circulationaha.118.039125] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB, Canada (S.v.D.)
| | - Jason N Katz
- Department of Medicine and Surgery, Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill (J.N.K.)
| | - David A Morrow
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.A.M.)
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20
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Fanaroff AC, Peterson ED, Chen AY, Thomas L, Doll JA, Fordyce CB, Newby LK, Amsterdam EA, Kosiborod MN, de Lemos JA, Wang TY. Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non-ST-Segment Elevation Myocardial Infarction. JAMA Cardiol 2019; 2:36-44. [PMID: 27806171 DOI: 10.1001/jamacardio.2016.3855] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives To examine interhospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with low, moderate, or high mortality risk. Design, Setting, and Participants This study was a retrospective analysis of 28 018 Medicare patients 65 years or older admitted with NSTEMI to 346 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION)-Get With the Guidelines from April 1, 2011, through December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Data analysis was performed from May 7 through October 8, 2015. Exposures Hospitals with high (>70% of patients with NSTEMI treated in an ICU during the index hospitalization), intermediate (30%-70%), or low (<30%) ICU utilization. Main Outcomes and Measures Thirty-day mortality. Results Of 28 018 patients with NSTEMI 65 years or older (median age, 77 years [interquartile range, 71-84 years]; female, 13 055 [46.6%]; nonwhite race, 3931 [14.0%]), 11 934 (42.6%) had an ICU stay. The proportion of patients with NSTEMI treated in the ICU varied across hospitals (median, 38%; interquartile range, 26%-54%), but no significant differences were found in hospital or patient characteristics among high, intermediate, or low ICU utilization hospitals. Compared with high ICU utilization hospitals, low or intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. The median ACTION risk score for patients treated in the ICU at low and intermediate ICU utilization hospitals was 34 compared with 33 for patients not treated in the ICU; at high ICU utilization hospitals, the median ACTION mortality risk score was 33 for patients treated in the ICU and 34 for patients not treated in the ICU. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs low: 8.7% vs 8.7%; adjusted odds ratio, 0.91; 95% CI, 0.76-1.08; intermediate vs low: 9.6% vs 8.7%; adjusted odds ratio, 1.06; 95% CI, 0.94-1.20). The association between hospital ICU utilization and mortality did not change when considered among patients with ACTION risk scores greater than 40, 30 to 40, and less than 30 (adjusted interaction P = .86). Conclusions and Relevance Utilization of the ICU for older patients with NSTEMI varied significantly among hospitals. This variability was not explained by hospital characteristics or driven by patient risk. Mortality after myocardial infarction did not significantly differ among high, intermediate, or low ICU utilization hospitals.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Duke University, Durham, North Carolina2Duke Clinical Research Institute, Durham, North Carolina
| | - Eric D Peterson
- Division of Cardiology, Duke University, Durham, North Carolina2Duke Clinical Research Institute, Durham, North Carolina
| | - Anita Y Chen
- Duke Clinical Research Institute, Durham, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jacob A Doll
- Division of Cardiology, Veterans Affairs Puget Sound Health System and the University of Washington, Seattle
| | - Christopher B Fordyce
- Division of Cardiology, Duke University, Durham, North Carolina2Duke Clinical Research Institute, Durham, North Carolina
| | - L Kristin Newby
- Division of Cardiology, Duke University, Durham, North Carolina2Duke Clinical Research Institute, Durham, North Carolina
| | - Ezra A Amsterdam
- Division of Cardiology, University of California, Davis, Sacramento
| | | | - James A de Lemos
- Division of Cardiology, University of Texas-Southwestern, Dallas
| | - Tracy Y Wang
- Division of Cardiology, Duke University, Durham, North Carolina2Duke Clinical Research Institute, Durham, North Carolina
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Shavadia JS, Chen AY, Fanaroff AC, de Lemos JA, Kontos MC, Wang TY. Intensive Care Utilization in Stable Patients With ST-Segment Elevation Myocardial Infarction Treated With Rapid Reperfusion. JACC Cardiovasc Interv 2019; 12:709-717. [PMID: 31000008 DOI: 10.1016/j.jcin.2019.01.230] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/11/2018] [Accepted: 01/15/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aims of this study were to describe variability in intensive care unit (ICU) utilization for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI), evaluate the proportion of these patients who developed in-hospital complications requiring ICU care, and assess whether ICU use patterns and complication rates vary across categories of first medical contact to device times. BACKGROUND In the era of rapid primary percutaneous coronary intervention, ICUs may be overutilized as patients presenting with STEMI are less likely to develop complications requiring ICU care. METHODS Using data from the Chest Pain-MI Registry linked to Medicare claims, the authors examined patterns of ICU utilization among hemodynamically stable patients with STEMI ≥65 years of age treated with uncomplicated primary percutaneous coronary intervention, stratified by timing of reperfusion: early (first medical contact-to-device time ≤60 min), intermediate (61 to 90 min), or late (>90 min). RESULTS Of 19,507 patients with STEMI treated at 707 hospitals, 82.3% were treated in ICUs, with a median ICU stay of 1 day (interquartile range [IQR]: 1 to 2 days). The median FMC-to-device time was 79 min (IQR: 63 to 99 min); 22.0% of patients had early, 44.8% intermediate, and 33.2% late reperfusion. ICU utilization rates did not differ between patients with early, intermediate, and late reperfusion times (82%, 83%, and 82%; p for trend = 0.44). Overall, 3,159 patients (16.2%) developed complications requiring ICU care while hospitalized: 3.7% died, 3.7% had cardiac arrest, 8.7% shock, 0.9% stroke, 4.1% high-grade atrioventricular block requiring treatment, and 5.7% respiratory failure. Patients with longer FMC-to-device times were more likely to develop at least 1 of these complications (early 13.4%, intermediate 15.7%, and late 18.7%; p for trend <0.001; adjusted odds ratio [early as reference] for intermediate: 1.13 [95% confidence interval: 1.01 to 1.25]; adjusted odds ratio for late: 1.22 [95% confidence interval: 1.08 to 1.37]). CONCLUSIONS Although >80% of stable patients with STEMI are treated in the ICU after primary percutaneous coronary intervention, the risk for developing a complication requiring ICU care is 16%. Implementing a risk-based triage strategy, inclusive of factors such as degree of reperfusion delay, could optimize ICU utilization for patients with STEMI.
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Affiliation(s)
- Jay S Shavadia
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
| | - Anita Y Chen
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Michael C Kontos
- Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Tracy Y Wang
- Duke Clinical Research Institute, Durham, North Carolina
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22
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Tran DT, Ohinmaa A, Thanh NX, Welsh RC, Kaul P. The Healthcare Cost Burden of Acute Myocardial Infarction in Alberta, Canada. PHARMACOECONOMICS - OPEN 2018; 2:433-442. [PMID: 29623635 PMCID: PMC6249191 DOI: 10.1007/s41669-017-0061-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
OBJECTIVES Little is known about the cost burden of acute myocardial infarction (AMI) on healthcare systems. Accordingly, we examined the long-term trends of healthcare costs for AMI in the province of Alberta, Canada. METHODS We linked five Albertan health databases, including ambulatory care, hospitalization, practitioner claims, pharmaceutical information network, and population registry to identify patients with a primary diagnosis of AMI between 2004 and 2013. We used the Alberta Interactive Health Data Application to provide unit costs for ambulatory care and inpatient services, claim paid amounts for physician services, and the Alberta Drug Benefit List for drug prices. Healthcare costs for AMI were grouped into ambulatory care, hospitalization, physician costs, and drug costs. All costs were converted to 2016 Canadian dollar values ($Can). RESULTS A total of 52,912 patients with AMI were included in the analysis. Patient age decreased over time, as did the proportion of females. AMI cost the Alberta healthcare system Can$1033 million during the study period; of which the largest proportion was hospitalization costs (Can$716.4 million, 63.1%), followed by drug costs (Can$147.2 million, 21.1%), ambulatory care costs (Can$94.5 million, 8.8%) and physician costs (Can$74.9 million, 7.0%). The cost per AMI hospitalization decreased from Can$14,116 in 2004 to Can$11,792 in 2013 (p < 0.001). CONCLUSIONS Healthcare costs for AMI are significant; however, they decreased slightly during the study period. Hospital services accounted for the largest share of the costs. There are opportunities for further savings in AMI care.
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Affiliation(s)
- Dat T Tran
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
- Canadian VIGOUR Centre, University of Alberta, 2-132 Li Ka Shing Centre, Edmonton, AB, Canada.
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Institute of Health Economics, Edmonton, AB, Canada
| | - Nguyen X Thanh
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Institute of Health Economics, Edmonton, AB, Canada
| | - Robert C Welsh
- Canadian VIGOUR Centre, University of Alberta, 2-132 Li Ka Shing Centre, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
- Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, 2-132 Li Ka Shing Centre, Edmonton, AB, Canada
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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23
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van Diepen S, Tran DT, Ezekowitz JA, Zygun DA, Katz JN, Lopes RD, Newby LK, McAlister FA, Kaul P. The high cost of critical care unit over-utilization for patients with NSTE ACS. Am Heart J 2018; 202:84-88. [PMID: 29906667 DOI: 10.1016/j.ahj.2018.05.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/14/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is substantial variability among hospitals in critical care unit (CCU) utilization for patients admitted with non-ST-Segment Elevation Acute Coronary Syndromes (NSTE ACS). We estimated the potential cost saving if all hospitals adopted low CCU utilization practices for patients with NSTE ACS. METHODS National hospital claims data were used to identify all patients with a primary diagnosis of NSTE ACS initially admitted to an acute care hospital between 2007 and 2013. Hospital CCU utilization was classified as low (<30%), medium (30-70%), or high (>70%). RESULTS Among the 270,564 NSTE ACS hospitalizations (71.6% non-ST-segment elevation myocardial infarction; 28.4% unstable angina) admitted to 261 hospitals, 41.9% (inter-hospital range 0.3%-95.1%) were admitted to a CCU. The proportion of patients admitted to a CCU in low, medium and high utilization hospitals was 16.3%, 49.5%, and high 81.1%, respectively. No differences in adjusted inpatient mortality were observed by hospital CCU utilization. The overall inpatient costs of caring for NSTE ACS were $1.1 billion. CCU care accounted for 45.2% of all hospitalization costs including 22.6%, 49.9%, and 69.0% (P < .001) of costs in low, medium and high utilization centers. The national potential direct cost savings of medium and high CCU utilization centers adopting low NSTE ACS CCU utilization practices was $113.4 million over the study period. CONCLUSIONS In a population-based contemporary cohort, CCU utilization for patients with NSTE ACS varied widely and in-hospital mortality was similar between low, medium and high utilization centers. CCU care accounted for 45% of hospitalization costs; thus, implementing policies and admission practices to align hospital resources with patient care needs have the potential to reduce overall health care costs.
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24
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Verma S, Kaul P, Lin M, Ezekowitz JA, Zygun DA, Fordyce CB, Wang TY, McAlister FA, van Diepen S. Acute Coronary Syndromes and Heart Failure Critical Care Units Utilization and Outcomes in Teaching and Community Hospitals: A National Population-Based Analysis. Can J Cardiol 2018; 34:1365-1368. [PMID: 30269834 DOI: 10.1016/j.cjca.2018.07.419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 11/28/2022] Open
Abstract
Acute coronary syndromes (ACS) and heart failure (HF) are the leading diagnoses in patients admitted to critical care units (CCUs). Little is known about the differences between CCU resource use and outcomes across hospital types. The Canadian Institute for Health Information was used to identify patients hospitalized with primary diagnoses of ACS or HF. CCUs were categorized as teaching, large community, medium community, and small community hospitals. Outcomes included CCU rates of admission, use of critical care therapy/procedures, and in-hospital mortality. Among 204,900 patients hospitalized with ACS or HF, 73,338 (35.8%, hospital range 0% to 81.4%) were admitted to CCUs, and it varied across hospital types: 41.0% in teaching, 30.0% in large, 45.4% in medium, and 30.9% in small community hospitals (P < 0.001). The percentage of patients admitted to CCUs who received critical care therapies in teaching, large, medium, and small hospitals were as follows: 73.6%, 50.9%, 24.6%, and 8.8% (P < 0.0001). Compared with the in-hospital mortality rate for patients admitted to CCUs in teaching hospitals (8.2%), outcomes were worse for CCU patients in large (11.0%, adjusted odds ratio [aOR] 1.50; 95% CI, 1.19-1.90), medium (10.5%, aOR 1.56; 95% CI, 1.27-1.92), and small community hospitals (9.2%, aOR 1.59; 95% CI, 1.20-2.10). Patients admitted with ACS or HF to teaching hospital CCUs had a higher observed use of critical care therapies and lower mortality compared with community hospitals. These differences highlight the need to examine differences in CCU admission thresholds, resource utilization, and outcomes across hospitals types.
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Affiliation(s)
- Sanam Verma
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Padma Kaul
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada; Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada
| | - Meng Lin
- Alberta SPOR Support Unit, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada; Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada
| | - David A Zygun
- Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada
| | - Christopher B Fordyce
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tracy Y Wang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Finlay A McAlister
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Division of General Internal Medicine, University of Alberta, Edmonton, Canada
| | - Sean van Diepen
- Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada; Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Department of Critical Care, University of Alberta, Edmonton, Alberta, Canada.
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25
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Fanaroff AC, Chen AY, Thomas LE, Pieper KS, Garratt KN, Peterson ED, Newby LK, de Lemos JA, Kosiborod MN, Amsterdam EA, Wang TY. Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction. J Am Heart Assoc 2018; 7:JAHA.118.008894. [PMID: 29802146 PMCID: PMC6015341 DOI: 10.1161/jaha.118.008894] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Intensive care unit (ICU) use for initially stable patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high‐risk patients with NSTEMI for ICU admission. Methods and Results Using the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high‐grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU‐level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST‐segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C‐statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU. Conclusions The ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.
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Affiliation(s)
- Alexander C Fanaroff
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Anita Y Chen
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Laine E Thomas
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Karen S Pieper
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Kirk N Garratt
- Center for Heart and Vascular Health, Christiania Care Health System, Newark, DE
| | - Eric D Peterson
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - L Kristin Newby
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - James A de Lemos
- Division of Cardiology, University of Texas-Southwestern, Dallas, TX
| | - Mikhail N Kosiborod
- St Luke's Mid-America Heart Institute University of Missouri-Kansas City, Kansas City, MO
| | - Ezra A Amsterdam
- Division of Cardiology, University of California (Davis), Sacramento, CA
| | - Tracy Y Wang
- Division of Cardiology, Duke University, Durham, NC
- Duke Clinical Research Institute, Duke University, Durham, NC
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Faxén J, Hall M, Gale CP, Sundström J, Lindahl B, Jernberg T, Szummer K. A user-friendly risk-score for predicting in-hospital cardiac arrest among patients admitted with suspected non ST-elevation acute coronary syndrome - The SAFER-score. Resuscitation 2017; 121:41-48. [PMID: 28993178 DOI: 10.1016/j.resuscitation.2017.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/10/2017] [Accepted: 10/04/2017] [Indexed: 12/01/2022]
Abstract
AIM To develop a simple risk-score model for predicting in-hospital cardiac arrest (CA) among patients hospitalized with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). METHODS Using the Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART), we identified patients (n=242 303) admitted with suspected NSTE-ACS between 2008 and 2014. Logistic regression was used to assess the association between 26 candidate variables and in-hospital CA. A risk-score model was developed and validated using a temporal cohort (n=126 073) comprising patients from SWEDEHEART between 2005 and 2007 and an external cohort (n=276 109) comprising patients from the Myocardial Ischaemia National Audit Project (MINAP) between 2008 and 2013. RESULTS The incidence of in-hospital CA for NSTE-ACS and non-ACS was lower in the SWEDEHEART-derivation cohort than in MINAP (1.3% and 0.5% vs. 2.3% and 2.3%). A seven point, five variable risk score (age ≥60 years (1 point), ST-T abnormalities (2 points), Killip Class >1 (1 point), heart rate <50 or ≥100bpm (1 point), and systolic blood pressure <100mmHg (2 points) was developed. Model discrimination was good in the derivation cohort (c-statistic 0.72) and temporal validation cohort (c-statistic 0.74), and calibration was reasonable with a tendency towards overestimation of risk with a higher sum of score points. External validation showed moderate discrimination (c-statistic 0.65) and calibration showed a general underestimation of predicted risk. CONCLUSIONS A simple points score containing five variables readily available on admission predicts in-hospital CA for patients with suspected NSTE-ACS.
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Affiliation(s)
- Jonas Faxén
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital Stockholm, Sweden.
| | - Marlous Hall
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK; York Teaching Hospital NHS Foundation Trust, York, UK
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - Bertil Lindahl
- Uppsala Clinical Research Centre, University of Uppsala, Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Karolina Szummer
- Department of Medicine, Karolinska Institutet and Department of Cardiology, Karolinska University Hospital Stockholm, Sweden
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Holland EM, Moss TJ. Acute Noncardiovascular Illness in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2017; 69:1999-2007. [DOI: 10.1016/j.jacc.2017.02.033] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/12/2017] [Accepted: 02/10/2017] [Indexed: 12/22/2022]
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van Diepen S, Lin M, Ezekowitz JA, McAlister FA, Lee DS, Goodman SG, Armstrong PW, Kaul P. Interprovincial Differences in Canadian Coronary Care Unit Resource Use and Outcomes. Can J Cardiol 2016; 33:166-169. [PMID: 27914806 DOI: 10.1016/j.cjca.2016.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2016] [Revised: 10/08/2016] [Accepted: 10/09/2016] [Indexed: 11/18/2022] Open
Abstract
International registries have reported a wide variation in coronary care unit (CCU) admission rates for patients hospitalized with acute coronary syndrome (ACS) or heart failure (HF). Little is known about variation in Canadian interprovincial use and outcomes. Canadian Institute of Health Information data were used to identify hospitalized patients admitted to a CCU with a primary diagnosis of ACS or HF between April 1, 2007 and March 31, 2013. We examined interprovincial differences in CCU admission rates, use of CCU restricted therapies in the first 2 days of admission, and the association between CCU admission rate and risk-adjusted in-hospital mortality at the provincial level. The CCU admission rate among 220,759 patients hospitalized with ACS and HF was 33%, and this varied significantly across provinces (interprovincial range [IPR] 17%-50%; P < 0.001). A majority (59%; IPR, 48%-84%; P < 0.001) of patients admitted to the CCU did not receive critical care restricted therapies within 2 days. In-hospital mortality also varied across provinces (10%; IPR, 5%-13%; P < 0.001). Although statistically significant (P < 0.001), the correlation between CCU admission rates and provincial risk-adjusted in-hospital mortality was low (r = -0.30). These findings highlight the need for national CCU admission criteria designed to reduce variability and improve health care resource use and outcomes.
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Affiliation(s)
- Sean van Diepen
- Divisions of Critical Care and Cardiology, University of Alberta, Edmonton, Alberta, Canada; Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada.
| | - Meng Lin
- Alberta SPOR Support Unit, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences and University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shaun G Goodman
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul W Armstrong
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian Vigour Center, University of Alberta, Edmonton, Alberta, Canada; Alberta SPOR Support Unit, Edmonton, Alberta, Canada
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Valley TS, Sjoding MW, Goldberger ZD, Cooke CR. ICU Use and Quality of Care for Patients With Myocardial Infarction and Heart Failure. Chest 2016; 150:524-32. [PMID: 27318172 DOI: 10.1016/j.chest.2016.05.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 05/26/2016] [Accepted: 05/31/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Quality of care for acute myocardial infarction (AMI) and heart failure (HF) varies across hospitals, but the factors driving variation are incompletely understood. We evaluated the relationship between a hospital's ICU or coronary care unit (CCU) admission rate and quality of care provided to patients with AMI or HF. METHODS A retrospective cohort study of Medicare beneficiaries hospitalized in 2010 with AMI or HF was performed. Hospitals were grouped into quintiles according to their risk- and reliability-adjusted ICU admission rates for AMI or HF. We examined the rates that hospitals failed to deliver standard AMI or HF processes of care (process measure failure rates), 30-day mortality, 30-day readmissions, and Medicare spending after adjusting for patient and hospital characteristics. RESULTS Hospitals in the lowest quintile had ICU admission rates < 29% for AMI or < 8% for HF. Hospitals in the top quintile had rates > 61% for AMI or > 24% for HF. Hospitals in the highest quintile had higher process measure failure rates for some but not all process measures. Hospitals in the top quintile had greater 30-day mortality (14.8% vs 14.0% [P = .002] for AMI; 11.4% vs 10.6% [P < .001] for HF), but no differences in 30-day readmissions or Medicare spending were seen compared with hospitals in the lowest quintile. CONCLUSIONS Hospitals with the highest rates of ICU admission for patients with AMI or HF delivered lower quality of care and had higher 30-day mortality for these conditions. Hospitals with high ICU use may be targets to improve care delivery.
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Affiliation(s)
- Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI.
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI
| | - Zachary D Goldberger
- Division of Cardiology, Department of Internal Medicine, University of Washington, Seattle, WA
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI; Center for Health Outcomes and Policy, and the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
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Silverman MG, Morrow DA. Hospital triage of acute myocardial infarction: Is admission to the coronary care unit still necessary? Am Heart J 2016; 175:172-4. [PMID: 27179737 DOI: 10.1016/j.ahj.2016.01.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 01/20/2016] [Indexed: 10/22/2022]
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