Patient and Population-Level Approaches to Persistent Critical Illness and Prolonged Intensive Care Unit Stays

Urea to creatinine ratio as a predictor of persistent critical illness

INTRODUCTION

Persistent critical illness (PCI) is a syndrome in which the acute presenting problem has been stabilized, but the patient's clinical state does not allow ICU discharge. The burden associated with PCI is substantial. The most obvious marker of PCI is prolonged ICU length of stay (LOS), usually greater than 10 days. Urea to Creatinine ratio (UCr) has been suggested as an early marker of PCI development.

METHODS

A single-center retrospective study. Data of patients admitted to a general mixed medical-surgical ICU during Jan 1st 2018 till Dec 31st 2022 was extracted, including demographic data, baseline characteristics, daily urea and creatinine results, renal replacement therapy (RRT) provided, and outcome measures - length of stay, and mortality (ICU, and 90 days). Patients were defined as PCI patients if their LOS was >10 days. We used Fisher exact test or Chi-square to compare PCI and non-PCI patients. The association between UCr with PCI development was assessed by repeated measures linear model. Multivariate Cox regression was used for 1 year mortality assessment.

RESULTS

2098 patients were included in the analysis. Patients who suffered from PCI were older, with higher admission prognostic scores. Their 90-day mortality was significantly higher than non-PCI patients (34.58% vs 12.18%, p < 0.0001). A significant difference in UCr was found only on the first admission day among all patients. This was not found when examining separately surgical, trauma, or transplantation patients. We did not find a difference in UCr in different KDIGO (Kidney Disease Improving Global Outcomes) stages. Elevated UCr and PCI were found to be significantly associated with 1 year mortality.

CONCLUSION

In this single center retrospective cohort study, UCr was not found to be associated with PCI development.

Persistent inflammation, immunosuppression, and catabolism syndrome (PICS): a review of definitions, potential therapies, and research priorities

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) is a clinical endotype of chronic critical illness. PICS consists of a self-perpetuating cycle of ongoing organ dysfunction, inflammation, and catabolism resulting in sarcopenia, immunosuppression leading to recurrent infections, metabolic derangements, and changes in bone marrow function. There is heterogeneity regarding the definition of PICS. Currently, there are no licensed treatments specifically for PICS. However, findings can be extrapolated from studies in other conditions with similar features to repurpose drugs, and in animal models. Drugs that can restore immune homeostasis by stimulating lymphocyte production could have potential efficacy. Another treatment could be modifying myeloid-derived suppressor cell (MDSC) activation after day 14 when they are immunosuppressive. Drugs such as interleukin (IL)-1 and IL-6 receptor antagonists might reduce persistent inflammation, although they need to be given at specific time points to avoid adverse effects. Antioxidants could treat the oxidative stress caused by mitochondrial dysfunction in PICS. Possible anti-catabolic agents include testosterone, oxandrolone, IGF-1 (insulin-like growth factor-1), bortezomib, and MURF1 (muscle RING-finger protein-1) inhibitors. Nutritional support strategies that could slow PICS progression include ketogenic feeding and probiotics. The field would benefit from a consensus definition of PICS using biologically based cut-off values. Future research should focus on expanding knowledge on underlying pathophysiological mechanisms of PICS to identify and validate other potential endotypes of chronic critical illness and subsequent treatable traits. There is unlikely to be a universal treatment for PICS, and a multimodal, timely, and personalised therapeutic strategy will be needed to improve outcomes for this growing cohort of patients.

CHRONIC CRITICAL ILLNESS-INDUCED MUSCLE ATROPHY: INSIGHTS FROM A TRAUMA MOUSE MODEL AND POTENTIAL MECHANISM MEDIATED VIA SERUM AMYLOID A

ABSTRACT

Background: Chronic critical illness (CCI), which was characterized by persistent inflammation, immunosuppression, and catabolism syndrome (PICS), often leads to muscle atrophy. Serum amyloid A (SAA), a protein upregulated in critical illness myopathy, may play a crucial role in these processes. However, the effects of SAA on muscle atrophy in PICS require further investigation. This study aims to develop a mouse model of PICS combined with bone trauma to investigate the mechanisms underlying muscle weakness, with a focus on SAA. Methods: Mice were used to examine the effects of PICS after bone trauma on immune response, muscle atrophy, and bone healing. The mice were divided into two groups: a bone trauma group and a bone trauma with cecal ligation and puncture group. Tibia fracture surgery was performed on all mice, and PICS was induced through cecal ligation and puncture surgery in the PICS group. Various assessments were conducted, including weight change analysis, cytokine analysis, hematological analysis, grip strength analysis, histochemical staining, and immunofluorescence staining for SAA. In vitro experiments using C2C12 cells (myoblasts) were also conducted to investigate the role of SAA in muscle atrophy. The effects of inhibiting receptor for advanced glycation endproducts (RAGE) or JAK2 on SAA-induced muscle atrophy were examined. Bioinformatic analysis was conducted using a dataset from the GEO database to identify differentially expressed genes and construct a coexpression network. Results: Bioinformatic analysis confirmed that SAA was significantly upregulated in muscle tissue of patients with intensive care unit-induced muscle atrophy. The PICS animal models exhibited significant weight loss, spleen enlargement, elevated levels of proinflammatory cytokines, and altered hematological profiles. Evaluation of muscle atrophy in the animal models demonstrated decreased muscle mass, grip strength loss, decreased diameter of muscle fibers, and significantly increased expression of SAA. In vitro experiment demonstrated that SAA decreased myotube formation, reduced myotube diameter, and increased the expression of muscle atrophy-related genes. Furthermore, SAA expression was associated with activation of the FOXO signaling pathway, and inhibition of RAGE or JAK2/STAT3-FOXO signaling partially reversed SAA-induced muscle atrophy. Conclusions: This study successfully develops a mouse model that mimics PICS in CCI patients with bone trauma. Serum amyloid A plays a crucial role in muscle atrophy through the JAK2/STAT3-FOXO signaling pathway, and targeting RAGE or JAK2 may hold therapeutic potential in mitigating SAA-induced muscle atrophy.

Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic

During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.

Extracorporeal Membrane Oxygenation for Cardiac Arrest: Does Age Matter?

OBJECTIVES

The impact of age on hospital survival for patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for cardiac arrest (CA) is unknown. We sought to characterize the association between older age and hospital survival after ECPR, using a large international database.

DESIGN

Retrospective analysis of the Extracorporeal Life Support Organization registry.

PATIENTS

Patients 18 years old or older who underwent ECPR for CA between December 1, 2016, and October 31, 2020.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was adjusted odds ratio (aOR) of death after ECPR, analyzed by age group (18-49, 50-64, 65-74, and > 75 yr). A total of 5,120 patients met inclusion criteria. The median age was 57 years (interquartile range, 46-66 yr). There was a significantly lower aOR of survival for those 65-74 (0.68l 95% CI, 0.57-0.81) or those greater than 75 (0.54; 95% CI, 0.41-0.69), compared with 18-49. Patients 50-64 had a significantly higher aOR of survival compared with those 65-74 and greater than 75; however, there was no difference in survival between the two youngest groups (aOR, 0.91; 95% CI, 0.79-1.05). A sensitivity analysis using alternative age categories (18-64, 65-69, 70-74, and ≥ 75) demonstrated decreased odds of survival for age greater than or equal to 65 compared with patients younger than 65 (for age 65-69: odds ratio [OR], 0.71; 95% CI, 0.59-0.86; for age 70-74: OR, 0.84; 95% CI, 0.67-1.04; and for age ≥ 75: OR, 0.64; 95% CI, 0.50-0.81).

CONCLUSIONS

This investigation represents the largest analysis of the relationship of older age on ECPR outcomes. We found that the odds of hospital survival for patients with CA treated with ECPR diminishes with increasing age, with significantly decreased odds of survival after age 65, despite controlling for illness severity and comorbidities. However, findings from this observational data have significant limitations and further studies are needed to evaluate these findings prospectively.

The Good, the Bad, and the Serum Creatinine: Exploring the Effect of Muscle Mass and Nutrition

Muscle wasting (sarcopenia) is one of the hallmarks of critical illness. Patients admitted to intensive care unit develop sarcopenia through increased protein catabolism, a decrease in protein syntheses, or both. Among the factors known to promote wasting are chronic inflammation and cytokine imbalance, insulin resistance, hypermetabolism, and malnutrition. Moreover, muscle wasting, known to develop in chronic kidney disease patients, is a harmful consequence of numerous complications associated with deteriorated renal function. Plenty of published data suggest that serum creatinine (SCr) reflects increased kidney damage and is also related to body weight. Based on the concept that urea and creatinine are nitrogenous end products of metabolism, the urea:creatinine ratio (UCR) could be applied but with limited clinical usability in case of kidney damage, hypovolemia, excessive, or protein intake, where UCR can be high and independent of catabolism. Recent data suggest that the sarcopenia index should be considered an alternative to serum creatinine. It is more reliable in estimating muscle mass than SCr. However, the optimal biomarker of catabolism is still an unresolved issue. The SCr is not a promising biomarker for renal function and muscle mass based on the influence of several factors. The present review highlights recent findings on the limits of SCr as a surrogate marker of renal function and the assessment modalities of nutritional status and muscle mass measurements.

Difficult diagnosis in the ICU: making the right call but beware uncertainty and bias

Dealing with an uncertain or missed diagnosis is commonplace in the intensive care unit setting. Affected patients are subject to a potential decrease in quality of care and a greater risk of a poor outcome. The diagnostic process is a complex task that starts with information gathering, followed by integration and interpretation of data, hypothesis generation and, finally, confirmation of a (hopefully correct) diagnosis. This may be particularly challenging in the patient who is critically ill where a good history may not be forthcoming and/or clinical, laboratory and imaging features are non-specific. The aim of this narrative review is to analyse and describe common causes of diagnostic error in the intensive care unit, highlighting the multiple types of cognitive bias, and to suggest a diagnostic framework. To inform this review, we performed a literature search to identify relevant articles, particularly those pertinent to unclear diagnoses in patients who are critically ill. Clinicians should be cognisant as to how they formulate diagnoses and utilise debiasing strategies. Multidisciplinary teamwork and more time spent with the patient, supported by effective and efficient use of electronic healthcare records and decision support resources, is likely to improve the quality of the diagnostic process, patient care and outcomes.

Biological signatures and prediction of an immunosuppressive status-persistent critical illness-among orthopedic trauma patients using machine learning techniques

BACKGROUND

Persistent critical illness (PerCI) is an immunosuppressive status. The underlying pathophysiology driving PerCI remains incompletely understood. The objectives of the study were to identify the biological signature of PerCI development, and to construct a reliable prediction model for patients who had suffered orthopedic trauma using machine learning techniques.

METHODS

This study enrolled 1257 patients from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Lymphocytes were tracked from ICU admission to more than 20 days following admission to examine the dynamic changes over time. Over 40 possible variables were gathered for investigation. Patients were split 80:20 at random into a training cohort (n=1035) and an internal validation cohort (n=222). Four machine learning algorithms, including random forest, gradient boosting machine, decision tree, and support vector machine, and a logistic regression technique were utilized to train and optimize models using data from the training cohort. Patients in the internal validation cohort were used to validate models, and the optimal one was chosen. Patients from two large teaching hospitals were used for external validation (n=113). The key metrics that used to assess the prediction performance of models mainly included discrimination, calibration, and clinical usefulness. To encourage clinical application based on the optimal machine learning-based model, a web-based calculator was developed.

RESULTS

16.0% (201/1257) of all patients had PerCI in the MIMIC-III database. The means of lymphocytes (%) were consistently below the normal reference range across the time among PerCI patients (around 10.0%), whereas in patients without PerCI, the number of lymphocytes continued to increase and began to be in normal range on day 10 following ICU admission. Subgroup analysis demonstrated that patients with PerCI were in a more serious health condition at admission since those patients had worse nutritional status, more electrolyte imbalance and infection-related comorbidities, and more severe illness scores. Eight variables, including albumin, serum calcium, red cell volume distributing width (RDW), blood pH, heart rate, respiratory failure, pneumonia, and the Sepsis-related Organ Failure Assessment (SOFA) score, were significantly associated with PerCI, according to the least absolute shrinkage and selection operator (LASSO) logistic regression model combined with the 10-fold cross-validation. These variables were all included in the modelling. In comparison to other algorithms, the random forest had the optimal prediction ability with the highest area under receiver operating characteristic (AUROC) (0.823, 95% CI: 0.757-0.889), highest Youden index (1.571), and lowest Brier score (0.107). The AUROC in the external validation cohort was also up to 0.800 (95% CI: 0.688-0.912). Based on the risk stratification system, patients in the high-risk group had a 10.0-time greater chance of developing PerCI than those in the low-risk group. A web-based calculator was available at https://starxueshu-perci-prediction-main-9k8eof.streamlitapp.com/.

CONCLUSIONS

Patients with PerCI typically remain in an immunosuppressive status, but those without PerCI gradually regain normal immunity. The dynamic changes of lymphocytes can be a reliable biomarker for PerCI. This work developed a reliable model that may be helpful in improving early diagnosis and targeted intervention of PerCI. Beneficial interventions, such as improving nutritional status and immunity, maintaining electrolyte and acid-base balance, curbing infection, and promoting respiratory recovery, are early warranted to prevent the onset of PerCI, especially among patients in the high-risk group and those with a continuously low level of lymphocytes.

Acquisition of new medical devices among the persistently critically ill: A retrospective cohort study in the Veterans Affairs

Patients who develop persistent critical illness remain in the ICU predominately because they develop new late-onset organ failure(s), which may render them at risk of acquiring a new medical device. The epidemiology and short-term outcomes of patients with persistent critical illness who acquire a new medical device are unknown. We retrospectively studied a cohort admitted to the Veterans Affairs (VA) ICUs from 2014 to 2019. Persistent critical illness was defined as an ICU length of stay of at least 14 days. Receipt of new devices was defined as acquisition of a new tracheostomy, feeding tube (including gastrostomy and jejunostomy tubes), implantable cardiac device, or ostomy. Logistic regression models were fit to identify patient factors associated with the acquisition of each new medical device. Among hospitalized survivors, 90-day posthospitalization discharge location and mortality were identified. From 2014 to 2019, there were 13,184 ICU hospitalizations in the VA which developed persistent critical illness. In total, 30.4% of patients (N = 3998/13,184) acquired at least 1 medical device during their persistent critical illness period. Patients with an initial higher severity of illness and prolonged hospital stay preICU admission had higher odds of acquiring each medical device. Among patients who survived their hospitalization, discharge location and mortality did not significantly differ among those who acquired a new medical device as compared to those who did not. Less than one-third of patients with persistent critical illness acquire a new medical device and no significant difference in short-term outcomes was identified. Future work is needed to understand if the acquisition of new medical devices is contributing to the development of persistent critical illness.

Catabolism in Critical Illness

OBJECTIVES

Ongoing risk of death and poor functional outcomes are important consequences of prolonged critical illness. Characterizing the catabolic phenotype of prolonged critical illness could illuminate biological processes and inform strategies to attenuate catabolism. We aimed to examine if urea-to-creatinine ratio, a catabolic signature of prolonged critical illness, was associated with mortality after the first week of ICU stay.

DESIGN

Reanalysis of multicenter randomized trial of glutamine supplementation in critical illness (REducing Deaths due to OXidative Stress [REDOXS]).

SETTING

Multiple adult ICUs.

PATIENTS

Adult patients admitted to ICU with two or more organ failures related to their acute illness and surviving to day 7.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The association between time-varying urea-to-creatinine ratio and 30-day mortality was tested using Bayesian joint models adjusted for prespecified-covariates (age, kidney replacement therapy, baseline Sequential Organ Failure Assessment, dietary protein [g/kg/d], kidney dysfunction, and glutamine-randomization). From 1,021 patients surviving to day 7, 166 (16.3%) died by day 30. After adjustment in a joint model, a higher time-varying urea-to-creatinine ratio was associated with increased mortality (hazard ratio [HR], 2.15; 95% credible interval, 1.66-2.82, for a two-fold greater urea-to-creatinine ratio). This association persisted throughout the 30-day follow-up. Mediation analysis was performed to explore urea-to-creatinine ratio as a mediator-variable for the increased risk of death reported in REDOXS when randomized to glutamine, an exogenous nitrogen load. Urea-to-creatinine ratio closest to day 7 was estimated to mediate the risk of death associated with randomization to glutamine supplementation (HR, 1.20; 95% CI, 1.04-1.38; p = 0.014), with no evidence of a direct effect of glutamine (HR, 0.90; 95% CI, 0.62-1.30; p = 0.566).

CONCLUSIONS

The catabolic phenotype measured by increased urea-to-creatinine ratio is associated with increased risk of death during prolonged ICU stay and signals the deleterious effects of glutamine administration in the REDOXS study. Urea-to-creatinine ratio is a promising catabolic signature and potential interventional target.

Validating Measures of Disease Severity in Acute Respiratory Distress Syndrome

Rationale: Quantifying acute respiratory disease syndrome (ARDS) severity is essential for prognostic enrichment to stratify patients for invasive or higher-risk treatments; however, the comparative performance of many ARDS severity measures is unknown.Objectives: To validate ARDS severity measures for their ability to predict hospital mortality and an ARDS-specific outcome (defined as death from pulmonary dysfunction or the need for extracorporeal membrane oxygenation [ECMO] therapy).Methods: We compared five individual ARDS severity measures including the ratio of arterial oxygen tension/pressure to fraction of inspired oxygen (Pa_O2/Fi_O2 ratio), oxygenation index, ventilatory ratio, lung compliance, and radiologic assessment of lung edema (RALE); two ARDS composite severity scores including the Murray Lung Injury Score, and a novel score combining RALE, Pa_O2/Fi_O2 ratio, and ventilatory ratio; and the Acute Physiology and Chronic Health Evaluation IV score, using data collected at ARDS onset in patients hospitalized at a single center in 2016 and 2017. Discrimination of hospital mortality and the ARDS-specific outcome was evaluated using the area under the receiver operator characteristic curve (AUROC). Measure calibration was also evaluated.Results: Among 340 patients with ARDS, 125 (37%) died during hospitalization and 36 (10.6%) had the ARDS-specific outcome, including one who received ECMO. Among the five individual ARDS severity measures, the RALE score had the highest discrimination of the ARDS-specific outcome (AUROC = 0.67; 95% confidence interval [CI], 0.58-0.77), although other ARDS severity measures had similar performance. However, their ability to discriminate overall mortality was low. In contrast, the Acute Physiology and Chronic Health Evaluation IV score best discriminated overall mortality (AUROC = 0.73; 95% CI, 0.67-0.79) but was unable to discriminate the ARDS-specific outcome (AUROC = 0.54; 95% CI, 0.44-0.65). Among ARDS composite severity scores, the lung injury score had an AUROC = 0.67 (95% CI, 0.58-0.75) for the ARDS-specific outcome whereas the novel score had an AUROC = 0.70 (95% CI, 0.61-0.79). Patients grouped by quartile of the novel score had a 6%, 2%, 10%, and 24% rate of the ARDS-specific outcome.Conclusions: Although most ARDS severity measures had poor discrimination of hospital mortality, they performed better at predicting death from severe pulmonary dysfunction or ECMO needs. A novel composite score had the highest discrimination of this outcome.

Erste Evaluation eines Programms zur Frührehabilitation von Langzeitintensivpatient_innen

First evaluation of an early rehabilitation programm for chronically critically ill patients Abstract. Introduction: Chronically critically ill patients are an increasing challenge for teams in intensive care units due to the burden of symptoms and the consumption of resources. Structured multimodal concepts are recommended for nursing care and treatment. A local, interprofessional program for early rehabilitation aims to provide optimal care for patients through a systematic, proactive and holistic treatment process with a rehabilitative focus. The program consists of specific assessments and systematic coordination of interprofessional early rehabilitation. Problem and objective: Interprofessional collaboration requires mutual acceptance and good communication from those involved. The functioning of selected processes as well as the satisfaction of the professionals are topics of a first formative evaluation. Methods: The team evaluated descriptive quality data as well as self-generated structured questionnaires. Results: Specific adjustments were made to the treatment plan for 52 of 112 patients in the program. The assessments are easy to carry out and support systematic early rehabilitation. From the perspective of the professionals involved, both the interprofessional collaboration and their understanding for the patients improved. Discussion and transfer: The program optimizes treatment and promotes good interprofessional collaboration. The formative evaluation provides valuable information for future process changes such as the inclusion of patients as well as further disciplines and program development beyond the boundaries of the intensive care unit.

Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country

Background

An increasing number of patients become chronic critically ill (CCI) and dependent on long-term therapies in the intensive care unit (ICU). Mortality and healthcare costs increase in these patients. In order to deal with this problem, the magnitude and risk factors for CCI must first be determined. Therefore, we aimed at evaluating the incidence cost and risk factors for CCI in our ICU.

Materials and methods

This retrospective cohort study was compiled by recruiting patients admitted to our ICU between January 1, 2017, and December 31, 2018. Patients with an ICU stay of more than 21 days were defined as CCI. Patients who did not survive in the first 21 days were excluded from the study because it could be not known whether these patients would progress to CCI. During the study period, 1,166 patients were followed up, and 475 (40%) of them were excluded and 691 patients were included in the final analyses.

Results

During the study period, 691 patients were included in the study and 152 of them (22%) were CCI. Age, acute physiology and chronic health evaluation (APACHE)-2 score, length of stay, and daily costs were higher in patients with CCI. The cost for a patient with CCI is sixfold that of a patient without CCI. ICU mortality was 47% in patients without CCI and 54% in the CCI patients (p < 0.001).

Conclusion

CCI affects an increasing number of patients and leads to increased mortality rates and cost. Prolonged duration in ICU may cause complications such as secondary infections, sepsis episodes, and acute renal injury. The treatment of these complications may lead to increased mortality and cost.

How to cite this article

Yildirim S, Durmaz Y, Şan Y, Taşkiran İ, Cinleti BA, Kirakli C. Cost of Chronic Critically Ill Patients to the Healthcare System: A Single-center Experience from a Developing Country. Indian J Crit Care Med 2021;25(5):519–523.

Late Vasopressor Administration in Patients in the ICU: A Retrospective Cohort Study

BACKGROUND

Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU.

RESEARCH QUESTION

What is the epidemiology of late vasopressor administration in the ICU?

STUDY DESIGN AND METHODS

We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for ≥ 4 days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3 days), late (on day 4 or later and none on day 3), and continuous (within the initial 2 days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality.

RESULTS

Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95% CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95% CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50% of patients started a new antibiotic within 24 h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95% CI, 1.15-1.38) compared with only early vasopressor administration.

INTERPRETATION

Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality.

Effective Care Practices in Patients Receiving Prolonged Mechanical Ventilation. An Ethnographic Study

Rationale: Patients receiving prolonged mechanical ventilation experience low survival rates and incur high healthcare costs. However, little is known about how to optimally organize and manage their care.Objectives: To identify a set of effective care practices for patients receiving prolonged mechanical ventilation.Methods: We performed a focused ethnographic evaluation at eight long-term acute care hospitals in the United States ranking in either the lowest or highest quartile of risk-adjusted mortality in at least four of the five years between 2007 and 2011.Measurements and Main Results: We conducted 329 hours of direct observation, 196 interviews, and 39 episodes of job shadowing. Data were analyzed using thematic content analysis and a positive-negative deviance approach. We found that high- and low-performing hospitals differed substantially in their approach to care. High-performing hospitals actively promoted interdisciplinary communication and coordination using a range of organizational practices, including factors related to leadership (e.g., leaders who communicate a culture of quality improvement), staffing (e.g., lower nurse-to-patient ratios and ready availability of psychologists and spiritual care providers), care protocols (e.g., specific yet flexible respiratory therapy-driven weaning protocols), team meetings (e.g., interdisciplinary meetings that include direct care providers), and the physical plant (e.g., large workstations that allow groups to interact). These practices were believed to facilitate care that is simultaneously goal directed and responsive to individual patient needs, leading to more successful liberation from mechanical ventilation and improved survival.Conclusions: High-performing long-term acute care hospitals employ several organizational practices that may be helpful in improving care for patients receiving prolonged mechanical ventilation.

Hospital-level variation in the development of persistent critical illness

PURPOSE

Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness.

METHODS

This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness.

RESULTS

In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049-0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051-0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041-0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33-1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness.

CONCLUSION

Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness.

Timing of Onset, Burden, and Postdischarge Mortality of Persistent Critical Illness in Scotland, 2005-2014: A Retrospective, Population-Based, Observational Study

We aimed to understand the prevalence, timing of onset, resource use, and long-term outcomes of patients who developed persistent critical illness in a national dataset.

Design

Retrospective cohort. Using a physiologic risk adjustment model from ICU admission, we examined the relative ability of acute (related to reason for ICU presentation) and antecedent (demographics, comorbidities) characteristics to discriminate hospital mortality models. Persistent critical illness was defined as the point during an ICU stay when, at the population-level, patients' acute diagnoses and physiologic disturbance are no longer more accurate at discriminating who survives than are baseline demographics and comorbidity. We examined the change across ICU stay in the relative discrimination of those characteristics, and short-term (in-hospital and 30 d after admission) and medium-term (90 d after admission) survival. Finally, we analyzed the changes in the population definition of persistent critical illness over time.

Setting

Patients admitted as level 3 to Scottish ICUs between 2005 and 2014.

Patients

Seventy-two-thousand two-hundred fifty-three adult level 3 ICU admissions in 23 ICUs across Scotland.

Interventions

None.

Measurements and Main Results

The onset of persistent critical illness, occurs at an average of 5.0 days (95% CI, 3.9-6.4 d) across this dataset. The crossing point increased across the decade, by an average of 0.36 days (95% CI, 0.22-0.50 d) per year. In this dataset, 24,425 (33.8%) remained in the ICU long enough to meet this greater than 5-day definition of persistent critical illness. The care of such patients involved 72.3% ICU days used by any level 3 patient; 46.5% of all Scottish ICU bed-days were after day 5. Although rates of 30 days after admission survival rose dramatically during the decade under study, these rates were similar for those with shorter or longer ICU stays, as were the rates of 90-day survival among those who survived at least 30 days.

Conclusions

Persistent critical illness occurred in one in three ICU patients in Scotland. These minority of patients accounted for disproportionate hospital resources but did not have worse 30- or 90-day postadmission survival.