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

Characteristics and Outcomes of Patients Requiring Repeat Intensive Care Unit Consults

Objective

To better understand the mortality and notable characteristics of patients initially denied intensive care unit (ICU) admission that are later admitted on reconsultation.

Patients and Methods

We collected data regarding all adult inpatients (n=3725) who received one or more ICU consults at an academic tertiary care hospital medical center between January 1, 2018 and October 1, 2021. We compared patients who were initially denied ICU admission and later admitted on reconsultation (C2A1, n=144) with those who were admitted after the first consultation (C1A1, n=2286) and those denied at first consult and never later admitted (C1A0, n=1295).

Results

Ten percent of patients initially rejected by the ICU were later admitted on reconsultation. There was no significant difference in the adjusted hospital death odds ratios between C1A1 and C2A1 (0.67; 95% CI 0.43-1.01; P=.11). Assessing subgroups of the C2A1 population, we found that 8.2% (n=100) of full code patients were later admitted to the ICU on reconsultation vs 23.2% (n=40) of do not attempt resuscitation patients (P<.001); 7.6% (n=77) of patients initially consulted from the emergency department were later admitted to the ICU on reconsultation vs 15.1% (n=52) of patients initially consulted from an inpatient setting (P<.001).

Conclusion

In this cohort, we demonstrated that patients admitted on repeat ICU consultation have no significant difference in mortality compared with equivalent patients admitted after the first consultation. Understanding and further exploring the consequences of these ICU reconsultations is vital to developing optimal critical care triaging practices.

Triage of Critically Ill Patients: Characteristics and Outcomes of Patients Refused as Too Well for Intensive Care

BACKGROUND

The appropriate selection of patients for the intensive care unit (ICU) is a concern in acute care settings. However, the description of patients deemed too well for the ICU has been rarely reported.

METHODS

We conducted a single-centre retrospective observational study of all patients either deemed "too well" for or admitted to the ICU during one year. Refused patients were screened for unexpected events within 7 days, defined as either ICU admission without another indication, or death without treatment limitations. Patients' characteristics and organisational factors were analysed according to refusal status, outcome and delay in ICU admission.

RESULTS

Among 2219 enrolled patients, the refusal rate was 10.4%. Refusal was associated with diagnostic groups, treatment limitations, patients' location on a ward, night time and ICU occupancy. Unexpected events occurred in 16 (6.9%) refused patients. A worse outcome was associated with time spent in hospital before refusal, patients' location on a ward, SOFA score and physician's expertise. Delayed ICU admissions were associated with ICU and hospital length of stay.

CONCLUSIONS

ICU triage selected safely most patients who would have probably not benefited from the ICU. We identified individual and organisational factors associated with ICU refusal, subsequent ICU admission or death.

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

Background

In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector.

Purpose

The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care.

Recommendations

In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years.

Conclusion

In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

Mechanical ventilation patterns and trends over 20 years in an Israeli hospital system: policy ramifications

Background

Mechanical ventilation is a life supporting modality increasingly utilized when caring for severely ill patients. Its increasing use has extended the survival of the critically ill leading to increasing healthcare expenditures. We examined changes in the hospital-wide use of mechanical ventilation over 20 years (1997–2016) in two Israeli hospitals to determine whether there were specific patterns (e.g. seasonality, weekday vs. weekend) and trends (e.g. increases or decreases) among various hospital departments and units.

Methods

Retrospective analysis of prospectively collected data on all mechanically ventilated patients over 20-years in a two-hospital Israeli medical system was performed. Data were collected for each hospital unit caring for ventilated patients. Time-series analysis examined short and long-term trends, seasonality and intra-week variation.

Results

Over two decades overall ventilator-days increased from 11,164 (31 patients/day) in 1997 to 24,317 (67 patients/day) in 2016 mainly due to more patients ventilated on internal medicine wards (1997: 4 patients/day; 2016: 24 patients/day). The increases in other hospital areas did not approach the magnitude of the internal medicine wards increases. Ventilation on wards reflected the insufficient number of ICU beds in Israel. A detailed snapshot over 4 months of patients ventilated on internal medicine wards (n = 745) showed that they tended to be elderly (median age 75 years) and that 24% were ventilated for more than a week. Hospital-wide ventilation patterns were the weighted sum of the various individual patient units with the most noticeable pattern being peak winter prevalence on the internal medical wards and in the emergency department. This seasonality is not surprising, given the greater incidence of respiratory ailments in winter.

Conclusions

Increased mechanical ventilation plus seasonality have budgetary, operational and staffing consequences for individual hospitals and the entire healthcare system. The Israeli healthcare leadership needs to plan and support expanding, equipping and staffing acute and chronic care units that are staffed by providers trained to care for such complex patients.

Electronic supplementary material

The online version of this article (10.1186/s13584-019-0291-y) contains supplementary material, which is available to authorized users.