Mortality and functional status at one-year of follow-up in elderly patients with prolonged ICU stay

Use of resources in elderly patients consulting the emergency department: analysis of the Emergency Department and Elder Needs Cohort (EDEN-21)

The elderly population frequently consults the emergency department (ED). This population could have greater use of EDs and hospital health resources. The EDEN cohort of patients aged 65 years or older visiting the ED allowed this association to be investigated. To analyse the association between healthcare resource use and the characteristics of patients over 65 years of age who consult hospital EDs. We performed an analysis of the EDEN cohort, a retrospective, analytical, and multipurpose registry that includes patients over 65 years of age who consulted in 52 Spanish EDs. The impact of age, sex, and characteristics of ageing on the following outcomes was studied: need for hospital admission (primary outcome) and need for observation, stay in the ED > 12 h, prolonged hospital stay > 7 days, need for intensive care unit (ICU) and return to the ED at 30 days related to the index visit (secondary outcomes). The association was analysed by calculating the adjusted odds ratios (aOR) and their 95% confidence intervals (CI), using a logistic regression model. A total of 25,557 patients with a mean age of 78.3 years were analysed, 45% were males. Of note was the presence of comorbidity, a Charlson index ≥ 3 (33%), and polypharmacy (66%). Observation in the ED was required by 26%, 25.4% were admitted to the hospital, and 0.9% were admitted to the ICU. The ED stay was > 12 h in 12.5% and hospital stay > 7 days in 13.5% of cases. There was a progressive increase in healthcare resource use based on age, with an aOR for the need for observation of 2.189 (95% CI 2.038-2.352), ED stay > 12 h 2.136 (95% CI 1.942-2.349) and hospital admission 2.579 (95% CI 2.399-2.772) in the group ≥ 85 years old. Most of the characteristics inherent to ageing (cognitive impairment, falls in the previous 6 months, polypharmacy, functional dependence, and comorbidity) were associated with significant increases in the use of healthcare resources, except for ICU admission, which was less in all the variables studied. Age and the characteristics inherent to ageing are associated with greater use of structural healthcare resources.

Critically ill patients with high predicted mortality: Incidence and outcome

OBJECTIVE

As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown.

DESIGN

Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA).

SETTING

Sixteen Portuguese multipurpose ICUs.

PATIENTS

Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mortality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Hospital, 30 days, 1 year mortality.

RESULTS

We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0±5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34-3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04-1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, P=.92). At one year of follow-up, 30% of patients in the high-risk group were alive.

CONCLUSIONS

Roughly 12% of patients admitted to the ICU for more than 24h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up.

The trajectory of very old critically ill patients

The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.

A scoping review of older patients' health-related quality of life, recovery and well-being after intensive care

AIMS

In the present study, we aimed to determine how Health-Related Quality of Life (HRQoL), recovery (function and capacity in daily life) and well-being are followed up and characterised in persons ≥65 years of age who were being cared for in an intensive care unit (ICU).

DESIGN

A scoping review.

METHODS

CINAHL, MEDLINE (Ovid) and PsycINFO databases were searched in October 2021. 20 studies met the inclusion criteria. The scoping review followed the principles outlined by Arksey and O'Malley, and the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) checklist and Joanna Briggs Institute (JBI) framework were used.

RESULTS

Results are presented under five subheadings: Study characteristics, Type of studies, Methods for follow-up, health-related quality of life, and Recovery. Time seems to be an important factor regarding HRQoL among older patients being cared for in an ICU, with most elderly survivors perceiving their HRQoL as acceptable after 1 year. Nevertheless, several studies showed patients' willingness to be readmitted to the ICU if necessary, indicating that life is worth fighting for.

PATIENT OR PUBLIC CONTRIBUTION

Due to the design of the study, this study involves no patient or public contribution.

Invasive Candidiasis in Patients with Solid Tumors: A Single-Center Retrospective Study

Background

Invasive candidiasis (ICs) is one of the common causes of death in patients with solid tumors. However, studies on the clinical characteristics of ICs with solid tumors are limited.

Methods

The purpose of this study was to retrospectively analyse the clinical characteristics, laboratory results and risk factor prediction of inpatients with ICs and solid tumors. We reviewed the clinical data and candida specimen information of hospitalized patients diagnosed with solid tumors combined with ICs at the First Hospital of China Medical University from January 2016 to December 2020. Multivariate logistic regression analysis was used to assess the prognostic factors associated with mortality in these patients.

Results

A total of 243 ICs patients with solid tumors were included in this study. The average ± SD age was 62.8 ± 11.7 (range: 27-93 years old), of which nearly 41% were ≥ 65 years old (99/243, 40.7%), and most were male (162/243, 66.6%). Most patients had malignant tumors of the digestive system. The most common candida was Candida parapsilosis (101/243, 41.5%), followed by Candida guilliermondii (83/243, 34.1%), Candida albicans (32/243, 13.1%), Candida glabrata (17/243, 6.9%), Candida tropicalis (7/243, 2.8%) and Candida krusei (3/243, 1.2%). Multivariate logistic regression analysis showed that the length of stay in the ICU, urinary catheter, total parenteral nutrition, stay in the ICU, renal failure and neutrophil count were prognostic factors related to death.

Conclusion

In this study, based on the clinical data of solid tumor patients with ICs in the past 5 years, the results showed that the length of stay in the ICU, urinary catheter, total parenteral nutrition, stay in the ICU, renal failure and neutrophil count were identified as the main prognostic factors. This study can be used to help clinicians carry out early intervention for high-risk patients.

[Functional evolution and mood of patients after admission for COVID-19 to intensive care unit]

OBJECTIVE

Describe the functional situation of patients one and two months after admission for COVID-19 pneumonia in an intensive care unit (ICU) and affect their mood one month after hospital discharge.

DESIGN

Prospective cohort study was carried out.

PATIENTS

Patients admitted to the ICU for COVID-19 pneumonia during the months of February to July 2020.

PRIMARY VARIABLES OF INTEREST

Demographic data, mortality, ICU stay and hospital stay, destination at discharge, functional status at baseline (Barthel Index), after discharge, at one month and two months, physiotherapy treatment and impact on mood (Hospital Anxiety and Depression Scale).

RESULTS

89 patients were admitted in ICU with a mortality rate of 48.3% in the ICU. Among the survivors, 42 patients completed the follow-up at two months. Functional deterioration was observed at ICU discharge in 97.6% and at hospital discharge in 76.2%. At follow-up, 66.7% of patients had recovered their baseline functional level one month after leaving the hospital and 85.7% had done so after two months. One month after discharge, 12% of the patients had results compatible with anxiety and 20% had results compatible with depression.

CONCLUSIONS

Patients admitted to the ICU for COVID-19 pneumonia have high hospital mortality, and those who survive show severe functional deterioration after admission. Two months after hospital discharge, most survivors recover their baseline functional status and mood prior to admission.

Machine-learning based prediction of prognostic risk factors in patients with invasive candidiasis infection and bacterial bloodstream infection: a singled centered retrospective study

Background

Invasive candidal infection combined with bacterial bloodstream infection is one of the common nosocomial infections that is also the main cause of morbidity and mortality. The incidence of invasive Candidal infection with bacterial bloodstream infection is increasing year by year worldwide, but data on China is still limited.

Methods

We included 246 hospitalised patients who had invasive candidal infection combined with a bacterial bloodstream infection from January 2013 to January 2018; we collected and analysed the relevant epidemiological information and used machine learning methods to find prognostic factors related to death (training set and test set were randomly allocated at a ratio of 7:3).

Results

Of the 246 patients with invasive candidal infection complicated with a bacterial bloodstream infection, the median age was 63 years (53.25–74), of which 159 (64.6%) were male, 109 (44.3%) were elderly patients (> 65 years), 238 (96.7%) were hospitalised for more than 10 days, 168 (68.3%) were admitted to ICU during hospitalisation, and most patients had records of multiple admissions within 2 years (167/246, 67.9%). The most common blood index was hypoproteinemia (169/246, 68.7%), and the most common inducement was urinary catheter use (210/246, 85.4%). Moreover, the most frequently infected fungi and bacteria were Candida parapsilosis and Acinetobacter baumannii, respectively. The main predictors of death prognosis by machine learning method are serum creatinine level, age, length of stay, stay in ICU during hospitalisation, serum albumin level, C-Reactive protein (CRP), leukocyte count, neutrophil count, Procalcitonin (PCT), and total bilirubin level.

Conclusion

Our results showed that the most common candida and bacteria infections were caused by Candida parapsilosis and Acinetobacter baumannii, respectively. The main predictors of death prognosis are serum creatinine level, age, length of stay, stay in ICU during hospitalisation, serum albumin level, CRP, leukocyte count, neutrophil count, PCT and total bilirubin level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07125-8.

Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia

Background

Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality.

Objective

To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission.

Methods

A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics.

Results

During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14–20, 21–27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14–20, 21–27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214–1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model.

Conclusions

Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.

Spanish version of the Perme Intensive Care Unit Mobility Score: Minimal detectable change and responsiveness

PURPOSE

The purpose of this study was to determine the minimal detectable change (MDC) and responsiveness of the Perme Score when used in the adult intensive care unit (ICU) population.

METHODS

This is a prospective longitudinal study which was conducted from November 2016 to July 2017 in Cali, Colombia. Four physical therapists with observer and evaluator roles, applied the Perme Score upon ICU admission and discharge. The Consensus-based Standards for the Selection of Health Measurement Instruments Protocol standards to analyze sensitivity to change were used. The sample size was defined considering the lowest concordance proportion reported (68.6%), and a Kappa Index of 0.2784 or higher to guarantee an adequate n, and a 95% reliability level.

RESULTS

One hundred and forty-two patients were enrolled in the study. There were 51.4% men with an average age of 58 ± 17 years. Invasive mechanical ventilation was employed in 42.0% of the patients. The MDC for the Perme Score was 1.36, and 80% of patients demonstrated higher or equal values, detecting a significant difference in the type of weaning and the length of stay in the ICU (p < 0.005).

CONCLUSIONS

The Perme Score has an MDC of 1.36 points and shows evidence of being sensitive to change. Therefore, the findings validate the responsiveness of the instrument.

Activities of daily living status and psychiatric symptoms after discharge from an intensive care unit: a single-center 12-month longitudinal prospective study

AIM

In post-intensive care syndrome (PICS), long-term survivors of critical illness present various physical and mental symptoms that can persist for years after discharge. Post-intensive care syndrome in Japan has not been well described, so this study aims to elucidate its epidemiology.

METHODS

We undertook a single-center prospective longitudinal cohort study in a mixed intensive care unit (ICU) in a Japanese tertiary hospital. Adult patients emergently admitted to the ICU were eligible for inclusion in the study. To assess activity of daily living (ADL) status and psychiatric symptoms, we posted a questionnaire at 3 and 12 months after discharge from the ICU. We evaluated ADL status, anxiety, depression, and post-traumatic stress disorder symptoms using the Barthel index, Hospital Anxiety and Depression Scale, and Impact of Event Scale - Revised, respectively.

RESULTS

Enrolled in this study were 204 patients. We received responses from 117/147 (80%) and 74/98 (76%) patients at 3 and 12 months, respectively. At 3 months, the prevalence of ADL disability, anxiety, depression, and post-traumatic stress disorder symptoms was 32%, 42%, 48%, and 20%, respectively. At 12 months, the prevalence was 22%, 33%, 39%, and 21%, respectively. The prevalence of any symptoms was 66% at 3 months and 55% at 12 months. Barthel index score at 12 months was improved significantly from that at 3 months. Hospital Anxiety and Depression Scale and Impact of Event Scale - Revised scores at 12 months showed no improvement.

CONCLUSIONS

At 3 and 12 months after ICU discharge, over half of our Japanese patients suffered ADL disability and/or psychiatric symptoms. The ADL disability improved at 1 year, but psychiatric symptoms did not.

[Functional status as an independent risk factor in elderly patients admitted to an Intensive Care Unit]

OBJECTIVE

To assess the association of previous functional status in elderly patients admitted to the ICU, estimated by the Barthel and Short Form-Late Life Function and Disability instrument scales, and the relationship with prognosis and functional capacity at hospital discharge.

MATERIAL AND METHODS

Observational prospective study of ICU-admitted patients older than 74 years, with a length of stay greater than 48hours. Demographic data, social background, comorbidities, disability questionnaire (Barthel, Short Form-Late Life Function and Disability instrument), main diagnosis and severity (SAPS 3) on ICU admission were recorded. Factors associated with mortality or poor functional status at hospital discharge (Barthel Index less than 35) were established by multivariate analysis.

RESULTS

During the study period, 219 elderly patients were admitted in ICU, of whom 129 (15%) had an ICU length of stay greater than 48hours. The median age was 80 years (77-83), with 52% women. Main diagnoses on admission included ischaemic heart disease (19%), another medical diagnosis (38%), and surgical procedure (43%). A Barthel score <36 (median 95, 85-100) was observed in 3% of the patients on admission. The median ICU length of stay was 5 days (4-8). ICU mortality was 6% (hospital mortality: 10%). On hospital discharge, 7% had severe dependence (Barthel <36). In this population, factors independently associated with mortality or poor functional status at hospital discharge were the pre-admission functional status, based on Short Form-Late Life Function and Disability instrument (OR 0.95, 95% CI, 0.91 to 0.98), and the severity on admission assessed by SAPS 3 (OR 1.10, 95% CI, 1.02 to 1.18), p=.0007.

CONCLUSIONS

In elderly patients requiring ICU admission, a higher SAPS 3 score and functional impairment on admission were associated with mortality or severe dependence upon discharge.

Critical care at the end of life: a population-level cohort study of cost and outcomes

BACKGROUND

Despite the high cost associated with ICU use at the end of life, very little is known at a population level about the characteristics of users and their end of life experience. In this study, our goal was to characterize decedents who received intensive care near the end of life and examine their overall health care use prior to death.

METHODS

This was a retrospective cohort study that examined all deaths in a 3-year period from April 2010 to March 2013 in Ontario, Canada. Using population-based health administrative databases, we examined healthcare use and cost in the last year of life.

RESULTS

There were 264,754 individuals included in the study, of whom 18% used the ICU in the last 90 days of life; 34.5% of these ICU users were older than 80 years of age and 53.0% had more than five chronic conditions. The average cost of stay for these decedents was CA$15,511 to CA$25,526 greater than for those who were not admitted to the ICU. These individuals also died more frequently in hospital (88.7% vs 36.2%), and spent more time in acute-care settings (18.7 days vs. 10.5 days).

CONCLUSIONS

We showed at a population level that a significant proportion of those with ICU use close to death are older, multi-morbid individuals who incur significantly greater costs and die largely in hospital, with higher rates of readmission, longer lengths of stay and higher rates of aggressive care.

Limitation of life-sustaining treatment in severe trauma in the elderly after admission to an intensive care unit

OBJECTIVE

To analyze the factors associated to limitation of life-sustaining treatment (LLST) measures in elderly patients admitted to an intensive care unit (ICU) due to trauma.

DESIGN

A retrospective, descriptive, observational study was carried out.

SETTING

ICU.

PATIENTS

A total of 149 patients aged 65 years or older admitted to the ICU due to trauma. Hospital mortality, the decision to limit life-sustaining treatment and the factors associated to these measures were analyzed.

INTERVENTIONS

None.

RESULTS

The mean patient age was 76.3±6.36 years. The average APACHE II and ISS scores were 15.9±7.4 and 19.6±11.4 points, respectively. LLST were used in 37 patients (24.8%). Factors associated to the use of these measures were patient age (OR 1.16; 95% CI 1.08 to 1.25], APACHE II score (OR 1.11; 95% CI 1.05-1.67), ISS score (OR 1.03; 95% CI 1.01 to 1.06), admission due to neurological impairment (OR 19.17; 95% CI 2.33 to 157.83) and traumatic brain injury (OR 2.89; 95% CI 1.05 to 7.96).

CONCLUSIONS

LLST is frequently established in elderly patients admitted to the ICU due to trauma, and is associated to hospital mortality. Factors associated with the use of these measures are patient age, higher APACHE II and ISS scores, admission due to neurological impairment, and the presence of head injuries.