[Characteristics and prognosis of patients with very long stay in an Intensive Care Unit]

[Analysis of the factors involved in the evolution of patients over 80 years of age admitted to the intensive care unit: Should we change our procedure?]

BACKGROUND AND OBJECTIVES

The care of older patients in intensive care units (ICU) is becoming more frequent. To describe characteristics of elderly patients admitted to the ICU and to analyze the factors associated with mortality.

PATIENTS AND METHODS

Retrospective cross-sectional study, with patients ≥80 years, admitted to the ICU of the Rey Juan Carlos University Hospital, from March 2012 to December 2018. Demographic variables, comorbidities and mortality in the ICU, in hospital and at one year were collected, analyzed by univariate analysis and binary logistic regression.

RESULTS

Six hundred twenty patients, mean age 83.6 years (SD: 3.25), 31% required invasive mechanical ventilation (IMV), 25% vasopressors and 29% renal replacement therapy (RRT) due to acute renal failure (ARF). The 60% were admissions of medical origin. In-hospital mortality was 156 patients (25%), 91 died in the ICU and 65 on the ward, with shorter ICU stays for the survivors (2.72; SD: 0.22) compared to the deceased (3.74; SD: 0.38), with statistically significant differences. 63% remained alive one year after ICU discharge. An explanatory model of ICU mortality was obtained by logistic regression that included the following factors: IMV (OR: 5.78, 95% CI 2.73-12.22), vasopressors (OR: 2.54, 95% CI 1.24-5.19), AKI/TRS (OR: 2.69, 95% CI 1.35-5.35), medical admission (OR: 2.88, 95% CI 1.40-5.92), urgent admission (OR: 2.33, 95% CI 1.30-4.18) and limitation of life support (LTSV) (OR: 47.35, 95% CI 22.96-97.68). The days in the ICU (OR: 0.93, 95% CI 0.87-0.99) would be inversely related to mortality.

CONCLUSIONS

In older patients, there is no increase in mortality, with a 1-year survival >63%. The need for IMV, the use of vasopressor drugs and ARF/RTS were factors associated with mortality in the multivariate analysis.

Training needs detected by nurses in an intensive care unit: a phenomenological study

INTRODUCTION

The competences of intensive care (ICU) nurses in their healthcare environment, have increased with the acquisition of new responsibilities associated with new care and devices for critical patients. Many studies suggest the need for specific training of nurses that work in these units. Based on this evidence, the European Federation of Critical Care Nurses Associations, recommends unifying the training of intensive care nurses. Therefore we set ourselves the following objective: to assess the training needs detected by ICU nurses through their experience and practical knowledge.

METHOD

Descriptive qualitative study, with a phenomenological approach, through semi-structured interview where the four areas (clinical practice, professional, management and educational) covered by the European Federation of Critical Care Nurses Associations were studied. Fifteen nurses from an adult polyvalent ICU were interviewed.

RESULTS

The interviewees acknowledged that the previous training was deficient for the care and support measures that they had to face. They considered that subsequent training and experience were decisive in order to carry out their work effectively. They also stated that support measures and care are topics to be developed continuously through targeted training.

CONCLUSION

The nurses in this research study acknowledged that training is needed to achieve the competences required in ICU, and these are affected by the type of unit and patients.

Characteristics and mortality of elderly patients admitted to the Intensive Care Unit of a district hospital

AIM

To study all the elderly patients (≥75 years) who were admitted in an Intensive Care Unit (ICU) of a Spanish hospital and identify factors associated with mortality.

PATIENTS AND METHODS

A retrospective, observational data collected prospectively in patients ≥75 years recruited from the ICU in the period of January 2004 to December 2010.

RESULTS

During the study period, 1661 patients were admitted to our unit, of whom 553 (33.3%) were older than 75 years. The mean age was 79.9 years, 317 (57.3%) were male, and the overall in-hospital mortality was 94 patients (17% confidence interval 14-20.3%). When comparing patients who survived to those who died, we found significant differences in mean age (P = 0.001), Acute Physiologic Assessment and Chronic Health Evaluation II and Simplified Acute Physiology Scoring II (SAPS II) on admission (P < 0.0001, postoperative patients (P = 0.001), and need for mechanical ventilation (P < 0.0001). Comparing age groups, we found statistically significant differences in SAPS II (P = 0.007), diagnosis of non-ST-segment elevation myocardial infarction (P = 0.014), complicated postoperative period (P = 0.001), and pacemaker (P = 0.034). Mortality between the groups was statistically significant (P = 0.004). The survival between the group of 65 and 74 years and patients >75 years was not significant (P = 0.1390).

CONCLUSIONS

The percentage of elderly patients in our unit is high, with low mortality rates. The age itself is not the sole determinant for admission to the ICU and other factors should be taken into account.

Long-term admission to the intensive care unit: a cost-benefit analysis

OBJECTIVE

To assess outcomes in long-term ICU patients, with follow-ups carried out at one year post discharge, in order to calculate the costs incurred by the hospital in relation to the benefits gained.

MATERIAL

Of 3639 patients consecutively admitted over the course of three years to ICU, 235 (6.5%) were assessed for the purposes of the study, having spent a period exceeding 20 days in intensive care.

METHOD

The survey tool used was the Spanish Minimum Data Set (MDS). The length of ICU stay and hospital stay following discharge from ICU were calculated, and one year post discharge the patient/next of kin was contacted in order to carry out a follow-up survey on survival and functional status (according to GOS-E scale).

RESULTS

The 235 study patients had a mean stay of 37 days, occupied 34% of ICU beds available and consumed 29% of the ICU's economic resources ($14,400,175). Their stay on hospital wards was (mean) 33 days. Mortality in ICU and on hospital wards was 40% higher amongst older patients, and those with a higher APACHE II and Charlson index score. Mortality rates were three times higher among neurosurgical patients: mortality at follow-up was 25%, and only 21% recovered an acceptable functional status.

CONCLUSIONS

Mortality rates in long-term ICU patients are high, both during their hospital stay and in the first year post discharge. Surviving patients do not exhibit a good level of recovery, and consume a large proportion of economic resources.

[Analysis of factors conditioning admission at the critical care unit of surgical patients. Prospective study of 764 patients operated for 1 year at a university and reference hospital]

OBJECTIVE

Assess what factors determine the income of surgical patients in critical care unit after surgery.

MATERIAL AND METHODS

It included a survey of the 10% of all patients operated by the services of General Surgery, Thoracic Surgery, Maxillofacial Surgery, Vascular Surgery, Urology and Otolaryngology during 2012. We performed a prospective, observational study. Pre-, intra-, and post-operative variables were analyzed. Comparisons were made between patients operated under elective and emergency surgery, and between patients admitted in critical care and admitted directly in the ward, using χ(2) of Pearson correlation with a confidence interval of 95%.

RESULTS

Seven hundred and sixty-four patients were included into the study, 304 were admitted in critical care after surgery and 460 were admitted in the ward. The medical history showed a statistically significant association with intensive care unit admission, well as the fact of being labeled with a high risk for the risk scales. Complexity and duration of the surgery showed a statistically significant association with intensive care unit admission, as well as the fact of present intra-operative complications. Emergency surgery was not significantly associated with intensive care unit admission of surgical patients, although these patients had significantly higher numbers of intra- and post-operative complications, and more exitus than those undergoing elective surgery.

CONCLUSIONS

A greater incidence of intensive care unit admission of patients undergoing emergency surgery should significantly reduce morbimortality rate. The existence of specific protocols for intensive care unit admission for urgent surgery, and greater availability of beds could be useful in this regard.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU

OBJECTIVE

To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).

DESIGN AND SCOPE

Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain.

PATIENTS

Adult patients who required mechanical ventilation (MV) for longer than 24 hours.

INTERVENTIONS

None.

STUDY VARIABLES

Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality.

RESULTS

A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV.

CONCLUSION

Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

[The end of life in the intensive care unit from the nursing perspective: a phenomenological study]

INTRODUCTION

Intensive Care Units do not adapt to the social and health reality regarding the phenomenon of death and this results in a high degree of dissatisfaction among professional, relatives and patients. The special characteristics of these units give the nursing staff a main roll as carers of critical dying patients. The principal aim of this study is to know the nursing staffs' experiences and attitudes towards the phenomenon of death in the intensive care units.

PARTICIPANTS AND METHOD

A descriptive qualitative study of phenomenological character was performed. Constant comparison and progressive incorporation of participants was made, using intentional sampling up to data saturation (n=16). The data collection technique used was a semi-structured in-depth interview, which were recorded and literally transcribed. The data collected was verified by the informants and analyzed according to the steps proposed by Taylor-Bogdan.

RESULTS

The analysis shows 5 thematic categories: death and beliefs, emotional work, environmental factors, decision-making management of death in intensive care units and relationships with relatives.

CONCLUSIONS

The management model of death in intensive care units focuses on medical intervention and overlooks the opinions of the nurses, relatives and patients. This study shows the contributions that can be provided by the nursing staff in decision making and in the care of the dying patients in these wards.

[Seasonal influence in characteristics of patients admitted to an intensive care unit]

OBJECTIVE

To investigate seasonal variability in the epidemiology and the outcome of critical illness.

DESIGN

Retrospective analysis of prospectively collected data during the period 2001-2008.

SETTING

Polyvalent intensive care unit (ICU) of a tertiary hospital in the Canary Islands.

PATIENTS

Adult patients who were hospitalized in the ICU from the Emergency Department, according to the season period (spring, summer, autumn and winter).

PRIMARY VARIABLES OF INTEREST

Demographic data, clinical diagnosis on ICU admission, APACHE II, need of mechanical ventilation and, finally, the mortality were collected.

RESULTS

During the study period, 3,115 patients, coming from the Emergency Department, were hospitalized in our ICU. Of these, 21% were admitted during the summer, an incidence rate that is statistically lower than in other seasons of the year (P<0.001). We did not find any statistically significant differences between the four groups according to the age, type of patients, severity at the moment of admission to the ICU, according to the APACHE II score or in the mortality rate in the ICU. However, significant differences were found in regards to gender. Admission of women during the summer was higher than in winter (33% vs 27%, P=0.037). Average stay in the ICU of patients admitted in the summer was similar to winter (4.9 days vs 5.8 days; P=0.052). Need for mechanical ventilation and days it was required, by diagnostic groups, were similar between the summer and the winter. The multivariate analysis did not show independent variables associated with the seasonal period in which the patients were admitted.

CONCLUSIONS

The stability of our climate implies that this factor does not influence the prognosis of patients who are admitted with critical illness.

[Outcome of the critical patient according to the sex and the age]

OBJECTIVE

To determine if gender and age are associated with differences in mortality in patients requiring critical care.

DESIGN

Retrospective analysis of prospectively collected data over 6 consecutive years.

SETTING

Polyvalent intensive care unit (ICU) of a tertiary hospital in the Canary Islands.

PATIENTS

Adult patients who were hospitalized in the ICU, divided on the basis of gender and age (<or>or=65 years).

PRIMARY VARIABLES OF INTEREST

Demographic and clinical diagnosis data on ICU admission, APACHE II, days of mechanical ventilation, days of renal replacement therapy (RRT) and the mortality were collected.

RESULTS

During the study period, 3786 patients were admitted to the ICU, 66.7% male and 2469 (65.2%)<65 years. Mortality in the ICU of the coronary group was greater in women (11.1% vs 6.7%; p=0.02), even though there were no significant differences between both genders in the APACHE II (p=0.56). No statistically significant differences were found according to gender in age (<or>or=65 years), in the APACHE II, or in the need for mechanical ventilation or renal replacement therapy as well as in the ICU mortality. We also found no differences in the mortality between the diagnostic groups and gender even when the APACHE II was significantly greater on admission, as occurred for the women<65 years of the coronary and traumas group and for women with surgery>or=65 years.

CONCLUSIONS

No significant differences were demonstrated in the outcome in relationship with gender except for in the coronary group in which mortality was greater in women. Age above or below 65 years had no influence on mortality in our patients.