Institutional variations in frequency of discharge of elderly intensive care survivors to postacute care facilities

Mobilization of ventilated older adults

BACKGROUND

Recent studies of ventilated, critically ill patients have shown early mobilization to be safe and resulting in better functional outcomes at discharge but have not focused on older adults.

OBJECTIVES

The objectives of this pilot study were to examine the feasibility of and to describe functional outcomes associated with providing early mobilization to critically ill, older adult patients.

METHODS

This is a prospective cohort study that took place in the medical and surgical intensive care units of a tertiary, academic medical center. Participants were aged 65 years or older, were on mechanical ventilation for 72 or more hours, and had a preadmission Barthel Index score of 70 or greater. Patients with an open ventriculostomy, continuous hemodialysis, or hospitalization of 7 or more days prior to intubation were excluded. A standardized early mobilization protocol was applied by a trained physical and occupational therapist to eligible participants according to previously published guidelines. Demographic information, hospitalization data, RAND 36-Item Short Form Health Survey (SF-36), and Barthel Index scores from preadmission, hospital discharge, and 30-day follow-up were collected.

RESULTS

Patients who survived to hospital discharge compared with nonsurvivors were similar in their admission and hospital stay demographics. Survivors reported significantly higher functioning than nonsurvivors on preadmission functional status on both the physical functioning and general health RAND SF-36 subscales. Nonsurvivors reported significantly lower physical functioning, general health, vitality, and mental health on preadmission function when compared with the published normative RAND SF-36 data for patients aged 75 years and older. Patients who did survive hospitalization reported significantly more bodily pain at 30-day follow-up than the published normative data. Patients met criteria for therapy 92% of planned interventions, 99% of those sessions were completed, and adverse events occurred in less than 1% of interventions.

CONCLUSION

Overall results indicate the feasibility and safety of implementing an early mobilization program to critically ill older adult patients.

A prognostic model for 6-month mortality in elderly survivors of critical illness

BACKGROUND

Although 1.4 million elderly Americans survive hospitalization involving intensive care annually, many are at risk for early mortality following discharge. No models that predict the likelihood of death after discharge exist explicitly for this population. Therefore, we derived and externally validated a 6-month postdischarge mortality prediction model for elderly ICU survivors.

METHODS

We derived the model from medical record and claims data for 1,526 consecutive patients aged ≥ 65 years who had their first medical ICU admission in 2006 to 2009 at a tertiary-care hospital and survived to discharge (excluding those patients discharged to hospice). We then validated the model in 1,010 patients from a different tertiary-care hospital.

RESULTS

Six-month mortality was 27.3% and 30.2% in the derivation and validation cohorts, respectively. Independent predictors of mortality (in descending order of contribution to the model's predictive power) were a do-not-resuscitate order, older age, burden of comorbidity, admission from or discharge to a skilled-care facility, hospital length of stay, principal diagnoses of sepsis and hematologic malignancy, and male sex. For the derivation and external validation cohorts, the area under the receiver operating characteristic curve was 0.80 (SE, 0.01) and 0.71 (SE, 0.02), respectively, with good calibration for both (P = 0.31 and 0.43).

CONCLUSIONS

Clinical variables available at hospital discharge can help predict 6-month mortality for elderly ICU survivors. Variables that capture elements of frailty, disability, the burden of comorbidity, and patient preferences regarding resuscitation during the hospitalization contribute most to this model's predictive power. The model could aid providers in counseling elderly ICU survivors at high risk of death and their families.

Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012

Introduction

A decrease in disease-specific mortality over the last twenty years has been reported for patients admitted to United States (US) hospitals, but data for intensive care patients are lacking. The aim of this study was to describe changes in hospital mortality and case-mix using clinical data for patients admitted to multiple US ICUs over the last 24 years.

Methods

We carried out a retrospective time series analysis of hospital mortality using clinical data collected from 1988 to 2012. We also examined the impact of ICU admission diagnosis and other clinical characteristics on mortality over time. The potential impact of hospital discharge destination on mortality was also assessed using data from 2001 to 2012.

Results

For 482,601 ICU admissions there was a 35% relative decrease in mortality from 1988 to 2012 despite an increase in age and severity of illness. This decrease varied greatly by diagnosis. Mortality fell by >60% for patients with chronic obstructive pulmonary disease, seizures and surgery for aortic dissection and subarachnoid hemorrhage. Mortality fell by 51% to 59% for six diagnoses, 41% to 50% for seven diagnoses, and 10% to 40% for seven diagnoses. The decrease in mortality from 2001 to 2012 was accompanied by an increase in discharge to post-acute care facilities and a decrease in discharge to home.

Conclusions

Hospital mortality for patients admitted to US ICUs has decreased significantly over the past two decades despite an increase in the severity of illness. Decreases in mortality were diagnosis specific and appear attributable to improvements in the quality of care, but changes in discharge destination and other confounders may also be responsible.

Clinical review: International comparisons in critical care - lessons learned

Critical care medicine is a global specialty and epidemiologic research among countries provides important data on availability of critical care resources, best practices, and alternative options for delivery of care. Understanding the diversity across healthcare systems allows us to explore that rich variability and understand better the nature of delivery systems and their impact on outcomes. However, because the delivery of ICU services is complex (for example, interplay of bed availability, cultural norms and population case-mix), the diversity among countries also creates challenges when interpreting and applying data. This complexity has profound influences on reported outcomes, often obscuring true differences. Future research should emphasize determination of resource data worldwide in order to understand current practices in different countries; this will permit rational pandemic and disaster planning, allow comparisons of in-ICU processes of care, and facilitate addition of pre- and post-ICU patient data to better interpret outcomes.