Assessment of the intermediate care unit triage system

Construction of reference criteria to admit patients to intermediate care units in France: a Delphi survey of intensivists, anaesthesiologists and emergency medicine practitioners (first part of the UNISURC project)

OBJECTIVES

No consensus criteria describe the medical eligibility of the patients to intermediate care units (IMCUs). In this first part of the UNISURC project, we aimed to develop criteria based on a consensus of physicians from the main specialties involved in IMCU admission decisions.

DESIGN

We selected criteria from IMCU literature, scoring systems and intensive care unit nursing workload. We submitted these criteria to a panel of experts in a Delphi survey. We used a two-round Delphi survey procedure to assess the validity and feasibility of each criterion.

SETTING

Medical practitioners in either public or private French institutions and proposed by the national scientific societies of anaesthesiology, emergency medicine and intensive care. The Delphi rounds took place in 2015-2016.

OUTCOME MEASURES

Validity and feasibility of the proposed criteria; uniformity of the judgement across the primary specialty and the hospital category of the responders.

RESULTS

The criteria submitted to vote were classified as one of: chronic factor (CF); acute factor (AF); specific pathway (SP); nursing activity (NA) and hospital environment (HE). Of 189 experts invited, 81 (41%) responded to the first round and 62 of them (76%) responded to the second round. A definite selection of 63 items was made, distributed across 6 CF, 18 AF, 31 SP, 3 NA and 5 HE. Validity and feasibility were influenced by the specialty or the public/private status of the institution of the responders for a few items.

CONCLUSION

We created a set of 63 consensus criteria with acceptable validity and feasibility to assess the medical eligibility of the patients to IMCUs. The second part of the UNISURC project will assess the distribution of each criterion in a prospective multicentre national cohort.

TRIAL REGISTRATION NUMBER

NCT02590172.

The Detrimental Impact of the COVID-19 Pandemic on Major Trauma Outcomes in the Netherlands: A Comprehensive Nationwide Study

OBJECTIVE

To evaluate the impact of the COVID-19 pandemic on the outcome of major trauma patients in the Netherlands.

SUMMARY BACKGROUND DATA

Major trauma patients highly rely on immediate access to specialized services, including ICUs, shortages caused by the impact of the COVID-19 pandemic may influence their outcome.

METHODS

A multi-center observational cohort study, based on the Dutch National Trauma Registry was performed. Characteristics, resource usage, and outcome of major trauma patients (injury severity score ≥16) treated at all trauma-receiving hospitals during the first COVID-19 peak (March 23 through May 10) were compared with those treated from the same period in 2018 and 2019 (reference period).

RESULTS

During the peak period, 520 major trauma patients were admitted, versus 570 on average in the pre-COVID-19 years. Significantly fewer patients were admitted to ICU facilities during the peak than during the reference period (49.6% vs 55.8%; P=0.016). Patients with less severe traumatic brain injuries in particular were less often admitted to the ICU during the peak (40.5% vs 52.5%; P=0.005). Moreover, this subgroup showed an increased mortality compared to the reference period (13.5% vs 7.7%; P=0.044). These results were confirmed using multivariable logistic regression analyses. In addition, a significant increase in observed versus predicted mortality was recorded for patients who had a priori predicted mortality of 50% to 75% (P=0.012).

CONCLUSIONS

The COVID-19 peak had an adverse effect on trauma care as major trauma patients were less often admitted to ICU and specifically those with minor through moderate brain injury had higher mortality rates.

Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients

BACKGROUND

It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients.

METHODS

Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria.

RESULTS

Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]).

CONCLUSIONS

None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.

The ratio of PACU length-of-stay to surgical duration: Practical observations

BACKGROUND

Operating room (OR) and post-anesthesia care unit (PACU) activity are closely linked since the number, type, and sequence of surgeries influence subsequent PACU activity. We aimed to explore the relationship between duration-of-surgery (DOS) and PACU length-of-stay (LOS), the PACU-LOS:DOS ratio, since it is among the determinants of the number of PACU beds and nurse staffing required to insure efficient egress of patients from the OR.

METHODS

PACU-LOS:DOS ratio was examined using retrospective data from a tertiary medical center's surgical information system (Phase 1) and prospectively collected data from a convenience sample of post-operative patients (Phase 2).

RESULTS

Phase 1 included 17 047 patients, the majority (73%) with PACU-LOS:DOS ratios >1.0, indicating PACU-LOS longer than DOS. Median PACU-LOS was 117 minutes, median DOS was 80 minutes, and median PACU-LOS/DOS ratio was 1.5. PACU-LOS showed greater variability than DOS because of extended PACU stays. Phase 2 (n = 2054) confirmed Phase 1 results (median PACU-LOS/DOS ratio - 1.8). In both phases at a DOS of >130 minutes PACU-LOS/DOS ratio became <1.0. In 24% of Phase 2 patients PACU-LOS was prolonged because of administrative issues. Post-operative, more than pre- and intra-operative, measurements influenced PACU-LOS.

CONCLUSIONS

The PACU-LOS/DOS ratio proved useful for demonstrating interactions between 2 central components of the surgical system. The many patients with PACU-LOS:DOS ratios >1.0 provides objective evidence for the number of PACU beds exceeding the number of ORs.

The intermediate care unit as a cost-reducing critical care facility in tertiary referral hospitals: a single-centre observational study

OBJECTIVES

To determine whether and to what extent the surgical intermediate care unit (IMCU) reduces healthcare costs.

DESIGN

Retrospective cohort study.

SETTING

The mixed-surgical IMCU of a tertiary academic referral hospital.

PARTICIPANTS

All admissions (n=2577) from 2012 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measure was the hypothetical cost savings due to the presence of the IMCU. For this, each admission day was classified as either low-acuity or high-acuity, based on the Therapeutic Intervention Scoring System-28, the required specific nursing interventions and the indication for admission at the IMCU. Costs (2018) used were €463 per hospital ward, €1307 per IMCU and €2224 per intensive care unit (ICU) admission day. Savings were calculated by subtracting the actual IMCU costs from the hypothetical costs in the absence of the IMCU.

RESULTS

There were 9037 admission days (n=2577 admissions) at the IMCU. The proportion of high-acuity admissions was 87.6%. Total costs at the IMCU were €11.808 888. Total hypothetical costs in absence of the IMCU were €18.115 284. Total cost savings were thus €6.306 395, or €1.576 599, per year.

CONCLUSIONS

The surgical IMCU may substantially reduce societal healthcare costs, making it a cost saving alternative to ICU care. Constant adequate triage is essential to optimise its potential.