A model based on intensity of medical care may improve outcomes for internal medicine patients in Italy

Improving acute care outcome in internal medicine: the role of early stabilization and intermediate care unit

The progressive reduction of acute care beds will necessitate hospital admission in medical settings solely for acutely ill patients requiring urgent organ support. Early stabilization of the acute condition, potentially through an appropriate treatment unit, may not only improve short-term patient outcomes but also reduce the length of hospital stay. To determine if stabilization of the acute condition in an intermediate care unit (IMCU) is associated with improved patient outcomes and reduced in-hospital stay. A prospective exploratory pilot observational study was conducted at the Department of Internal Medicine of the Alto Vicentino Hospital (Italy), including all patients admitted for non-intensive acute conditions between September and December 2022. The primary endpoint of the study was stabilization of the acute condition within 72 h of admission. Three hundred twenty four patients were enrolled. 73.5% (238/324) of patients achieved stabilization at 72 h, compared to 26.5% (86/324) who did not achieve stabilization. Among the variables found to be significant in the multivariate analysis, admission to the IMCU was associated with achieving stabilization within 72 h with an odds ratio of 2.28 (95% CI 1.29-4.01, p < 0.004). Meanwhile, for 30-day mortality, patient stabilization was found to be protective with an odds ratio of 0.11 (95% CI 0.04-0.29, p < 0.001). Early stabilization is associated with lower 30-day mortality and shorter lengths of stay. Treatment in an IMCU shows higher rates of 72-h stabilization.

COmplexity of CARE and Discharge barriers: the 'modern internal medicine patient'. Results from the CO-CARED Study

The ongoing demographic, epidemiological and social changes are dramatically raising the clinical and care complexity of patients admitted to internal medicine (IM) departments. Collecting evidence for a better characterization of patients is crucial to tailor future interventions based on patient's real needs. The aim of this prospective multicenter study was to describe the complexity of care of patients hospitalized in IM by calculating the complexity of care (ICC) score, through the combination of clinical instability (NEWS score) and care dependency scales (mICD). Furthermore, social frailty was assessed according to potential difficulty in discharge planning. 3912 patients were enrolled (median age 78 years); 71% had a Charlson Comorbidity Index ≥ 5. The ICC score was high in 14.7% of patients, while 15% exhibited a NEWS score at least moderate. One in four patients presented moderate to critical social frailty. The length of stay was correlated with social frailty, mICD and ICC scores, but not with NEWS. In-hospital mortality was correlated with the severity of all the considered scores. A relevant proportion of IM patients exhibited a high complexity of care. Our data support a model in which approximately 15% of IM beds are designated for clinically unstable patients managed in intermediate care sub-units. The substantial burden of social frailty highlights the urgency of national plans allowing at the same time to cover the needs of not self-sufficient and socially disadvantaged patients, and to efficiently address the issue of emergency department boarding.

Unveiling key predictors of sepsis mortality in intermediate care units: a decision tree study

BACKGROUND

Sepsis remains a leading cause of mortality, especially among patients admitted to non-ICU settings like intermediate care units (IMCUs). Current prognostic tools have limitations in predicting outcomes in these patients. This study aimed to identify key predictors of mortality using decision tree analysis.

METHODS

We conducted a prospective observational study from January 2023 to June 2024, enrolling 254 septic patients admitted to the IMCU of Santorso Hospital, Italy. Clinical, laboratory, and demographic data were collected, and decision tree analysis was performed to identify factors associated with 30-day mortality. Variables were compared using univariate and multivariate analyses, and significant predictors were incorporated into the decision tree model.

RESULTS

The 30-day mortality rate was 14.6%. Serum albumin was identified as the root node of the decision tree, with lower levels (≤2.3 g/dL) strongly associated with mortality. Additional predictors were identified as higher NEWS scores (OR 1.153, p = 0.002) and older age (OR 1.062, p = 0.021). Traditional scoring systems like SOFA and APACHE did not significantly predict outcomes in this setting.

CONCLUSIONS

Serum albumin is a key prognostic marker in septic patients admitted to IMCUs, alongside NEWS and age. These findings suggest that albumin levels at admission may aid in early risk stratification and clinical decision-making in non-ICU environments. Future studies should validate these results across different healthcare settings to optimize sepsis management.

Relationship between fluid bolus administration and the prognostic role of serum albumin in patients with sepsis

BACKGROUND

Serum albumin plays a pivotal role in the exchange between interstitial and vascular compartments, and reduced levels of this biomarker appear to be associated with negative prognosis in septic patients. The correlation between the volume effect in sepsis therapy and the kinetics of serum albumin is unclear.

AIM

To investigate the relationship between serum albumin and fluid bolus in relation to its prognostic role in septic patients.

METHODS

A single-center prospective observational study conducted from September 2022 to February 2024. All patients with sepsis admitted from the Emergency Department to the Intermediate Medical Care Unit (IMCU) were considered. Post-fluid bolus serum albumin was obtained after fluid bolus. The albumin value was correlated with the volume effect of the fluid bolus, and multivariate models were performed to evaluate its potential independent effect on 30-day mortality.

RESULTS

179 patients were enrolled. Pre-fluid bolus serum albumin was 2.55 g/dL (SD 0.51) with a multivariate OR for 30-day mortality of 1.170 (95 % CI 1.055-1.297, p = 0.003). After the fluid bolus, which resulted in a fluid balance percentage of +23.1 % (SD 7.1) and a mean Fractional Plasma Dilution of -0.48 (SD 0.18), albumin showed a mean decrease of -0.28 g/dL (SD 0.28) with a multivariate OR for 30-day mortality of 1.198 (95 % CI 1.065-1.348, p = 0.003). Post-fluid bolus albumin was negatively correlated with cumulative fluid balance and hemodilution.

CONCLUSIONS

The volume effect of fluid bolus is correlated with a decrease in serum albumin, and low albumin levels are associated with a high risk of mortality.