Adverse outcomes of delayed intensive care unit

Association between the timing of ICU admission and mortality in patients with hospital-onset sepsis: a nationwide prospective cohort study

BACKGROUND

Based on sparse evidence, the current Surviving Sepsis Campaign guideline suggests that critically ill patients with sepsis be admitted to the intensive care unit (ICU) within 6 h. However, limited ICU bed availability often makes immediate transfer difficult, and it is unclear whether all patients will benefit from early admission to the ICU. Therefore, the purpose of this study was to determine the association between the timing of ICU admission and mortality in patients with hospital-onset sepsis.

METHODS

This nationwide prospective cohort study analyzed patients with hospital-onset sepsis admitted to the ICUs of 19 tertiary hospitals between September 2019 and December 2020. ICU admission was classified as either early (within 6 h) or delayed (beyond 6 h). The primary outcome of in-hospital mortality was compared using logistic regression adjusted for key prognostic factors in the unmatched and 1:1 propensity-score-matched cohorts. Subgroup and interaction analyses assessed whether in-hospital mortality varied according to baseline characteristics.

RESULTS

A total of 470 and 286 patients were included in the early and delayed admission groups, respectively. Early admission to the ICU did not significantly result in lower in-hospital mortality in both the unmatched (adjusted odds ratio [aOR], 1.35; 95% confidence interval [CI], 0.99-1.85) and matched cohorts (aOR, 1.38; 95% CI, 0.94-2.02). Subgroup analyses showed that patients with increasing lactate levels (aOR, 2.10; 95% CI, 1.37-3.23; P for interaction = 0.003), septic shock (aOR, 2.06; 95% CI, 1.31-3.22; P for interaction = 0.019), and those who needed mechanical ventilation (aOR, 1.92; 95% CI, 1.24-2.96; P for interaction = 0.027) or vasopressor support (aOR, 1.69; 95% CI, 1.17-2.44; P for interaction = 0.042) on the day of ICU admission had a higher risk of mortality with delayed admission.

CONCLUSIONS

Among patients with hospital-onset sepsis, in-hospital mortality did not differ significantly between those with early and delayed ICU admission. However, as early intensive care may benefit those with increasing lactate levels, septic shock, and those who require vasopressors or ventilatory support, admission to the ICU within 6 h should be considered for these subsets of patients.

Length-of-Stay in the Emergency Department and In-Hospital Mortality: A Systematic Review and Meta-Analysis

The effect of emergency department (ED) length of stay (EDLOS) on in-hospital mortality (IHM) remains unclear. The aim of this systematic review and meta-analysis was to determine the association between EDLOS and IHM. We searched the PubMed, Medline, Embase, Web of Science, Cochrane Controlled Register of Trials, CINAHL, PsycInfo, and Scopus databases from their inception until 14−15 January 2022. We included studies reporting the association between EDLOS and IHM. A total of 11,337 references were identified, and 52 studies (total of 1,718,518 ED patients) were included in the systematic review and 33 in the meta-analysis. A statistically significant association between EDLOS and IHM was observed for EDLOS over 24 h in patients admitted to an intensive care unit (ICU) (OR = 1.396, 95% confidence interval [CI]: 1.147 to 1.701; p < 0.001, I2 = 0%) and for low EDLOS in non-ICU-admitted patients (OR = 0.583, 95% CI: 0.453 to 0.745; p < 0.001, I2 = 0%). No associations were detected for the other cut-offs. Our findings suggest that there is an association between IHM low EDLOS and EDLOS exceeding 24 h and IHM. Long stays in the ED should not be allowed and special attention should be given to patients admitted after a short stay in the ED.

Delayed Admission to the Intensive Care Unit and Mortality of Critically Ill Adults: Systematic Review and Meta-analysis

Delayed admission of patients to the intensive care unit (ICU) is increasing worldwide and can be followed by adverse outcomes when critical care treatment is not provided timely. This systematic review and meta-analysis appraised and synthesized the published literature about the association between delayed ICU admission and mortality of adult patients. Articles published from inception up to August 2021 in English-language, peer-reviewed journals indexed in CINAHL, PubMed, Scopus, Cochrane Library, and Web of Science were searched by using key terms. Delayed ICU admission constituted the intervention, while mortality for any predefined time period was the outcome. Risk for bias was evaluated with the Newcastle-Ottawa Scale and additional criteria. Study findings were synthesized qualitatively, while the odds ratios (ORs) for mortality with 95% confidence intervals (CIs) were combined quantitatively. Thirty-four observational studies met inclusion criteria. Risk for bias was low in most studies. Unadjusted mortality was reported in 33 studies and was significantly higher in the delayed ICU admission group in 23 studies. Adjusted mortality was reported in 18 studies, and delayed ICU admission was independently associated with significantly higher mortality in 13 studies. Overall, pooled OR for mortality in case of delayed ICU admission was 1.61 (95% CI 1.44-1.81). Interstudy heterogeneity was high (I² = 66.96%). According to subgroup analysis, OR for mortality was remarkably higher in postoperative patients (OR, 2.44, 95% CI 1.49-4.01). These findings indicate that delayed ICU admission is significantly associated with mortality of critically ill adults and highlight the importance of providing timely critical care in non-ICU settings.

Association between pre-intensive care unit (ICU) hospital length of stay and ICU outcomes in a resource-limited setting

Background

Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings.

Objectives

The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality.

Methods

This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS.

Results

The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source.

Conclusion

Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes.

Contributions of the study

The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.