Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787-2793. [PMID: 18766102 DOI: 10.1097/ccm.0b013e318186aec8]

Does space make waste? The influence of ICU bed capacity on admission decisions

BACKGROUND

Intensive care unit (ICU) beds are a scarce resource, and admissions may require prioritization when demand exceeds supply. However, there are few empiric data on whether the availability of ICU beds influences triage and processes of care for hospitalized patients who develop sudden clinical deterioration.

METHODS RESULTS

The cohort consisted of 3,494 patients. Reduced ICU bed availability was associated with a decreased likelihood of ICU admission within 2 hours of MET activation (P = 0.03) and with an increased likelihood of change in patient goals of care (P <0.01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% confidence interval (CI), -5.1% to 57.3%) less likely to be admitted to the ICU and were 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than two ICU beds were available. However, hospital mortality did not vary significantly by ICU bed availability (P = 0.82).

CONCLUSIONS

For hospitalized patients with sudden clinical deterioration, ICU bed scarcity decreases the probability of ICU admission and increases the probability of initiating comfort measures on the ward but does not influence hospital mortality.

Clinical review: the role of the intensivist and the rapid response team in nosocomial end-of-life care

In-hospital end-of-life care outside the ICU is a new and increasing aspect of practice for intensive care physicians in countries where rapid response teams have been introduced. As more of these patients die from withdrawal or withholding of artificial life support, determining whether a patient is dying or not has become as important to intensivists as the management of organ support therapy itself. Intensivists have now moved to making such decisions in hospital wards outside the boundaries of their usual closely monitored environment. This strategic change may cause concern to some intensivists; however, as custodians of the highest technology area in the hospital, intensivists are by necessity involved in such processes. Now, more than ever before, intensive care clinicians must consider the usefulness of key concepts surrounding nosocomial death and dying and the importance and value of making a formal diagnosis of dying in the wards. In this article, we assess the conceptual background, reference points, challenges and implications of these emerging aspects of intensive care medicine.

Identifying intensive care unit discharge planning tools: protocol for a scoping review

BACKGROUND

Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use.

METHODS AND ANALYSIS

Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool.

ETHICS AND DISSEMINATION

Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.

Introduction to the postanaesthetic care unit

High-risk, noncardiac surgery represents only 12.5% of surgical procedures, but 83.3% of deaths. The postanaesthetic care unit (PACU) addresses the need for an improved level of care for these patients by providing postoperative high-dependency or intensive care (Level 2 or 3). The PACU aims to improve the structure of care provision for high-risk surgical patients. By maintaining 24-hour cover at the same staffing level, the risk of poorer ‘out-of- hours’ care is reduced. In a PACU, whose remit is solely postoperative care, evidence-based protocols can be established to standardize the care given. The aim is to provide 24 hours of postoperative optimized care, thus targeting the period when these patients are most vulnerable, to reduce the risk of complications developing and identify complications promptly, should they occur. The PACU is set up to facilitate certain processes to aid optimized care in the postoperative period. These include invasive and noninvasive ventilation, goal-directed haemodynamic management, invasive monitoring and optimal pain management. Identification of high-risk patients who might benefit from PACU care is not always straightforward. However, tools are available to aid the clinician, supplementing clinical assessment and basic investigations. These include clinical prediction rules and cardiopulmonary exercise testing. Both the setting up and the running of a PACU clearly have cost implications. However, the reduction in postoperative morbidity, and thus patients’ length of stay, should, overall, reduce costs. The benefits of a PACU should therefore be seen in terms of improved surgical outcomes, reducing postoperative morbidity and mortality, and cost savings.

Characteristics of critically ill patients in ICUs in mainland China

OBJECTIVES

We sought to describe the demographics, case mix, interventions, and clinical outcome of critically ill patients admitted to ICUs in Mainland China.

DESIGN

A 2-month (July 1, 2009, to August 31, 2009) prospective, observational cohort study.

SETTING

Twenty-two ICUs in Mainland China.

PATIENTS

Adult patients admitted to participating ICUs during the study period with an ICU length of stay >24 hrs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, including demographics, underlying diseases, severity of illness, admission status, complications, intervention and treatment during ICU stay, and clinical outcome were recorded in case report form. The primary outcome measure was all-cause hospital mortality. Independent predictors for hospital mortality were determined with multivariate logistic regression analysis. One thousand two hundred ninety-seven patients met the inclusion criteria for the study, 821 (63.3%) were male, and mean age was 58.5 ± 19.2 yrs. Mean Acute Physiology and Chronic Health Evaluation II score was 18.0 ± 8.1, and mean Sequential Organ Failure Assessment score was 6.5 ± 3.8. One third of the patients were postoperative ICU admissions. Seven hundred sixty-five patients (59.0%) developed infections, followed by severe sepsis or septic shock (484, 37.3%), acute kidney injury (398, 30.7%), and acute lung injury/acute respiratory distress syndrome (351, 27.1%). Mechanical ventilation was used in almost three fourths of the patients, whereas any type of renal replacement therapy was used in 173 patients (13.3%). Hospital mortality was 20.3%. Multivariate logistic regression analysis found that Acute Physiology and Chronic Health Evaluation II score, solid tumor, severe sepsis/septic shock, acute lung injury/acute respiratory distress syndrome, and acute kidney injury were independent risk factors for hospital mortality.

CONCLUSIONS

Critically ill patients in ICUs in Mainland China exhibited a case mix similar to those of Western countries, although there are significant differences in intensive care unit admission rates and disease severity between Western and Chinese ICUs.

Type 2 diabetes and 1-year mortality in intensive care unit patients

BACKGROUND

Data on the prognostic impact of diabetes and diabetic complications in intensive care unit (ICU) patients are limited and inconsistent. We, therefore, examined mortality in ICU patients with type 2 diabetes with and without pre-existing heart and kidney diseases compared with nondiabetic patients.

DESIGN

We conducted this population-based cohort study in Northern Denmark during 2005-2011. We included all ICU patients aged 40 years or older from the 17 ICUs in the area and identified type 2 diabetes by either a filled prescription for an antidiabetic drug, a previous diagnosis of diabetes, or an elevated glycosylated haemoglobin level. Diabetic patients were disaggregated according to pre-existing diagnoses of heart disease (myocardial infarction or heart failure) and kidney disease. We estimated 1-year mortality by the Kaplan-Meier method and hazard ratios of death (HRs) during follow-up using Cox regression, controlling for confounding factors and stratified by relevant subgroups.

RESULTS

Among 45 018 ICU patients, 7219 (16·0%) had type 2 diabetes. Overall, 1-year mortality was 36·0% in ICU patients with type 2 diabetes, rising to 54·6% in patients with pre-existing heart and kidney diseases, compared with 29·1% in nondiabetic patients. Comparing diabetic with nondiabetic patients, the adjusted 0- to 30-day HR was 1·20 (95% confidence interval (CI): 1·13-1·26) and 1·19 (95% CI: 1·10-1·28) during the 31- to 365-day follow-up period. Pre-existing kidney disease further increased the impact of diabetes, while heart disease alone had no such effect.

CONCLUSIONS

ICU patients with type 2 diabetes had higher 1-year mortality compared with nondiabetic ICU patients, particularly those with pre-existing kidney disease.

Effect of intermediate care on mortality following emergency abdominal surgery. The InCare trial: study protocol, rationale and feasibility of a randomised multicentre trial

Background

Emergency abdominal surgery carries a 15% to 20% short-term mortality rate. Postoperative medical complications are strongly associated with increased mortality. Recent research suggests that timely recognition and effective management of complications may reduce mortality. The aim of the present trial is to evaluate the effect of postoperative intermediate care following emergency major abdominal surgery in high-risk patients.

Methods and design

The InCare trial is a randomised, parallel-group, non-blinded clinical trial with 1:1 allocation. Patients undergoing emergency laparotomy or laparoscopic surgery with a perioperative Acute Physiology and Chronic Health Evaluation II score of 10 or above, who are ready to be transferred to the surgical ward within 24 h of surgery are allocated to either intermediate care for 48 h, or surgical ward care. The primary outcome measure is all-cause 30-day mortality. We aim to enrol 400 patients in seven Danish hospitals. The sample size allows us to detect or refute a 34% relative risk reduction of mortality with 80% power.

Discussion

This trial evaluates the benefits and possible harm of intermediate care. The results may potentially influence the survival of many high-risk surgical patients. As a pioneer trial in the area, it will provide important data on the feasibility of future large-scale randomised clinical trials evaluating different levels of postoperative care.

Trial registration

Clinicaltrials.gov identifier: NCT01209663

Risk and clinical-outcome indicators of delirium in an emergency department intermediate care unit (EDIMCU): an observational prospective study

BACKGROUND

Identification of delirium in emergency departments (ED) is often underestimated; within EDs, studies on delirium assessment and relation with patient outcome in Intermediate Care Units (IMCU) appear missing in European hospital settings. Here we aimed to determine delirium prevalence in an EDIMCU (Hospital de Braga, Braga, Portugal) and assessed routine biochemical parameters that might be delirium indicators.

METHODS

The study was prospective and observational. Sedation level was assessed via the Richmond Agitation-Sedation Scale and delirium status by the Confusion Assessment Method for the ICU. Information collected included age and gender, admission type, Charlson Comorbidity Index combined condition score (Charlson score), systemic inflammatory response syndrome criteria (SIRS), biochemical parameters (blood concentration of urea nitrogen, creatinine, hemoglobin, sodium and potassium, arterial blood gases, and other parameters as needed depending on clinical diagnosis) and EDIMCU length of stay (LOS). Statistical analyses were performed as appropriate to determine if baseline features differed between the 'Delirium' and 'No Delirium' groups. Multivariate logistic regression was performed to assess the effect of delirium on the 1-month outcome.

RESULTS

Inclusion and exclusion criteria were met in 283 patients; 238 were evaluated at 1-month for outcome follow-up after EDIMCU discharge ("good" recovery without complications requiring hospitalization or institutionalization; "poor" institutionalization in permanent care-units/assisted-living or death). Delirium was diagnosed in 20.1% patients and was significantly associated with longer EDIMCU LOS. At admission, Delirium patients were significantly older and had significantly higher blood urea, creatinine and osmolarity levels and significantly lower hemoglobin levels, when compared with No Delirium patients. Delirium was an independent predictor of increased EDIMCU LOS (odds ratio 3.65, 95% CI 1.97-6.75) and poor outcome at 1-month after discharge (odds ratio 3.51, CI 1.84-6.70), adjusted for age, gender, admission type, presence of SIRS criteria, Charlson score and osmolarity at admission.

CONCLUSIONS

In an EDIMCU setting, delirium was associated with longer LOS and poor outcome at 1-month post-discharge. Altogether, findings support the need for delirium screening and management in emergency settings.

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.

Year in review 2011: Critical Care--Resource management

Increasing complexity and costs are a fundamental problem in critical care medicine, leading researchers to study opportunities and threats to continue to provide high-quality care in a more efficient health system. Over the past decades, we have learned from industrial methods that quality improvement and resource management can help achieve these results. Last year, Critical Care published a number of papers that highlight key points of critical care resource management. Each of these is grouped into one of three broad categories, based on domains of quality: (a) outcomes, in which we review long-term outcome data with an emphasis on the aging population, strategies to help mitigate the psychological burden of critical care, adverse events, and the appropriate use of resources, such as prolonged mechanical ventilation and intensive care unit (ICU) beds; (b) processes of care, in which we review variability in the provision of critical care, owing to gender, insurance status, and delays in ICU admission; knowledge translation studies in critical care; goal-directed therapy for postoperative patients and decision-making in the ICU; and (c) structure, in which we review strategies to improve quality through changes in design and the structural limitations to provide care in resource-limited settings.

International comparisons of intensive care: informing outcomes and improving standards

PURPOSE OF REVIEW

Interest in international comparisons of critical illness is growing, but the utility of these studies is questionable. This review examines the challenges of international comparisons and highlights areas in which international data provide information relevant to clinical practice and resource allocation.

RECENT FINDINGS

International comparisons of ICU resources demonstrate that definitions of critical illness and ICU beds vary due to differences in ability to provide organ support and variable staffing. Despite these limitations, recent international data provide key information to understand the pros and cons of different availability of ICU beds on patient flow and outcomes, and also highlight the need to ensure long-term follow-up due to heterogeneity in discharge practices for critically ill patients. With increasing emphasis on curbing costs of healthcare, systems that deliver lower cost care provide data on alternative options, such as regionalization, flexible allocation of beds, and bed rationing.

SUMMARY

Differences in provision of critical care can be leveraged to inform decisions on allocation of ICU beds, improve interpretation of clinical outcomes, and assess ways to decrease costs of care. International definitions of key components of critical care are needed to facilitate research and ensure rigorous comparisons.

Picking up the pieces: towards a better future for critical care medicine in three South American countries

The demand for intensivists is increasing around the world, not only to meet the needs of a growing aging population, but also to fill positions in the intensive care unit now occupied by other specialists, since there is compelling evidence that the presence of critical care practitioners improves patient outcomes. Notwithstanding this, the shortage of intensivists is a problem recognized throughout the world. In this article, we discuss these issues in Argentina, Brazil, and Uruguay, three upper-middle income Latin American countries where critical care has been a medical specialty for decades and intensive care unit coverage traditionally has followed the 24/7 model. The lack of intensivists is multifactorial: the specialty is not taught to medical students; there is a general perception of a negative lifestyle compared with the practice of other medical specialties, due mainly to the constant 24-hour shift work; and there is general dissatisfaction with incomes, which has forced many intensivists into multijob schemes. The expected-and feared-consequences are the 40 to 70% vacant posts in residencies of critical care. Despite these drawbacks, scientific societies and colleges are intensely committed, pointing out these problems to the press, calling the health authorities for action, and permanently generating educational activities. Surprisingly, 83% of surveyed intensivists would choose critical care medicine again, evidencing the strong vocational component in its practice, which seems to predominate over negative aspects.

Do elderly intensive care unit patients receive less intensive care treatment and have higher mortality?

BACKGROUND

The number of elderly (≥ 80 years) will increase markedly in Norway over the next 20 years, increasing the demand for health-care services, including intensive care. The aims of this study were to see if intensive care unit (ICU) resource use and survival are different for elderly ICU patients than for younger adult ICU patients.

MATERIALS AND METHODS

A retrospective cohort study comparing ICU patients between 50 and 79.9 years (Group I) with patients over 80 years (Group II) registered in the Norwegian Intensive Care Registry from 2006 to 2009. A subgroup analysis of 5-year age groups was performed.

RESULTS

A total of 27,921 patients were analysed. The ICU/hospital mortalities were 14.3%/21.4% (Group I) and 19.8%/32.4% (Group II). Overall mortality increased with increasing age, and hospital mortality rate increased more than ICU mortality. The observed difference in admission categories could not explain the significant difference in median length of stay (LOS), 2.3 days (Group I) vs. 2.0 days (Group II). The elderly received less mechanical ventilatory support (40.6% vs. 56.1%) and had shorter median ventilatory support time, 0.8 days vs. 1.9 days. Median LOS dropped from around 80 years on, ventilator support time from around 65-70 years.

CONCLUSION

Octogenarians had shorter ICU stays, had higher overall mortality, had a shift of dying at the ward rather than in the ICU, and received less and shorter mechanical ventilatory support.

Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study

BACKGROUND

Mortality from severe sepsis and septic shock differs across continents, countries, and regions. We aimed to use data from the Surviving Sepsis Campaign (SSC) to compare models of care and outcomes for patients with severe sepsis and septic shock in the USA and Europe.

METHODS

The SSC was introduced into more than 200 sites in Europe and the USA. All patients identified with severe sepsis and septic shock in emergency departments or hospital wards and admitted to intensive care units (ICUs), and those with sepsis in ICUs were entered into the SSC database. Patients entered into the database from its launch in January, 2005, through January, 2010, in units with at least 20 patients and 3 months of enrolment of patients were included in this analysis. Patients included in the cohort were limited to those entered in the first 4 years at every site. We used random-effects logistic regression to estimate the hospital mortality odds ratio (OR) for Europe relative to the USA. We used random-effects linear regression to find the relation between lengths of stay in hospital and ICU and geographic region.

FINDINGS

25 375 patients were included in the cohort. The USA included 107 sites with 18 766 (74%) patients, and Europe included 79 hospital sites with 6609 (26%) patients. In the USA, 12 218 (65·1%) were admitted to the ICU from the emergency department whereas in Europe, 3405 (51·5%) were admitted from the wards. The median stay on the hospital wards before ICU admission was longer in Europe than in the USA (1·0 vs 0·1 days, difference 0·9, 95% CI 0·8-0·9). Raw hospital mortality was higher in Europe than in the USA (41·1%vs 28·3%, difference 12·8, 95% CI 11·5-14·7). The median length of stay in ICU (7·8 vs 4·2 days, 3·6, 3·3-3·7) and hospital (22·8 vs 10·5 days, 12·3, 11·9-12·8) was longer in Europe than in the USA. Adjusted mortality in Europe was not significantly higher than that in the USA (32·3%vs 31·3%, 1·0, -1·7 to 3·7, p=0·468). Complete compliance with all applicable elements of the sepsis resuscitation bundle was higher in the USA than in Europe (21·6%vs 18·4%, 3·2, 2·2-4·4).

INTERPRETATION

The significant difference in unadjusted mortality and the fact that this difference disappears with severity adjustment raise important questions about the effect of the approach to critical care in Europe compared with that in the USA. The effect of ICU bed availability on outcomes in patients with severe sepsis and septic shock requires further investigation.

An observational study to determine the effect of delayed admission to the intensive care unit on patient outcome

INTRODUCTION

Delayed patient admission to the intensive care unit (ICU) due to lack of bed availability is a common problem, but the effect on patient outcome is not fully known.

METHODS

A retrospective study was performed using departmental computerised records to determine the effect of delayed ICU admission and temporary management within the operating theatre suite on patient outcome. Emergency surgical and medical patients admitted to the ICU (2003 to 2007) were divided into delay (more than three hours from referral to admission) and no-delay (three or fewer hours from referral to admission) groups. Our primary outcome measure was length of ICU stay. Secondary outcome measures were mortality rates and duration of organ support.

RESULTS

A total of 1,609 eligible patients were included and 149 (9.3%) had a delayed admission. The delay and no-delay groups had similar baseline characteristics. Median ICU stay was 5.1 days (delay) and 4.5 days (no-delay) (P = 0.55) and ICU mortality was 26.8% (delay) and 24.2% (no-delay) (P = 0.47). Following adjustment for demographic and baseline characteristics there was no difference in either length of ICU stay or mortality rates between groups. ICU admission delay was associated with both an increased requirement for advanced respiratory support (92.3% delay vs. 76.4% no-delay, P <0.01) and a longer time spent ventilated (median four days delay vs. three days no-delay, P = 0.04).

CONCLUSIONS

No significant difference in length of ICU stay or mortality rate was demonstrated between the delay and no-delay cohorts. Patients within the delay group had a significantly greater requirement for advanced respiratory support and spent a longer time ventilated.

Mortality after surgery in Europe: a 7 day cohort study

BACKGROUND

Clinical outcomes after major surgery are poorly described at the national level. Evidence of heterogeneity between hospitals and health-care systems suggests potential to improve care for patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an international study designed to assess outcomes after non-cardiac surgery in Europe.

METHODS

We did this 7 day cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital mortality. Secondary outcome measures were duration of hospital stay and admission to critical care. We used χ(2) and Fisher's exact tests to compare categorical variables and the t test or the Mann-Whitney U test to compare continuous variables. Significance was set at p<0·05. We constructed multilevel logistic regression models to adjust for the differences in mortality rates between countries.

FINDINGS

We included 46,539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9-3·6). 1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0-3·0] for Iceland to 21·5% [16·9-26·2] for Latvia). After adjustment for confounding variables, important differences remained between countries when compared with the UK, the country with the largest dataset (OR range from 0·44 [95% CI 0·19-1·05; p=0·06] for Finland to 6·92 [2·37-20·27; p=0·0004] for Poland).

INTERPRETATION

The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated. Variations in mortality between countries suggest the need for national and international strategies to improve care for this group of patients.

FUNDING

European Society of Intensive Care Medicine, European Society of Anaesthesiology.

The risks and rewards of expanding ICU capacity

ICU capacity strain is associated with increased morbidity and lost hospital revenue, leading many hospitals to increase the number of ICU beds. However, this approach can lead to inefficiency and waste. A recent report in Critical Care highlights a different approach: creating new service lines for low-risk patients. In this case, the authors started a post-anesthesia care unit with an intensivist-led care team, resulting in lower hospital costs with no changes in ICU mortality. Although this type of change carries some risks, and will not work for every hospital, it is an example of the creative solutions hospitals must sometimes undertake to maintain the supply of critical care in response to a rising demand.

Is there a Starling curve for intensive care?

Large differences exist in the provision of ICU beds worldwide, with a complicated mix of risks and benefits to the population of having either too few or too many beds. Having too few beds can result in delayed admission of patients to the ICU or no admission at all, with either scenario potentially increasing mortality. Potential societal benefits of having few beds include lower costs for health care and less futile intensive care at the end of life. With added ICU beds for a population, mortality benefit should accrue, but there is still the question of whether the addition of beds always means that more lives will be saved or whether there is a point at which no additional mortality benefit is gained. With an abundance of ICU beds may come the possibility of increasing harm in the forms of unnecessary costs, poor quality of deaths (ie, excessively intensive), and iatrogenic complications. The possibility of harm may be likened to the concept of falling off a Starling curve, which is traditionally used to describe worsening heart function when overfilling occurs. This commentary examines the possible implications of having too few or too many ICU beds and proposes the concept of a family of Starling curves as a way to conceptualize the balance of societal benefits and harms associated with different availability of ICU beds for a population.

Constructing episodes of inpatient care: data infrastructure for population-based research

Background

Databases used to study the care of patients in hospitals and Intensive Care Units (ICUs) typically contain a separate entry for each segment of hospital or ICU care. However, it is not uncommon for patients to be transferred between hospitals and/or ICUs, and when transfers occur it is necessary to combine individual entries to accurately reconstruct the complete episodes of hospital and ICU care. Failure to do so can lead to erroneous lengths-of-stay, and rates of admissions, readmissions, and death.

Methods

This study used a clinical ICU database and administrative hospital abstracts for the adult population of Manitoba, Canada from 2000–2008. We compared five methods for identifying patient transfers and constructing hospital episodes, and the ICU episodes contained within them. Method 1 ignored transfers. Methods 2–5 considered the time gap between successive entries (≤1 day vs. ≤2 days), with or without use of data fields indicating inter-hospital transfer. For the five methods we compared the resulting number and lengths of hospital and ICU episodes.

Results

During the study period, 48,551 hospital abstracts contained 53,246 ICU records. For Method 1 these were also the number of hospital and ICU episodes, respectively. Methods 2–5 gave remarkably similar results, with transfers included in approximately 25% of ICU-containing hospital episodes, and 10% of ICU episodes. Comparison with Method 1 showed that failure to account for such transfers resulted in overestimating the number of episodes by 7-10%, and underestimating mean or median lengths-of-stay by 9-30%.

Conclusions

In Manitoba is it not uncommon for critically ill patients to be transferred between hospitals and between ICUs. Failure to account for transfers resulted in inaccurate assessment of parameters relevant to researchers, clinicians, and policy-makers. The details of the method used to identify transfers, at least among the variations tested, made relatively little difference. In addition, we showed that these methods for constructing episodes of hospital and ICU care can be implemented in a large, complex dataset.

Development and preliminary evaluation of a telephone-based coping skills training intervention for survivors of acute lung injury and their informal caregivers

PURPOSE

Survivors of acute lung injury (ALI) and their informal caregivers have difficulty coping with the physical and emotional challenges of recovery from critical illness. We aimed to develop and pilot test a telephone-based coping skills training intervention for this population.

METHODS

Fifty-eight participants were enrolled overall. A total of 21 patients and 23 caregivers participated in a cross-sectional study to assess coping and its association with psychological distress. This also informed the development of an ALI coping skills training intervention in an iterative process involving content and methodological experts. The intervention was then evaluated in seven patients and seven caregivers in an uncontrolled, prospective, pre-post study. Outcomes included acceptability, feasibility, and symptoms of psychological distress measured with the Hospital Anxiety and Depression Scale (HADS) and Post-Traumatic Symptom Scale (PTSS).

RESULTS

Survivors and their caregivers used adaptive coping infrequently, a pattern that was strongly associated with psychological distress. These findings informed the development of a 12-session intervention for acquiring, applying, and maintaining coping skills. In the evaluation phase, participants completed 77 (92 %) of a possible 84 telephone sessions and all (100 %) reported the intervention's usefulness in their daily routine. Mean change scores reflecting improvements in the HADS (7.8 U) and PTSS (10.3 U) were associated with adaptive coping (r = 0.50-0.70) and high self-efficacy (r = 0.67-0.79).

CONCLUSIONS

A novel telephone-based coping skills training intervention was acceptable, feasible, and may have been associated with a reduction in psychological distress among survivors of ALI and their informal caregivers. A randomized trial is needed to evaluate the intervention.

[Intensive care capacities in Germany: provision and usage between 1991 and 2009]

BACKGROUND

The development of provision and usage of intensive care capacity in Germany in the last two decades has not yet been sufficiently studied.

METHODS

Based on the official statistical data provided by the Federal Statistical Office (Statistisches Bundesamt) with respect to hospitals, the hospitals were analyzed in four categories: small hospitals (≤199 beds), medium size hospitals (200-499 beds), large hospitals (500-999 beds) and very large hospitals (≥1,000 beds). For the period between 1991 and 2009 the development of hospitals, hospital beds, the number and occupancy of intensive care unit beds, the number of cases and the length of stay of intensive care patients were analyzed.

RESULTS

While the total number of hospital beds decreased, the number of critical care beds increased. During the period between 1991 and 2009 the occupancy rate increased. Also the proportion of critical care beds from all hospital beds doubled and currently exceeds 8% for very large hospitals. An increase in the length of stay in the intensive care units was also observed.

CONCLUSIONS

The provision and usage of intensive care capacities have increased steadily and independently of the hospital size in Germany in the last two decades. Major effects of cost reduction measures, such as the introduction of diagnosis-related reimbursement on the provision and usage of intensive care medicine were not observed.

Nurse workload in implementing a tight glycaemic control protocol in a UK hospital: a pilot time-in-motion study

AIMS AND OBJECTIVES

The cumulative time that critical care nurses spend implementing a tight glycaemic control (TGC) protocol was estimated in a time-in-motion (TiM) study conducted in a hospital in the UK.

BACKGROUND

TGC protocols were introduced to the critical care setting to reduce hyperglycaemic events in high-risk patients. The time burden to critical care nurses of implementing such protocols has not yet been studied in the UK.

DESIGN

A prospective TiM pilot study was conducted in an eligible UK intensive care unit by four protocol-trained observers over five consecutive weekdays from 3 to 7 November 2008. Three nurses were also interviewed on site to gather their attitudes and perceptions about the benefits of and time associated with administering a TGC protocol.

METHODS

Independent observers shadowed nurses, observing when a blood glucose measurement was taken, when each predefined subtask was completed and the duration of each task. Semistructured interviews with nurses were conducted in-person and one-on-one by a trained study member.

RESULTS

Considered together, the episodic median duration of all TGC activities was 6·65 min. Across a total shift, nurses devoted approximately 7% of their time to administering a TGC protocol. Nurses perceived that a TGC protocol is beneficial to patient safety and outcomes in a critical care setting but acknowledged that the tasks can be mildly to moderately tedious.

CONCLUSIONS

This TiM analysis indicated that the additional responsibility of implementing a TGC protocol represents a substantive commitment of nursing time in a critical care setting.

RELEVANCE TO CLINICAL PRACTICE

The episodic data of our pilot study in the UK contributes further evidence that TGC protocols may be arduous to maintain and constitute a substantial investment of nursing time.

The accuracy of administrative data for identifying the presence and timing of admission to intensive care units in a Canadian province

BACKGROUND

A prerequisite for using administrative data to study the care of critically ill patients in intensive care units (ICUs) is that it accurately identifies such care. Only limited data exist on this subject.

OBJECTIVE

To assess the accuracy of administrative data in the Canadian province of Manitoba for identifying the existence, number, and timing of admissions to adult ICUs.

RESEARCH DESIGN

For the period 1999 to 2008, we compared information about ICU care from Manitoba hospital abstracts, with the criterion standard of a clinical ICU database that includes all admissions to adult ICUs in its largest city of Winnipeg. Comparisons were made before and after a national change in administrative data requirements that mandated specific data elements identifying the existence and timing of ICU care.

RESULTS

In both time intervals, hospital abstracts were extremely accurate in identifying the presence of ICU care, with positive predictive values exceeding 98% and negative predictive values exceeding 99%. Administrative data correctly identified the number of separate ICU admissions for 93% of ICU-containing hospitalizations; inaccuracy increased with more ICU stays per hospitalization. Hospital abstracts were highly accurate for identifying the timing of ICU care, but only for hospitalizations containing a single ICU admission.

CONCLUSIONS

Under current national-reporting requirements, hospital administrative data in Canada can be used to accurately identify and quantify ICU care. The high accuracy of Manitoba administrative data under the previous reporting standards, which lacked standardized coding elements specific to ICU care, may not be generalizable to other Canadian jurisdictions.

Once more unto the breach, dear friends, once more

The first issue of the World Journal of Critical Care Medicine (WJCCM), whose preparatory work was initiated on December 16, 2010, will be published on February 4, 2012. The WJCCM Editorial Board has now been established and consists of 105 distinguished experts from 27 countries. Our purpose of launching the WJCCM is to publish peer-reviewed, high-quality articles via an open-access online publishing model, thereby acting as a platform for communication between peers and the wider public, and maximizing the benefits to editorial board members, authors and readers.

Economic analysis of alvimopan for prevention and management of postoperative ileus

STUDY OBJECTIVE

To determine whether alvimopan for prevention of postoperative ileus in patients undergoing small- or large-bowel resection by laparotomy is associated with lower total costs compared with standard care.

DESIGN

Pharmacoeconomic analysis using a formal decision model.

DATA SOURCE

Four phase III clinical trials, two pooled analyses, and one meta-analysis.

PATIENT POPULATION

A cohort of patients who underwent bowel resection with primary anastomosis by laparotomy and received either standardized, accelerated postoperative care (usual care) or usual care plus alvimopan.

MEASUREMENTS AND MAIN RESULTS

Clinical outcomes, obtained from pooled analyses of published studies, were time to discharge order written, postoperative nasogastric tube insertion, postoperative ileus-related readmission within 7 days, and occurrence of nausea and vomiting. Cost inputs included drugs, nursing labor, readmissions, and hospitalizations. Costs were assessed by determining the net cost of alvimopan use and subsequent reduction in length of stay. Sensitivity and scenario analyses were conducted. Costs for alvimopan were $570 based on an average of 9.5 doses. Given the 18.4-hour mean reduction in time to discharge order written, use of alvimopan reduced hospitalization costs by $2021. Mean difference in overall cost of care, as determined by Monte Carlo simulation, was $1168 (95% certainty interval -$437 to $5879), favoring the use of alvimopan. In the sensitivity analysis, association of alvimopan with lower costs was robust to several changes in key parameters including cost and number of doses of alvimopan, time to discharge order written, readmission rates, and hospitalization cost. In the scenario analyses, alvimopan use yielded a net cost of $226 when no difference in time to discharge order written was assumed. In the scenario analysis using data from a study that did not enforce opioid use, alvimopan resulted in a cost saving of $65/patient.

CONCLUSION

Alvimopan was cost saving for prevention of postoperative ileus in patients undergoing bowel resection by laparotomy, although these potential cost savings were highly dependent on a difference in time to discharge order written. This finding is not applicable to the less-invasive laparoscopic surgical approach for which quality data on alvimopan use are lacking. Limitations of this analysis included use of time to discharge order written as a proxy for length of stay and difficulty interpreting study results due to inconsistent reporting and conduct of the clinical trials evaluating alvimopan. More research is needed to determine the cost-effectiveness of alvimopan.

Costs of critical care medicine

The main drivers of critical care medicine (CCM) costs are the numbers and use of intensive care unit (ICU) beds. The Russell equation, an indirect costing methodology, is most commonly used to estimate national CCM costs. Calculating national CCM costs in a standardized manner remains challenging because there is no universal approach to defining the types of hospitals, ICU beds, days, and billing codes to be included in the overall cost. Although numerous CCM cost-containment strategies have been proposed or implemented, CCM cost reduction remains elusive, and measuring cost remains challenging,given the complexities involved in assessing costs.

A model to predict short-term death or readmission after intensive care unit discharge

OBJECTIVE

Early unplanned readmission to the intensive care unit (ICU) carries a poor prognosis, and post-ICU mortality may be related, in part, to premature ICU discharge. Our objectives were to identify independent risk factors for early post-ICU readmission or death and to construct a prediction model.

DESIGN

Retrospective analysis of a prospective database was done.

SETTING

Four ICUs of the French Outcomerea network participated.

PATIENTS

Patients were consecutive adults with ICU stay longer than 24 hours who were discharged alive to same-hospital wards without treatment-limitation decisions.

MAIN RESULTS

Of 5014 admitted patients, 3462 met our inclusion criteria. Age was 60.6 ± 17.6 years, and admission Simplified Acute Physiology Score II (SAPS II) was 35.1 ± 15.1. The rate of death or ICU readmission within 7 days after ICU discharge was 3.0%. Independent risk factors for this outcome were age, SAPS II at ICU admission, use of a central venous catheter in the ICU, Sepsis-related Organ Failure Assessment and Systemic Inflammatory Response Syndrome scores before ICU discharge, and discharge at night. The predictive model based on these variables showed good calibration. Compared with SAPS II at admission or Stability and Workload Index for Transfer at discharge, discrimination was better with our model (area under receiver operating characteristics curve, 0.74; 95% confidence interval, 0.68-0.79).

CONCLUSION

Among patients without treatment-limitation decisions and discharged alive from the ICU, 3.0% died or were readmitted within 7 days. Independent risk factors were indicators of patients' severity and discharge at night. Our prediction model should be evaluated in other ICU populations.

Climate and cultural aspects in intensive care units

Research carried out in the field of work and organisational psychology shows that work unit climate and culture are important determinants of work unit performance. We briefly summarise what we have learnt about the climate-performance relationship in work units distinct from ICUs. Then, we show how the ICU culture can be measured, and summarise research on the culture-performance relationship in ICUs.

Evaluating the effectiveness of a tailored multifaceted performance feedback intervention to improve the quality of care: protocol for a cluster randomized trial in intensive care

BACKGROUND

Feedback is potentially effective in improving the quality of care. However, merely sending reports is no guarantee that performance data are used as input for systematic quality improvement (QI). Therefore, we developed a multifaceted intervention tailored to prospectively analyzed barriers to using indicators: the Information Feedback on Quality Indicators (InFoQI) program. This program aims to promote the use of performance indicator data as input for local systematic QI. We will conduct a study to assess the impact of the InFoQI program on patient outcome and organizational process measures of care, and to gain insight into barriers and success factors that affected the program's impact. The study will be executed in the context of intensive care. This paper presents the study's protocol.

METHODS/DESIGN

We will conduct a cluster randomized controlled trial with intensive care units (ICUs) in the Netherlands. We will include ICUs that submit indicator data to the Dutch National Intensive Care Evaluation (NICE) quality registry and that agree to allocate at least one intensivist and one ICU nurse for implementation of the intervention. Eligible ICUs (clusters) will be randomized to receive basic NICE registry feedback (control arm) or to participate in the InFoQI program (intervention arm). The InFoQI program consists of comprehensive feedback, establishing a local, multidisciplinary QI team, and educational outreach visits. The primary outcome measures will be length of ICU stay and the proportion of shifts with a bed occupancy rate above 80%. We will also conduct a process evaluation involving ICUs in the intervention arm to investigate their actual exposure to and experiences with the InFoQI program.

DISCUSSION

The results of this study will inform those involved in providing ICU care on the feasibility of a tailored multifaceted performance feedback intervention and its ability to accelerate systematic and local quality improvement. Although our study will be conducted within the domain of intensive care, we believe our conclusions will be generalizable to other settings that have a quality registry including an indicator set available.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN50542146.

Economics of ICU organization and management

The intensive care unit (ICU) is a complex system and the economic implications of altering care patterns in the ICU can be difficult to unravel. Few studies have specifically examined the economics of implementing organizational and management changes or acknowledged the many competing economic interests of patient, hospital,payer, and society. With continuously increasing healthcare costs,there is a great need for more studies focused on the optimal organization of the ICU. These studies should not focus solely on reductions in ICU length of stay but should strive to measure the true costs of care within a given healthcare system.

The ALIEN study: incidence and outcome of acute respiratory distress syndrome in the era of lung protective ventilation

PURPOSE

While our understanding of the pathogenesis and management of acute respiratory distress syndrome (ARDS) has improved over the past decade, estimates of its incidence have been controversial. The goal of this study was to examine ARDS incidence and outcome under current lung protective ventilatory support practices before and after the diagnosis of ARDS.

METHODS

This was a 1-year prospective, multicenter, observational study in 13 geographical areas of Spain (serving a population of 3.55 million at least 18 years of age) between November 2008 and October 2009. Subjects comprised all consecutive patients meeting American-European Consensus Criteria for ARDS. Data on ventilatory management, gas exchange, hemodynamics, and organ dysfunction were collected.

RESULTS

A total of 255 mechanically ventilated patients fulfilled the ARDS definition, representing an incidence of 7.2/100,000 population/year. Pneumonia and sepsis were the most common causes of ARDS. At the time of meeting ARDS criteria, mean PaO(2)/FiO(2) was 114 ± 40 mmHg, mean tidal volume was 7.2 ± 1.1 ml/kg predicted body weight, mean plateau pressure was 26 ± 5 cmH(2)O, and mean positive end-expiratory pressure (PEEP) was 9.3 ± 2.4 cmH(2)O. Overall ARDS intensive care unit (ICU) and hospital mortality was 42.7% (95%CI 37.7-47.8) and 47.8% (95%CI 42.8-53.0), respectively.

CONCLUSIONS

This is the first study to prospectively estimate the ARDS incidence during the routine application of lung protective ventilation. Our findings support previous estimates in Europe and are an order of magnitude lower than those reported in the USA and Australia. Despite use of lung protective ventilation, overall ICU and hospital mortality of ARDS patients is still higher than 40%.

Epidemiology of critical care syndromes, organ failures, and life-support interventions in a suburban US community

BACKGROUND

ICU services represent a significant and increasing proportion of medical care. Population-based epidemiologic studies are essential to inform physicians and policymakers about current and future ICU demands. We aimed to determine the incidence of critical care syndromes, organ failures, and life-support interventions in a defined US suburban community with unrestricted access to critical care services.

METHODS

This population-based observational cohort from January 1 to December 31, 2006, in Olmsted County, Minnesota, included all consecutive critically ill adult residents admitted to the ICU. Main outcomes were incidence of critical care syndromes, life-support interventions, and organ failures as defined by standard criteria. Incidences are reported per 100,000 population (95% CIs) and were age adjusted to the 2006 US population.

RESULTS

A total of 1,707 ICU admissions were identified from 1,461 patients. Incidences of critical care syndromes were respiratory failure, 430 (390-470); acute kidney injury, 290 (257-323); severe sepsis, 286 (253-319); all-cause shock, 194 (167-221); acute lung injury, 86 (68-105); all-cause coma, 43 (30-55); and overt disseminated intravascular coagulation, 18 (10-26). Incidence of mechanical ventilation was invasive, 310 (276-344); noninvasive, 180 (154-206); vasopressors and inotropes, 183(155-208). Renal replacement therapy incidence was 96 (77-116). Of the cohort, 1,330 patients (91%) survived to hospital discharge. Short- and long-term survival decreased by the number of failing organs.

CONCLUSIONS

In a suburban US community with high access to critical care services, cumulative incidences of critical care syndromes and life-support interventions were higher than previously reported. The results of this study have important implications for future planning of critical care delivery.

Recommendations on basic requirements for intensive care units: structural and organizational aspects

OBJECTIVE

To provide guidance and recommendations for the planning or renovation of intensive care units (ICUs) with respect to the specific characteristics relevant to organizational and structural aspects of intensive care medicine.

METHODOLOGY

The Working Group on Quality Improvement (WGQI) of the European Society of Intensive Care Medicine (ESICM) identified the basic requirements for ICUs by a comprehensive literature search and an iterative process with several rounds of consensus finding with the participation of 47 intensive care physicians from 23 countries. The starting point of this process was an ESICM recommendation published in 1997 with the need for an updated version.

RESULTS

The document consists of operational guidelines and design recommendations for ICUs. In the first part it covers the definition and objectives of an ICU, functional criteria, activity criteria, and the management of equipment. The second part deals with recommendations with respect to the planning process, floorplan and connections, accommodation, fire safety, central services, and the necessary communication systems.

CONCLUSION

This document provides a detailed framework for the planning or renovation of ICUs based on a multinational consensus within the ESICM.

Major sources of critical incidents in intensive care

Introduction

In recent years, critical incident (CI) reporting has increasingly been regarded as part of ongoing quality management. CI databanks also aim to improve health and safety issues for patients as well as staff. The aim of this study was to identify frequent causes of adverse events in critical care with the potential to harm patients, staff or visitors by analysing data from a voluntary and optionally anonymous critical incident reporting system.

Methods

The study includes all critical incidents reported during a 90-month period in a 13-bed adult general intensive care unit (ICU). Reporting of incidents was performed via an electronic reporting system or by a manual critical incident report. All CIs were classified in the following main categories: equipment, administration, pharmaceuticals, clinical practice, and health & safety hazards. The overall distribution of incidents within the different categories was compared with the regional database of ICUs in the Cheshire and Mersey region of northwest England for 2008.

Results

A total of 1127 CIs were reported during the study period. The frequencies within the main categories were: equipment 338 (30%), clinical practice 257 (22.8%), pharmaceuticals 238 (21.1%), administration 213 (18.9%), health and safety hazards 81 (7.2%). The regional database had a similar frequency of critical incidents within the different categories, suggesting that our results may reflect a general distribution pattern of CIs in intensive care.

Conclusions

Critical incident reporting helps to identify frequent causes of adverse events in critical care. Improvements in quality of care following implementation of preventative strategies such as introduction of regular equipment training sessions will have to be assessed further in future studies.

The challenge of admitting the very elderly to intensive care

The aging of the population has increased the demand for healthcare resources. The number of patients aged 80 years and older admitted to the intensive care unit (ICU) increased during the past decade, as has the intensity of care for such patients. Yet, many physicians remain reluctant to admit the oldest, arguing a "squandering" of societal resources, that ICU care could be deleterious, or that ICU care may not actually be what the patient or family wants in this instance. Other ICU physicians are strong advocates for admission of a selected elderly population. These discrepant opinions may partly be explained by the current lack of validated criteria to select accurately the patients (of any age) who will benefit most from ICU hospitalization. This review describes the epidemiology of the elderly aged 80 years and older admitted in the ICU, their long-term outcomes, and to discuss some of the solutions to cope with the burden of an aging population receiving acute care hospitalization.

'Score to Door Time', a benchmarking tool for rapid response systems: a pilot multi-centre service evaluation

Introduction

Rapid Response Systems were created to minimise delays in recognition and treatment of deteriorating patients on general wards. Physiological 'track and trigger' systems are used to alert a team with critical care skills to stabilise patients and expedite admission to intensive care units. No benchmarking tool exists to facilitate comparison for quality assurance. This study was designed to create and test a tool to analyse the efficiency of intensive care admission processes.

Methods

We conducted a pilot multicentre service evaluation of patients admitted to 17 intensive care units from the United Kingdom, Ireland, Denmark, United States of America and Australia. Physiological abnormalities were recorded via a standardised track and trigger score (VitalPAC™ Early Warning Score). The period between the time of initial physiological abnormality (Score) and admission to intensive care (Door) was recorded as 'Score to Door Time'. Participants subsequently suggested causes for admission delays.

Results

Score to Door Time for 177 admissions was a median of 4:10 hours (interquartile range (IQR) 1:49 to 9:10). Time from physiological trigger to activation of a Rapid Response System was a median 0:47 hours (IQR 0:00 to 2:15). Time from call-out to intensive care admission was a median of 2:45 hours (IQR 1:19 to 6:32). A total of 127 (71%) admissions were deemed to have been delayed. Stepwise linear regression analysis yielded three significant predictors of longer Score to Door Time: being treated in a British centre, higher Acute Physiology and Chronic Health Evaluation (APACHE) II score and increasing age. Binary regression analysis demonstrated a significant association (P < 0.045) of APACHE II scores >20 with Score to Door Times greater than the median 4:10 hours.

Conclusions

Score to Door Time seemed to be largely independent of illness severity and, when combined with qualitative feedback from centres, suggests that admission delays could be due to organisational issues, rather than patient factors. Score to Door Time could act as a suitable benchmarking tool for Rapid Response Systems and helps to delineate avoidable organisational delays in the care of patients at risk of catastrophic deterioration.

Characteristics and outcomes of very elderly patients after first hospitalization for heart failure

BACKGROUND

The very elderly (age 80 years and older) with heart failure (HF) is a growing population that is rarely included in clinical trials. The aim of this investigation was to describe the characteristics and outcomes of very elderly patients after a first HF hospitalization.

METHODS AND RESULTS

We identified very elderly patients (age 80 years and older) discharged with HF from the Veteran's Administration National Patient Care Database from 1999 to 2008. Outcomes of interest were death during index admission, 30-day and 1-year mortality, and 30-day all-cause and HF readmissions. We used generalized estimating equations to evaluate outcome differences between age groups within the very elderly cohort (ages 80 to 84, 85 to 89, and 90 and older), adjusting for comorbidities, demographics, and clustering by treatment facility. We identified 21 397 very elderly veterans with a first HF hospitalization during the study period. Thirty-day mortality decreased from 14% to 7% (both P<0.001) and 1-year mortality decreased from 49% to 27% (P<0.001). Although these improvements were most notable for patients age 90 and older (1-year mortality improved by 25.9%), the adjusted odds of death within 1 year were highest for the oldest veterans (odds ratio, 1.85; 95% confidence interval, 1.64 to 2.09, using the 80- to 85-year age group as reference). For all patients, 30-day all-cause readmissions remained largely unchanged and did not differ between age groups.

CONCLUSIONS

Mortality for very elderly HF patients has improved over time, but 30-day readmissions remain frequent. Future studies should identify interventions to reduce cardiac and noncardiac rehospitalization of very elderly HF patients.