Priority Levels in Medical Intensive Care at an Academic Public Hospital

Clinical Utility of the Tokyo Guidelines 2018 for Acute Cholangitis in the Emergency Department and Comparison with Novel Markers (Neutrophil-to-Lymphocyte and Blood Nitrogen Urea-to-Albumin Ratios)

Introduction: The Tokyo Guidelines 2018 (TG2018) is a scoring system used to recommend the clinical management of AC. However, such a scoring system must incorporate a variety of clinical outcomes of acute cholangitis (AC). In an emergency department (ED)-based setting, where efficiency and practicality are highly desired, clinicians may find the application of various parameters challenging. The neutrophil-to-lymphocyte ratio (NLR) and blood urea nitrogen-to-albumin ratio (BAR) are relatively common biomarkers used to assess disease severity. This study evaluated the potential value of TG2018 scores measured in an ED to predict a variety of clinical outcomes. Furthermore, the study also compared TG2018 scores with NLR and BAR scores to demonstrate their usefulness. Methods: This retrospective observational study was performed in an ED. In total, 502 patients with AC visited the ED between January 2016 and December 2021. The primary endpoint was to evaluate whether the TG2018 scoring system measured in the ED was a predictor of intensive care, long-term hospital stays (≥14 days), percutaneous transhepatic biliary drainage (PTBD) during admission care, and endotracheal intubation (ETI). Results: The analysis included 81 patients requiring intensive care, 111 requiring long-term hospital stays (≥14 days), 49 requiring PTBD during hospitalization, and 14 requiring ETI during hospitalization. For the TG2018 score, the adjusted OR (aOR) using (1) as a reference was 23.169 (95% CI: 9.788-54.844) for (3) compared to (1). The AUC of the TG2018 for the need for intensive care was 0.850 (95% CI: 0.815-0.881) with a cutoff of >2. The AUC for long-term hospital stays did not exceed 0.7 for any of the markers. the AUC for PTBD also did not exceed 0.7 for any of the markers. The AUC for ETI was the highest for BAR at 0.870 (95% CI: 0.837-0.899) with a cutoff value of >5.2. Conclusions: The TG2018 score measured in the ED helps predict various clinical outcomes of AC. Other novel markers such as BAR and NLR are also associated, but their explanatory power is weak.

Predictors of ICU Mortality among Mechanically Ventilated Patients: An Inception Cohort Study from a Tertiary Care Center in Addis Ababa, Ethiopia

BACKGROUND

Mechanical ventilation is a life-saving intervention for patients with critical illnesses, yet it is associated with higher mortality in resource-constrained settings. This study intended to determine factors associated with the mortality of mechanically ventilated adult intensive care unit (ICU) patients.

METHODS

A one-year retrospective inception cohort study was conducted using manual chart review in ICU patients (age >13) admitted to Tikur Anbessa Specialized Hospital (Addis Ababa, Ethiopia) from September 2019 to September 2020; mechanically ventilated patients were followed to hospital discharge. Demographic, clinical, and outcome data were collected; logistic regression was used to determine mortality predictors in the ICU.

RESULT

A total of 160 patients were included; 85/160 (53.1%) were females and the mean (SD) age was 38.9 (16.2) years. The commonest indication for ICU admission was a respiratory problem (n = 97/160, 60.7%). ICU and hospital mortality were 60.7% (n = 97/160) and 63.1% (n = 101/160), respectively. Coma (Glasgow Coma Score <8 or 7 with an endotracheal tube (7T)) (adjusted odds ratio [AOR] 6.3, 95% confidence interval 1.19-33.00), cardiovascular diagnosis (AOR 5.05 [1.80-14.15]), and a very low serum albumin level (<2 g/dl) (AOR 4.9 [1.73-13.93]) were independent predictors of mortality (P < 0.05). The most commonly observed complication was ICU acquired infection (n = 48, 30%).

CONCLUSIONS

ICU mortality in ventilated patients is high. Coma, a very low serum albumin level (<2 g/dl), and cardiovascular diagnosis were independent predictors of mortality. A multifaceted approach focused on developing and implementing context appropriate guidelines and improving skilled healthcare worker availability may prove effective in reducing mortality.

Machine Learning Model Development and Validation for Predicting Outcome in Stage 4 Solid Cancer Patients with Septic Shock Visiting the Emergency Department: A Multi-Center, Prospective Cohort Study

A reliable prognostic score for minimizing futile treatments in advanced cancer patients with septic shock is rare. A machine learning (ML) model to classify the risk of advanced cancer patients with septic shock is proposed and compared with the existing scoring systems. A multi-center, retrospective, observational study of the septic shock registry in patients with stage 4 cancer was divided into a training set and a test set in a 7:3 ratio. The primary outcome was 28-day mortality. The best ML model was determined using a stratified 10-fold cross-validation in the training set. A total of 897 patients were included, and the 28-day mortality was 26.4%. The best ML model in the training set was balanced random forest (BRF), with an area under the curve (AUC) of 0.821 to predict 28-day mortality. The AUC of the BRF to predict the 28-day mortality in the test set was 0.859. The AUC of the BRF was significantly higher than those of the Sequential Organ Failure Assessment score and the Acute Physiology and Chronic Health Evaluation II score (both p < 0.001). The ML model outperformed the existing scores for predicting 28-day mortality in stage 4 cancer patients with septic shock. However, further studies are needed to improve the prediction algorithm and to validate it in various countries. This model might support clinicians in real-time to adopt appropriate levels of care.

International Normalized Ratio-to-Albumin Ratio as a Novel Marker of Upper Gastrointestinal Bleeding Severity

Introduction

Upper gastrointestinal bleeding (UGIB) is a potentially life-threatening gastrointestinal emergency, and effective management depends on early risk stratification. The Glasgow–Blatchford and Rockall scores are commonly used prognostic measures for UGIB, although these scoring systems are relatively difficult to apply in early emergency settings. AIMS65 with five items, albumin, international normalized ratio, mental status, systolic blood pressure, and age (>65 years), showed efficacy in predicting long-term hospitalization and mortality. This study aimed to investigate the usefulness of the prothrombin time-international normalized ratio-to-albumin ratio (PTAR) in the emergency room for early UGIB risk stratification.

Methods

We retrospectively examined patients who visited a tertiary academic hospital's emergency department (ED) with UGIB as the chief presentation between January 2019 and December 2020. The cutoff values and diagnostic accuracies of the PTAR, Glasgow–Blatchford score, AIMS65 score, pre-endoscopy, and complete Rockall score were analyzed, and the performance of the PTAR was compared with that of other risk stratification methods. In total, 519 patients were enrolled: 163 patients were admitted in the intensive care unit (ICU) and 35 died during admission. Multiple logistic regression analyses confirmed the association of the PTAR with ICU admission and mortality. The adjusted odd ratio (aOR) of the PTAR for ICU admission care was 8.376 (2.722–25.774), and the aOR of the PTAR for mortality was 27.846 (8.701–89.116).

Conclusions

The PTAR measured in the ED is an independent factor related to ICU admission and mortality in patients with UGIB. Using ED blood laboratory results, which are reported relatively quickly and are easy to acquire and calculate, the PTAR can be used as a risk stratification marker in the early emergency setting.

Usefulness of the d-dimer to albumin ratio for risk assessment in patients with acute variceal bleeding at the emergency department: retrospective observational study

Background

Acute variceal bleeding (AVB) is a severe complication of portal hypertension that is caused by rupture of the esophageal or gastric varix. Scoring system for risk stratification of AVB is difficult to use because various variables must be entered, and it is difficult to apply early in the emergency department (ED). We compared and analyzed the usefulness of the D-dimer to albumin ratio (DAR) for risk stratification of AVB.

Methods

In this retrospective observational study, medical records of patients with AVB Between January 2019 and December 2020 were assessed. The primary endpoint was to evaluate whether DAR was a predictor of clinical outcomes for AVB. Receiver operating characteristic (ROC) curves were constructed using cut-off values determined by the Youden Index. Univariate and multivariate logistic regression analyses were performed to assess the factors contributing to the development of outcomes.

Results

Overall, 67 patients required intensive care. The cut-off value of DAR for patients requiring intensive care was 400. A DAR > 400 (adjusted HR: 5.636 [95% CI: 2.216–14.332]) independently predicted the need for ICU admission in these patients. Overall, 13 patients required long-term hospitalization. The cut-off value of DAR for patients requiring long-term hospitalization was 403. A DAR > 403 (adjusted HR: 9.899 [95% CI: 2.012–48.694]) independently predicted the need for long-term hospitalization. Overall, 95 patients required transfusion. The cut-off value of DAR for patients requiring transfusion was 121. A DAR > 121 (adjusted HR: 4.680 [95% CI: 1.703–12.862]) independently predicted the need for transfusion. Overall, 11 patients died during study period. The cut-off value of DAR for mortality was 450. A DAR > 450 (adjusted HR: 26.261 [95% CI: 3.054–225.827]) independently predicted mortality.

Conclusions

The DAR can be used for outcome assessment in patients with AVB with various scoring systems, but its explanatory power is not high.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-022-00696-4.

Resource Utilization in Children who Receive a Pediatric Intensive Care Unit Consult in the Emergency Department: A Retrospective Cohort Study

OBJECTIVES

To describe the characteristics, critical care resource requirements, and outcomes of children who were hospitalized after a Pediatric Intensive Care Unit (PICU) consult in the Emergency Department (ED).

METHODS

In this single-centre retrospective cohort study, we conducted chart reviews for children (<18 years) hospitalized following a PICU consult in the ED to examine patient characteristics, timing of consult, ED length of stay, Medical Emergency Team (MET) utilization, PICU nursing workload, and critical care interventions for children who were and were not admitted to the PICU.

RESULTS

During the one-year study period, 247 PICU consults were performed in the ED resulting in 161 (65.2%) direct admissions to PICU and 1 indirect PICU admission via the ward. Of 105 children with complex chronic conditions, 73 (69.5%) were admitted to PICU, including 32 (91.4%) of 35 children with chronic home ventilatory needs, only 2 (6.2%) of whom received a critical care intervention beyond respiratory support. Within 24 h of hospitalization, 112 (69.1%) of 162 PICU admissions received a critical care-specific intervention. Of 86 (34.8%) ward admissions, 16 (18.6%) were reviewed by the MET. Children admitted to the ward had a significantly longer post-consult ED length of stay than children admitted to PICU (median 428 min vs. 130 min; p <0.0001).

CONCLUSIONS

Over two-thirds of children admitted to PICU from the ED required early critical care interventions, with the remainder potentially benefitting from closer monitoring or a higher frequency of non-critical care interventions than can be reasonably provided on general inpatient wards. More research is needed to evaluate critical care and hospital resource utilization when children are triaged to the ward following a PICU consult in the ED.

Empiric Treatment in HAP/VAP: “Don’t You Want to Take a Leap of Faith?”

Ventilator-associated pneumonia is a frequent cause of ICU-acquired infections. These infections are associated with high morbidity and mortality. The increase in antibiotic resistance, particularly among Gram-negative bacilli, makes the choice of empiric antibiotic therapy complex for physicians. Multidrug-resistant organisms (MDROs) related infections are associated with a high risk of initial therapeutic inadequacy. It is, therefore, necessary to quickly identify the bacterial species involved and their susceptibility to antibiotics. New diagnostic tools have recently been commercialized to assist in the management of these infections. Moreover, the recent enrichment of the therapeutic arsenal effective on Gram-negative bacilli raises the question of their place in the therapeutic management of these infections. Most national and international guidelines recommend limiting their use to microbiologically documented infections. However, many clinical situations and, in particular, the knowledge of digestive or respiratory carriage by MDROs should lead to the discussion of the use of these new molecules, especially the new combinations with beta-lactamase inhibitors in empirical therapy. In this review, we present the current epidemiological data, particularly in terms of MDRO, as well as the clinical and microbiological elements that may be taken into account in the discussion of empirical antibiotic therapy for patients managed for ventilator-associated pneumonia.

A Single-Center Retrospective Evaluation of Unplanned Pediatric Critical Care Upgrades

Background Inappropriate triage of critically ill pediatric patients can lead to poor outcomes and suboptimal resource utilization. This study aimed to determine and describe the demographic characteristics, diagnostic categories, and timing of unplanned upgrades to the pediatric intensive care unit (PICU) that required short (< 24 hours of care) and extended (≥ 24 hours of care) stays. In this article, we hypothesized that we will identify demographic characteristics, diagnostic categories, and frequent upgrade timing periods in both of these groups that may justify more optimal triage strategies.

Methods This was a single-institution retrospective study of unplanned PICU upgrades between 2012 and 2018. The cohort was divided into two groups (short and extended PICU stay). We reviewed the electronic health record and evaluated for: demographics, mortality scores, upgrade timing (7a-3p, 3p-11p, 11p-7a), lead-in time (time spent on clinical service before upgrade), patient origin, and diagnostic category.

Results Four hundred and ninety-eight patients' unplanned PICU upgrades were included. One hundred and nine patients (21.9%) required a short and 389 (78.1%) required an extended PICU stay. Lead-in time (mean, standard deviation) was significantly lower in the short group (0.65 ± 0.66 vs. 0.91 ± 0.82) (p = 0.0006). A higher proportion of short group patients (59, 46.1%) were upgraded during the 3p-11p shift (p = 0.0077).

Conclusion We found that approximately one-fifth of PICU upgrades required less than 24 hours of critical care services, were more likely to be transferred between 3p-11p, and had lower lead-in times. In institutions where ill pediatric patients can be admitted to either a PICU or a monitored step-down unit, this study highlights quality improvement opportunities, particularly in recognizing which pediatric patients truly need critical care.

Primary palliative care integrated model in paediatric ICU: an international cross-sectional study

OBJECTIVES

Numbers are rising of chronically and critically ill, technology-dependent children, who are admitted to paediatric intensive care units (PICUs). An integrated model of care (IMOC), that combines paediatric critical care and primary paediatric palliative care (PPC), in which either approach varies depending on the disease trajectory and is provided by the critical care team, might be a fundamental component of the best available standard of care for patients with life-threatening conditions. The objective of this study is to assess how PICUs around the world, implement an IMOC.

METHODS

International multicentre cross-sectional observational study. Data was gathered from 34 PICUs from 18 countries in the Americas, Europe, Asia and Africa. Provision of primary PPC was studied for each child admitted at the PICU. We evaluated score differences in each domain of the Initiative for Paediatric Palliative Care (IPPC) curriculum with multilevel generalised linear models.

RESULTS

High-income country (HIC) units made up 32.4% of the sample, upper-middle income countries (UMICs) 44.1%, lower-middle income/lower income countries (LMIC/LICs) 23.5%. HICs had four statistically significantly higher IPPC scores compared with UMICs (domains: 1 holistic care; 2 family support, 3B family involvement; 6B grief/bereavement healthcare provider support) and two compared with LMIC/LICs (domains: 6A grief/bereavement family support; 6B grief/bereavement healthcare provider support).HICs had a statistically significant overall higher IPPC score than UMICs. Adjusting for patient/centre characteristics, shorter shifts and multiple comorbidities were associated with higher IPPC scores.

CONCLUSIONS

All centres offered some PPC provision and partially applied an IMOC. These results are encouraging, however, differences related to income and patients/unit evidence opportunities for improvement.

TRIAL REGISTRATION NUMBER

ISRCTN12556149.

Critical Care Utilization and Outcomes of Interhospital Medical Transfers at Lower Risk of Death

PURPOSE

To evaluate utilization and mortality outcomes of interhospital transferred critically-ill medical patients with lower predicted risk of hospital mortality.

MATERIALS & METHODS

Multisite retrospective cohort analysis of patients with Acute Physiology and Chronic Health Evaluation (APACHE) IV-a predicted mortality of ≤20% from 335 ICUs in 208 hospitals in the Philips eICU database between 2014-2015. Differences in length-of-stay (LOS) and mortality between transferred and local patients were evaluated using negative binomial logistic regression and logistic regression, respectively. Stratified analyses were conducted for subgroups of predicted mortality: 0%-5%, 6%-10%, 11%-15%, and 16%-20%.

RESULTS

Transfers had a higher risk of longer ICU and hospital LOS across all risk strata (IRR 1.12; 95% CI 1.09-1.16, P < 0.001 and IRR 1.11; 95% CI 1.07-1.14, P < 0.001 respectively). Mortality was higher among transfers, largely driven by the 6%-10% mortality risk strata (OR 1.30; 95% CI 1.09-1.54, P = 0.003).

CONCLUSIONS

Interhospital transfer of critically-ill medical patients with lower illness severity is associated with higher ICU and hospital utilization and increased mortality. Better understanding of factors driving patient selection for and characteristics of interhospital transfer for this population will have an impact on ICU resource utilization, care efficiency, and hospital quality.

Evaluation of Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses and Reduction of Nonbeneficial ICU Treatments

IMPORTANCE

For critically ill patients with advanced medical illnesses and poor prognoses, overuse of invasive intensive care unit (ICU) treatments may prolong suffering without benefit.

OBJECTIVE

To examine whether use of time-limited trials (TLTs) as the default care-planning approach for critically ill patients with advanced medical illnesses was associated with decreased duration and intensity of nonbeneficial ICU care.

DESIGN, SETTING, AND PARTICIPANTS

This prospective quality improvement study was conducted from June 1, 2017, to December 31, 2019, at the medical ICUs of 3 academic public hospitals in California. Patients at risk for nonbeneficial ICU treatments due to advanced medical illnesses were identified using categories from the Society of Critical Care Medicine guidelines for admission and triage.

INTERVENTIONS

Clinicians were trained to use TLTs as the default communication and care-planning approach in meetings with family and surrogate decision makers.

MAIN OUTCOMES AND MEASURES

Quality of family meetings (process measure) and ICU length of stay (clinical outcome measure).

RESULTS

A total of 209 patients were included (mean [SD] age, 63.6 [16.3] years; 127 men [60.8%]; 101 Hispanic patients [48.3%]), with 113 patients (54.1%) in the preintervention period and 96 patients (45.9%) in the postintervention period. Formal family meetings increased from 68 of 113 (60.2%) to 92 of 96 (95.8%) patients between the preintervention and postintervention periods (P < .01). Key components of family meetings, such as discussions of risks and benefits of ICU treatments (preintervention, 15 [34.9%] vs postintervention, 56 [94.9%]; P < .01), eliciting values and preferences of patients (20 [46.5%] vs 58 [98.3%]; P < .01), and identifying clinical markers of improvement (9 [20.9%] vs 52 [88.1%]; P < .01), were discussed more frequently after intervention. Median ICU length of stay was significantly reduced between preintervention and postintervention periods (8.7 [interquartile range (IQR), 5.7-18.3] days vs 7.4 [IQR, 5.2-11.5] days; P = .02). Hospital mortality was similar between the preintervention and postintervention periods (66 of 113 [58.4%] vs 56 of 96 [58.3%], respectively; P = .99). Invasive ICU procedures were used less frequently in the postintervention period (eg, mechanical ventilation preintervention, 97 [85.8%] vs postintervention, 70 [72.9%]; P = .02).

CONCLUSIONS AND RELEVANCE

In this study, a quality improvement intervention that trained physicians to communicate and plan ICU care with family members of critically ill patients in the ICU using TLTs was associated with improved quality of family meetings and a reduced intensity and duration of ICU treatments. This study highlights a patient-centered approach for treating critically ill patients that may reduce nonbeneficial ICU care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04181294.

Use of intensive care unit priority model in directing intensive care unit admission in Sudan: A prospective cross-sectional study

Background:

The shortage of specialized intensive care beds is one of the principal factors that limit intensive care unit (ICU) admissions. This study explores the utilization of priority criteria in directing ICU admission and predicting outcomes.

Methods:

This was a prospective cross-sectional study conducted in two ICUs in Sudan from April to December 2018. Patients were assessed for ICU admission and were ranked by priority into Groups 1, 2, 3, and 4 (1 highest priority and 4 lowest priority), and these groups were compared using independent t-test, Chi-square, and ANOVA.

Results:

A total of 180 ICU admitted patients were enrolled, 53% were male. The prioritization categories showed that 86 (47.8%), 50 (27.8%), 13 (7.2%), and 31 (17.2%) were categorized as priority 1, 2, 3, and 4, respectively. Patients in priority groups 3 and 4had significantly higher ICU mortality rates compared to those in groups 1 and 2 (P < 0.001), were likely to be older (P < 0.001), had significantly more comorbidities (P = 0.001), were more likely to be dependent (P < 0.001), and had longer ICU length of stay (P = 0.028).

Conclusion:

Patients classified as priority 3 and 4 were predominantly older and had many comorbidities. They were likely to be dependent, stay longer in ICU, and exhibit mortality.

Development and validation of the VitaL CLASS score to predict mortality in stage IV solid cancer patients with septic shock in the emergency department: a multi-center, prospective cohort study

BACKGROUND

Clinical decision-making of invasive high-intensity care for critically ill stage IV cancer patients in the emergency department (ED) is challenging. A reliable and clinically available prognostic score for advanced cancer patients with septic shock presented at ED is essential to improve the quality of intensive care unit care. This study aimed to develop a new prognostic score for advanced solid cancer patients with septic shock available early in the ED and to compare the performance to the previous severity scores.

METHODS

This multi-center, prospective cohort study included consecutive adult septic shock patients with stage IV solid cancer. A new scoring system for 28-day mortality was developed and validated using the data of development (January 2016 to December 2017; n = 469) and validation sets (January 2018 to June 2019; n = 428). The developed score's performance was compared to that of the previous severity scores.

RESULTS

New scoring system for 28-day mortality was based on six variables (score range, 0-8): vital signs at ED presentation (respiratory rate, body temperature, and altered mentation), lung cancer type, and two laboratory values (lactate and albumin) in septic shock (VitaL CLASS). The C-statistic of the VitaL CLASS score was 0.808 in the development set and 0.736 in the validation set, that is superior to that of the Sequential Organ Failure Assessment score (0.656, p = 0.01) and similar to that of the Acute Physiology and Chronic Health Evaluation II score (0.682, p = 0.08). This score could identify 41% of patients with a low-risk group (observed 28-day mortality, 10.3%) and 7% of patients with a high-risk group (observed 28-day mortality, 73.3%).

CONCLUSIONS

The VitaL CLASS score could be used for both risk stratification and as part of a shared clinical decision-making strategy for stage IV solid cancer patients with septic shock admitting at ED within several hours.

Rethinking How We Measure Costs in Implementation Research

BACKGROUND

Hospitals and other health care delivery organizations are sometimes resistant to implementing evidence-based programs, citing unknown budgetary implications.

OBJECTIVE

In this paper, I discuss challenges when estimating health care costs in implementation research.

DESIGN

A case study with intensive care units highlights how including fixed costs can cloud a short-term analysis.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN MEASURES

Health care costs, charges and payments.

KEY RESULTS

Cost data should accurately reflect the opportunity costs for the organization(s) providing care. Opportunity costs are defined as the benefits foregone because the resources were not used in the next best alternative. Because there is no database of opportunity costs, cost studies rely on accounting data, charges, or payments as proxies. Unfortunately, these proxies may not reflect the organization's opportunity costs, especially if the goal is to understand the budgetary impact in the next few years.

CONCLUSIONS

Implementation researchers should exclude costs that are fixed in the time period of observation because these assets (e.g., space) cannot be used in the next best alternative. In addition, it is common to use costs from accounting databases where we implicitly assume health care providers are uniformly efficient. If providers are not operating efficiently, especially if there is variation in their efficiency, then this can create further problems. Implementation scientists should be judicious in their use of cost estimates from accounting data, otherwise research results can misguide decision makers.

Development and validation of delirium prediction model for critically ill adults parameterized to ICU admission acuity

Background

Risk prediction models allow clinicians to forecast which individuals are at a higher risk for developing a particular outcome. We developed and internally validated a delirium prediction model for incident delirium parameterized to patient ICU admission acuity.

Methods

This retrospective, observational, fourteen medical-surgical ICU cohort study evaluated consecutive delirium-free adults surviving hospital stay with ICU length of stay (LOS) greater than or equal to 24 hours with both an admission APACHE II score and an admission type (e.g., elective post-surgery, emergency post-surgery, non-surgical) in whom delirium was assessed using the Intensive Care Delirium Screening Checklist (ICDSC). Risk factors included in the model were readily available in electric medical records. Least absolute shrinkage and selection operator logistic (LASSO) regression was used for model development. Discrimination was determined using area under the receiver operating characteristic curve (AUC). Internal validation was performed by cross-validation. Predictive performance was determined using measures of accuracy and clinical utility was assessed by decision-curve analysis.

Results

A total of 8,878 patients were included. Delirium incidence was 49.9% (n = 4,431). The delirium prediction model was parameterized to seven patient cohorts, admission type (3 cohorts) or mean quartile APACHE II score (4 cohorts). All parameterized cohort models were well calibrated. The AUC ranged from 0.67 to 0.78 (95% confidence intervals [CI] ranged from 0.63 to 0.79). Model accuracy varied across admission types; sensitivity ranged from 53.2% to 63.9% while specificity ranged from 69.0% to 74.6%. Across mean quartile APACHE II scores, sensitivity ranged from 58.2% to 59.7% while specificity ranged from 70.1% to 73.6%. The clinical utility of the parameterized cohort prediction model to predict and prevent incident delirium was greater than preventing incident delirium by treating all or none of the patients.

Conclusions

Our results support external validation of a prediction model parameterized to patient ICU admission acuity to predict a patients’ risk for ICU delirium. Classification of patients’ risk for ICU delirium by admission acuity may allow for efficient initiation of prevention measures based on individual risk profiles.

Seasonal variation of clinical characteristics and prognostic of adult patients admitted to an intensive care unit

OBJECTIVE

To evaluate seasonal variations of clinical characteristics, therapeutic resource use, and outcomes of critically ill patients admitted to an intensive care unit.

METHODS

A retrospective cohort study conducted from January 2011 to December 2016 in adult patients admitted to the intensive care unit (ICU) of a University Hospital. Data were collected on the type of admission, APACHE II, SOFA, and TISS 28 scores at ICU admission. Length of hospital stay and vital status at hospital discharge were recorded. A significance level of 5% was adopted.

RESULTS

During the study period, 3.711 patients were analyzed. Patients had a median age of 60.0 years (interquartile range = 45.0 - 73.0), and 59% were men. The independent risk factors associated with increased hospital mortality rate were age, chronic disease, seasonality, diagnostic category, need for mechanical ventilation and vasoactive drugs, presence of acute kidney injury, and sepsis at admission.

CONCLUSION

It was possible to observe variations of the clinical characteristics and prognosis of patients; summer months presented a higher proportion of clinical and emergency surgery patients, with higher mortality rates. Sepsis at ICU admission did not show seasonal behavior. A seasonal pattern was found for mortality rate.

Time-Limited Trials Among Critically Ill Patients With Advanced Medical Illnesses to Reduce Nonbeneficial Intensive Care Unit Treatments: Protocol for a Multicenter Quality Improvement Study

Background

Invasive intensive care unit (ICU) treatments for patients with advanced medical illnesses and poor prognoses may prolong suffering with minimal benefit. Unfortunately, the quality of care planning and communication between clinicians and critically ill patients and their families in these situations are highly variable, frequently leading to overutilization of invasive ICU treatments. Time-limited trials (TLTs) are agreements between the clinicians and the patients and decision makers to use certain medical therapies over defined periods of time and to evaluate whether patients improve or worsen according to predetermined clinical parameters. For patients with advanced medical illnesses receiving aggressive ICU treatments, TLTs can promote effective dialogue, develop consensus in decision making, and set rational boundaries to treatments based on patients’ goals of care.

Objective

The aim of this study will be to examine whether a multicomponent quality-improvement strategy that uses protocoled TLTs as the default ICU care-planning approach for critically ill patients with advanced medical illnesses will decrease duration and intensity of nonbeneficial ICU care without changing hospital mortality.

Methods

This study will be conducted in medical ICUs of three public teaching hospitals in Los Angeles County. In Aim 1, we will conduct focus groups and semistructured interviews with key stakeholders to identify facilitators and barriers to implementing TLTs among ICU patients with advanced medical illnesses. In Aim 2, we will train clinicians to use protocol-enhanced TLTs as the default communication and care-planning approach in patients with advanced medical illnesses who receive invasive ICU treatments. Eligible patients will be those who the treating ICU physicians consider to be at high risk for nonbeneficial treatments according to guidelines from the Society of Critical Care Medicine. ICU physicians will be trained to use the TLT protocol through a curriculum of didactic lectures, case discussions, and simulations utilizing actors as family members in role-playing scenarios. Family meetings will be scheduled by trained care managers. The improvement strategy will be implemented sequentially in the three participating hospitals, and outcomes will be evaluated using a before-and-after study design. Key process outcomes will include frequency, timing, and content of family meetings. The primary clinical outcome will be ICU length of stay. Secondary outcomes will include hospital length of stay, days receiving life-sustaining treatments (eg, mechanical ventilation, vasopressors, and renal replacement therapy), number of attempts at cardiopulmonary resuscitation, frequency of invasive ICU procedures, and disposition from hospitalization.

Results

The study began in August 2017. The implementation of interventions and data collection were completed at two of the three hospitals. As of September 2019, the study was at the postintervention stage at the third hospital. We have completed focus groups with physicians at each medical center (N=29) and interviews of family members and surrogate decision makers (N=18). The study is expected to be completed in the first quarter of 2020, and results are expected to be available in mid-2020.

Conclusions

The successful completion of the aims in this proposal may identify a systematic approach to improve communication and shared decision making and to reduce nonbeneficial invasive treatments for ICU patients with advanced medical illnesses.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16301

The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying

OBJECTIVE

Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients.

DESIGN

Retrospective cohort study.

SETTING

Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015.

PATIENTS

Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa-predicted mortality of 3% or less.

EXPOSURE

ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles.

MEASUREMENTS AND MAIN RESULTS

We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8 ± 2.1 and 5.2 ± 5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa-predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10-1.49] for low-; 1.24 [95% CI, 1.07-1.42] for medium-, and 1.14 [95% CI, 0.99-1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82-0.90] for low-, 0.88 [95% CI, 0.85-0.92] for medium-, and 0.95 [95% CI, 0.92-0.99] for high-acuity ICUs).

CONCLUSIONS

Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

Characteristics and Outcomes of Potentially Inappropriate Admissions to the Intensive Care Unit

Background

Admission of patients perceived as potentially inappropriate for intensive care is a very sensitive and controversial issue. We aimed to evaluate the use of medical resources in the intensive care unit (ICU) and outcomes of patients according to a physician’s judgment of appropriateness.

Methods

ICU physicians classified patients who were admitted to the medical ICU of a tertiary hospital as appropriate or inappropriate for intensive care within 24 hours of admission. Patient outcomes including mortality were analyzed according to appropriateness. Additionally, the usage and duration of mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) were analyzed according to appropriateness.

Results

In total, 105 patients (male, 55.4%; mean age, 62 years) were included. Twelve (11.4%) patients were considered inappropriate for intensive care based on guidance published by the Society of Critical Care Medicine through a questionnaire survey of physicians. There was no significant difference between patients considered inappropriate or appropriate for ICU admission regarding the use and duration of MV, RRT, and ECMO. In contrast, the ICU, in-hospital, 28-day, 90-day, and total mortality rates were significantly higher among patients with inappropriate admission than among patients with appropriate admission (ICU mortality: 50.0% vs. 25.8%, P=0.008; in-hospital mortality: 58.3% vs. 43.0%, P=0.028; 28-day mortality: 58.3% vs. 33.3%, P=0.019; 90-day mortality: 66.7% vs. 44.1%, P=0.023).

Conclusions

Despite higher mortality, the amount of medical resources used for patients considered potentially inappropriate for intensive care did not differ from the resources used for patients considered suitable for ICU care.

2018 Update on Medical Overuse

IMPORTANCE

Overuse of medical care is a well-recognized problem in health care, associated with patient harm and costs. We sought to identify and highlight original research articles published in 2017 that are most relevant to understanding medical overuse.

OBSERVATIONS

A structured review of English-language articles published in 2017 was performed, coupled with examination of tables of contents of high-impact journals to identify articles related to medical overuse in adult care. Manuscripts were appraised for their quality, clinical relevance, and impact. A total of 1446 articles were identified, 910 of which addressed medical overuse. Of these, 111 articles were deemed to be the most relevant based on originality, methodologic quality, and scope. The 10 most influential articles were selected by author consensus. Findings included that unnecessary electrocardiograms are common (performed in 22% of patients at low risk) and can lead to a cascade of services, lipid monitoring rarely affects care, patients who were overdiagnosed with cancer experienced anxiety and criticism about not seeking treatment, calcium and vitamin D supplementation does not reduce hip fracture (relative risk, 1.09; 95% CI, 0.85-1.39), and pregabalin does not improve symptoms of sciatica but frequently has adverse effects (40% of patients experienced dizziness). Antipsychotic medications increased the severity of delirium in patients receiving hospice care and were associated with an increased risk of death (hazard ratio, 1.7; P = .003), and robotic-assisted radical nephrectomy was without benefits by being slower and more costly than laparoscopic surgery. High-sensitivity troponin testing often yielded false-positive results, as 16% of patients with positive troponin results in a US hospital had a myocardial infarction. One-third of patients who received a diagnosis of asthma had no evidence of asthma. Restructuring the electronic health record was able to reduce unnecessary testing (from 31.3 to 13.9 low-value tests performed per 100 patient visits).

CONCLUSIONS AND RELEVANCE

Many current practices were found to represent overuse, with no benefit and potential harms. Other services were used inappropriately. Reviewing these findings and extrapolating to their patients will enable health care professionals to improve the care they provide.

Nonbeneficial Intensive Care: Misalignments Between Provider Assessments of Benefit and Use of Invasive Treatments

BACKGROUND

The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians' impressions that ICU care may be nonbeneficial.

METHODS

Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit.

RESULTS

There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians' impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score.

CONCLUSIONS

Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

Intensive Care Unit Admission and Survival among Older Patients with Chronic Obstructive Pulmonary Disease, Heart Failure, or Myocardial Infarction

RATIONALE

Admission to an intensive care unit (ICU) may be beneficial to patients with pneumonia with uncertain ICU needs; however, evidence regarding the association between ICU admission and mortality for other common conditions is largely unknown.

OBJECTIVES

To estimate the relationship between ICU admission and outcomes for hospitalized patients with exacerbation of chronic obstructive pulmonary disease (COPD), exacerbation of heart failure (HF), or acute myocardial infarction (AMI).

METHODS

We performed a retrospective cohort study of all acute care hospitalizations from 2010 to 2012 for U.S. fee-for-service Medicare beneficiaries aged 65 years and older admitted with COPD exacerbation, HF exacerbation, or AMI. We used multivariable adjustment and instrumental variable analysis to assess each condition separately. The instrumental variable analysis used differential distance to a high ICU use hospital (defined separately for each condition) as an instrument for ICU admission to examine marginal patients whose likelihood of ICU admission depended on the hospital to which they were admitted. The primary outcome was 30-day mortality. Secondary outcomes included hospital costs.

RESULTS

Among 1,555,798 Medicare beneficiaries with COPD exacerbation, HF exacerbation, or AMI, 486,272 (31%) were admitted to an ICU. The instrumental variable analysis found that ICU admission was not associated with significant differences in 30-day mortality for any condition. ICU admission was associated with significantly greater hospital costs for HF ($11,793 vs. $9,185, P < 0.001; absolute increase, $2,608 [95% confidence interval, $1,377-$3,840]) and AMI ($19,513 vs. $14,590, P < 0.001; absolute increase, $4,922 [95% confidence interval, $2,665-$7,180]), but not for COPD.

CONCLUSIONS

ICU admission did not confer a survival benefit for patients with uncertain ICU needs hospitalized with COPD exacerbation, HF exacerbation, or AMI. These findings suggest that the ICU may be overused for some patients with these conditions. Identifying patients most likely to benefit from ICU admission may improve health care efficiency while reducing costs.