Outcomes of critically ill elderly patients: is high-dependency care for geriatric patients worthwhile?

Long-Term Outcome of Critically Ill Advanced Cancer Patients Managed in an Intermediate Care Unit

Background: To analyze the long-term outcomes for advanced cancer patients admitted to an intermediate care unit (ImCU), an analysis of a do not resuscitate orders (DNR) subgroup was made. Methods: A retrospective observational study was conducted from 2006 to January 2019 in a single academic medical center of cancer patients with stage IV disease who suffered acute severe complications. The Simplified Acute Physiology Score 3 (SAPS 3) was used as a prognostic and severity score. In-hospital mortality, 30-day mortality and survival after hospital discharge were calculated. Results: Two hundred and forty patients with stage IV cancer who attended at an ImCU were included. In total, 47.5% of the cohort had DNR orders. The two most frequent reasons for admission were sepsis (32.1%) and acute respiratory failure (excluding sepsis) (38.7%). Mortality in the ImCU was 10.8%. The mean predicted in-hospital mortality according to SAPS 3 was 51.9%. The observed in-hospital mortality was 37.5% (standard mortality ratio of 0.72). Patients discharged from hospital had a median survival of 81 (30.75−391.25) days (patients with DNR orders 46 days (19.5−92.25), patients without DNR orders 162 days (39.5−632)). The observed mortality was higher in patients with DNR orders: 52.6% vs. 23.8%, p 0 < 0.001. By multivariate logistic regression, a worse ECOG performance status (3−4 vs. 0−2), a higher SAPS 3 Score and DNR orders were associated with a higher in-hospital mortality. By multivariate analysis, non-invasive mechanical ventilation, higher bilirubin levels and DNR orders were significantly associated with 30-day mortality. Conclusion: For patients with advanced cancer disease, even those with DNR orders, who suffer from acute complications or require continuous monitoring, an ImCU-centered multidisciplinary management shows encouraging results in terms of observed-to-expected mortality ratios.

Models of Care in Geriatric Intensive Care—A Scoping Review on the Optimal Structure of Care for Critically Ill Older Adults Admitted in an ICU

A growing proportion of critically ill patients admitted in ICUs are older adults. The need for improving care provided to older adults in critical care settings to optimize functional status and quality of life for survivors is acknowledged, but the optimal model of care remains unknown. We aimed to identify and describe reported models of care.

The association of the Activities of Daily Living and the outcome of old intensive care patients suffering from COVID-19

Purpose

Critically ill old intensive care unit (ICU) patients suffering from Sars-CoV-2 disease (COVID-19) are at increased risk for adverse outcomes. This post hoc analysis investigates the association of the Activities of Daily Living (ADL) with the outcome in this vulnerable patient group.

Methods

The COVIP study is a prospective international observational study that recruited ICU patients ≥ 70 years admitted with COVID-19 (NCT04321265). Several parameters including ADL (ADL; 0 = disability, 6 = no disability), Clinical Frailty Scale (CFS), SOFA score, intensive care treatment, ICU- and 3-month survival were recorded. A mixed-effects Weibull proportional hazard regression analyses for 3-month mortality adjusted for multiple confounders.

Results

This pre-specified analysis included 2359 patients with a documented ADL and CFS. Most patients evidenced independence in their daily living before hospital admission (80% with ADL = 6). Patients with no frailty and no disability showed the lowest, patients with frailty (CFS ≥ 5) and disability (ADL < 6) the highest 3-month mortality (52 vs. 78%, p < 0.001). ADL was independently associated with 3-month mortality (ADL as a continuous variable: aHR 0.88 (95% CI 0.82–0.94, p < 0.001). Being “disable” resulted in a significant increased risk for 3-month mortality (aHR 1.53 (95% CI 1.19–1.97, p 0.001) even after adjustment for multiple confounders.

Conclusion

Baseline Activities of Daily Living (ADL) on admission provides additional information for outcome prediction, although most critically ill old intensive care patients suffering from COVID-19 had no restriction in their ADL prior to ICU admission. Combining frailty and disability identifies a subgroup with particularly high mortality.

Trial registration number: NCT04321265.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-00996-9.

A retrospective cohort study on association of age and physician decision making for or against rapid sequence intubation in unconscious patients

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness.

Performance of Critical Care Outcome Prediction Models in an Intermediate Care Unit

BACKGROUND

Intermediate care units (IMCUs) are heterogeneous in design and operation, which makes comparative effectiveness studies challenging. A generalizable outcome prediction model could improve such comparisons. However, little is known about the performance of critical care outcome prediction models in the intermediate care setting. The purpose of this study is to evaluate the performance of the Acute Physiology and Chronic Health Evaluation version II (APACHE II), Simplified Acute Physiology Score version II (SAPS II) and version 3 (SAPS 3), and Mortality Probability Model version III (MPM₀III) in patients admitted to a well-characterized IMCU.

MATERIALS AND METHODS

In the IMCU of an academic medical center (July to December 2012), the discrimination and calibration of each outcome prediction model were evaluated using the area under the receiver-operating characteristic and Hosmer-Lemeshow goodness-of-fit test, respectively. Standardized mortality ratios (SMRs) were also calculated.

RESULTS

The cohort included data from 628 unique IMCU admissions with an inpatient mortality rate of 8.3%. All models exhibited good discrimination, but only the SAPS II and MPM₀III were well calibrated. While the APACHE II and SAPS 3 both markedly overestimated mortality, the SMR for the SAPS II and MPM₀III were 0.91 and 0.91, respectively.

CONCLUSIONS

The SAPS II and MPM₀III exhibited good discrimination and calibration, with slight overestimation of mortality. Each model should be further evaluated in multicenter studies of patients in the intermediate care setting.

Hospital mortality prediction for intermediate care patients: Assessing the generalizability of the Intermediate Care Unit Severity Score (IMCUSS)

PURPOSE

The Intermediate Care Unit Severity Score (IMCUSS) is an easy to calculate predictor of in-hospital death, and the only such tool developed for patients in the intermediate care setting. We sought to examine its external validity.

MATERIALS AND METHODS

Using data from patients admitted to the intermediate care unit (IMCU) of an urban academic medical center from July to December of 2012, model discrimination and calibration for predicting in-hospital death were assessed using the area under the receiver operating characteristic (AUROC) and the Hosmer-Lemeshow goodness-of-fit chi-squared (HL GOF X²) test, respectively. The standardized mortality ratio (SMR) with 95% confidence intervals (95% CI) was also calculated.

RESULTS

The cohort included data from 628 unique admissions to the IMCU. Overall hospital mortality was 8.3%. The median IMCUSS was 10 (Interquartile Range: 0-16), with 229 (36%) patients having a score of zero. The AUROC for the IMCUSS was 0.72 (95% CI: 0.64-0.78), the HL GOF X² = 30.7 (P < 0.001), and the SMR was 1.22 (95% CI: 0.91-1.60).

CONCLUSIONS

The IMCUSS exhibited acceptable discrimination, poor calibration, and underestimated mortality. Other centers should assess the performance of the IMCUSS before adopting its use.

Morbidity of cardiac arrest in the very elderly

The objective of this retrospective cohort study was to assess mortality and morbidity after cardiac arrest in hospital inpatients aged 80 years or older, in an Australian tertiary hospital. We studied patients aged 80 years or older who suffered an in-hospital cardiac arrest from 1 January 2000 to 31 December 2016. The main outcome measures were one-year survival and narrative morbidity. Two hundred and eighty-five patients were identified. Absolute one-year survival after cardiac arrest was, at best, 12.6%. Narrative descriptions of morbidity demonstrate high healthcare utilisation, dependency or residential care, and significant impairments of physical and social function. In conclusion, one-year survival after cardiac arrest in the very elderly is poor. In those who survive, significant morbidity is present.

Outcomes of Nonagenarians Admitted to the Cardiac Intensive Care Unit by the Elders Risk Assessment Score for Long-Term Mortality Risk Stratification

There are limited data on outcomes of older adults admitted to cardiac intensive care units (CICU), and there are no data on outcomes after admission to the CICU in nonagenarians. Our purpose was to identify whether the Elders Risk Assessment (ERA) index could risk stratify older adults after CICU admission. We retrospectively identified 453 nonagenarians admitted to the CICU between 2004 and 2013. End points included mortality, length of stay, incidence of delirium, and discharge disposition. Average age of the cohort was 92 ± 2 years, and the average ERA score was 13 ± 6. A total of 258 patients were female (57%). Most common admission indication was acute decompensated heart failure (57%) followed by acute myocardial infarction (49%). Loss of independence was observed after CICU admission, with 66% of patients living independently before admission, decreasing to 47% at discharge. Overall length of stay was 6 ± 5 days and CICU stay was 2 ± 2 days. Fifteen percent of patients died before hospital discharge. Median survival was 452 (interquartile range 40 to 1,371) days. ERA score effectively predicted survival (log-rank test, p = 0.002). ERA score of 16 or greater and ERA score of 9 to 15 were both associated with increased risk of mortality compared with the reference (score 4 to 8): hazard ratio 2.00, 95% confidence interval 1.37 to 2.90, p = 0.003, and hazard ratio 1.48, 95% confidence interval 1.06 to 2.08, p = 0.02, respectively. In conclusion, nonagenarians admitted to CICU experience reasonable outcomes. The ERA score effectively risk stratifies nonagenarians admitted to the CICU and may help with identification of vulnerable patients at risk of adverse outcomes.

Critical Illness in the Elderly: Review of Pathophysiology of Aging and Outcome of Intensive Care

The goal of this article is to review the literature on age and its influence on the pathophysiology of critical illness, outcome after critical illness, and end of life decision making in critically ill elderly patients. Sources for this review included the MEDLINE database and bibliographies of original articles, reviews, and book chapters. The population is aging and the need for medical care and its costs increase with increasing age. A majority of the elderly lead independent lives, although some need help with various functional activities related to daily living. It is difficult to separate the effects of aging from the effects of the comorbidities that develop with increasing age. The physiologic reserve decreases in the elderly and they may not be able to tolerate a critical injury or illness as well as a younger individual. As the elderlyare usually on multiple medications, they are prone to have more drug interactions and side effects, and need close monitoring of the drugs and adjustment of the dosage. Mortality after a critical illness in the elderly is higher compared to younger patients, and it is more related to the acuity of physiologic disturbance than age alone. The effect of age alone on long-term outcome is not well studied, but individuals with poor functional status and/or increased comorbidities have a poor short-term outcome. Functional status usually deteriorates after critical illness, but the long-term survivors usually recover functional abilities, and they are satisfied with their quality of life. Decision making at the end of life is difficult because of the paucity of data on long-term mortality and quality of life, lack of information about patient wishes, and the uncertainty of the prognosis. Because many elderly patients survive critical illness and may return to their previous lifestyle, age alone should not weigh heavily in end of life decisions. As with other age groups, end of life decisions in the elderly should be made after considering long-term outcomes, patient goals, and the benefits and burdens of life-sustaining technology.

Intensive care and invasive ventilation in the elderly patient, implications of chronic lung disease and comorbidities

Aims: Elderly patients have an increasing prevalence of illness that requires consideration of critical care and invasive ventilatory support. Although critical care of even the very elderly can provide value, with increasing age the potential risks of treatment and diminishing returns with respect to quality and quantity of life result in a need for careful evaluation. Variable combinations of impaired organ function, active disease and residual pathology from past disease and injury all affect critical care, with the consequence that the elderly are a very heterogeneous population. Recognizing that critical care is a limited resource, it is important to identify patients who may be at increased risk or least likely to benefit from treatment. Patients with functional impairments, nutritional deficiencies and multiple comorbidities may be at highest risk of poor outcomes. Those with very severe disease, extreme age and requirements for prolonged ventilatory support have high in-hospital mortality. Functional impairments, comorbidities and severity of illness are usually more important considerations than chronologic age. The objective of this review is to identify how common problems of the elderly affect critical care and decisions concerning use of invasive ventilatory support.

Management of Patients Aged ≥85 Years With ST-Elevation Myocardial Infarction

Guidelines mandate urgent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of age. Whether this strategy is optimal in patients aged ≥85 years remains uncertain. We aimed to assess the clinical characteristics and outcomes of patients aged ≥85 years with STEMI stratified by their management strategy. We analyzed baseline clinical characteristics of 101 consecutive patients aged ≥85 years who presented with STEMI to a tertiary Australian hospital. Patients were stratified based on whether they underwent invasive management with urgent coronary angiography ± percutaneous coronary intervention or conservative management. Our primary outcome was long-term mortality. Independent predictors of conservative management and long-term mortality were assessed by multivariate logistic regression and Cox proportional hazard modeling respectively. Of the 101 patients included, 45 underwent invasive management. Independent predictors of having conservative management were older age, anterior STEMI, and cognitive impairment (all p <0.01). Patients managed invasively had lower in-hospital (13.3% vs 32.1%, p = 0.03), 30-day (13.3% vs 37.5%, p <0.01), 12-month (22.2% vs 57.1%, p <0.01), and long-term (40.0% vs 75.0%, p <0.01) mortality. Invasive management was an independent predictor of lower long-term mortality (hazard ratio 0.29, 95% CI 0.11 to 0.76, p <0.01). In conclusion, patients aged ≥85 years with STEMI who were older, had cognitive impairment or presented with anterior ST-elevation were more likely to be managed conservatively. Those who underwent invasive management had reasonable short- and long-term outcomes.

Epidemiology of admissions to 11 stand-alone high-dependency care units in the UK

PURPOSE

High-dependency care units (HDUs) are a focus of research to optimize critical care resource allocation. HDUs provide a level of care between the general ward and the intensive care unit (ICU). However, few data report on the case mix and outcomes of patients in these units.

METHODS

Retrospective observational cohort study of patients admitted to 11 stand-alone HDUs in the UK from 2008 to 2011. We stratified patients by location prior to HDU admission and location on discharge from HDU, and we summarized the case mix, transitions of care, and mortality.

RESULTS

Of 9008 patients admitted to 11 stand-alone HDUs, 56.5% were male and the mean age was 62.7 ± 17.9 years. The majority of patients admitted to HDUs were non-surgical (59.3%), with 22.4 and 20.1% admitted from the ICU and general ward, respectively; 41.3% were admitted from the operating room or recovery suite. The median length of stay in HDU was 1.8 days (IQR 0.9-3.5) and in-HDU mortality was 5.1%. Among HDU survivors (n = 8551), 8.5% were discharged to an ICU, 80.9% to a general ward, and 10.6% to other care areas. For patients admitted to HDU from an ICU, only 5.8% were readmitted to ICU. Hospital mortality for the HDU population was 14.8%; for patients discharged to an ICU, hospital mortality was 43.6%.

CONCLUSIONS

In a sample of 11 stand-alone HDUs in the UK, patients are from many different hospital locations. Hospital mortality for patients requiring HDU care is high, particularly for patients who require transfer to an ICU.

Understanding and reducing disability in older adults following critical illness

OBJECTIVE

To review how disability can develop in older adults with critical illness and to explore ways to reduce long-term disability following critical illness.

DATA SOURCES

We searched PubMed, CINAHL, Web of Science and Google Scholar for studies reporting disability outcomes (i.e., activities of daily living, instrumental activities of daily living, and mobility activities) and/or cognitive outcomes among patients treated in an ICU who were 65 years or older. We also reviewed the bibliographies of relevant citations to identify additional citations.

STUDY SELECTION

We identified 19 studies evaluating disability outcomes in critically ill patients who were 65 years and older.

DATA EXTRACTION

Descriptive epidemiologic data on disability after critical illness.

DATA SYNTHESIS

Newly acquired disability in activities of daily living, instrumental activities of daily living, and mobility activities was commonplace among older adults who survived a critical illness. Incident dementia and less severe cognitive impairment were also highly prevalent. Factors related to the acute critical illness, ICU practices, such as heavy sedation, physical restraints, and immobility, as well as aging physiology, and coexisting geriatric conditions can combine to result in these poor outcomes.

CONCLUSIONS

Older adults who survive critical illness have physical and cognitive declines resulting in disability at greater rates than hospitalized, noncritically ill and community dwelling older adults. Interventions derived from widely available geriatric care models in use outside of the ICU, which address modifiable risk factors including immobility and delirium, are associated with improved functional and cognitive outcomes and can be used to complement ICU-focused models such as the ABCDEs.

Design and Performance of a New Severity Score for Intermediate Care

Background

Application of illness-severity scores in Intermediate Care Units (ImCU) shows conflicting results. The aim of the study is to design a severity-of-illness score for patients admitted to an ImCU.

Methods

We performed a retrospective observational study in a single academic medical centre in Pamplona, Spain. Demographics, past medical history, reasons for admission, physiological parameters at admission and during the first 24 hours of ImCU stay, laboratory variables and survival to hospital discharge were recorded. Logistic regression analysis was performed to identify variables for mortality prediction.

Results

A total of 743 patients were included. The final multivariable model (derivation cohort = 554 patients) contained only 9 variables obtained at admission to the ImCU: previous length of stay 7 days (6 points), health-care related infection (11), metastatic cancer (9), immunosuppressive therapy (6), Glasgow comma scale 12 (10), need of non-invasive ventilation (14), platelets 50000/mcL (9), urea 0.6 g/L (10) and bilirubin 4 mg/dL (9). The ImCU severity score (ImCUSS) is generated by summing the individual point values, and the formula for determining the expected in-hospital mortality risk is: e^{ImCUSS points*0.099 – 4,111} / (1 + e^{ImCUSS points*0.099 – 4,11}1). The model showed adequate calibration and discrimination. Performance of ImCUSS (validation cohort = 189 patients) was comparable to that of SAPS II and 3. Hosmer-Lemeshow goodness-of-fit C test was χ² 8.078 (p=0.326) and the area under receiver operating curve 0.802.

Conclusions

ImCUSS, specially designed for intermediate care, is based on easy to obtain variables at admission to ImCU. Additionally, it shows a notable performance in terms of calibration and mortality discrimination.

Do Intensive Care Unit treatment modalities predict mortality in geriatric patients: An observational study from an Indian Intensive Care Unit

Background:

Ageing being a global phenomenon, increasing number of elderly patients are admitted to Intensive Care Units (ICU). Hence, there is a need for continued research on outcomes of ICU treatment in the elderly.

Objectives:

Examine age-related difference in outcomes of geriatric ICU patients. Analyze ICU treatment modalities predicting mortality in patients >65 years of age.

Materials and Methods:

A retrospective observational study was conducted in 2317 patients admitted in a multi-specialty ICU of a tertiary care hospital over 2-year study period from January 1, 2011 to December 31, 2012. A clinical database was collected which included age, sex, specialty under which admitted, APACHE-II and SOFA scores, patient outcome, average length of ICU stay, and the treatment modalities used in ICU including mechanical ventilation, inotropes, hemodialysis, and tracheostomy. Patients were divided into two groups: <65 years (Control group) and >65 years (Geriatric age group).

Results:

The observed overall ICU mortality rate in the study population was 19.6%; no statistical difference was observed between the control and geriatric age group in overall mortality (P > 0.05). Mechanical ventilation (P = 0.003, odds ratio [OR] =0.573, 95% confidence interval [CI] =0.390–0.843) and use of inotropes (P = 0.018, OR = 0.661, 95% CI = 0.456–0.958) were found to be predictors of mortality in elderly population. On multivariate analysis, inotropic support was found to be an independent ICU treatment modality predicting mortality in the geriatric age group (β coefficient = 1.221, P = 0.000).

Conclusion:

Intensive Care Unit mortality rates increased in the geriatric population requiring mechanical ventilation and inotropes during ICU stay. Only inotropic support could be identified as independent risk factor for mortality.

Prognostic factors associated with adverse outcome among critically ill elderly patients admitted to the intensive care unit

INTRODUCTION

Despite concerns over the appropriateness and quality of care provided in the intensive care unit (ICU) at the end of life, the number of elderly patients who receive critical care is increasing. Despite this, many physicians have doubts as to whether elderly patients are good candidates for ICU care because of the apparently poor outcome during and after critical care in this population. The objective of the present study was to describe the clinical characteristics and outcome of a geriatric population admitted to the ICU.

MATERIALS AND METHODS

A single-center, prospective, observational study was carried out among geriatric patients, aged 75 years or older, admitted to ICU.

RESULTS

A total of 71 patients were admitted to ICU during the study period. Their mean age was 83 years (range 75-98 years), with a mean Acute Physiology and Chronic Health Evaluation-II score of 21.8 (range 8-39) on admission to ICU. A total of 48 patients (68%) required mechanical ventilation, and 39 (55%) received at least one vasoactive drug. The mean ICU length of stay was 4.6 days (range 1-18 days), and it was similar for ICU survivors and non-survivors (4.7 vs 4.5). A total of 14 patients (19.7%) were admitted after cardiac arrest, and eight (57.1%) of them died in ICU. A total of 28 patients (39.4%) died in the hospital, and 18 (25.4%) died in ICU.

CONCLUSION

Advanced age, critical illness, cardiopulmonary resuscitation, and needs for mechanical ventilation and/or vasopressor therapy are independent risk factors associated with adverse outcome in elderly patients admitted to ICU. Alternatives for ICU admission should be considered in geriatric patients with severe critical illnesses.

Perioperative mortality and morbidity prediction using POSSUM, P-POSSUM and APACHE II in Chinese gastric cancer patients: surgical method is a key independent factor affecting prognosis

INTRODUCTION

Gastric cancer is the fourth most common cancer worldwide. Predicting morbidity and mortality is important in deciding timing of surgery and type of surgery offered. APACHE II, POSSUM, and P-POSSUM are the most reliable scoring methods in use today. This is the first paper to evaluate the utility of all three scoring systems in China.

METHODS

We collected data on 851 patients (583 male and 268 female) who underwent surgery between 1991 and 2011. Physiological and pathological data was entered in spreadsheet format and analyzed using STATA version 11.0 to generate ROC curves for each scoring system.

RESULTS

In predicting mortality, P-POSSUM and POSSUM were most effective and APACHE II was ineffective. POSSUM predicted a higher morbidity risk than was actually encountered. Age and type of operation were found to be independent risk factors for mortality.

DISCUSSION

The utility of the APACHE II score in gastric cancer patients is limited. APACHE II is suitable for considering group versus individual effect. The POSSUM score is useful in general surgery, but needs improvement. We found the P-POSSUM score to be superior for morbidity and mortality prediction. P-POSSUM is useful for both the general population and for a specific cohort. The type of surgery is a key decision point for surgeons, and independently affects prognosis. Based upon these findings and clinical scoring systems, clinicians can develop individualized treatment algorithms.

Prognosis of elderly patients subjected to mechanical ventilation in the ICU

OBJECTIVE

To analyze the prognosis of mechanically ventilated elderly patients in the Intensive Care Unit (ICU).

DESIGN AND SCOPE

Sub-analysis of a prospective multicenter observational cohort study conducted over a period of two years in 13 medical-surgical ICUs in Spain.

PATIENTS

Adult patients who required mechanical ventilation (MV) for longer than 24 hours.

INTERVENTIONS

None.

STUDY VARIABLES

Demographic data, APACHE II, SOFA, reason for MV, comorbidity, functional condition, reintubation, duration of MV, tracheotomy, ICU mortality, in-hospital mortality.

RESULTS

A total of 1661 patients were recruited. Males accounted for 67.9% (n=1127), with a mean age of 62.1 ± 16.2 years. APACHE II: 20.3 ± 7.5. Total SOFA: 8.4 ± 3.5. Four hundred and twenty-three patients (25.4%) were ≥ 75 years of age. Comorbidity and functional condition rates were poorer in these patients (p<0.001 for both variables). Mortality in the ICU was higher in the elderly patients (33.6%) than in the younger subjects (25.9%) (p=0.002). Also, in-hospital mortality was higher in those ≥ 75 years of age. No differences in duration of MV, prevalence of tracheostomy or reintubation incidence were found. Regarding the indication for MV, only the patient ≥ 75 years of age with pneumonia, sepsis or trauma had a higher in-ICU mortality than the younger patients (46.3% vs 33.1%, p=0.006; 55% vs 25.8%, p=0.002; 63.6% vs 4.5%, p<0,001, respectively). No differences were found referred to other reasons for MV.

CONCLUSION

Older patients (≥ 75 years) have significantly higher in-ICU and in-hospital mortality than younger patients without differences in the duration of mechanical ventilation. Differences in mortality were at the expense of pneumonia, sepsis and trauma.

Mortality predictors in hospitalized elderly patients

AIM

To find out which of the two predictors, Charlson co-morbidity index or vitamin B12, better estimates the risk of in-hospital mortality in seriously ill patients.

METHOD

Electronic hospital records of 1509 elderly patients aged 65 and older were retrospectively surveyed.

RESULTS

Albumin, age and elevated vitamin B12 levels were significantly associated with increased in-hospital mortality. Charlson co-morbidity index was not significantly associated with death. The highest mortality (24.3%) was found in the group of patients who were concomitantly in the lowest albumin quartile and the highest vitamin B12 levels quartile. In this group, mortality increased significantly with age. By elasticity calculation, vitamin B12 capability to predict mortality was higher by ≈ 3 times than that of Charlson co-morbidity index.

CONCLUSION

In view of the fact that vitamin B12 levels have been found to predict mortality, they should be measured in geriatric practice, in addition to albumin levels, as a practical and reliable tool for identifying high risk elderly hospitalized patients. Probably, a combination of two or more available and inexpensive routinely taken tests can give a better estimation of mortality than some complicated tools, like Charlson co-morbidity index.

Is age a predictor of mortality in a U.K. medical high dependency unit?

BACKGROUND

The population aged older than 65 yr is set to increase by 32% by 2033. In resource-limited environments, difficult decisions regarding access to high dependency care for the elderly are increasingly important. The aim of this study was to determine whether age is a predictor of mortality in patients admitted to an open medical high dependency unit (MHDU).

METHODS

Prospective observational cohort study of 100 consecutive patients admitted to an MHDU with a primary medical diagnosis over a 3 month period. The primary endpoint was 30 day mortality.

RESULTS

Overall mortality at 30 days was 21% (n=21). Patients aged <65 yr were 41%, 29% were 65-74 yr, and 30% were aged 75 yr and above. There were no significant differences in mortality between groups (12%, 31%, and 23%, respectively). When considering Acute Physiology and Chronic Health Evaluation scores ≥25, there was no significant difference in mortality between age groups [35% <70 yr (7/20) vs. 29% ≥70 yr (4/14), P=1.000]. The final model at multivariable regression analysis identified that ≥2 organ support (odds ratio 10.84, 95% confidence interval 3.28-35.84) and pre-admission moderate/nursing home care [4.44 (1.05-18.70)] were significantly associated with worse outcome. The majority of survivors (88%) were discharged at their pre-admission functional status; those who declined in function were not significantly older than those who did not.

CONCLUSIONS

Age does not predict the outcome from an MHDU. Those requiring ≥2 organ support, higher levels of pre-admission home support, or both had higher mortality. Selected elderly medical patients should not be denied high dependency unit care.

Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial

BACKGROUND

Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the efficacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care.

METHODS

Sedated adults (>/=18 years of age) in the ICU who had been on mechanical ventilation for less than 72 h, were expected to continue for at least 24 h, and who met criteria for baseline functional independence were eligible for enrolment in this randomised controlled trial at two university hospitals. We randomly assigned 104 patients by computer-generated, permuted block randomisation to early exercise and mobilisation (physical and occupational therapy) during periods of daily interruption of sedation (intervention; n=49) or to daily interruption of sedation with therapy as ordered by the primary care team (control; n=55). The primary endpoint-the number of patients returning to independent functional status at hospital discharge-was defined as the ability to perform six activities of daily living and the ability to walk independently. Therapists who undertook patient assessments were blinded to treatment assignment. Secondary endpoints included duration of delirium and ventilator-free days during the first 28 days of hospital stay. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00322010.

FINDINGS

All 104 patients were included in the analysis. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0.02; odds ratio 2.7 [95% CI 1.2-6.1]). Patients in the intervention group had shorter duration of delirium (median 2.0 days, IQR 0.0-6.0 vs 4.0 days, 2.0-8.0; p=0.02), and more ventilator-free days (23.5 days, 7.4-25.6 vs 21.1 days, 0.0-23.8; p=0.05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony.

INTERPRETATION

A strategy for whole-body rehabilitation-consisting of interruption of sedation and physical and occupational therapy in the earliest days of critical illness-was safe and well tolerated, and resulted in better functional outcomes at hospital discharge, a shorter duration of delirium, and more ventilator-free days compared with standard care.

FUNDING

None.

[Elderly patient in an intensive critical unit]

Admission of elderly patients to intensive care units (ICU) is an increasing phenomenon. The severity of the disease causing admission and the basal functional patient's status are conditions more important than age to predict mortality and long term functional outcome. Studies demonstrate that elderly ICU survivors recover after discharge the majority part of their functional capability and perception of quality of life. On the contrary, these patients develop higher number of geriatric syndromes, mainly confusional syndrome. The culture of geriatric comprehensive assessment should be implemented in ICU and especially after discharge. The use of simple and validates scales (Barthel's Index, Lawton's Index and EuroQol-5D...) must be incorporated into the clinical practice. This is a good tool that could be useful for the specialists involved in the usually difficult decision of whether an elderly patient should or not be admitted to an ICU.

Predictors of mortality in acute renal failure in a developing country: a prospective study

Acute renal failure (ARF) occurs in wide range of conditions, making the evaluation of its prognosis a difficult task. Data regarding prognostic factors in ARF in a general population in developing countries are scarce. The objective of the study was to describe predictors of mortality in ARF that are relevant in the developing world. This prospective study was carried out over a one-year period; all hospitalized adults with ARF were included in the study. Predictors of mortality studied included causes of ARF, pre-existing diseases, and severity as well as complications of ARF. Of 33,301 patients admitted during the study period, 294 (0.88%) were either admitted with or developed ARF after hospitalization. Mean age was 43.9 +/- 16.9 (18-86 yrs). Sepsis was the most common cause (63.26%). Pre-existing diseases like cardiovascular disease (CVSD), respiratory system disease (RSD), central nervous system disease (CNSD), hypertension, diabetes mellitus (DM), and malignancy were significantly higher in elderly as compared to younger patients. On univariate analysis sepsis, hypoperfusion as a cause of ARF and hospital-acquired ARF were associated with higher mortality. Pre-existing diseases viz. RSD, CVSD, CNSD, and DM had higher mortality. Among the severity and complications of ARF, oliguria, bleeding and infection during the course of ARF and critical illness were predictors of poor outcome. Age > 60 yrs was associated with significantly higher mortality. However, on multivariate analysis, only critical illness (odds ratio 37.3), age > 60 years (odds ratio of 5.6), and sepsis as cause of ARF (odds ratio of 2.6) were found to be independent predictors of mortality.

Should elderly patients be admitted to the intensive care unit?

As the general population ages, an increasing number of patients over 80 years are being admitted to the intensive care unit (ICU). Selection of older patients for ICU admission results in lower rates of co-morbidities and underlying fatal diseases. After adjustment for disease severity, ICU and post-ICU mortality rates are higher in elderly patients than in younger populations. Age itself explains only a small part of the increased hospital mortality, suggesting that specific information such as functional, cognitive, and nutritional status, as well as co-morbidities, should be collected to predict mortality in elderly ICU patients. The long-term prognosis depends chiefly on functional status, whereas initial disease severity no longer influences mortality. According to our review, it is impossible to define evidence-based recommendations for ICU admission of the elderly. This justifies further studies that encompass several aspects, such as the initial triage process and the long-term prognosis (mortality, autonomy and quality of life).

Spectrum of renal failure in elderly patients

This prospective study was undertaken to study the spectrum of renal failure and the outcome in elderly patients. Patients included in the study group were elderly (age>60 years) who either attended outpatient renal clinic and or were hospitalized. Renal failure was classified as acute renal failure (ARF), rapidly progressive renal failure (RPRF) and chronic renal failure (CRF). A total of 4255 elderly patients were seen, of these 236 (5.5%) had renal failure. Mean age was 65.1+/-4.2 years (60-86 years). CRF was the commonest, seen in 137 (58.1%) followed by ARF 69 (29.2%) and RPRF in 30 (12.7%) patients. Diabetic nephropathy was the commonest cause of CRF, seen in 58.4% followed by chronic interstitial nephritis in 9.5% and chronic glomerulonephritis in 8.7% of patients. Of 137 patients 53 (38.7%) presented in end stage renal disease (ESRD). Of these 41 (77.3%) were initiated on maintenance hemodialysis and 12 (22.6%) on continuous ambulatory peritoneal dialysis. Only 15 patients were on dialytic support at the end of 1 year. Sepsis contributed to ARF in 75.4% of cases. Forty of 69 patients (57.9%) needed dialytic support. Forty (57.9%) were critically ill, defined as presence of two or more organ system failures (excluding renal failure). Forty two patients (60.9%) died patients. Acute interstitial nephritis (AIN) was the commonest cause of RPRF seen in 10 (33.3%) patients followed by vasculitis in 7 (23.3%). Myeloma cast nephropathy contributed towards RPRF in 20% of patients. Of 30 patients, 10 (33.3%) reached ESRD at end of 3 months of follow up, 4 (13.3%) died due to sepsis. Only 2 showed complete recovery while 14 (46.6%) had partial improvement. AIN patients had a relatively better outcome.

Predictors of mortality in elderly patients with acute renal failure in a developing country

This prospective study was undertaken to systematically analyze the predictors of mortality in the elderly in a developing country. All elderly patients with ARF hospitalized at this tertiary care centre over 1 year were studied. Various predictors analyzed were hospital-acquired ARF, causative factors of ARF, preexisting hypertension and diabetes mellitus, severity of renal failure (initial and peak serum creatinine, need for dialysis), and complications of ARF: infection during the course of illness; serum albumin levels and critical illness defined as presence of two or more organ system failures excluding renal failure. Of 33,301 patients admitted, 4,255 (12.7%) were elderly. Of these 69 (1.6%) had ARF. On analysis of the whole group, both young and elderly, age >60 years had an independent predictor of mortality (odds ratio 5.6, P = 0.001). Forty-two of the 69 (60.9%) elderly ARF patients died. The mortality was significantly increased in those elderly with hospital-acquired ARF (79.2%, P = 0.027), those with sepsis as a cause of ARF (71.2%, P = 0.004), those who required dialysis (72.5%, P = 0.022), those developing an infection during the course of ARF (87.9%, P = 0.000) and in those with a critical illness (90.0%, P = 0.00). On logistic regression analysis of those variables that were significant on univariate analysis, only critical illness (odds ratio 9.97) and infection during course (odds ratio 9.72) were the independent predictors of mortality. To conclude, ARF complicates only 1.6% of hospitalized elderly patients but is associated with a high mortality rate of 61%. Infection during the course of illness and critical illness were the independent predictors of mortality.

Functional assessment of older patients in the emergency department: comparison between standard instruments, medical records and physicians' perceptions

Background

We evaluated the accuracy of physician recognition of functional status impairment in older emergency departments (ED) patients. In particular, we evaluated the accuracy of medical records (a comparison of the information in the medical record with the functional status based on proxy interviews), and the accuracy of physician knowledge (a comparison of the information obtained from the responsible physician with the functional status based on proxy interviews).

Methods

Cross-sectional study on 101 frail older patients selected at random from among those attending ED, their ED physicians, and respondents. The study was conducted at ED in four general university teaching hospitals in a city, from July through November 2003. Functional data shown on patients' medical records were compared against functional data obtained from respondents (family members), using Kendall's Tau-b statistic. In addition patients' Katz Indices (which assesses six basic activities of daily living – basic ADL) based on interviews with ED physicians were compared against those obtained from respondents, using the coefficient of concordance weighted kappa (κ). Each patient and his respondent were paired with a single physician.

Results

The correlation between information on dependence for basic ADL obtained from medical records and that furnished by respondents, was 0.41 (95% CI 0.27–0.55). Concordance between the respective Katz Indices obtained from physicians and respondents was 0.47 (95% CI 0.38–0.57).

Conclusion

Older subjects' functional status is not properly assessed by emergency department physicians.

Long-term survival, quality of life, and quality-adjusted life-years among critically ill elderly patients*

OBJECTIVES

To assess mortality, quality of life (QOL), and quality-adjusted life-years (QALYs) for critically ill elderly patients.

DESIGN

Cross-sectional survey.

SETTING

A ten-bed medical-surgical intensive care unit (ICU) in a tertiary care university hospital.

PATIENTS

The study group included 882 elderly patients (> or =65 yrs of age) and 1,827 controls (<65 yrs of age) treated during the period of 1995 to 2000.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Mortality was assessed during the ICU and hospital stays, and 12, 24, and 36 months after ICU discharge. The cumulative 3-yr mortality rate among the elderly (57%) was higher (p < .05) than that among the controls (40%). The majority (66%) of the elderly nonsurvivors died within 1 month after intensive care discharge. All elderly patients with day-1 Sequential Organ Failure (SOFA) scores >15 died during the ICU stay. QOL was assessed with EQ-5D and RAND-36 measures from 10 months to 7 yrs after discharge. The majority (88%) of the elderly survivors assessed their present health state as good or satisfactory; 66% found it to be similar or better than 12 months earlier, and 48% similar or better than their preadmission state. QOL measures by RAND-36 revealed that aging decreased their competencies most in physical functioning, physical role limitations, and vitality, but the elderly had better values in mental health than the controls. However, QALYs of the elderly respondents were 21% to 35% lower than the mean QALY minus 2 sd units of the age- and gender-adjusted general population.

CONCLUSIONS

High age alone is not a valid reason to refuse intensive care, but the benefits perceived by intensive care seem to decrease with aging, if reflected as QALYs. However, 97% of the elderly survivors lived at home and 88% of them considered their QOL satisfactory or good after hospital discharge. Therefore, more reliable information on the outcome for the elderly is clearly needed.

Short- and long-term outcomes of older patients in intermediate care units

OBJECTIVE

To evaluate short- and long-term outcomes of elderly patients (>or=65 years) treated at an intermediate care unit (IMCU) and to identify outcome predictors.

DESIGN AND SETTING

Prospective observational study in the IMCU of a university teaching hospital.

PARTICIPANTS

We studied 412 patients over 8 months, classified into three groups: under 65years (control group, n=158), 65-80 (n=186), and >80 (n=68).

MEASUREMENTS

At admission: APACHE II, TISS-28 first day, Charlson Index, diagnosis, and prior Barthel Index.

OUTCOME MEASURES

in-hospital mortality, length of stay, discharge destination, and 2-year mortality and readmissions. Data analysis included multivariate logistic regression and receiver operating characteristics area under the curve (ROC AUC).

RESULTS

No statistically significant differences between groups were observed in hospital mortality (14.1%), discharge to a long-term facility (2.7%), or 2-year readmissions (1.2+/-2.1). However, hospital stay was longer in patients aged 65-80years (14 vs.10 days) and 2-year mortality was higher in those 65 or over (34% vs.10.6%). In the overall series in-hospital mortality was predicted by APACHE II, first-day TISS-28, and diagnosis (ROC AUC 0.81), and 2-year mortality by Charlson Index and age (ROC AUC 0.77). In the elderly patients 2-year mortality was predicted by Charlson and Barthel indices (ROC AUC 0.70).

CONCLUSIONS

Illness severity and therapeutic intervention at admission to IMCU were predictors of short-term mortality, whereas the strongest predictor of long-term mortality was comorbidity. Our results suggest that comprehensive assessment of elderly patients at admission to IMCUs may improve outcome prediction.

Cardiac disease in the non-cardiac surgical population: effect on survival

Mortality from cardiac disease is decreasing, yet the prevalence of ischemic heart disease, diabetes and hypertension is increasing. This, combined with an aging population, affects the characteristics of the surgical population. Survival in this subgroup of the non-cardiac surgical population has not been studied in a UK setting. This study aimed to determine the mortality rate at 1, 6 and 24 months for patients with underlying cardiac risk factors undergoing elective non-cardiac surgery, and to identify independent risk factors associated with 1-year mortality (death within 365 days of original operation date). Following ethical approval, 1622 patients were included in the study. Demographic, pre-, peri- and postoperative variables were collected from medical and nursing notes. Follow-up was completed using the National Office of Statistics tracking system. Copies of death certificates were obtained on all patients who had died within 12 months of surgery. Risk factors for 1-year mortality were identified using multiple regression modelling. Survival at 12 months was 89%. The majority of cardiac-related deaths occurred within the first 6 months of surgery. Independent risk factors associated with 1-year mortality were advanced age, preoperative angina, odds ratio=1.59 (1.02-2.47), surgery type, perioperative blood transfusion and a prolonged hospital stay. A significant portion of the non-cardiac surgical population who have underlying cardiac disease risk factors are at risk of a cardiac-related death within 1 year of surgery. Patients with angina had nearly a 60% greater risk of death compared with asymptomatic patients. In the hospital setting, nurses with the appropriate pre-assessment and critical care competencies are pivotal to the successful management of this group of patients. In the long term, careful follow-up by the primary care team can help modify cardiac risk factors and potentially reduce cardiac-related mortality.

Noninvasive continuous positive airway pressure in elderly cardiogenic pulmonary edema patients

OBJECTIVE

To compare the physiological effects and the clinical efficacy of continuous positive airway pressure (CPAP) vs standard medical treatment in elderly patients (> or =75 years) with acute hypoxemic respiratory failure related to cardiogenic pulmonary edema.

DESIGN

A prospective, randomized, concealed, and unblinded study of 89 consecutive patients who were admitted to the emergency departments of one general, and three teaching, hospitals.

INTERVENTION

Patients were randomly assigned to receive standard medical treatment alone ( n=46) or standard medical treatment plus CPAP ( n=43).

MEASUREMENTS

Improvement in PaO(2)/FIO(2) ratio, complications, length of hospital stay, early 48-h and overall mortality, compared between the CPAP and standard treatment groups.

RESULTS

Study groups were comparable with regard to baseline physiological and clinical characteristics (age, sex ratio, autonomy, medical history, cause of pulmonary edema). Within 1 h, noninvasive continuous positive airway pressure led to decreased respiratory rate (respiratory rate, 27+/-7 vs 35+/-6 breaths/min; p=0.009), and improved oxygenation (PaO(2)/F(I)O(2), 306+/-104 vs 157+/-71; p=0.004) compared with baseline, whereas no differences were observed within the standard treatment group. Severe complications occurred in 17 patients in the standard treatment group, vs 4 patients in the noninvasive continuous positive airway pressure group ( p=0.002). Early 48-h mortality was 7% in the noninvasive continuous positive airway pressure group, compared with 24% in the standard treatment group ( p=0.017); however, no sustained benefits were observed during the overall hospital stay.

CONCLUSION

Noninvasive continuous positive airway pressure promotes early clinical improvement in elderly patients attending emergency departments for a severe pulmonary edema, but only reduces early 48-h mortality.

Prognosis of patients aged 80 years and over admitted in medical intensive care unit

OBJECTIVE

To determine the prognostic indicators of long-term survival after admission to a medical intensive care unit (MICU) for patients aged 80 years and over. DESIGN. Prospective cohort study.

SETTING

A 14-bed MICU in a 970-bed, acute care, tertiary, university hospital in Paris, France.

PATIENTS

A total of 233 patients aged 80 years and over discharged from a MICU during a 2-year period.

MEASUREMENTS AND MAIN RESULTS

Severity at admission was estimated using the Simplified Acute Physiology Score. The underlying condition was classified using the MacCabe classification. The functional status was assessed using the Knaus classification. The outcome after MICU discharge was determined after a median 2-year follow-up. The functional outcome was assessed by telephone interviews, employing the Instrumental Activities of Daily Living (IADL). The in-MICU mortality was 19.5% including death occurring during the 2 days following discharge. The long-term survival rates for patients admitted to the MICU were 59% at 2 months, 33% at 2 years, and 29% at 3 years. The multivariate analysis identified two prognostic factors of death after discharge: presence of an underlying fatal disease (HR 1.7; 95% CI 1.1-2.6) and severe functional limitation (HR 1.7; 95% CI 1.2-2.6). The IADL was excellent or good for 56% of the surviving patients.

CONCLUSION

Long-term survival after MICU is mainly related to the underlying condition, whereas known factors for in-MICU survival do not influence long-term prognosis.

Long-term outcome in ICU patients: what about quality of life?

OBJECTIVE

Analysis of mortality and quality of life (QOL) after intensive care unit (ICU) discharge.

DESIGN

Prospective, observational study.

SETTING

Mixed, 31-bed, medico-surgical ICU.

PATIENTS

Consecutive adult ICU admissions between June 25 and September 10, 2000, except admissions for uncomplicated elective postoperative surveillance. INTERVENTIONS. None.

MEASUREMENTS AND RESULTS

Age, past history, admission APACHE II, SOFA score (admission, maximum, discharge), ICU and hospital mortality were recorded. A telephone interview employing the EuroQol 5D system was conducted 18 months after discharge. Of 202 patients, 34 (16.8%) died in the ICU and 23 (11.4%) died in the hospital after ICU discharge. Of the 145 patients discharged alive from hospital, 22 could not be contacted and 27 (13.4%) had died after hospital discharge. Of the 96 patients (47.5%) who completed the questionnaire, 38% had a worse QOL than prior to ICU admission, but only 8.3% were severely incapacitated. Twenty-three patients (24%) had reduced mobility, 15 (15.6%) had limited autonomy, 24 (25%) had alteration in usual daily activities, 29 (30.2%) expressed more anxiety/depression, and 42 (44%) had more discomfort or pain. Twenty-eight (62.2% of those who worked previously) patients had returned to work 18 months after ICU discharge.

CONCLUSIONS

Comparing QOL after discharge with that before admission, patients more frequently report worse QOL for the domains of pain/discomfort and anxiety/depression than for physical domains. Factors commonly associated with a change in QOL were previous problems in the affected domains, prolonged hospital length of stay (LOS), greater disease severity at admission and degree of organ dysfunction during ICU stay.

Noninvasive mechanical ventilation in acute cardiogenic pulmonary edema

Acute cardiogenic pulmonary edema is a frequent life-threatening emergency. During the last 10 years, increasing attention has focused on the use of noninvasive ventilation to treat patients with various forms of acute respiratory failure. Numerous physiologic data and clinical studies support the use of noninvasive ventilation during cardiogenic pulmonary edema. Noninvasive ventilation results in rapid improvement of clinical signs of respiratory distress and gas exchange and decreases the need for endotracheal intubation for patients in the ICU with acute hypercapnic respiratory failure related to cardiogenic pulmonary edema. However, no sustained benefit (, decreased late mortality) or benefit for less severe forms of cardiogenic pulmonary edema has been demonstrated yet. Moreover, there are still few data that support the use of a specific mode of ventilation over the others.

A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients

STUDY OBJECTIVES

To describe the characteristics and outcomes of patients admitted to intermediate-care areas (ICAs) and to compare them with those of ICU patients who receive monitoring only on day 1 and are at a low risk (i.e., < 10%) for receiving subsequent active life-supporting therapy (i.e., low-risk monitor patients).

DESIGN

Nonrandomized, retrospective, cohort study.

SETTING

Thirteen US teaching hospitals and 19 nonteaching hospitals.

PATIENTS

A consecutive sample of 8,971 patients at 37 ICAs and 5,116 low-risk (i.e., < 10%) monitor patients at 59 ICUs in 32 US hospitals.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We recorded demographic and clinical characteristics, resource use, and outcomes for the ICA and ICU low-risk monitor patients. Patient data and outcomes for this study were collected concurrently or retrospectively. ICA and ICU low-risk monitor patients were similar in regard to gender, race, and frequency of comorbitities, but ICA patients were significantly (p < 0.001) older, had fewer physiologic abnormalities (mean acute physiology score, 16.7 vs 19.8, respectively), and were more frequently admitted due to nonoperative diagnoses. The mean length of stay for ICA patients was significantly longer (3.9 days) than for ICU low-risk monitor patients (2.6 days; p < 0.001). The hospital mortality rate was significantly higher for ICA patients (3.1%) compared to ICU low-risk monitor patients (2.3%; p = 0.002).

CONCLUSIONS

The clinical features of ICA patients are similar, but not identical to, those of less severely ill ICU monitor patients. Comparisons of hospital death rates and lengths of stay for these patients should be adjusted for characteristics that previously have been shown to influence these outcomes.