Long-Term Mortality and Hospital Resource Use in ICU Patients With Alcohol-Related Liver Disease

Comparing Outcomes and Infection Risk in Medical, Surgical, and Trauma Intensive Care Patients with Alcohol Use Disorder

Introduction: Alcohol is the most frequently abused drug in the United States, and alcohol use disorder (AUD) is a common comorbidity in intensive care units (ICUs). Patients and Methods: We performed a retrospective chart review of patients admitted to an ICU between January 2017 and March 2019 at a tertiary hospital serving a large rural population. Patients with diagnoses of AUDs were included. Patients were excluded if they did not require ICU care. Patient demographics, hospital course, infection type, culture results, and mortality were evaluated. We compared medical, surgical, and trauma ICU patient outcomes and infections. Results: In total, 527 patients met inclusion and exclusion criteria. Trauma ICU patients had the least pre-existing comorbidities, and surgical ICU patients had the longest lengths of stay. There was no difference in in-hospital mortality between ICU groups; however, surgical and medical ICU patients had significantly greater rates of in-hospital mortality compared with trauma ICU patients. Infections were common across all ICU types, occurring in 40% of patients. There was no difference in infection rate between ICU types. In multi-variable analysis controlling for age, gender, liver failure, chronic kidney disease, thrombocytopenia, complications, and blood transfusions, infection remained an independent predictor of in-hospital mortality (adjusted odds ratio 3.3, 95% confidence interval 1.7-6.4). Septic shock occurred in 57% of infections and was associated with an increased risk of mortality (38% vs. 2%, p < 0.001). Pneumonia was the most common infection occurring in 28% of the cohort, followed by bacteremia (7%), skin/soft tissue infections (6%), urinary tract infection (5%), intra-abdominal infections (4%), and C. difficile (2%). Conclusions: AUDs in all types of ICU patients are associated with high rates of infections and high morbidity and mortality.

National ICU Registries as Enablers of Clinical Research and Quality Improvement

OBJECTIVES

Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement.

DATA SOURCES

English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix.

STUDY SELECTION

Original research, review articles, letters, and commentaries, were considered.

DATA EXTRACTION

Data from relevant literature were identified, reviewed, and integrated into a concise narrative review.

DATA SYNTHESIS

CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs.

CONCLUSIONS

ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.

Quality standards for the management of alcohol-related liver disease: consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology ARLD special interest group

OBJECTIVE

Alcohol-related liver disease (ALD) is the most common cause of liver-related ill health and liver-related deaths in the UK, and deaths from ALD have doubled in the last decade. The management of ALD requires treatment of both liver disease and alcohol use; this necessitates effective and constructive multidisciplinary working. To support this, we have developed quality standard recommendations for the management of ALD, based on evidence and consensus expert opinion, with the aim of improving patient care.

DESIGN

A multidisciplinary group of experts from the British Association for the Study of the Liver and British Society of Gastroenterology ALD Special Interest Group developed the quality standards, with input from the British Liver Trust and patient representatives.

RESULTS

The standards cover three broad themes: the recognition and diagnosis of people with ALD in primary care and the liver outpatient clinic; the management of acutely decompensated ALD including acute alcohol-related hepatitis and the posthospital care of people with advanced liver disease due to ALD. Draft quality standards were initially developed by smaller working groups and then an anonymous modified Delphi voting process was conducted by the entire group to assess the level of agreement with each statement. Statements were included when agreement was 85% or greater. Twenty-four quality standards were produced from this process which support best practice. From the final list of statements, a smaller number of auditable key performance indicators were selected to allow services to benchmark their practice and an audit tool provided.

CONCLUSION

It is hoped that services will review their practice against these recommendations and key performance indicators and institute service development where needed to improve the care of patients with ALD.

Treatment profile and long-term outcome of intensive care unit-admitted patients with liver cirrhosis or other liver disease in relation to alcohol consumption

OBJECTIVE

To examine the impact of alcohol consumption on the treatment profile, mortality and causes of death in intensive care unit (ICU)-admitted patients with liver cirrhosis and other liver disease.

METHODS

Data on liver disease and ICU treatment of patients with previously diagnosed liver disease between 2015 and 2017 were retrospectively collected from medical records at Oulu University Hospital, Finland. The median follow-up was 367 days. The causes of death were obtained from Statistics Finland.

RESULTS

From 250 patients, high-risk alcohol consumption was present in 74.7% (71 of 95) cirrhotic patients and 43.2% (67 of 155) patients in the other liver disease group. Gastrointestinal causes were the most common admission causes. Despite the higher SOFA scores in the alcoholic liver cirrhosis patients compared with the non-alcoholic cirrhosis, there were no differences in the need for organ support, length of ICU stay or outcome between the groups or the subgroups. There were no differences in 1-year mortality between the cirrhosis groups (alcoholic cirrhosis 43.7% versus non-alcoholic cirrhosis 45.8%, p = 1.0) or between the other liver disease groups (patients with alcohol consumption 37.3% versus patients without alcohol consumption 36.4%, p = 1.0). The patients with high-risk alcohol consumption died more often due to liver disease, whereas the patients without high-risk alcohol consumption died often due to malignancies.

CONCLUSIONS

We report no significant impact of alcohol consumption on the ICU treatment profile or mortality of patients with cirrhosis or other liver disease. The high mortality underlines the importance of preventive measures after ICU admission.