Impact of the post-World War II generation on intensive care needs in Norway

The association of premorbid conditions with 6-month mortality in acutely admitted ICU patients over 80 years

BACKGROUND

Premorbid conditions influence the outcome of acutely ill adult patients aged 80 years and over who are admitted to the ICU. The aim of this study was to determine the influence of such premorbid conditions on 6 month survival.

METHODS

Prospective cohort study in 242 ICUs from 22 countries including patients 80 years or above, admitted over a 6 months period to an ICU between May 2018 and May 2019. Only emergency (acute) ICU admissions in adult patients ≥ 80 years of age were eligible. Patients who were admitted after planned/elective surgery were excluded. We measured the Clinical Frailty Scale (CFS), the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), disability with the Katz activities of daily living (ADL) score, comorbidities and a Polypharmacy Score (CPS).

RESULTS

Overall, the VIP2 study included 3920 patients. During ICU stay 1191 patients died (30.9%), and another 436 patients (11.1%) died after ICU discharge but within the first 30 days of admission, and an additional 895 patients died hereafter but within the first 6 months after admission (22.8%). The 6 months mortality was 64%. The median CFS was 4 (IQR 3-6). Frailty (CFS ≥ 5) was present in 26.6%. Cognitive decline (IQCODE above 3.5) was found in 30.2%. The median IQCODE was 3.19. A Katz ADL of 4 or less was present in 27.7%. Patients who surviving > 6 months were slightly younger (median age survivors 84 with IQR 81-86) than patients dying within the first 6 months (median age 84, IQR 82-87, p = 0.013), were less frequently frail (CFS > 5 in 19% versus 34%, p < 0.01) and were less dependent based on their Katz activities of daily living measurement (median Katz score 6, IQR 5-6 versus 6 points, IQR 3-6, p < 0.01).

CONCLUSIONS

We found that Clinical Frailty Scale, age, and SOFA at admission were independent prognostic factors for 6 month mortality after ICU admission in patients age 80 and above. Adding other geriatric syndromes and scores did not improve the model. This information can be used in shared-decision making.

CLINICALTRIALS

gov: NCT03370692.

Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic

INTRODUCTION

It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic.

MATERIAL AND METHODS

Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health.

RESULTS

Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8.

DISCUSSION

A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.

Impact of age on mortality and transfer to long-term care in patients in an intensive care unit

BACKGROUND

In the global trend of population aging, age is one of the significant factors to be considered in critically ill patients. However, the impact of age on clinical outcomes and long-term prognosis in this population varies across different studies.

METHODS

We conducted a retrospective cohort analysis for patients admitted to the medical intensive care unit (ICU) (30 beds) between January 2017 and December 2020 at the tertiary referral hospital in Korea. Patients were classified into three groups according to age: <65 years, old age (65-79 years), and very old age (≥ 80 years). Subsequently, enrolled patients were analyzed for acute mortality and long-term prognosis.

RESULTS

Among the 1584 patients, the median age was 67.0 (57.0-76.0) years, and 65.2% were male. Median ICU length of stay (LOS) (8, 9, and 10 days in < 65, 65-79, and ≥ 80 years, respectively; p = 0.006) and the proportion of patients who were transferred to long-term care hospital at the time of discharge (12.9% vs. 28.3% vs. 39.4%, respectively; p < 0.001) increased with age. Multivariable logistic analysis showed no significant difference in the 28-day mortality in the old age (adjusted odds ratio [aOR] 0.88; 95% confidence interval [CI] 0.65-1.17) and very old age (aOR 1.05; 95% CI 0.71-1.55) groups compared to that in patients with age < 65 years. However, the relevance of the proportion of ICU LOS ≥ 7 days and transfers to other hospitals after discharge increased with age.

CONCLUSIONS

Age did not affect acute mortality in critical illness patients. However, surviving older age groups required more long-term care facilities compared to patients younger than 65 years after acute management. These results indicate that in an aging society, the importance of not only acute management but also long-term care facilities may increase for critical illness patients.

Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

There is a growing population of older adults requiring admission to the intensive care unit (ICU). This population outpaces the ability of clinicians with geriatric training to assist in their management. Specific training and education for intensivists in the care of older patients is valuable to help understand and inform clinical care, as physiologic changes of aging affect each organ system. This review highlights some of these aging processes and discusses clinical implications in the vulnerable older population. Other considerations when caring for these older patients in the ICU include functional outcomes and morbidity, as opposed to merely a focus on mortality. An overall holistic approach incorporating physiology of aging, applying current evidence, and including the patient and their family in care should be used when caring for older adults in the ICU.

Intensive care of geriatric patients-a thin line between under- and overtreatment

Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.

Mortality of Older Patients Admitted to an ICU: A Systematic Review

OBJECTIVES

To conduct a systematic review of mortality and factors independently associated with mortality in older patients admitted to ICU.

DATA SOURCES

MEDLINE via PubMed, EMBASE, the Cochrane Library, and references of included studies.

STUDY SELECTION

Two reviewers independently selected studies conducted after 2000 evaluating mortality of older patients (≥ 75 yr old) admitted to ICU.

DATA EXTRACTION

General characteristics, mortality rate, and factors independently associated with mortality were extracted independently by two reviewers. Disagreements were solved by discussion within the study team.

DATA SYNTHESIS

Because of expected heterogeneity, no meta-analysis was performed. We selected 129 studies (median year of publication, 2015; interquartile range, 2012-2017) including 17 based on a national registry. Most were conducted in Europe and North America. The median number of included patients was 278 (interquartile range, 124-1,068). ICU and in-hospital mortality were most frequently reported with considerable heterogeneity observed across studies that was not explained by study design or location. ICU mortality ranged from 1% to 51%, in-hospital mortality from 10% to 76%, 6-month mortality from 21% to 58%, and 1-year mortality from 33% to 72%. Factors addressed in multivariate analyses were also heterogeneous across studies. Severity score, diagnosis at admission, and use of mechanical ventilation were the independent factors most frequently associated with ICU mortality, whereas age, comorbidities, functional status, and severity score at admission were the independent factors most frequently associated with 3- 6 and 12 months mortality.

CONCLUSIONS

In this systematic review of older patients admitted to intensive care, we have documented substantial variation in short- and long-term mortality as well as in prognostic factors evaluated. To better understand this variation, we need consistent, high-quality data on pre-ICU conditions, ICU physiology and treatments, structure and system factors, and post-ICU trajectories. These data could inform geriatric care bundles as well as a core data set of prognostic factors to inform patient-centered decision-making.

Clinical characteristics and outcomes of mechanically ventilated elderly patients in intensive care units: a Chinese multicentre retrospective study

Background

In recent years, the number of elderly patients receiving mechanical ventilation (MV) in intensive care units (ICUs) has increased. However, the evidence on the outcomes of elderly mechanically ventilated patients is scant in China. Our objective was to evaluate the characteristics and outcomes in elderly patients (≥65 years) receiving MV in the ICU.

Methods

We performed a multicentre retrospective study involving adult patients who were admitted to the ICU and received at least 24 hours of MV. Patients were divided into three age groups: under 65, 65-79, and ≥80 years. The primary outcome was hospital mortality. We performed univariate and multivariate logistic regression analysis to identify factors associated with hospital mortality.

Results

A total of 853 patients were analysed. Of those, 61.5% were ≥65 years of age, and 26.0% were ≥80 years of age. There were significant differences in the principal reason for MV among the three age groups (P<0.001). Advanced age was significantly associated with total duration of MV, ICU length of stay (LOS), and ICU costs (all P<0.001), but not with hospital LOS and hospital costs (P>0.05). In addition, mortality rates in the ICU, hospital, and at 60 days significantly increased with age (all P<0.001). In the age group of 80 years and older, the mortality rates were 47.7%, 49.5%, and 50.0%, respectively. Multivariate logistic regression analysis had found that age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, partial pressure of oxygen in arterial blood/fraction of inspired oxygen (PaO₂/FiO₂) ratio, total duration of MV, ICU LOS, and the decision to withhold/withdraw life-sustaining treatments were independent influence factors for mortality rates.

Conclusions

Mechanically ventilated elderly patients (≥65 years) have a higher ICU and hospital mortality, but the hospital LOS and hospital costs are similar to younger patients. Advanced age should be considered as a significant independent risk factor for hospital mortality of mechanically ventilated ICU patients.

Management of Very Old Patients in Intensive Care Units

The global population is aging and the demand for critical care wards increasing. Aging is associated not only with physiological and cognitive vulnerability, but also with a decline in organ function. A new topic in geriatric care is how to appropriately use critical care resources and provide the best treatment plan for very old patients (VOPs). Our special geriatric intensive care unit has admitted nearly 500 VOPs. In this review, we share our VOP treatment strategy and summarize the key points as “ABCCDEFGHI bundles.” The aim is to help intensivists to provide more comprehensive therapy for VOPs in intensive care units.

Frailty as a Prognostic Indicator in Intensive Care

BACKGROUND

The percentage of patients in intensive care who are 80 years old or older is continually increasing. Such patients already made up more than 20% of all patients in intensive care in Germany in the years 2007-2011. Meanwhile, effective treatments that support the organs of the body and keep severely ill patients alive are also being continually developed and refined. Frailty is a key prognostic parameter. The scientifically based assessment of frailty can be highly useful in intensive care medicine with regard to consented decision-making, individualized prognostication, treatment planning, and aftercare.

METHODS

Pertinent publications were retrieved by a selective search in the PubMed database. On the basis of the literature assessment, a variety of screening instruments were used to assess frailty and its significance for very old, critically ill patients in German intensive care units.

RESULTS

Only a small number of screening instruments are suitable for routine use in German intensive care units. The scores vary in diagnostic precision. The Clinical Frailty Scale (CFS) enables highly accurate prognostication; it considers the patient in relation to his or her social environment, and to the reference population. Categorization is achieved by means of pictograms that are supplemented with brief written descriptions. The CFS can be used prospectively and is easy to learn. Its interrater reliability is high (weighted Cohen's κ: 0.85 [0.84; 0.87]), and it has been validated for routine use in intensive care units in Germany.

CONCLUSION

None of the available scores enable perfect prognostication. In Germany, frailty in intensive-care patients is currently best assessed on a simple visual scale (CFS).

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Elderly Patients in the Intensive Care Unit

Very old intensive care unit (ICU) patients, aged ≥ 80 years, are by no mean newcomers, but during the last decades their impact on ICU admissions has grown in parallel with the increase in the number of elderly persons in the community. Hence, from being a "rarity," they have now become common and constitute one of the largest subgroups within intensive care, and may easily be the largest group in 20 years and make up 30 to 40% of all ICU admissions. Obviously, they are not admitted because they are old but because they are with various diseases and problems like any other ICU patient. However, their age and the presence of common geriatric syndromes such as frailty, cognitive decline, reduced activity of daily life, and several comorbid conditions makes this group particularly challenging, with a high mortality rate. In this review, we will highlight aspects of current and future epidemiology and current knowledge on outcomes, and describe the effects of the aforementioned geriatric syndromes. The major challenge for the coming decades will be the question of whom to treat and the quest for better triage criteria not based on age alone. Challenges with the level of care during the ICU stay will also be discussed. A stronger relationship with geriatricians should be promoted to create a better and more holistic care and aftercare for survivors.

The very old in intensive care: Admission characteristics, mortality and supports needed at six months postdischarge

OBJECTIVE

To describe survival and six-month outcomes (residence, community supports) in the very old (≥80 years) admitted to intensive care in Waitemata District Health Board, New Zealand.

METHODS

Hospital records of patients 80 years and over admitted from August 2015 to June 2017 were reviewed.

RESULTS

One hundred and seventeen patients were admitted (median age: 83). Standard ICU risk scores predicted survival to hospital discharge. Patients admitted electively were more likely to survive to discharge than emergency ICU/HDU admissions (P = .007). Ninety-two (79%) survived to hospital discharge, and 84 (72%) survived to 6 months. Eighty-four were discharged home (91% of survivors), and 79 were living at home at 6 months (94% of survivors). Community supports increased from admission (34, 29%) to 6 months later (34, 43% of community dwellers). Forty-four (47.8% surviving to discharge) were readmitted within 6 months.

CONCLUSIONS

Most patients are alive at discharge and 6 months, with a majority requiring no formal supports.

Substance abuse-related admissions in a mixed Norwegian intensive care population

BACKGROUND

Alcohol and drug abuse are potentially modifiable risk factors for critical illness. The aims of this study were to describe patients with substance abuse-related admissions (abbreviated SARA) in a mixed intensive care (ICU) population in Oslo, and to compare these patients with patients with non-SARA.

METHODS

Cross-sectional prospective study of a mixed medical and surgical ICU-population in Oslo, Norway. Data were collected consecutively using a questionnaire, medical records, and toxicology results. SARA included admissions due to acute or chronic complications of alcohol or drug abuse, as well as substance abuse-related injuries.

RESULTS

Of the 852 patients included, 168 (20%) had SARA; 102 (12%) alcohol-related and 66 (8%) drug-related. Male patients aged 18-39 had the highest proportion of SARA (47/97, 49%). Among the trauma patients, 69/182 (38%) were influenced by alcohol and drugs at the time of injury. Patients with SARA were significantly younger (median age 48 vs 66), had lower Charlson comorbidity index (mean 1.4 vs 2.5) and shorter length of stay (median days 2.4 vs 4.9), than non-SARA patients. Hospital mortality was similar when adjusting for age (OR 0.8, P = .27, non-SARA as reference).

CONCLUSION

Overall, one in five ICU admissions was associated with substance abuse. For male patients aged 18-39 this ratio was nearly half. More than one third of the trauma patients were influenced by alcohol or drugs at time of injury.

[Geriatric intensive care : Consensus paper of DGIIN, DIVI, DGAI, DGGG, ÖGGG, ÖGIAIN, DGP, DGEM, DGD, DGNI, DGIM, DGKliPha and DGG]

The proportion of elderly, frail, and multimorbid people has increased dramatically in recent decades resulting from demographic changes and will further increase, which will impact acute medical care. Prospective, randomized studies on geriatric intensive care are still lacking. There are also no international or national recommendations regarding the management of critically ill elderly patients. Based on an expert opinion, this consensus paper provides 16 statements that should be considered when dealing with geriatric critical care patients.

Cumulative Prognostic Score Predicting Mortality in Patients Older Than 80 Years Admitted to the ICU

OBJECTIVES

To develop a scoring system model that predicts mortality within 30 days of admission of patients older than 80 years admitted to intensive care units (ICUs).

DESIGN

Prospective cohort study.

SETTING

A total of 306 ICUs from 24 European countries.

PARTICIPANTS

Older adults admitted to European ICUs (N = 3730; median age = 84 years [interquartile range = 81‐87 y]; 51.8% male).

MEASUREMENTS

Overall, 24 variables available during ICU admission were included as potential predictive variables. Multivariable logistic regression was used to identify independent predictors of 30‐day mortality. Model sensitivity, specificity, and accuracy were evaluated with receiver operating characteristic curves.

RESULTS

The 30‐day‐mortality was 1562 (41.9%). In multivariable analysis, these variables were selected as independent predictors of mortality: age, sex, ICU admission diagnosis, Clinical Frailty Scale, Sequential Organ Failure Score, invasive mechanical ventilation, and renal replacement therapy. The discrimination, accuracy, and calibration of the model were good: the area under the curve for a score of 10 or higher was .80, and the Brier score was .18. At a cut point of 10 or higher (75% of all patients), the model predicts 30‐day mortality in 91.1% of all patients who die.

CONCLUSION

A predictive model of cumulative events predicts 30‐day mortality in patients older than 80 years admitted to ICUs. Future studies should include other potential predictor variables including functional status, presence of advance care plans, and assessment of each patient's decision‐making capacity.

Caring for the critically ill patients over 80: a narrative review

Background

There is currently no international recommendation for the admission or treatment of the critically ill older patients over 80 years of age in the intensive care unit (ICU), and there is no valid prognostic severity score that includes specific geriatric assessments.

Main body

In this review, we report recent literature focusing on older critically ill patients in order to help physicians in the multiple-step decision-making process. It is unclear under what conditions older patients may benefit from ICU admission. Consequently, there is a wide variation in triage practices, treatment intensity levels, end-of-life practices, discharge practices and frequency of geriatrician’s involvement among institutions and clinicians. In this review, we discuss important steps in caring for critically ill older patients, from the triage to long-term outcome, with a focus on specific conditions in the very old patients.

Conclusion

According to previous considerations, we provide an algorithm presented as a guide to aid in the decision-making process for the caring of the critically ill older patients.

Electronic supplementary material

The online version of this article (10.1186/s13613-018-0458-7) contains supplementary material, which is available to authorized users.

Haloperidol for delirium in critically ill patients - protocol for a systematic review

BACKGROUND

In the intensive care unit, the prevalence of delirium is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer intensive care unit stay, increased long-term mortality, and cognitive impairment. Thus, the burden of delirium for patients, relatives, and societies is considerable. The objective of this systematic review was to critically access the evidence of randomised clinical trials on the effects of haloperidol vs. placebo or any other agents for delirium in critically ill patients.

METHODS

We will search for randomised clinical trials in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently screen and select references for inclusion using Covidence, extract data and assess the methodological quality of the included randomised clinical trials using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will analyse the extracted data using Review Manager, STATA 15, and Trial Sequential.

ANALYSIS

The aim of this study was to assess the quality of the evidence, we will create a 'Summary of Findings' table containing our primary and secondary outcomes using the GRADE assessment.

DISCUSSION

Our ambition with this systematic review is to provide reliable and powered evidence to better inform decision makers on the use of or future trials with haloperidol for the management of delirium in critically ill patients.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey

BACKGROUND

Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80.

METHODS

We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80.

RESULTS

We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions.

CONCLUSION

There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.

Costs and expected gain in lifetime health from intensive care versus general ward care of 30,712 individual patients: a distribution-weighted cost-effectiveness analysis

BACKGROUND

Clinicians, hospital managers, policy makers, and researchers are concerned about high costs, increased demand, and variation in priorities in the intensive care unit (ICU). The objectives of this modelling study are to describe the extra costs and expected health gains associated with admission to the ICU versus the general ward for 30,712 patients and the variation in cost-effectiveness estimates among subgroups and individuals, and to perform a distribution-weighted economic evaluation incorporating extra weighting to patients with high severity of disease.

METHODS

We used a decision-analytic model that estimates the incremental cost per quality-adjusted life year (QALY) gained (ICER) from ICU admission compared with general ward care using Norwegian registry data from 2008 to 2010. We assigned increasing weights to health gains for those with higher severity of disease, defined as less expected lifetime health if not admitted. The study has inherent uncertainty of findings because a randomized clinical trial comparing patients admitted or rejected to the ICU has never been performed. Uncertainty is explored in probabilistic sensitivity analysis.

RESULTS

The mean cost-effectiveness of ICU admission versus ward care was €11,600/QALY, with 1.6 QALYs gained and an incremental cost of €18,700 per patient. The probability (p) of cost-effectiveness was 95% at a threshold of €22,000/QALY. The mean ICER for medical admissions was €10,700/QALY (p = 97%), €12,300/QALY (p = 93%) for admissions after acute surgery, and €14,700/QALY (p = 84%) after planned surgery. For individualized ICERs, there was a 50% probability that ICU admission was cost-effective for 85% of the patients at a threshold of €64,000/QALY, leaving 15% of the admissions not cost-effective. In the distributional evaluation, 8% of all patients had distribution-weighted ICERs (higher weights to gains for more severe conditions) above €64,000/QALY. High-severity admissions gained the most, and were more cost-effective.

CONCLUSIONS

On average, ICU admission versus general ward care was cost-effective at a threshold of €22,000/QALY (p = 95%). According to the individualized cost-effectiveness information, one in six ICU admissions was not cost-effective at a threshold of €64,000/QALY. Almost half of these admissions that were not cost-effective can be regarded as acceptable when weighted by severity of disease in terms of expected lifetime health. Overall, existing ICU services represent reasonable resource use, but considerable uncertainty becomes evident when disaggregating into individualized results.

Nurses' experience of the transfer of ICU patients to general wards: A great responsibility and a huge challenge

AIMS AND OBJECTIVES

The aim of the study was to describe nurses' experiences of patients' transition from ICUs to general wards and their suggestions for improvements.

BACKGROUND

In the ICU, the most seriously ill patients with life-threatening conditions and multiple organ dysfunction syndromes are cared for and carefully monitored by specially trained professionals using advanced techniques for the prevention of failure of vital functions. The transfer of ICU patients to general wards means a change from a high to a lower level, including the loss of one-to-one nursing and a reduction of visible monitoring equipment and general close attention.

DESIGN

A qualitative descriptive design.

METHODS

Eight nurses from three different inpatient units in Norway, five from a university hospital and three from a local hospital were selected through a convenience sample. Interviews with open questions were conducted, and qualitative content analysis was used to explore the data.

RESULTS

Nurses' experiences were described in one main category: ICU patients' transition-a great responsibility and a huge challenge, and two generic categories: (i) a challenging transition for nurses, patients and relatives and (ii) dialogue and competencies as tools for improvement, with six subcategories.

CONCLUSION

A number of factors affected patient care, such as poor cooperation, communication, reporting, expertise and clinical gaze. It was clear that the general wards had major challenges, and a number of improvements were suggested.

RELEVANCE TO CLINICAL PRACTICE

This study shows that there is still a gap between the ICU and general wards and that nurses continue to struggle with this. It is therefore important that the managers responsible for the quality of care together with the professionals take seriously the criticism in the present and previous studies and work towards a safe transition for patients.

Pharmacological interventions for delirium in intensive care patients: a protocol for an overview of reviews

BACKGROUND

The prevalence of delirium in intensive care unit (ICU) patients is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer ICU stay, increased long-term mortality and cognitive impairment. Thus, the burden of delirium for patients, relatives and societies is considerable. Today, reviews of randomised clinical trials are produced in large scales sometimes making it difficult to get an overview of the available evidence. A preliminary search identified several reviews investigating the effects of pharmacological interventions for the management and prevention of delirium in ICU patients. The conclusions of the reviews showed conflicting results. Despite this unclear evidence, antipsychotics, in particular, haloperidol is often the recommended pharmacological intervention for delirium in ICU patients. The objective of this overview of reviews is to critically assess the evidence of reviews of randomised clinical trials on the effect of pharmacological management and prevention of delirium in ICU patients.

METHODS/DESIGN

We will search for reviews in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently select references for inclusion using Covidence, extract data and assess the methodological quality of the included systematic reviews using the ROBIS tool. Any disagreement will be resolved by consensus. We will present the data as a narrative synthesis and summarise the main results of the included reviews. In addition, we will present an overview of the bias risk assessment of the systematic reviews.

DISCUSSION

Results of this overview may establish a way forward to find and update or to design a high quality systematic review assessing the effects of the most promising pharmacological intervention for delirium in ICU patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO - CRD42016046628 .

Long-term survival and quality of life after intensive care for patients 80 years of age or older

Background

Comparison of survival and quality of life in a mixed ICU population of patients 80 years of age or older with a matched segment of the general population.

Methods

We retrospectively analyzed survival of ICU patients ≥80 years admitted to the Haukeland University Hospital in 2000–2012. We prospectively used the EuroQol-5D to compare the health-related quality of life (HRQOL) between survivors at follow-up and an age- and gender-matched general population. Follow-up was 1–13.8 years.

Results

The included 395 patients (mean age 83.8 years, 61.0 % males) showed an overall survival of 75.9 (ICU), 59.5 (hospital), and 42.0 % 1 year after the ICU. High ICU mortality was predicted by age, mechanical ventilator support, SAPS II, maximum SOFA, and multitrauma with head injury. High hospital mortality was predicted by an unplanned surgical admission. One-year mortality was predicted by respiratory failure and isolated head injury. We found no differences in HRQOL at follow-up between survivors (n = 58) and control subjects (n = 179) or between admission categories. Of the ICU non-survivors, 63.2 % died within 2 days after ICU admission (n = 60), and 68.3 % of these had life-sustaining treatment (LST) limitations. LST limitations were applied for 71.3 % (n = 114) of the hospital non-survivors (ICU 70.5 % (n = 67); post-ICU 72.3 % (n = 47)).

Conclusions

Overall 1-year survival was 42.0 %. Survival rates beyond that were comparable to those of the general octogenarian population. Among survivors at follow-up, HRQOL was comparable to that of the age- and sex-matched general population. Patients admitted for planned surgery had better short- and long-term survival rates than those admitted for medical reasons or unplanned surgery for 3 years after ICU admittance. The majority of the ICU non-survivors died within 2 days, and most of these had LST limitation decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-015-0053-0) contains supplementary material, which is available to authorized users.

Age, risk, and life expectancy in Norwegian intensive care: a registry-based population modelling study

Background

Knowledge about the expected life years gained from intensive care unit (ICU) admission could inform priority-setting decisions across groups of ICU patients and across medical specialties. The aim of this study was to estimate expected remaining lifetime for patients admitted to ICUs during 2008–2010 and to estimate the gain in life years from ICU admission.

Methods

This is a descriptive, population modelling study of 30,712 adult mixed ICU admissions from the Norwegian Intensive Care Registry. The expected remaining lifetime for each patient was estimated using a decision-analytical model. Transition probabilities were based on registered Simplified Acute Physiology Score (SAPS) II, and standard and adjusted Norwegian life-tables.

Results

The hospital mortality was 19.4% (n = 5,958 deaths). 24% of the patients were estimated to die within the first year after ICU admission in our model. Under an intermediate (base case), optimistic (O), and pessimistic (P) scenario with respect to long-term mortality, the average expected remaining lifetime was 19.4, 19.9, and 12.7 years. The majority of patients had a life expectancy of more than five years (84.8% in the base case, 89.4% in scenario O, and 55.6% in scenario P), and few had a life expectancy of less than one year (0.7%, 0.1%, and 12.7%). The incremental gain from ICU admission compared to counterfactual general ward care was estimated to be 0.04 (scenario P, age 85+) to 1.14 (scenario O, age < 45) extra life years per patient.

Conclusions

Our research demonstrated a novel way of using routinely collected registry data to estimate and evaluate the expected lifetime outcomes for ICU patients upon admission. The majority had high life expectancies. The youngest age groups seemed to benefit the most from ICU admission. The study raises the question whether availability and rationing of ICU services are too strict in Norway.

[Intensive care services resources in Spain]

OBJECTIVES

To identify the resources related to the care of critically ill patients in Spain, which are available in the units dependent of the Services of Intensive Care Medicine (ICM) or other services/specialties, analyzing their distribution according to characteristics of the hospitals and by autonomous communities.

DESIGN

Prospective observational study.

SETTING

Spanish hospitals.

PARTICIPANTS

Heads of the Services of ICM.

MAIN OUTCOME VARIABLES

Number of units and beds for critically ill patients and functional dependence.

RESULTS

The total number of registries obtained with at least one Service of ICM was 237, with a total of 100,198 hospital beds. Level iii (43.5%) and level ii (35%) hospitals predominated. A total of 73% were public hospitals and 55.3% were non-university centers. The total number of beds for adult critically ill patients, was 4,738 (10.3/100,000 inhabitants). The services of ICM registered had available 258 intensive are units (ICUs), with 3,363 beds, mainly polyvalent ICUs (81%) and 43 intermediate care units. The number of patients attended in the Services of ICM in 2008 was 174,904, with a percentage of occupation of 79.5% A total of 228 units attending critically ill patients, which are dependent of other services with 2,233 beds, 772 for pediatric patients or neonates, were registered. When these last specialized units are excluded, there was a marked predominance of postsurgical units followed by coronary and cardiac units.

CONCLUSIONS

Seventy one per cent of beds available in the Critical Care Units in Spain are characterized by attending severe adult patients, are dependent of the services of ICM, and most of them are polyvalent.

[Anaesthesia for the elderly at Nordland Hospital Bodø 1993-2009]

BACKGROUND

We investigated the development in the number of anaesthetised patients ≥ 67 years at Nordland Hospital Bodø and whether the age group ≥ 80 years had more problems under anaesthesia.

MATERIAL AND METHOD

We used anonymised information on anaesthesia from the DIPS patient data system at Nordland Hospital in Bodø from 1993-2009 and population data from Statistics Norway.

RESULTS

The total number of registered anaesthesias increased by 26.8%, from 6,770 in 1993 to 8,584 in 2009. 25,259 (92.7%) of anaesthesias for patients ≥ 67 years were in connection with surgery. The number, and the percentage of the total number, of anaesthesias for patients aged 67-79 years increased from 931 (13.8%) to 1,337 (15.6%). The percentage therefore increased by 13.0%, while the percentage of the population represented by this age group decreased by 10.7%. For patients ≥ 80 years the number and percentage increased from 341 (5.0%) to 696 (8.1%) anaesthesias, i.e. a percentage increase of 62.0%. At the same time the percentage of northern Norwegians ≥ 80 years increased by 30.6%. 4,490 (53.1%) of patients ≥ 80 years had an ASA classification of 3-5 compared to 6,745 (35.9%) in the age group 67-79 years (p < 0.001). Anaesthesia problems were recorded in 1,044 (12.3%) of patients ≥ 80 years and 2,349 (12.5%) of patients aged 67-79 years respectively (p = 0.73).

INTERPRETATION

The increase in anaesthesias for elderly patients at Nordland Hospital Bodø cannot be explained by population changes alone. That patients ≥ 80 years do not have more problems during anaesthesia than patients aged 67-79 years may be attributed to better surveillance and use of different methods of anaesthesia, but also to imprecise and deficient registration.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

The impact of pre-admission morbidity level on 3-year mortality after intensive care: a Danish cohort study

BACKGROUND

Chronic diseases are common among intensive care unit (ICU) patients and may worsen their prognosis. We examined the prevalence and impact of pre-admission/index morbidity among ICU patients compared with a general population cohort.

METHODS

Our study encompassed all 28,172 adult patients admitted to ICUs in northern Denmark in 2005-2007 and 281,671 age- and sex-matched individuals from the general population. We used a nationwide hospital registry to obtain a 5-year history of 19 chronic diseases and computed Charlson Comorbidity Index (CCI) for each study participant and grouped them into low (CCI=0), moderate (CCI=1-2), and high (CCI=3+) morbidity levels. We computed mortality and mortality rate ratios (MRRs) adjusted for confounders, and compared the mortality between ICU patients and the general population cohort.

RESULTS

Low, moderate, and high pre-admission morbidity levels were present in 51.5%, 34.1%, and 14.4% of ICU patients, respectively. In these groups, 30-day mortality was 10.8%, 18.4%, and 26.7%, respectively. Three-year mortality was 21.3%, 43.1%, and 63.2%, respectively. The adjusted 30-day MRR was 1.30 [95% confidence intervals (CI): 1.21-1.39] and 1.86 (95% CI: 1.71-2.01) for ICU patients with moderate and high morbidity levels, both compared with a low morbidity level. The general population had a lower morbidity level and mortality at all morbidity levels throughout the study period. Interaction between ICU admission and high morbidity level added 5.1% to the mortality during the second and third year of follow-up.

CONCLUSION

A high pre-admission morbidity level was frequent among ICU patients and associated with a worsened prognosis. Morbidity had more impact on mortality among ICU patients compared with a general population cohort.