The impact of emergency department length of stay on the outcomes of trauma patients requiring hospitalization: a retrospective observational study

BACKGROUND: We aimed to explore the impact of the emergency department length of stay(EDLOS) on the outcome of trauma patients.METHODS: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS(<4 h, 4–12 h,12–24 h, and >24 h). Data were analyzed using Chi-square test(categorical variables), Student’s t-test(continuous variables), correlation coefficient, analysis of variance and mu...     

After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care

Objective To examine the influence of time of admission on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (ICU) without 24-h per day in-house intensivist coverage. Design Data analyzed came from a comprehensive, prospectively collected ICU database. Setting A 12-bed pediatric ICU located in a university-affiliated tertiary referral children's hospital. Patients Subjects consisted of 4,456 consecutive nonelective patients admitted over a 10-year period (1997–2006). Interventions None. Measurements and results Patients were categorized according to time of admission to the ICU as either in-hours (0800–1800 Monday–Friday and 0800–1200 on weekends), when an intensivist is present in the ICU, or after-hours (all other times), when intensivists attend only on an as-needed basis. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the Paediatric Index of Mortality (PIM). Patients admitted after hours had a lower risk-adjusted mortality than those admitted during normal working hours, with an odds ratio for death of 0.712 (95% confidence interval 0.518–0.980, p = 0.037). Length of stay was also significantly shorter for patients admitted after hours (44.05 h vs. 50.0 h, p = 0.001). Conclusions A lack of in-house intensivist presence is not associated with any increase in mortality or length of stay for patients admitted to our pediatric ICU; on the contrary, after-hours admission in this cohort was associated with a decreased risk-adjusted mortality and a shorter length of stay.     

Mortality rates under the care of junior and senior surgery residents in a surgical intensive care unit/neurologic intensive care unit: A 5-year retrospective cohort study at Taoyuan Armed Forces General Hospital

Background

The quality and outcome of health care administered in intensive care units (ICUs) of teaching hospitals are dependent on a myriad of factors; however, few studies have assessed mortality rates and length of stay in surgical intensive care and neurologic intensive care units (SICU/NICU) in relation to the experience of junior and senior surgery residents.

Objective

The aim of this study was to determine whether there were differences in the outcomes of ICU patients cared for by junior surgery residents or senior surgery residents by assessing mortality rates and length of stay in the SICU/NICU.

Design

This was a retrospective cohort analysis. Mortality rates, length of SICU/NICU stay, and baseline characteristics were assessed in 2 patient groups: group 1, patients managed by junior surgical residents; group 2, patients managed by senior surgical residents. Categorical variables were compared by χ²/Fisher exact test, and continuous data (age and ICU stay) were compared using the Mann-Whitney U test. Acute Physiology and Chronic Health Evaluation II score was used for ICU prognostic models.

Setting

The Taoyuan Armed Forces General Hospital (Taoyuan, Taiwan, ROC) consists of an 8-bed SICU and an 8-bed NICU.

Patients

Data were collected from 2274 patients from January 1, 2002, to December 31, 2006, from the intensive care units (SICU/NICU) of the department of surgery.

Interventions

None.

Results

Significant differences between the 2 groups were found in total patient mortality and the duration of intensive care unit stay. Of 1806 patients in group 1, 446 (24.7%) died, whereas 83 (17.7%) of 468 in group 2 died (P = .002). The major difference of mortality rate was in the division of neurology surgery; 291 (26.6%) of 1092 patients in group 1 died, whereas 55 (19.2%) of 287 in group 2 died (P = .009), with most deaths due to spontaneous intracranial hemorrhage (P = .012) and central nervous system tumors (P = .048). Median length of SICU/NICU stay for group 1 was 3.0 days vs 3.5 days for group 2 (P = .003).

Conclusions

The quality of care of critically ill patients is improved when more experienced residents are providing care. We suggest that residents rotated into the special units such as SICU/NICU for care of critically ill patients should be at least at third year of training.     

Frailty is not independently associated with intensive care unit length of stay: An observational study

BackgroundFrailty is independently associated with morbidity and mortality in critically ill patients. However, the association between preadmission frailty and the degree of treatment received in the intensive care unit (ICU) remains unclear.ObjectiveTo describe patient length of stay in an ICU and the treatments provided according to the extent of patient frailty.MethodsSingle-centre retrospective cohort study of adult patients admitted to a tertiary ICU between January 2018 and December 2019. Frailty was assessed using the Clinical Frailty Scale (CFS). The primary outcome was ICU length of stay stratified by CFS score (1–8). Secondary outcomes were the proportion of patients with each CFS score treated with vasoactive agents, invasive ventilation, noninvasive ventilation, renal replacement therapy, and tracheostomy. Poisson regression and competing risks regression was used to analyse associations between ICU length of stay and potential confounders.ResultsThe study cohort comprised 2743 patients, with CFS scores known for 2272 (83%). Length of stay in the ICU increased with each increment in the CFS up to a score of 5, beyond which it decreased with higher frailty scores. After adjusting for age, illness severity, admission type, and treatment limitation, CFS scores were not independently associated with length of stay in the ICU (P = 0.31). The proportion of patients receiving specific ICU treatments peaked at different CFS scores, being highest for vasoactive agents at CFS 5 (47%), invasive ventilation CFS 3 (51%), noninvasive ventilation CFS 6 (11%), renal replacement therapy CFS 6 (8.2%), and tracheostomy CFS 5 (2.2%). Increasing frailty was associated with increased mortality and discharge to a destination other than home.ConclusionsThe extent of frailty is not independently associated with length of stay in the ICU. The proportion of patients receiving specific ICU treatments peaked at different CFS scores.     

Time to rehabilitation admission and associated outcomes for patients with traumatic brain injury

OBJECTIVE: To examine the association between time from injury to rehabilitation admission and outcomes for patients with traumatic brain injuries (TBIs). DESIGN: Retrospective chart review. SETTING: One hundred-bed inpatient rehabilitation facility with a 20-bed brain injury unit. PARTICIPANTS: Patients with TBIs discharged from initial inpatient rehabilitation between 2003 and 2004 (N=158). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Outcomes examined were functional independence at discharge (motor, cognitive, total FIM scores), rehabilitation length of stay (LOS), and rehabilitation cost. RESULTS: Significant linear trends were observed for time to admission and motor FIM scores, total FIM scores, rehabilitation LOS, and cost. All linear regression models contained time to admission as a significant predictor of rehabilitation outcomes. Over half of the variability in outcomes was explained by predictors including time to admission and case-mix group or individual FIM scores with the exception of discharge motor FIM score, for which only 45% of the variability was explained. CONCLUSIONS: Patients who progress to rehabilitation earlier do better functionally and have lower costs and shorter LOSs. Furthermore, the time to rehabilitation admission is easily calculated and could be used by rehabilitation providers in adjunct with admission FIM scores to estimate resource utilization.     

Introducing Critical Care Outreach: a ward-randomised trial of phased introduction in a general hospital

Objective The purpose of the study was to investigate the effects of introducing a critical care outreach service on in-hospital mortality and length of stay in a general acute hospital.Design A pragmatic ward-randomised trial design was used, with intervention introduced to all wards in sequence. No blinding was possible.Setting Sixteen adult wards in an 800-bed general hospital in the north of England.Patients and participants All admissions to the 16 surgical, medical and elderly care wards during 32-week study period were included (7450 patients in total, of whom 2903 were eligible for the primary comparison).Interventions Essential elements of the Critical Care Outreach service introduced during the study were a nurse-led team of nurses and doctors experienced in critical care, a 24-h service, emphasis on education, support and practical help for ward staff.Measurements and results The main outcome measures were in-hospital mortality and length of stay. Outreach intervention reduced in-hospital mortality compared with control (two-level odds ratio: 0.52 (95% CI 0.32–0.85). A possible increased length of stay associated with outreach was not fully supported by confirmatory and sensitivity analyses.Conclusions The study suggests outreach reduces mortality in general hospital wards. It may also increase length of stay, but our findings on this are equivocal.Electronic Supplementary Material Supplementary material is available in the online version of this article at An editorial regarding this article can be found in the same issue ()     

Epidemiologic aspects and results of applying the TRISS methodology in a Spanish trauma intensive care unit (TICU)

Objective Analysis of epidemiologic aspects in a trauma intensive care unit (TICU) and assessment of predicted outcomes.Design Prospective study. Samples collected over a 2-year period.Setting A Spanish TICU at a tertiary care centre.Patients A group of 404 trauma patients.Interventions TRISS methodology was applied.Main results Mean age was 35.8±17 years. Mortality was 19.6% over a median ISS=17. Blunt trauma was more frequent than penetrating trauma (90.1% versus 9.9%). Car accident was the major aetiological factor (32.4%) and the highest mortality was among struck pedestrians (26.4%). The cranial region showed the highest incidence of lesion (57.9%) and the neurological complications on stage were the commonest reported on the discharge forms (49.7%). Mechanical ventilatory support (MVS) was applied in 53.2% of patients, with a relative mortality of 35.8%. Survivors differed significantly from nonsurvivors in terms of age, Glasgow Coma Scale rating, RTS, ISS, TRISS, stage and number of complications reported. The risk factors found to be associated with mortality were injury to cranial and abdominal/pelvic regions and age over 65. The TRISS total accuracy was 0.88 (sensitivity=0.67; specificity=0.93; area under the ROC curve=0.85±0.03). Forward stepwise logistic regression analysis selected age, ISS and RTS as the best predictors of survival. When our TRISS results were compared with those anticipated on the basis the MTOS, an injury severity mismatch appeared (z=0.02; M=0.78).Conclusions We found a 19.6% mortality in the TICU. Cranial and abdominal/pelvic injury and age over 65 were the main risk factors on admittance. Clinically, we finally agreed with the majority of TRISS outcome predictions. However, we could not statistically validate the apparent clinical goodness of the TRISS methodology.Abbreviations RTS Revised trauma score - ISS Injury severity score - MTOS Major trauma outcome study     

Toward less sedation in the intensive care unit: a prospective observational study

Purpose

Excessive sedation is associated with prolonged mechanical ventilation and longer intensive care unit (ICU) and hospital stays. We evaluated the feasibility of using minimal sedation in the ICU.

Methods

Prospective observational study in a university hospital 34-bed medico-surgical department of intensive care. All adult patients who stayed in the ICU for more than 12 hours over a 2-month period were included. Intensive care unit admission diagnoses, severity scores, use of sedatives and/or opiates, duration of mechanical ventilation, length of ICU stay, and 28-day mortality were recorded for each patient.

Results

Of the 335 patients (median age, 61 years) admitted during the study period, 142 (42%) received some sedation, most commonly with midazolam and propofol. Sedative agents were administered predominantly for short periods of time (only 10% of patients received sedation for >24 hours). One hundred fifty-five patients (46%) received mechanical ventilation, generating 15?240 hours of mechanical ventilation, of these, only 2993 (20%) hours were accompanied by a continuous sedative infusion. Self-extubation occurred in 6 patients, but only 1 needed reintubation.

Conclusions

In a mixed medical-surgical ICU, minimal use of continuous sedation seems feasible without apparent adverse effects.     

地震伤员的急救与麻醉处理策略

目的探讨地震伤员的急救与麻醉处理方法。方法 64例地震伤员经积极的麻醉前准备,合理选择麻醉方法 ,早期有效液体治疗,麻醉期间维持循环、呼吸、肝肾功能,注意生命指标动态变化。结果局部麻醉及静脉麻醉38例,麻醉手术顺利,全部救治成功;26例气管插管全麻伤员有16例清醒拔管安全返回病房,9例保留气管导管送监护室,死亡1例。结论对地震伤员的科学救治、规范施救是减少死亡率和致残率的重要环节;选择恰当的麻醉方法 ,合理的麻醉用药,强有力的呼吸支持,有效的循环功能保护及麻醉恢复期的监管等综合措施是大规模地震伤员救治的根本保证。     

The use of propofol for medium and long-term sedation in critically ill adult patients: a meta-analysis

Objective  To investigate the effects of using propofol for medium and long-term sedation on mortality and length of intensive care unit (ICU) stay of critically ill adult patients. Design  Randomised controlled studies comparing propofol with an alternative sedative agent in critically ill adult patients were included without language restriction from the Cochrane Controlled Trial Register (2007 issue 3), EMBASE, and MEDLINE databases (1966 to 1 December 2007). Two reviewers reviewed the quality of the studies and performed data extraction independently. Measurements and results  Sixteen randomised controlled studies with a total of 1,386 critically ill adult patients were considered. Nine of the pooled studies (56%) limited the doses of propofol infusion to <6 mg/kg h⁻¹. Mortality was not significantly different between patients sedated with propofol, or an alternative sedative agent (odds ratio [OR] 1.05, 95% confidence interval [CI] 0.80–1.38, P = 0.74; I ²  = 0%). Using propofol for medium and long-term sedation was associated with a significant reduction in length of ICU stay (overall weighted-mean-difference [WMD] in days −0.99, 95%CI −1.51 to −0.47, P = 0.0002; I ² = 82.26%) when compared to an alternative sedative agent; however, this benefit became insignificant (overall WMD in days −0.98, 95%CI −2.86 to 0.89, P = 0.30; I ² = 78.8%) when the comparison was limited to between propofol and midazolam. Conclusions  Using propofol for prolonged sedation in critically ill patients appears to be safe and may reduce duration of mechanical ventilation. It reduces the length of ICU stay when compared to long acting benzodiazepines, but not when compared to midazolam.     

Adverse outcomes associated with delayed intensive care consultation in medical and surgical inpatients

Purpose

The impact of delay in obtaining an intensive care unit (ICU) consult from inpatient wards is unclear. The goal of this study was to examine the effect of time to ICU consult from medical and surgical wards on mortality and length of stay (LOS).

Materials and Methods

This was a retrospective study of 241 adult medical and surgical inpatients admitted at 2 tertiary care ICUs in Canada between 2007 and 2009. Neither institution has medical emergency teams (METs). Patient demographics, time when the patient would have fulfilled MET calling criteria (MET time), time of ICU consult, and ICU admission were analyzed. The main outcome variables were 30-day mortality and ICU LOS.

Results

Multivariate analysis demonstrated an increase in mortality (odds ratio, 1.8; 95% confidence interval, 1.1-2.9; P = .01) with increased duration from MET time to ICU consult for medical patients. There was no effect of this period on ICU LOS in medical patients. In contrast, in surgical patients, the MET time to ICU consult duration was associated with an increased ICU LOS (coefficient, 2.1 for delay; 95% confidence interval, 0.26-3.8; P = .02) but had no effect on mortality.

Conclusions

Increased duration to ICU consult from MET time is associated with adverse outcomes. These adverse outcomes are different between medical and surgical patients.     

Duration of red blood cells storage and outcome in critically ill patients

Purpose

There is conflicting evidence on the effect of red blood cells (RBC) storage duration and clinical outcomes. We aimed to investigate the association between RBC storage duration and clinical outcomes in patients admitted to the intensive care unit (ICU).

Materials and Methods

We retrospectively (2001-2011) studied adults admitted to the ICUs of 2 hospitals who received RBC. Using the mean, maximum and minimum age of RBC units transfused, we evaluated the association between RBC storage duration and mortality. We also analyzed the association between mean age of RBC units and length of stay (LOS) in survivors. We performed sensitivity analyses in patients who only received RBC in ICU and who only received leukodepleted RBC.

Results

We studied 8416 patients who received a median of 4 (interquartile range, 2-7) RBC units. After multivariate analysis, age of RBC was not independently associated with mortality, including in the subgroup analyses. Furthermore, there was no clinically relevant relationship between mean RBC age and LOS.

Conclusions

RBC storage duration was not associated with increased mortality nor ICU and hospital LOS. These results support the view that the effect of RBC storage duration on outcomes in critically ill patients is uncertain.     

Length of stay and mortality due to Clostridium difficile infection acquired in the intensive care unit

Purpose

The purpose of this study was to determine the attributable intensive care unit (ICU) and hospital length of stay and mortality of ICU-acquired Clostridium difficile infection (CDI).

Materials and methods

In this retrospective cohort study of 3 tertiary and 3 community ICUs, we screened all patients admitted between April 2006 and December 2011 for ICU-acquired CDI. Using both complete and matched cohort designs and Cox proportional hazards analysis, we determined the association between CDI and ICU and hospital length of stay and mortality. Adjustment or matching variables were site, age, sex, severity of illness, and year of admission; any infection as an ICU admitting or acquired diagnosis before the diagnosis of CDI and diagnosis of CDI were time-dependent exposures.

Results

Of 15 314 patients admitted to the ICUs during the study period, 236 developed CDI in the ICU. In the complete cohort analysis, the hazard ratios (95% confidence interval) for CDI related to ICU and hospital discharge were 0.82 (0.72, 0.94) and 0.83 (0.73, 0.95), respectively (0.5 additional ICU days and 3.4 hospital days), and related to death in ICU and hospital, they were 1.00 (0.73, 1.38) and 1.19 (0.93, 1.52), respectively. In the matched analysis, the hazard ratios for CDI related to ICU and hospital discharge were 0.91 (0.81, 1.03) and 0.98 (0.85, 1.13), respectively, and related to death in ICU and hospital, they were 1.18 (0.85, 1.63) and 1.08 (0.82, 1.43), respectively.

Conclusions

C difficile infection acquired in ICU is associated with an increase in length of ICU and hospital stay but not with any difference in ICU or hospital mortality.     

Atrial fibrillation in trauma patients requiring intensive care

Objectives To evaluate the incidence and risk factors of atrial fibrillation (AF) in trauma patients. Design and setting Prospective observational study in a surgical intensive care unit (ICU). Patients All trauma patients admitted in the surgical ICU except those who had AF at admission. Measurements and results AF occurred in 16/293 patients (5.5%). AF patients were older, had a higher number of regions traumatized, and received more fluid therapy, transfusion products, and catecholamines. They more frequently experienced systemic inflammatory response syndrome, sepsis, shock, and acute renal failure and had higher scores of severity (Simplified Acute Physiology Score, SAPS II; Injury Severity Score). ICU length of stay and resources use were also increased. ICU and hospital mortality rates were twice higher in AF patients whereas standardized mortality ratio (observed/expected mortality by SAPS II) was similar in the two groups. We found five independent risk factors of developing AF: catecholamine use (OR = 5.7, 95% CI 1.7–19.1), SAPS II of 30 or higher (OR = 11.6, 95% CI 1.3–103.0), three or more regions traumatized (OR = 6.2, 95% CI 1.8–21.4), age 40 years or higher (OR = 6.3, CI 1.4–28.7), and systemic inflammatory response syndrome (OR = 4.4, 95% CI 1.2–16.1). Conclusions In addition to age and catecholamine use, inflammation and severity of injury may be involved in the development of AF in trauma patients. Our results suggest that AF could rather be a marker of a higher severity of illness without major effect on mortality. This article is discussed in the editorial available at: .     

143例ICU老年创伤患者的流行病学分析

目的探讨单中心老年创伤重症患者流行病学特点,为临床救治提供参考。 方法回顾性分析2017年1月至2018年6月陆军军医大学大坪医院重症医学科（ICU）收治的65岁以上老年创伤患者143例,分析患者性别、年龄、致伤机制、损伤严重程度评分（ISS）、并发症、住院时间等资料。采用Mann-Whitney检验比较ISS评分、急性生理与慢性健康评分（APACHE Ⅱ评分）、ICU时间、住院时间在不同受伤机制和不同年龄之间的差异,使用Pearson χ²检验比较年龄分层计数、基础疾病分类计数、好转出院例数在不同受伤机制和不同年龄之间的差异,应用Logistic回归分析法分析并发症发生的危险因素。 结果所有创伤患者中,男性患者71例（49.65%,71/143）,女性72例（50.34%,72/143）;年龄65~99岁,平均年龄（78±1）岁;多发伤43例（30.07%,43/143）,单部位伤100例（69.93%,100/143）。跌倒伤是首位致伤原因90例（62.94%,90/143）,其次为车祸伤40例（27.97%,40/143）。跌倒伤ISS［9（9,9）分vs 22（16,27）分,Z=7.574,P<0.001］、APACHE II评分［15（14,17）分vs 17（15,21）分,P=0.001］均较低,住ICU时间［2（1,3）d vs 8（1,16）d,Z=4.407,P<0.001］和住院时间［（16（12,22.25）d vs 30（19,49）d,Z=4.779,P<0.001）］较非跌倒伤更短,好转出院率比较差异无统计学意义（P>0.05）。≥80岁患者与<80岁患者比较,APACHE Ⅱ评分明显升高［16（15,20）分vs 14（15,18）分,Z=2.093,P=0.036）］,住ICU的时间更长［3（1,10）d vs 1（1,7.5）d,Z=2.013,P=0.044］。APACHE Ⅱ评分是并发症发生的危险因素（OR=1.771,P=0.01）。 结论老年患者入住ICU的主要原因是跌倒伤,其次是车祸伤。除年龄外,APACHE Ⅱ评分高时,住ICU时间更长和并发症发生率更高。     

The influence of length of stay in the ICU on power of discrimination of a multipurpose severity score (SAPS)

Objective To assess how the power of discrimination of a multipurpose severity score (Simplified Acute Physiology Score; SAPS) changes in relation to the length of stay (LOS) in the intensive care unit (ICU).Design In order to compute the SAPS probability, a model derived from logistic regression was developed in a cohort of 8059 patients. Measures of calibration (goodness-of-fit statistics) and discrimination [receiver operating characteristic (ROC) curve and relative area under the curve (AUC)] were adopted in a developmental set (5389 patients) and a validation set (2670 patients), both randomly selected. Once the logit was developed and the model validated, the whole database (8059 patients) was again assembled. To evaluate the accuracy of first-day SAPS probability over time, area under the ROC curve was computed for each of the initial 10 days of ICU care and for day 15.Setting 24 Italian ICUs.Patients A total of 8059 patients out of 10065 consecutive admissions over a period of 3 years (1990–1992) were included in this study. Patients whose SAPS was not correctly compiled (n=687), patients younger than 18 years (n=442), and patients whose LOS was less than 24 h (n=877) were excluded from this analysis.Interventions None.Measurements and results The logistic model gave good results in terms of calibration and discrimination, both in the developmental set (goodness-of-fit:X ²=9.24,p=0.32; AUC=0.79±0.01) and in the validation set (goodness-of-fit:X ²=8.95,p=0.537; AUC=0.78±0.01). The AUC for the whole database showed a loss in discrimination closely related to LOS: 0.79±0.01 at a day 1 and 0.59±0.02 at day 15.Conclusion The logistic model that we developed meets high standards for discrimination and calibration. However, SAPS loses its discriminative power over time; accuracy of prediction is maintained at an acceptable level only in patients who stay in the ICU no longer than 5 days. The stay in the ICU represents a complex variable, which is not predictable, that influences the performance of SAPS on the first day.ARCHIDIA (Archivio Diagnostico): A complete list of study participants appears in theAppendix