Identifying potentially ineffective care in the sickest critically ill patients on the third ICU day

OBJECTIVE: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: Adult patients with first-ICU-day predicted mortality rate > or = 80%. MEASUREMENTS: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay. RESULTS: A total of 302 patients (age [mean +/- SD], 64.7 +/- 15.8 years; 54.3% male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7%. The first- and third-ICU-day APSs were 106.8 +/- 19.8 and 70.5 +/- 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 +/- 5.3% and 86.5 +/- 14.8%, respectively. The hospital mortality rate was 61.3%, and the 100-day survival rate 28.5%. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3%). Only 2 of these 34 patients (6%) survived to hospital discharge, compared to 115 of 268 patients (43%) without an increase in APS (p < 0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3% (95% confidence interval, 11.1 to 20.7%), specificity was 98.8% (95% confidence interval, 93.7 to 99.8%), positive predictive value was 97.1% (95% confidence interval, 85.1 to 99.5%), and negative predictive value was 31.7% (95% confidence interval, 26.4 to 37.5%). CONCLUSIONS: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate > or = 80%.     

Intensive care unit admissions with cirrhosis: Risk-stratifying patient groups and predicting individual survival

Prognosis for acutely ill patients with cirrhosis is influenced by the severity of hepatic abnormalities and by dysfunction of other organ systems. The purpose of this study was to examine the usefulness of the Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) prognostic system for risk-stratifying groups of intensive care unit (ICU) patients with cirrhosis and in predicting individual survival. We used data for 17,440 ICU admissions at 40 American hospitals to select 117 of the 537 patients with a history of cirrhosis who were ventilated on ICU day 1, a group known to have a high mortality rate. We then calculated each patient's probability of hospital death on ICU days 1 through 7, using seven previously validated multivariate equations. Hospital mortality was 63% for the 117 study patients. The most important determinants of risk for hospital death on ICU day 1 were the acute physiology score of APACHE III, ICU admission diagnosis, and operative status. Daily changes in the acute physiology score caused a rise or fall in the probability of hospital mortality and was useful in assessing individual response to therapy. APACHE III accurately risk stratifies critically ill patients with cirrhosis because it accounts for many of the factors known to influence prognosis. This capability can be used to assess severity of illness and risk-stratify patients with cirrhosis during clinical trials. Daily prognostic estimates based on physiological changes over time reflect patient response and can help physicians to assess the incremental benefit of therapy. (Hepatology 1996 Jun;23(6):1393-401)     

Performance of APACHE III models in an Australian ICU

STUDY OBJECTIVE: Evaluation of the performance of the APACHE (acute physiology and chronic health evaluation) III ICU and hospital mortality models at an Australian tertiary adult ICU. DESIGN: Noninterventional, observational study. SETTING: Metropolitan, Australian, tertiary referral medical/surgical ICU. PATIENTS: A total of 3,398 consecutive eligible admissions from January 1, 1995, to December 31, 1997. MEASUREMENTS: Prospective collection of demographic, diagnostic, physiologic, laboratory, admission, and discharge data. RESULTS: The patient sample was younger and more commonly male, with more comorbidities and a different operative and referral source mix, compared to the APACHE III development sample. Receiver operating characteristic curve areas for ICU (0.92) and hospital mortality (0.90) demonstrated excellent discrimination. Observed ICU mortality (9.9%) did not significantly differ from the prediction of the APACHE III model (8.9%) or the APACHE III model adjusted for hospital characteristics (10.5%). The hospital mortality (16.0%) was underestimated by the APACHE III model [13.6%; chi(2)(1) = 7.4; p = 0.01]. With proprietary adjustments for hospital characteristics (14.9%) or referenced to the US database (15.6%), agreement was closer. Good calibration was found with all models except the unadjusted hospital mortality model. CONCLUSION: In contrast to other non-American studies, this Australian study demonstrates that the APACHE III can perform well on independent assessment. As perfect discrimination and calibration cannot coexist in a probabilistic model with dichotomous outcomes, performance of APACHE III models with proprietary adjustment for hospital characteristic provide a good compromise for use in quality surveillance.     

Predicting outcome from intensive care for patients with rheumatologic diseases.

OBJECTIVE. To evaluate 2 prognostic scoring systems in patients with an underlying rheumatologic diagnosis admitted to an intensive care unit (ICU). METHODS. A retrospective case series review, carried out at a medical ICU in a military referral hospital. All adult ICU admissions with a known rheumatologic diagnosis were evaluated during 28 consecutive months. There were 48 ICU admissions available for review in 36 patients (1.33 ICU admissions/patient) during the study period. All patients were assigned an APACHE II and TISS score based on the first 24 h of ICU admission. RESULTS. Eleven ICU admissions resulted in patient death (22.9%) and the remaining 37 admissions (77.1%) in patient survival and hospital discharge. Overall patient mortality was 30.6% for the study population. The APACHE II and TISS scores were each significantly different for survivor and nonsurvivor subgroups (APACHE II p less than 0.0001; TISS p less than 0.0001). CONCLUSIONS. In this group of patients evaluated at a single institution both the APACHE II and TISS scoring systems allowed subgroup separation between survivors and nonsurvivors of ICU admission. However, these scoring methods demonstrated limitations in terms of outcome prediction when applied to the individual patient.     

Risks for developing critical illness with GI hemorrhage

STUDY OBJECTIVES: To define risk factors, identifiable on initial presentation, that predict subsequent physiologic derangements that are consistent with critical illness in patients presenting to hospital with GI hemorrhage (GIH). DESIGN: Observational, cohort study. SETTING: Fourteen-bed medical ICU in a 300-bed community teaching hospital. PATIENTS: One hundred ninety-three patients were studied during 199 separate hospital admissions for GIH. METHODS AMD MEASUREMENTS: Demographic and physiologic variables were extracted from the medical records of patients admitted with GIH. Comprehensive data, from after 2 h in the emergency department to the time of discharge or death, were used to determine whether patients met established ICU admission criteria. Physiologic and demographic data from the initial 2-h period were then compared for patients who subsequently met and for those who did not meet ICU admission criteria. Independent predictors of meeting ICU admission criteria were identified using multiple logistic regression analyses. Sensitivity and specificity associated with the combined use of these predictors were assessed. RESULTS: Thirty-four patients satisfied ICU admission criteria after the initial 2-h period in the emergency department. Sixty-five patients, including 29 of 34 patients who met ICU admission criteria, were actually admitted to the ICU. Among those who never fulfilled ICU admission criteria, the duration of hospital stay was longer for those admitted to the ICU than for those not admitted to ICU (6.6 +/- 0.6 days vs 5.2 +/- 0.3 days; p = 0.04). The admission prothrombin time (international normalized ratio > 1.2), hypotension (systolic BP < 90 mm Hg), acute neurologic changes, and initial APACHE (acute physiology and chronic health evaluation) II score ( > or =15) were the best independent predictors for meeting the defined criteria for admission to ICU. The presence of one or more of these in the first 2 h of presentation was associated with a sensitivity of 88% and specificity of 74% for predicting subsequent critical instability. The area under the receiver operator characteristic curve for use of these four variables was 86% for predicting whether patients met ICU admission criteria. CONCLUSIONS: Many patients with GIH were admitted to the ICU who never met local criteria for admission, and these patients experienced a significantly longer length of hospital stay than other, similarly ill patients. Coagulopathy, hypotension, neurologic dysfunction, and a higher (> or = 15) APACHE II score in the first 2 h of hospitalization were the best independent predictors of the subsequent development of critical illness.     

Risk assessment for inpatient survival in the long-term acute care setting after prolonged critical illness

OBJECTIVE: The past decade has witnessed growth in the long-term acute care (LTAC) hospital industry. There are no reliable risk assessment models that can adjust outcomes across such facilities with different criteria for admitting patients. Variation in reported outcomes makes it difficult to determine whether a patient, or group of patients, may benefit from such care. This study sought to determine the extent to which survival in the LTAC setting is associated with age, race, residual organ system failures (OSFs), or APACHE (acute physiology and chronic health evaluation) III scores at the time of admission to LTAC. DESIGN: Retrospective medical record review. SETTING: Four freestanding facilities of a LTAC hospital. PATIENTS: A sample of 300 hospital admissions weighted to represent the study hospital population. MEASUREMENTS: Inpatient survival modeled as a function of age, APACHE III score calculated within 72 h prior to LTAC admission, and residual OSFs present on admission to LTAC. RESULTS: Logistic regression analysis shows age and OSF were most predictive of inpatient survival (receiver operating characteristic curve area = 0.81). APACHE III score was not predictive of survival in the multivariate model. CONCLUSIONS: Survival in LTAC is primarily associated with age and OSFs, which should be used to adjust for patient populations among LTAC settings when comparing outcomes. Our model identifies a group of patients with the poorest likelihood of survival in the LTAC setting, and may be used to facilitate dialogue with patients and family in cases where continued aggressive care is least effective.     

Prognostic value of a new quantitative D-dimer test in critically ill patients 24 and 48 h following admission to the intensive care unit.

A D-dimer assay may predict mortality in medical critically ill patients, although no consensus on the clinical utility of this diagnostic test has been reached. A prospective single-center study was designed to evaluate whether D-dimer levels, as measured by a new, rapid assay, correlate with poor outcome in critically ill patients. A total of 95 blood samples were collected from medical and surgical adult patients 24 and 48 h following admission to the intensive care unit (ICU). D-dimer was assayed by the Miniquant quantitative test and correlated to the ICU length of stay, the hospital length of stay, the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Simplified Acute Physiology Score (SAPS) 24 and 48 h following admission to the ICU, organ system failure index and hospital mortality. The 24-h D-dimer level correlated with the 48 h APACHE II and SAPS scores (r = 0.41, P = 0.01; and r = 0.39, P = 0.01, respectively). The 48-h D-dimer level correlated with the APACHE II and SAPS scores at 48 h and with the organ system failure index (number of organ failure) (r = 0.54, P = 0.0008; r = 0.60, P = 0.0001; and r = 0.37, P = 0.02, respectively). Neither the 24-h nor the 48-h D-dimer levels were predictive of in-hospital mortality in a multivariate model. We conclude that this simple and new laboratory test may serve as an additional tool to predict the clinical severity of patients admitted to the ICU.     

Intensive care for very elderly patients: outcome and risk factors for in-hospital mortality.

OBJECTIVES: To evaluate outcome and risk factors, particularly the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, for in-hospital mortality in very elderly patients after admission to an intensive care unit (ICU). METHODS: Retrospective chart review of patients > or =85 years admitted to the ICU. We recorded age, sex, previous medical history, primary diagnosis, date of admission and discharge or death, APACHE II score on admission, use of mechanical ventilation and inotropics, and complications during ICU admission. RESULTS: 104 patients > or =85 years (1.3% of all ICU admissions) were studied. The ICU and in-hospital mortality rates for these patients were 22 and 36% respectively. Factors correlated with a greater in-hospital mortality were: an admission diagnosis of acute respiratory failure (chi2; P = 0.007), the use of mechanical ventilation (chi2; P = 0.00005) and inotropes (chi2; P = 0.00001), complications during ICU admission (chi2; P = 0.004), in particular acute renal failure (chi2; P = 0.005), and an APACHE II score > or =25 (chi2; P = 0.001). The APACHE II scoring system and the use of inotropes were independently correlated with mortality. CONCLUSION: ICU and in-hospital mortality are higher in very elderly patients, particularly in those with an APACHE II score > or =25. The most important predictors of mortality are the use of inotropes and the severity of the acute illness.     

Clinical course, prognostic factors, and outcome prediction for HIV patients in the ICU. The PIP (Pulmonary complications, ICU support, and prognostic factors in hospitalized patients with HIV) study

STUDY OBJECTIVE: To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU. DESIGN: Prospective, observational. SETTING: A university-affiliated medical center. METHODS:: We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4(+) lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS. RESULTS: The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4(+) lymphocyte count (median, 27.5 cells/microL vs 59 cells/microL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001). CONCLUSIONS: The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.     

Outcome of lung transplant patients admitted to the medical ICU

INTRODUCTION: Lung transplantation is an acceptable treatment option for end-stage lung disease. Short-term survival has improved, but lung transplant recipients remain at high risk for a variety of complications that can necessitate care in an ICU. Little is known about the epidemiology, clinical outcomes, and risk factors for survival among lung transplant recipients admitted to the ICU. METHODS: All lung transplant recipients at a single institution discharged from the hospital after their transplant and subsequently admitted to the medical ICU (MICU) between March 1, 1999, and February 28, 2001, were included. Patients were followed until death or February 28, 2002. Demographic data collected included transplant type and date, APACHE (acute physiology and chronic health evaluation) III scores, last preadmission and best posttransplant FEV(1) in liters, admitting diagnosis, use of mechanical ventilation, and previous MICU admission. RESULTS: There were 51 patients admitted to the MICU during the study period (73 total admissions). Their demographic data, pretransplant diagnoses, and type of transplant were similar to those of the rest of Duke University Medical Center lung transplant patients. Fifty-three percent (27 of 51 patients) required mechanical ventilation during their first MICU admission. Thirty-seven percent (19 of 51 patients) died during their first MICU admission. Fifty-nine percent (16 of 27 patients) receiving mechanical ventilation died. Patients who died had lower FEV(1) to posttransplant best FEV(1) ratio prior to MICU admission, and also had higher APACHE III scores on MICU admission compared to survivors: FEV(1), 51.3 +/- 21.9% (n = 14) vs 75.5 +/- 20.4% (n = 30) [p = 0.001]; APACHE III score, 77.7 +/- 21.4 (n = 19) vs 60.1 +/- 16.5 (n = 32) [p = 0.002]. Survival rates by Kaplan-Meier analysis at 1 year and 2 years after initial MICU admission were 43.1% and 40.9%, respectively. The longest survivor is currently alive 1,087 days after initial MICU admission. CONCLUSION: Admission to the MICU is common in lung transplant recipients. MICU care, including mechanical ventilation, is associated with a poor prognosis in lung transplant recipients, but is appropriate for selected patients with good allograft function.     

Clinical course and outcome of patients admitted to an ICU for status asthmaticus.

STUDY OBJECTIVES: To describe the prognostic factors, clinical course, and outcome of patients with status asthmaticus treated in a medical ICU (MICU). DESIGN: Analysis of prospective data. SETTING: A multidisciplinary MICU of an inner-city university hospital. PATIENTS: We collected data on 132 hospital admissions of 89 patients with status asthmaticus treated in our MICU from August 1995 through July 1998. MEASUREMENTS: APACHE (acute physiology and chronic health evaluation) II scores were among the parameters measured. RESULTS: Seventy-nine percent of the patients were female, and 67% were African American (mean +/- SD age, 42.4 +/- 15.1 years). Patients in 48 of the 132 hospital admissions (36%) required invasive mechanical ventilation; sepsis developed in patients during 17 hospital admissions (13%), nonpulmonary organ failure developed during 16 hospital admissions (12%), and ARDS developed during 2 hospital admissions (2%). Pneumothorax developed in four patients and required tube thoracostomy in all four patients. The median APACHE II score was 11. Predicted mortality and actual mortality were 6.7% and 8.3%, respectively. The two most common immediate causes of death were pneumothorax (n = 3) and nosocomial infection (n = 3). All the deaths occurred in female patients. Compared with survivors, nonsurvivors had higher APACHE II scores (median, 26 vs 15; p < 0.0001), PaCO(2) (63.8 +/- 21.3 mm Hg vs 47.8 +/- 19.1 mm Hg, p = 0.0101), and lower arterial pH (7.09 +/- 0.12 vs 7.27 +/- 0.12, p < 0.0001), respectively. Patients in 10 of 48 hospital admissions (21%) who required mechanical ventilation died. CONCLUSIONS: The hospital mortality of patients admitted to an MICU for status asthmaticus is higher than expected. Higher APACHE II score and PaCO(2) and lower arterial pH within 24 h of hospital admission are associated with increased mortality. Sepsis and nonpulmonary organ failure are more likely to develop in nonsurvivors than survivors.     

Time trend analysis of long term outcome of patients with haematological malignancies admitted at dutch intensive care units

A few decades ago, the chances of survival for patients with a haematological malignancy needing Intensive Care Unit (ICU) support were minimal. As a consequence, ICU admission policy was cautious. We hypothesized that the long‐term outcome of patients with a haematological malignancy admitted to the ICU has improved in recent years. Furthermore, our objective was to evaluate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) II score. A total of 1095 patients from 5 Dutch university hospitals were included from 2003 until 2015. We studied the prevalence of patients' characteristics over time. By using annual odds ratios, we analysed which patients' characteristics could have had influenced possible trends in time. A approximated mortality rate was compared with the ICU mortality rate, to study the predictive value of the APACHE II score. Overall one‐year mortality was 62%. The annual decrease in one‐year mortality was 7%, whereas the APACHE II score increased over time. Decreased mortality rates were particularly observed in high‐risk patients (acute myeloid leukaemia, old age, low platelet count, bleeding as admission reason and need for mechanical ventilation within 24 h of ICU admission). Furthermore, the APACHE II score overestimates mortality in this patient category.     

A cross-cultural comparison of critical care delivery: Japan and the United States

OBJECTIVE: To compare the utilization and outcomes of critical care services in a cohort of hospitals in the United States and Japan. DESIGN: Prospective data collection on 5,107 patients and detailed organizational characteristics from each of the participating Japanese study hospitals between 1993 and 1995, with comparisons made to prospectively collected data on the 17,440 patients included in the US APACHE (acute physiology and chronic health evaluation) III database. SETTING: Twenty-two Japanese and 40 US hospitals. PATIENTS: Consecutive, unselected patients from medical, surgical, and mixed medical/surgical ICUs. MEASUREMENTS: Severity of illness, predicted risk of in-hospital death, and ICU and hospital length of stay (LOS) were assessed using APACHE III. Japanese ICU directors completed a detailed survey describing their units. MAIN RESULTS: US and Japanese ICUs have a similar array of modalities available for care. Only 1.0% (range, 0.56 to 2.7%) of beds in Japanese hospitals were designated as ICUs. The organization of the Japanese and US ICUs varied by hospital, but Japanese ICUs were more likely to be organized to care for heterogeneous diagnostic populations. Sample case-mix differences reflect different disease prevalence. ICU utilization for women is significantly lower (35.5% vs 44.8% of patients) and there were relatively fewer patients > or = 85 years old in the Japanese ICU cohort (1.2% vs 4.6%), despite a higher per capita rate of individuals > or = 85 years old in Japan. The utilization of ICUs for patients at low risk of death significantly less in Japan (10.2%) than in the United States (12.9%). The APACHE III score stratified patient risk. Overall mortality was similar in both national samples after accounting for differences in hospital LOS, utilizing a model that was highly discriminating (receiver operating characteristic, 0.87) when applied to the Japanese sample. The application of a US-based mortality model to a Japanese sample overestimated mortality across all but the highest (> 90%) deciles of risk. Significant variation in expected performance was noted between hospitals. Risk-adjusted ICU LOS was not significantly longer in Japan; however, total hospital stay was nearly twice that found in the US hospitals, reflecting differences in hospital utilization philosophies. CONCLUSIONS: Similar high-technology critical care is available in both countries. Variations in ICU utilization reflect differences in case-mix and bed availability. Japanese ICU utilization by gender reflects differences in disease prevalence, whereas differences in utilization by age may reflect differences in cultural norms regarding the limits of care. Such differences provide context from which to assess the delivery of care across international borders. Miscalibration of predictive models applied to international data samples highlight the impact that differences in resource use and local practice cultures have on outcomes. Models may require modification in order to account for these differences. Nevertheless, with large databases, it is possible to assess critical care delivery systems between countries accounting for differences in case-mix, severity of illness, and cultural normative standards facilitating the design and management such systems.     

Intensivmedizin bei älteren Patienten: Wie nützlich sind die Scoresysteme APACHE II und III?

OBJECTIVE: Scores like APACHE (Acute Physiology And Chronic Health Evaluation) were evaluated for unselected intensive care unit (ICU) admissions. Can they also be used for risk stratification and quality assurance in selected subgroups like elderly patients? METHODS: Over a 3-year period data of all admissions of a 12 bed interdisciplinary ICU were collected. APACHE II and III scores and probabilities of hospital deaths were compared with observed outcomes. The discriminatory power was evaluated by calculating the areas under the receiver operating characteristic (ROC) curves. Calibration was analyzed with standardized mortality ratios (SMR) and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: Of 3382 admissions due to exclusion criteria, 2795 patients were analyzed, 1396 (49.9%) of these were > or = 65 years, mean age 75 (65-99) years. 62.5% were non-operative, 37.5% postoperative admissions, 35% after emergency operations. ICU mortality was 11.7%, hospital mortality 25.1%. The areas under the ROC curves were 0.77 for APACHE II and 0.79 for APACHE III (whole collective 0.83 and 0.85, respectively). The SMR was 1.17 for APACHE II and 1.23 for APACHE III compared with 1.06 and 1.22 for all patients, respectively. Calibration for elderly patients was insufficient for APACHE II (Hosmer-Lemeshow chi-square = 19, p < 0.025) as well as for APACHE III (chi-square = 41, p < 0.001), while it was good for all patients for APACHE II (chi-square = 12, p > 0.1) but not so for APACHE III (chi-square = 48, p < 0.001). CONCLUSIONS: APACHE II and III both show good discrimination for elderly patients although a little inferior than for all patients. Both scores can be used for risk stratification of elderly ICU patients. Mortality prognosis is not sufficient for geriatric patients although APACHE II calibrates well for all. Application of these scores for quality assurance in selected subgroups like elderly patients cannot be recommended based on these data.     

Risk factors for hospitalization and severe outcomes of 2009 pandemic H1N1 influenza in Quebec, Canada

BACKGROUND/ OBJECTIVE: This case-control study was carried out to estimate risk factors associated with hospitalizations and severe outcomes [intensive care unit (ICU) admission or death] among patients with illness because of laboratory-confirmed 2009 pandemic A/H1N1 virus (pH1N1) during the first wave of pH1N1 activity in the province of Quebec, Canada. PATIENTS/ METHODS: We collected epidemiologic information by phone using a standardized questionnaire from patients with laboratory-confirmed pH1N1 illness during the first spring/summer pandemic wave in Quebec, Canada. Risk factors associated with hospitalization were assessed by comparing hospitalized to community cases and for ICU admission or death through comparison with hospitalized cases. RESULTS: Cases (321 hospitalized patients including 47 ICU admissions and 15 deaths) were compared to controls (395 non-hospitalized patients) by using multivariable logistic regression adjusted for gender, age, education, being a health care worker, smoking, seasonal influenza vaccination, delay to consultation, antiviral use before admission, pregnancy, underlying medical conditions, and obesity. Age <5 years, underlying medical conditions (neuromuscular, cardiac, pulmonary, and renal conditions, diabetes, asthma, and other), and delayed consultation were associated with hospitalization. The strongest association with hospitalization was observed for neuromuscular disorders. Antiviral medication before hospital admission protected against severe disease. Association of obesity with hospitalization was not significant after adjustment in multivariable analysis. Among hospitalized patients, age ≥60 years and immune suppression were associated with death. CONCLUSIONS: Previously identified risk factors for seasonal influenza were also associated with increased risk of severe pH1N1 outcomes. The independent role of obesity needs to be further defined.     

Long-term mortality outcome associated with prolonged admission to the ICU

STUDY OBJECTIVES: Patients requiring prolonged admission to the ICU consume significant health-care resources and have a high rate of in-hospital death. The long-term mortality outcome of these patients has not been well defined in a nonselected cohort. The objective of this study was to describe the occurrence and factors predictive of prolonged ICU stay at admission, and to define the long-term (>/= 1 year) mortality outcome. DESIGN: Population-based cohort. SETTING: All adult multisystem and cardiovascular surgical ICUs in the Calgary Health Region (CHR) from July 1, 1999, to March 31, 2002. PATIENTS: Adult (>/= 18 years old) residents of the CHR admitted to regional ICUs. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: During the study, 4,845 patients had a median length of stay of 2 days (interquartile range, 1 to 4 days); 2,115 patients (44%) were admitted for < 2 days, 1,496 patients (31%) were admitted for 2 to 3 days; 1,018 patients (21%) were admitted from 4 to 13 days; and 216 patients (4%) had a prolonged (>/= 14 day) admission to the ICU. A higher severity of illness, the presence of shock, and bloodstream infection were independently associated with a prolonged ICU admission, and cardiovascular surgery was associated with a lower risk. Patients with prolonged ICU admissions were nearly twice as likely to die as patients with shorter ICU admissions: 53 of 216 patients (25%) vs 584 of 4,629 patients (13%) [p = 0.0001]. Among the 3,924 survivors to hospital discharge, the rates of mortality during the year following ICU admission were as follows: 59 deaths in 1,758 patients (3%) admitted < 2 days, 74 deaths in 1,267 patients (6%) with 2- to 3-day admissions, 78 deaths in 766 patients (10%) with 4- to 13-day admissions, and 10 deaths in 133 patients (8%) with admissions >/= 14 days. CONCLUSIONS: One in 25 critically ill patients will have prolonged ICU admission and higher ICU-related mortality. However, survivors of prolonged ICU admission have good long-term mortality outcome after acute illness.     

Survival of HIV-infected patients admitted to the intensive care unit in the era of highly active antiretroviral therapy

We retrospectively studied outcomes for HIV-infected patients admitted to the intensive care unit (ICU) between January 1999 and June 2009. Patient demographics, receipt of highly active antiretroviral therapy (HAART), reason for ICU admission and survival to ICU and hospital discharge were recorded. Comparison was made against outcomes for general medical patients contemporaneously admitted to the same ICU. One hundred and ninety-two HIV-infected patients had 222 ICU admissions; 116 patients required mechanical ventilation (MV) and 43 required renal replacement therapy. ICU admission was due to an HIV-associated diagnosis in 113 patients; 37 had Pneumocystis pneumonia. Survival to ICU discharge and hospital discharge for HIV-infected patients was 78% and 70%, respectively, and was 75% and 68% among 2065 general medical patients with 2274 ICU admissions; P = 0.452 and P = 0.458, respectively. HIV infection was newly diagnosed in 42 patients; their ICU and hospital survival was 69% and 57%, respectively. From multivariable analysis, factors associated with ICU survival were patient's age (odds ratio [OR] = 0.74 [95% confidence interval (CI) = 0.53-1.02] per 10-year increase), albumin (OR = 1.05 [1.00-1.09] per 1 g/dL increase), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR = 0.55 [0.35-0.87] per 10 unit increase), receipt of HAART (OR = 2.44 [1.01-4.94]) and need for MV (OR = 0.14 [0.06-0.36]). In the era of HAART, HIV-infected patients should be offered ICU admission if it is likely to be of benefit.     

Hospital volume-outcome relationships among medical admissions to ICUs

BACKGROUND: Positive relationships between hospital volume and outcomes have been demonstrated for several surgeries and medical conditions. However, little is known about the volume-outcome relationship in patients admitted to medical ICUs. OBJECTIVE: To determine the relationship between hospital volume and risk-adjusted in-hospital mortality for patients admitted to ICUs with respiratory, neurologic, and GI disorders. DESIGN: Retrospective cohort study. SETTING: Twenty-nine hospitals in a single metropolitan area. PATIENTS: Adult ICU admissions from 1991 through 1997. METHODS: Using Cox proportional hazards models, we compared in-hospital mortality between tertiles of hospital volume (high, medium, and low) for respiratory (n = 16,949), neurologic (n = 13,805), and GI (n = 12,881) diseases after adjusting for age, gender, admission severity of illness, admitting diagnosis, and source. Severity of illness was measured using the APACHE (acute physiology and chronic health evaluation) III methodology. RESULTS: Among respiratory and neurologic ICU admissions, hazard ratios were similar (p > or = 0.05) in patients in low-, medium-, and high-volume hospitals. However, among GI diagnoses, risk of mortality was lower in high-volume hospitals, relative to low-volume hospitals (hazard ratio, 0.68; 95% confidence interval [CI], 0.54 to 0.85; p < 0.001), and was somewhat lower in medium-volume hospitals (hazard ratio, 0.83; 95% CI, 0.68 to 1.01; p = 0.06). Among subgroups based on severity of illness, high-volume hospitals had lower mortality, relative to low-volume hospitals, among sicker patients (APACHE III score > 57) in the respiratory cohort (hazard ratio, 0.77; 95% CI, 0.59 to 0.99) and the GI cohort (hazard ratio, 0.67; 95% CI, 0.53 to 0.85). CONCLUSIONS: Associations between ICU volume and risk-adjusted mortality were significant for patients with GI diagnoses and for sicker patients with respiratory diagnoses. However, associations were not significant for patients with neurologic diagnoses. The lack of a consistent volume-outcome relationship may reflect unmeasured patient complexity in higher-volume hospitals, relative standardization of care across ICUs, or lack of efficacy of some accepted ICU processes of care.     

Is there a role for inhaled nitric oxide as a rescue therapy in respiratory failure associated with hematologic malignancies?

Inhaled nitric oxide has been demonstrated to improve oxygenation in critically ill patients requiring mechanical ventilation. We therefore performed a retrospective review to determine the outcome of patients with hematological malignancies and acute respiratory failure who received inhaled nitric oxide (INO) in a multidisciplinary intensive care unit of a single tertiary referral medical center.Thirteen patients with hematological malignancies who required endotracheal intubation and mechanical ventilation and received INO for acute respiratory failure between January 1998 and December 2002 were identified. Mean +/- standard deviation (SD) age was 47.6 (+/-13.2) years. The mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE) III score on the day of ICU admission was 94.1 +/- 33.7 with a mean (SD) predicted probability of ICU death of 42.4% (+/-28.6). Mean APACHE III score on the day of initiating INO was 107.6 (+/-34.4) with a predicted mortality in the intensive care unit of 72.7% (+/-23.3). Mean PaO(2) to FiO(2) (PF) ratios (+/-SD) prior to, and immediately after, the initiation of INO were 62.6 (+/-28.2) and 111 (+/-65.1), respectively (P < 0.001). The median duration of INO therapy was 41.8 h (interquartile range, 6.3-98.2). Patients with hematological malignancies and acute respiratory failure to whom INO was administered had clinical deterioration since ICU admission. Despite a marked initial improvement in arterial oxygen tension, all patients ultimately died in the intensive care unit, 8 of them within 48 h of initiating INO. Therefore, despite initial improvement in oxygenation, we did not observe any survival benefit to INO in this setting.     

Community-acquired bacteremia at a teaching versus a nonteaching hospital: impact of acute severity of illness on 30-day mortality

BACKGROUND: Few studies have focused recently on the epidemiology of community-acquired bacteremia (CAB) and there have been few comparisons of CAB in teaching versus nonteaching hospitals. OBJECTIVES: To compare the clinical characteristics, acute severity of illness, and 30-day mortality of patients with CAB admitted to a teaching and a nonteaching hospital and to define predictors of 30-day mortality among patients with CAB that would be identifiable at the time of admission to the hospital. METHODS: This was a retrospective study of CAB at a teaching hospital (n = 174 episodes) compared to a community nonteaching hospital (n = 74 episodes) during 1995. Data collected included demographic characteristics, underlying diseases, sources of CAB, and antimicrobial therapy. Acute severity of illness on admission was measured by using the acute physiology score component of the Acute Physiology and Chronic Health Evaluation III system (APS APACHE III).Main Outcome Measure: Status, dead or alive, 30 days after admission for CAB. RESULTS: At the nonteaching hospital, patients were older but, on average, significantly less acutely ill (as measured by the admission APS APACHE III score) than were those at the teaching hospital. In contrast, patients with HIV infection, posttransplantation, or on hemodialysis were identified only at the teaching hospital. Overall, organisms causing CAB at both hospitals were similar except that Staphylococcus aureus CAB occurred significantly more often at the teaching hospital and Escherichia coli CAB occurred more often at the nonteaching hospital. There was no significant difference in 30-day mortality in patients with CAB between the teaching hospital (19.3%) and the nonteaching hospital (16.7%; P =.63). APS APACHE III score on admission identified episodes of CAB with a low- and a high-risk for 30-day mortality at both hospitals. Independent predictors of 30-day mortality were APACHE III score on admission (P <.001) and pneumonia as a source of CAB (P =.012). CONCLUSIONS: Among patients with CAB, acute severity of illness on admission was the most important predictor of 30-day mortality at both hospitals. Even though patients with CAB were, on average, more severely ill at the time of admission to the teaching hospital, 30-day mortality rates were not significantly different between the two hospitals because deaths correlated with high APS APACHE III scores at both facilities. The APS APACHE III score on admission provides important prognostic information among patients with CAB.