Early indicators of prolonged intensive care unit stay: impact of illness severity,physician staffing,and pre-intensive care unit length of stay

OBJECTIVE: Scoring systems that predict mortality do not necessarily predict prolonged length of stay or costs in the intensive care unit (ICU). Knowledge of characteristics predicting prolonged ICU stay would be helpful, particularly if some factors could be modified. Such factors might include process of care, including active involvement of full-time ICU physicians and length of hospital stay before ICU admission. DESIGN: Demographic data, clinical diagnosis at ICU admission, Simplified Acute Physiology Score, and organizational characteristics were examined by logistic regression for their effect on ICU and hospital length of stay and weighted hospital days (WHD), a proxy for high cost of care. SETTING: A total of 34 ICUs at 27 hospitals participating in Project IMPACT during 1998. PATIENTS: A total of 10,900 critically ill medical, surgical, and trauma patients qualifying for Simplified Acute Physiology Score assessment. INTERVENTIONS: None. RESULTS: Overall, 9.8% of patients had excess WHD, but the percentage varied by diagnosis. Factors predicting high WHD include Simplified Acute Physiology Score survival probability, age of 40 to 80 yrs, presence of infection or mechanical ventilation 24 hrs after admission, male sex, emergency surgery, trauma, presence of critical care fellows, and prolonged pre-ICU hospital stay. Mechanical ventilation at 24 hrs predicts high WHD across diagnostic categories, with a relative risk of between 2.4 and 12.9. Factors protecting against high WHD include do-not-resuscitate order at admission, presence of coma 24 hrs after admission, and active involvement of full-time ICU physicians. CONCLUSIONS: Patients with high WHD, and thus high costs, can be identified early. Severity of illness only partially explains high WHD. Age is less important as a predictor of high WHD than presence of infection or ventilator dependency at 24 hrs. Both long ward stays before ICU admission and lack of full-time ICU physician involvement in care increase the probability of long ICU stays. These latter two factors are potentially modifiable and deserve prospective study.     

Adjustment of intensive care unit outcomes for severity of illness and comorbidity scores

PURPOSE: Comparison of outcomes among intensive care units (ICUs) requires adjustment for patient variables. Severity of illness scores are associated with hospital mortality, but administrative databases rarely include the elements of these scores. However, these databases include the elements of comorbidity scores. The purpose of this study was to compare the value of these scores as adjustment variables in statistical models of hospital mortality and hospital and ICU length of stay after adjustment for other covariates. MATERIALS AND METHODS: We used multivariable regression to study 1808 patients admitted to a 13-bed medical-surgical ICU in a 400-bed tertiary hospital between December 1998 and August 2003. RESULTS: For all patients, after adjusting for age, sex, major clinical category, source of admission, and socioeconomic determinants of health, we found that Acute Physiology and Chronic Health Evaluation (APACHE) II and comorbidity scores were significantly associated with hospital mortality and that comorbidity but not APACHE II was significantly associated with hospital length of stay. Separate analysis of hospital survivors and nonsurvivors showed that both APACHE II and comorbidity scores were significantly associated with hospital length of stay and APACHE II score was associated with ICU length of stay. CONCLUSION: The value of APACHE II and comorbidity scores as adjustment variables depends on the outcome and population of interest.     

Factors influencing length of stay in the intensive care unit.

BACKGROUND: Long stays in the intensive care unit are associated with high costs and burdens on patients and patients' families and in turn affect society at large. Although factors that affect length of stay and outcomes of care in the intensive care unit have been studied extensively, the conclusions reached have not been reviewed to determine whether they reveal an organizational pattern that might be of practical use in reducing length of stay in the unit. OBJECTIVE: To identify and categorize the factors associated with prolonged stays in the intensive care unit and to describe briefly the nonmedical interventions to date designed to reduce length of stay. METHODS: Articles published between January 1990 and March 2005 in English-language journals indexed by MEDLINE were searched for studies on outcomes and costs of care in the intensive care unit and on care at the end of life. RESULTS: The emerging consensus is that length of stay in the intensive care unit is exacerbated by several increasingly discernible medical, social, psychological, and institutional factors. At the same time, several nonmedical, experimental interventions have been designed to reduce length of stay. CONCLUSIONS: Interventions involving palliative care, ethics consultations, and other methods to increase communication between healthcare personnel, patients, and patients' families may be helpful in decreasing length of stay in the intensive care unit. Further studies are needed to provide a strategy for targeting specific risk factors indicated by the literature review.     

Dynamic assessment of severity of illness in pediatric intensive care

Severity of illness in 293 pediatric ICU patients was assessed by a daily estimate of ICU survival. The probability of nonsurvival was obtained by logistic regression analysis, using physiologic stability index (PSI) values from previous days as time-dependent covariates. Only PSI values from the previous 2 days gave statistically significant predictions of short-term (less than 24 h) outcome. When the prediction model derived from these data was tested prospectively on a separate set of 345 pediatric patients, there was excellent agreement between observed and predicted short-term mortality. Receiver operating characteristic curves for the 345 patients were statistically equivalent to those originally derived for the 293 patients, and this prediction model had significantly (p less than .025) more accuracy than prediction based on admission PSI. These results indicate that this model for daily risk assessment is statistically reliable and objective, as verified against eventual outcome. In the 345 patients, ICU mortality was predicted with 89% sensitivity and 91% specificity. This prediction model may be used to stratify patient groups for clinical studies, or identify very low-risk patients for potential early ICU discharge.     

Outcome and functional capacity after prolonged intensive care unit stay

BACKGROUND: An important proportion of critically ill patients who survives their acute illness remains in a critical state requiring intensive care management for weeks to months. Nevertheless, data on risk factors for in-hospital mortality and especially for long-term mortality and functional capacity are scarce. This study investigated outcome and prognostic factors in long-term critically ill patients. METHODS: This retrospective observational cohort study was performed at our mixed adult 8-bed cardiologic ICU at a 2200-bed University Hospital. Patient data from our local database connected to an Austrian multicenter program for quality assurance in intensive care were analyzed. Data were collected between March 1(st), 1998 and December 31(st), 2003. Patients with an ICU stay > or =30 days formed the long-term study group. Morbidity and functional capacity were assessed using the Barthel mobility index in telephone interviews. RESULTS: Patients spending > or =30 days in the ICU numbered 135 (10%) and occupied 5962 bed-days, representing 40.9% of the total bed-days. Compared with patients with an ICU stay <30 days, patients in the long-term group had a significantly higher SAPS II score during the first 24 hours after ICU admission (54 [IQR 41-65] vs. 38 [IQR 27-56], p < 0.001). There was a trend towards male preponderance in the long-term group (98/135 [82.6%] vs. 782/1215 [64.4%], p = 0.05). Differences in ICU and in-hospital mortality were not significant (28/135 (20.7%) vs. 295/1215 (24.3%), p = 0.620 and 46/135 [34.1%] vs. 360/1215 [29.6%], p = 0.285, respectively). After 12 and 48 months, the overall cumulative rates of death in hospital survivors were 14% and 26%, respectively in the short-term ICU group and 31% and 61% in the long-term group. A log-rank test revealed a significantly higher probability of survival in the short-term group after hospital discharge (log rank = 34.3, p < 0.001). Multivariate analysis of hospital survivors and non-survivors in the long-term group showed that the need for renal replacement therapy during the ICU stay was the sole independent predictor for in-hospital death and death within 1 year after ICU discharge (OR = 2.88; 95%CI 1.12-7.41, p = 0.028 and OR = 3.66, 95%CI 1.36-9.83, p = 0.01, respectively). In 28/31 long-term survivors (90%) in the long-term ICU group, the Barthel index indicated no or only moderate disability during daily activities. CONCLUSION: Hospital mortality rates in critically ill patients with a stay <30 or > or =30 days were comparable. The necessity for renal replacement therapy was the sole independent predictor for in-hospital and 1-year mortality in long-term ICU patients. Critically ill patients with a stay > or =30 days have a high and ongoing risk of death after hospital discharge; however, a substantial number of these patients are long-term survivors with no or only moderate disability during daily activities.     

Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study

Introduction

Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taking severity of illness at baseline and throughout ICU stay into account.

Methods

A prospective cohort study was conducted. We included patients who survived an ICU stay of at least a day; exclusions were neurocritical care patients and patients who sustained deep sedation during the entire ICU stay. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM-ICU) and additionally, patients who received haloperidol were considered delirious. Twelve months after ICU admission, data on mortality were obtained and HRQoL and cognitive functioning were measured with the European Quality of Life – Six dimensions self-classifier (EQ-6D). Regression analyses were used to assess the associations between delirium and the outcome measures adjusted for gender, type of admission, the Acute Physiology And Chronic Health Evaluation IV (APACHE IV) score, and the cumulative Sequential Organ Failure Assessment (SOFA) score throughout ICU stay.

Results

Of 1101 survivors of critical illness, 412 persons (37%) had been delirious during ICU stay, and 198 (18%) died within twelve months. When correcting for confounders, no significant association between delirium and long-term mortality was found (hazard ratio: 1.26; 95% confidence interval (CI) 0.93 to 1.71). In multivariable analysis, delirium was not associated with HRQoL either (regression coefficient: -0.04; 95% CI -0.10 to 0.01). Yet, delirium remained associated with mild and severe problems with cognitive functioning in multivariable analysis (odds ratios: 2.41; 95% CI 1.57 to 3.69 and 3.10; 95% CI 1.10 to 8.74, respectively).

Conclusions

In this group of survivors of critical illness, delirium during ICU stay was not associated with long-term mortality or HRQoL after adjusting for confounding, including severity of illness throughout ICU stay. In contrast, delirium appears to be an independent risk factor for long-term self-reported problems with cognitive functioning.     

Mortality rate and length of stay of patients admitted to the intensive care unit in July

OBJECTIVE: At the beginning of each academic year in July, inexperienced residents and fellows begin to care for patients. This inexperience can lead to poor patient outcome, especially in patients admitted to the intensive care unit (ICU). The objective of this study was to determine the impact of July ICU admission on patient outcome. DESIGN: Retrospective, cohort study. SETTING: Academic, tertiary medical center. PATIENTS: Patients admitted to the ICU from October 1994 through September 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographics, Acute Physiology and Chronic Health Evaluation (APACHE) III score and predicted mortality, admission source, admission date, intensity of treatment, ICU length of stay (LOS), and hospital mortality of 29,084 patients were obtained. The actual and predicted weighted ICU LOS and their ratio were calculated. Logistic regression analysis was used to compare the hospital mortality rate of patients admitted to the ICU in July with those admitted during the rest of the year, with adjustment for potentially confounding variables. The patients' mean age was 62.3 +/- 17.6 yrs; 57.3% were male and 95.5% white. Both the customized predicted and observed hospital mortality rates of the entire cohort were 8.2%. The majority (76.7%) of the patients were discharged home, and 15.1% were discharged to other facilities. When adjusted for potentially confounding variables, ICU admission in July was not associated with higher hospital mortality rate compared with any other month. There were no significant differences in the discharge location of patients between July and any one of the other months. There were no statistically significant differences in the weighted ICU LOS ratio between July and any of the other months. CONCLUSIONS: ICU admission in July is not associated with increased hospital mortality rate or ICU length of stay.     

Predictors of intensive care unit and hospital length of stay in diabetic ketoacidosis

OBJECTIVE: To determine the predictive value for prolonged intensive care unit (ICU) and hospital length of stay (LOS) in patients with diabetic ketoacidosis (DKA) of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and Logistic Organ Dysfunction System (LODS), and to identify associated characteristics. DESIGN: Prospective cohort, 18-month observation. SUBJECTS AND SETTING: All admissions to a 12-bed, inner-city, university-affiliated hospital, medical ICU from July 1999 to December 2000. MEASUREMENTS: Data for APACHE II and LODS scoring systems were collected within 24 hours of admission. Lengths of ICU and hospital stay were the primary outcomes. Prolonged ICU and hospital LOS were defined as 3 or more and 6 or more days. RESULTS: A total of 584 patients, mean age 49, 56% men, 82% African American were admitted to the ICU. At admission they had (mean +/-SD) APACHE II (18 +/- 10), LODS (5 +/- 4), and predicted mortality of 32% +/- 29%. DKA was the admitting diagnosis in 42 (7.6%) patients; they had lower APACHE II (12 +/- 6), LODS (2 +/- 1), and predicted mortality 5% +/- 5% than the general ICU population (all, P <.001). Hospital mortality in non-DKA patients was 18%; there were no deaths in patients with DKA. Among DKA patients, those with insulin noncompliance had a shorter hospital stay (2.8 +/- 1 d) than those with an underlying illness as the DKA trigger (4.8 +/- 3, P =.02). Between patients with DKA, regardless of the LOS, there were no significant differences in APACHE II, LODS, or predicted mortality. CONCLUSIONS: ICU-admitted patients with DKA are less ill, and have lower disease severity scores, mortality, and shorter length of ICU and hospital stay than non-DKA patients. Disease severity scores are not, but precipitating cause is, predictor associated with prolonged hospital LOS in patients with DKA.     

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.     

Improved outcomes of children with malignancy admitted to a pediatric intensive care unit

OBJECTIVE: To assess the acute and long-term outcomes of children admitted to the intensive care unit with cancer or complications after bone marrow transplantation. DESIGN: Retrospective analysis of databases from a prospective pediatric intensive care unit (PICU) database supplemented by case notes review. SETTING: A PICU in a tertiary pediatric hospital. PATIENTS: All children with malignancy admitted to the PICU between May 1, 1987, and April 30, 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 206 admissions to the PICU during a 9-yr study period of 150 children with malignancies or complications after bone marrow transplantation. Forty patents died in the PICU (27% mortality rate). The most frequent indications for PICU admission were shock and respiratory disease. Of 56 children admitted with shock, there were 16 deaths (29% mortality rate). In 24 episodes of sepsis, inotropic and ventilatory support were required and 13 patients (54%) survived. Analysis of long-term survival gave estimates of 50% survival for all oncology patients admitted to the PICU and 42% for those admitted for shock. CONCLUSIONS: A high proportion of oncology patients admitted to the PICU requiring intensive intervention survive and go on to be cured of their malignancy. Our study suggests the PICU outcome for these patients has improved.     

Complications of care in a pediatric intensive care unit: A prospective study

Objectives (a) To examine the frequency, type, and severity of complications occurring in a pediatric intensive care unit; (b) to identify populations at risk; and (c) to study the impact of complications on morbidity and mortality.Design Prospective survey.Setting Pediatric intensive care unit (PICU) of a university-affiliated hospital.Patients 1035consecutive admissions over an 18-month period.Results 115 complications occurred during 83 (8.0%) admissions, for 2.7 complications per 100 PICU-days; 48 (42%) complications were major, 45 (39%) moderate, and 22 (19%) minor. Sixty complications (52%) were ventilator-related, 14 were drug-related, 13 procedure-related, 24 infectious, and 22 involved invasive devices (18 vascular catheters). Human error was involved in 41 (36%) cases, 21 of which were major (18%). Treatments included reintubation <24 h (28), intravenous antimicrobials (24), and invasive bedside procedures (14). Cardiopulmonary resuscitation was required in 6 patients. Thirteen patients with complications died (15.7%); 2 deaths were directly due to complications.Patients with complications were younger, had longer lengths of stay, and had a higher mortality. Length of stay was a positive risk factor for complication risk (odds ratio=1.09, 95% confidence interval: 1.05 to 1.13;p=0.0001); other patient characteristics had no predictive effect. Kaplan-Meier estimates showed that the most severe complications occurred early in the PICU stay. The best indicators of patient mortality were number of complications (odds ratio=2.96, 95% confidence interval 1.72 to 5.08;p=0.0001), and mortality risk derived from the Pediatric Risk of Mortality Score (odds ratio=1.08, 95% confidence interval 1.06 to 1.10;p=0.0001). Mortality was correlated with increasing severity of complications.Conclusion Complications have a significant impact on patient care. Patients may be at increased risk earlier in their PICU course, when the number of interventions may be greatest. Complications may increase patient mortality and predict patient death better than other patient variables.     

A microcosting study of intensive care unit stay in the Netherlands

The primary objective of this study was to estimate the actual daily costs of intensive care unit stay using a microcosting methodology. As a secondary objective, the degree of association between daily intensive care unit costs and some patient characteristics was examined. This multicenter, retrospective cost analysis was conducted in the medical-surgical adult intensive care units of 1 university and 2 general hospitals in the Netherlands for 2006, from a hospital perspective. A total of 576 adult patients were included, consuming a total of 2868 nursing days. The mean total costs per intensive care unit day were 1911, with labour (33%) and indirect costs (33%) as the most important cost drivers. An ordinary least squares analysis including age, Nine Equivalent of Nursing Manpower Use score/Therapeutic Intervention Scoring System score, mechanical ventilation, blood products, and renal replacement therapy was able to predict 50% of the daily intensive care unit costs.     

The impact of delirium in the intensive care unit on hospital length of stay

Study objective: To determine the relationship between delirium in the intensive care unit (ICU) and outcomes including length of stay in the hospital. Design: A prospective cohort study. Setting: The adult medical ICU of a tertiary care, university-based medical center. Participants: The study population consisted of 48 patients admitted to the ICU, 24 of whom received mechanical ventilation. Measurements: All patients were evaluated for the development and persistence of delirium on a daily basis by a geriatric or psychiatric specialist with expertise in delirium assessment using the Diagnostic Statistical Manual IV (DSM-IV) criteria of the American Psychiatric Association, the reference standard for delirium ratings. Primary outcomes measured were length of stay in the ICU and hospital. Results: The mean onset of delirium was 2.6 days (S.D.ǃ.7), and the mean duration was 3.4ǃ.9 days. Of the 48 patients, 39 (81.3%) developed delirium, and of these 29 (60.4%) developed the complication while still in the ICU. The duration of delirium was associated with length of stay in the ICU (r=0.65, P=0.0001) and in the hospital (r=0.68, P<0.0001). Using multivariate analysis, delirium was the strongest predictor of length of stay in the hospital (P=0.006) even after adjusting for severity of illness, age, gender, race, and days of benzodiazepine and narcotic drug administration. Conclusions: In this patient cohort, the majority of patients developed delirium in the ICU, and delirium was the strongest independent determinant of length of stay in the hospital. Further study and monitoring of delirium in the ICU and the risk factors for its development are warranted.     

In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial

Purpose

Particulate contamination due to infusion therapy carries a potential health risk for intensive care patients.

Methods

This single-centre, prospective, randomized controlled trial assessed the effects of filtration of intravenous fluids on the reduction of complications in critically ill children admitted to a pediatric intensive care unit (PICU). A total of 807 subjects were randomly assigned to either a control (n?=?406) or filter group (n?=?401), with the latter receiving in-line filtration. The primary endpoint was reduction in the rate of overall complications, which included the occurrence of systemic inflammatory response syndrome (SIRS), sepsis, organ failure (circulation, lung, liver, kidney) and thrombosis. Secondary objectives were a reduction in the length of stay on the PICU and overall hospital stay. Duration of mechanical ventilation and mortality were also analyzed.

Findings

Analysis demonstrated a significant reduction in the overall complication rate (n?=?166 [40.9?%] vs. n?=?124 [30.9?%]; P?=?0.003) for the filter group. In particular, the incidence of SIRS was significantly lower (n?=?123 [30.3?%] vs. n?=?90 [22.4?%]; P?=?0.01). Moreover the length of stay on PICU (3.89 [95?% confidence interval 2.97?4.82] vs. 2.98 [2.33?3.64]; P?=?0.025) and duration of mechanical ventilation (14.0 [5.6?22.4] vs. 11.0 [7.1?14.9] h; P?=?0.028) were significantly reduced.

Conclusion

In-line filtration is able to avert severe complications in critically ill patients. The overall complication rate during the PICU stay among the filter group was significantly reduced. In-line filtration was effective in reducing the occurrence of SIRS. We therefore conclude that in-line filtration improves the safety of intensive care therapy and represents a preventive strategy that results in a significant reduction of the length of stay in the PICU and duration of mechanical ventilation (ClinicalTrials.gov number: NCT00209768).     

Hospital mortality rate and length of stay in patients admitted at night to the intensive care unit

OBJECTIVE: Although admission of patients to a medical ward after 5:00 pm has been associated with increased mortality rate and possibly shorter hospital stay, the association between timing of admission to the intensive care unit and outcome has not been studied. The objective of this study was to determine whether there are any associations between the timing of patient admission to a medical intensive care unit and hospital outcome. DESIGN: A retrospective cohort study that used an Acute Physiology and Chronic Health Evaluation III database containing prospectively collected demographic, clinical, and outcome information for patients. Patients were divided according to the time of admission into daytime (from 7:00 am to 5:00 pm) and nighttime admissions. We further subdivided nighttime admissions into two groups (regular and heavy workload) according to the number of patients who were admitted during the same shift. SETTING: Medical intensive care unit (a 15-bed unit in an academic referral hospital). PATIENTS: 6,034 patients consecutively admitted to our medical intensive care unit over a 5-yr period starting April 10, 1995. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The patients admitted at night had a lower mortality rate (13.9 vs. 17.2%, p < .0001), adjusted for admission source and severity of illness. Their hospital stay was shorter, 11.0 days +/- 13.5 (median 7) vs. 12.7 +/- 14.8 (median 8; p < .0001), as was their intensive care unit stay, 3.5 +/- 4.4 days (median 2) vs. 3.9 +/- 4.7 (median 2; p < .0001), compared with the daytime admission group. The nighttime shifts that admitted three or more patients (heavy workload) had the same mortality rate (13.2%) as those with fewer admissions (14.5%; p = .5961). Hospital and intensive care unit stays were also similar in both workload groups. CONCLUSIONS: Nighttime admission to our intensive care unit is not associated with a higher mortality rate or a longer hospital or intensive care unit stay compared with daytime admission.