The characteristics and prognostic predictors of unplanned hospital admission within 72 hours after ED discharge

ObjectivesThe aims of this study were (1) to identify the characteristics of patients who return to the emergency department (ED) within 72 hours and are admitted to the hospital and (2) to identify the characteristics and predictors of in-hospital mortality subgroup.MethodsThis study was conducted in a tertiary teaching hospital to identify characteristics of adult nontraumatic revisit-admission patients from January 1 to December 31, 2011. Demographic data, cause of revisit, and the underlying diseases as well as the in-hospital complications were reviewed.ResultsOf the 72 188 ED discharged patients, 690 revisit-admission patients were enrolled. The top 3 disease classifications were infection (38.7%), neurology (11.3%), and gastroenterology (11.2%). The etiology of the revisit included recurrent symptoms (72%), disease complications (15.8%), and inadequate diagnosis (12.1%). A total of 150 patients (21.7%) had complications, including receiving operation (17.2%), intensive care unit admission (4.2%), and cardiovascular conditions (2.5%). Forty-nine patients (7.1%) died during hospitalization owing to sepsis (57.1%), malignancy (34.7%), cardiogenic diseases (4.1%), and cerebrovascular conditions (4.1%). The nonsurvival group was older (64.1 ± 15.3 vs 55.7 ± 17.8; P < .001), had more patients with a diagnosis of moderate to severe liver disease (18.4% vs 4.8%; P < .001), malignancy (69.3% vs 20.1%; P < .001), and metastatic solid tumor (38.8% vs 6.2%; P < .001).ConclusionsAge and diagnosis with malignancy, metastatic tumors, or moderate-to-severe liver disease were predictors of in-hospital mortality among 72-hour revisit-admission patients.     

Risk factors for discharge on a new antipsychotic medication after admission to an intensive care unit

PurposeIncreased awareness of delirium in the intensive care unit (ICU) has led to higher use of antipsychotic medications for treatment of delirium. These medications are often not discontinued at ICU or hospital discharge, which may increase the risk of inappropriate polypharmacy. Our study sought to identify risk factors for being discharged on a new antipsychotic medication after admission to a trauma-surgical ICU or neurocritical care unit.MethodsThis was a retrospective cohort study at an academic medical center and included patients who were admitted to the trauma-surgical ICU or neurocritical care unit and received an antipsychotic medication. Those younger than 18 years, died before hospital discharge, or did not have complete documentation were excluded.ResultsA total of 341 records were included in the final analysis. Of those, 82 (24%) were discharged on a new antipsychotic and 67% of those patients had no documented indication. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.030 [95% confidence interval, 1.030-1.110]) and days treated with benzodiazepines (odds ratio, 1.101 [95% confidence interval, 1.060-1.143]) were independently associated with being discharged on a new antipsychotic medication.ConclusionsThose patients with higher Acute Physiology and Chronic Health Evaluation II scores and more benzodiazepine days are at increased odds of being discharged on a new antipsychotic.     

Predictors of hospital admission after ED observation unit care

Background

Emergency department observation units (EDOUs) represent an opportunity to efficiently manage patients with common conditions requiring short-term hospital care. Understanding which patients are ultimately admitted to the hospital after care in an EDOU may enhance patient selection for EDOU care.

Methods

We conducted a retrospective analysis of US emergency department visits resulting in admission to observation status using the National Hospital Ambulatory Care Survey (NHAMCS) from 2009 to 2010, a nationally representative sample. We used survey-weighted logistic regression to identify predictors at the patient level, visit level, and hospital level for inpatient hospital admission after EDOU care.

Results

Between 2009 and 2010, there were 4.65 million patient visits (95% confidence interval [CI], 3.68-5.63) to EDOUs in the United States. Of those evaluated in an EDOU, 40.4% (95% CI, 34.5%-46.6%) were admitted to the hospital after EDOU care. Progressively older patient age was a strong predictor of hospital admission: patients age older than 65 years were more than 5 times more likely to be admitted than patients age younger than 18 years (odds ratio, 5.36; 95% CI, 2.26-12.73). The only other visit-level factor associated with admission was a reason for visit of chest pain; this was associated with a lower rate of hospital admission (odds ratio, 0.61; 95% CI, 0.41-0.91).

Conclusion

Across the United States in 2009 to 2010, older patient age was a strong predictor of admission after EDOU care, suggesting that older patients are more likely to require inpatient hospital services after EDOU care than younger patients.     

呼吸加强医疗病房患者预后因素研究

目的 探讨影响呼吸加强医疗病房患者预后的危险因素，为制定相应防治措施作参考。方法 回顾性分析216例呼吸加强医疗病房危重患者临床资料，采用Logistic回归分析，筛选和分析相关危险因素。结果急性生理和慢性健康评分Ⅱ(acute physiology and chronic health evaluationⅡ，APACHEⅡ评分)、免疫抑制状态和氧合指数(PaO2／FiO2)对评价患者预后有重要作用；APACHEⅡ评分OR值为1．135，P值为0．00；氧合指数OR值为0．997，P值为0．092；免疫抑制OR值为6．583，P值为0．013。结论 升高的APACHEⅡ评分和降低的氧合指数以及合并免疫功能受损将使患者死亡风险升高，医务人员应高度重视。     

Emotional consequences of intensive care unit delirium and delusional memories after intensive care unit admission: a systematic review

Purpose

The aim of this study was to review literature exploring the emotional consequences of delirium and delusional memories in intensive care unit patients.

Methods

A systematic review was performed using PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO.

Results

Fourteen articles were eligible for this review. Five of them assessed delirium during intensive care unit admission, and the remainder assessed delusional memories during or after admission. No association was found for delirium and adverse emotional outcome. Data regarding delusional memories and emotional outcome were heterogenic. Some studies presented worse scores on posttraumatic stress disorder screening tools in patients with delusional memories, whereas other studies found better scores in patients with delirium or delusional memories.

Conclusions

Based on current literature, no relationship could be shown for delirium and emotional outcome. Regarding delusional memories and adverse emotional outcome, results were in contradiction.     

重症医学科呼吸机相关性肺炎的发生及其危险因素分析

目的探讨重症医学科呼吸机相关性肺炎(ventilator-associated pneumonia,VAP)的发生及其危险因素,以便更好地指导临床工作。方法采用查阅病例的方式,回顾性分析158例在重症医学科住院行机械通气患者的临床资料,分析患者VAP的发生及其危险因素。结果机械通气时间、留置胃管是重症医学科患者VAP发生的主要危险因素(P0.01)。结论每天评估患者停止机械通气的可能性,尽早停止机械通气;保持口咽清洁,减少细菌定植;加强环境清洁和空气消毒管理;做好气管切开的护理;提高护理操作技术水平对降低VAP的发生具有重要的作用。     

监护病房高钠血症发生的危险因素和防治

目的：探讨监护病房高钠血症发生的可能危险因素及防治措施。方法：回顾分析43例患者的临床及辅助检查资料。结果：监护病房内神经系统疾病患者发生高钠血症的比例约为27．1％，住院时间越长发生高血钠的比较越高，其发生主要与临床高渗脱水剂的应用，意识障碍，中枢病变部位及伴发的高热，高血糖有关。结论：高钠血症是监护室常见并发症，应重视并对各种危险因素加以预防。     

Cognitive impairment after intensive care unit admission: a systematic review

Purpose

There is increasing evidence that critical illness and treatment in an intensive care unit (ICU) may result in significant long-term morbidity. The purpose of this systematic review was to summarize the current literature on long-term cognitive impairment in ICU survivors.

Methods

PubMed/MEDLINE, CINAHL, Cochrane Library, PsycINFO and Embase were searched from January 1980 until July 2012 for relevant articles evaluating cognitive functioning after ICU admission. Publications with an adult population and a follow-up duration of at least 2 months were eligible for inclusion in the review. Studies in cardiac surgery patients or subjects with brain injury or cardiac arrest prior to ICU admission were excluded. The main outcome measure was cognitive functioning.

Results

The search strategy identified 1,128 unique studies, of which 19 met the selection criteria and were included. Only one article compared neuropsychological test performance before and after ICU admission. The 19 studies that were selected reported a wide range of cognitive impairment in 4–62 % of the patients after a follow-up of 2–156 months.

Conclusion

The results of most studies of the studies reviewed suggest that critical illness and ICU treatment are associated with long-term cognitive impairment. Due to the complexity of defining cognitive impairment, it is difficult to standardize definitions and to reach consensus on how to categorize neurocognitive dysfunction. Therefore, the magnitude of the problem is uncertain.     

Risk factors for long intensive care unit stay after cardiopulmonary bypass in children

OBJECTIVES: To determine whether children who experience longer intensive care unit (ICU) stays after open heart surgery may be identified at admission by clinical criteria. To identify factors associated with longer ICU stays that are potential targets for quality improvement. SETTING: Tertiary pediatric cardiac surgical center. DESIGN: A retrospective review was performed of pre-, intra-, and postoperative factors for children undergoing open heart surgery. All factors were evaluated for strength of association with length of ICU stay (LOS) using a negative binomial model. After multiple analysis, factors were deemed significant if associated with a LOS with p < .02. PATIENTS: A total of 355 pediatric patients who had cardiac surgery with cardiopulmonary bypass in a 1-yr period from April 1999 until March 2000. MEASUREMENTS AND MAIN RESULTS: Children who fell above the 95th percentile for LOS in our institution occupied 30% of bed days and had a three-fold greater mortality. Of all clinical factors considered, those significantly associated with LOS were as follows: preoperative--mechanical ventilation, neonatal status, medical problems, and transfer from abroad; intraoperative--higher operative complexity, increased cardiopulmonary bypass time or ischemic time, and circulatory arrest; and postoperative--delayed sternal closure, sepsis, renal failure, pulmonary hypertension, chylothorax, diaphragm paresis, and arrhythmia. A model combining all factors identified preoperative mechanical ventilation, neonatal status, major medical problems, operative complexity, cardiopulmonary bypass time, and a postoperative complication score as independently associated with LOS (p < .01). CONCLUSIONS: At the time of ICU admission after open heart surgery, clinical criteria are evident that highlight a child's risk of longer ICU stay. These pre- and intraoperative factors relate to LOS independent of subsequent postoperative events. Those postoperative complications that are most strongly associated with increased LOS are identified and, therefore, made accessible to quality control.     

Procalcitonin concentrations as a predictor of unexpected readmission and mortality after intensive care unit discharge: A retrospective cohort study

Procalcitonin (PCT) has been used to guide treatment in critically ill patients with sepsis, but whether PCT at intensive care unit (ICU) discharge can stratify risks of post-ICU readmission or mortality is unknown. This cohort study compared the ability of PCT with C-reactive protein (CRP) in predicting unexpected adverse post-ICU events. Of the 1877 patients admitted to the multidisciplinary ICU between 1 April 2012 and 31 March 2014, 1653 (88.1%) were discharged without treatment limitations. A total of 71 (4.3%) were readmitted and 18 patients (1%) died unexpectedly after ICU discharge during the same hospitalization. Both PCT (0.6 vs 0.4 μg/L, P = .002) and a high CRP concentration > 100 mg/L (58% vs 41%, P = .004) at ICU discharge were associated with an increased risk of adverse post-ICU events in the univariate analyses; however, the ability of PCT to discriminate between patients with and without adverse post-ICU outcomes was limited (area under the receiver operating characteristic curve = 0.61; 95% confidence interval, 0.55-0.66). In the multivariable analysis, only a high CRP concentration (odds ratio, 1.92; 95% confidence interval, 1.12-3.11; P = .008) was associated with an increased adverse post-ICU events. Elevated PCT concentration at ICU discharge was inadequate in its predictive ability to guide ICU discharge.     

ICU患者压疮发生危险因素分析

目的：探讨导致ICU患者压疮发生的危险因素。方法：采用自行设计的“ICU患者压疮风险因素调查表”记录735例ICU患者的患病情况、主要治疗情况等资料。结果：性别、糖尿病、脑卒中、入ICU时间、是否持续进行动脉血压监测、水肿、平均动脉压、乳酸Lac、心率、Apachell评分是ICU患者发生压疮的影响因素。结论：ICU患者压疮发生是多因素共同参与的病理生理过程,护理人员应充分认识各种危险因素对ICU患者发生压疮的影响,对存在或可能存在危险因素的ICU患者实施重点防护以减少压疮的发生。     

Predictive factors of intensive care unit admission in patients with haematological malignancies and pneumonia

Objective To describe early signs at the onset of pneumonia occurring in the haematology ward which could be associated with a transfer to the ICU.Design A 13-month preliminary prospective observational cohort study.Setting Department of haematology and (32-bed) medical intensive care unit (ICU).Patients Fifty-three of 302 patients hospitalised in the haematology ward who developed presumptive clinical evidence of pneumonia were enrolled.Measurements and results At the onset of the clinical evidence of pneumonia (day 1), we compared variables between patients requiring an ICU admission and those who did not. Twenty-four patients (45%) required a transfer to the ICU. Factors associated with ICU admission were: numbers of involved quadrants: 2.3 vs 1, P=0.001 and oxygenation parameters (initial level of O₂ supplementation: 3.5 vs 0.9 l/min, P<0.05), the presence of hepatic failure (58% vs 10%, P<0.01), Gram-negative bacilli isolated in blood culture (7 vs 1, P=0.01). In the multivariate analysis, a decrease of 10% in the SaO₂ and the requirement of nasal supplementary O₂ at the onset of acute respiratory failure increased the risk of admission to MICU, respectively, by 18 and by 14. The overall 6-month mortality rate of the 53 patients was 28%.Conclusion Parameters of oxygenation and radiological score could be associated with this transfer on day 1 of the onset of pneumonia occurrence. A further study should evaluate an earlier selection of this type of patient, followed by an early admission to the MICU, in order to improve ICU outcome.     

Parental satisfaction,involvement, and presence after pediatric intensive care unit admission

Purpose

To describe satisfaction, involvement, presence, and preferences of parents following their child's admission to an intensive care unit (ICU).

Methods

A survey, administered 1 month after their child's ICU admission, described perceptions of parental satisfaction with their interaction with healthcare providers, their presence during resuscitation, involvement in treatment decision-making, and preferences if events were to be re-enacted.

Results

One hundred three parents of 91 patients were enrolled; 64 primary parents (70%) completed the survey at 1 month. The mean (SD) satisfaction rating was 87.6 (± 14.8) and involvement rating was 70.2 (± 34.4) on a scale from 0 (not satisfied/involved) to 100 (completely satisfied/involved). There were no differences in satisfaction (P = .46), involvement (P = .69) and change in preferences (P = .97) between parents who were present and not present. After adjusting for child's baseline illness, receipt of more ICU therapies was associated with worse parental satisfaction (P = .03). Twenty-four (38%) parents reported that if events were repeated, they would have changed their preferences.

Conclusions

Overall, parental satisfaction ratings were high, lower in parents of children receiving more ICU therapies, and not associated with presence during resuscitation. These data contrast the American Heart Association's recommendation and suggestion of benefit from parental presence during periods of intensive therapies.     

Poor functional status immediately after discharge from an intensive care unit

Purpose.?To evaluate the functional status of patients within the first week of discharge from an intensive care unit (ICU), and to identify predictors and explanatory factors of functional status.

Methods.?A prospective, observational, cohort study was conducted with consecutive ICU patients who had stayed in a mixed, closed-format, university-level ICU for longer than 48 h.

Results.?Between 3 and 7 days of discharge from the ICU, functional status (as primary outcome), walking ability, muscle strength, and sensory and cognitive functioning were assessed in 69 survivors. The overall functional status was poor (median Barthel Index 6). In their ability to perform basic activities of daily living, 67% percent were severely dependent, 15% were moderately dependent, and 9% were slightly dependent on other people. Independent walking was impossible for 73% of participants, grip strength was reduced for 50%, and 30% had cognitive impairments. Duration of ventilation was associated with functional status after ICU discharge. Reduced grip strength and walking ability were identified as explanatory factors for poorer functional status shortly after discharge from the ICU.

Conclusion.?In the first week after discharge from the ICU, the majority of the patients had substantial functional disabilities in activities of daily living. These disabilities were more severe in patients who experienced ventilation for a longer period of time. There is a need for prospective studies focusing on functional recovery to support informed decision-making concerning the care of critically ill patients after ICU discharge.