Abstract
BackgroundLittle is known about homeless patients in intensive care units (ICUs).ObjectivesTo compare clinical characteristics, treatments, and outcomes of homeless to non-homeless patients admitted to four ICUs in a large inner-city academic hospital.Methods63 randomly-selected homeless compared to 63 age-, sex-, and admitting-ICU-matched non-homeless patients.ResultsCompared to matched non-homeless, homeless patients (average age 48±12 years, 90% male, 87% admitted by ambulance, 56% mechanically ventilated, average APACHE II 17) had similar comorbidities and illness severity except for increased alcohol (70% vs 17%,p<0.001) and illicit drug(46% vs 8%,p<0.001) use and less documented hypertension (16% vs 40%,p = 0.005) or prescription medications (48% vs 67%,p<0.05). Intensity of ICU interventions was similar except for higher thiamine (71% vs 21%,p<0.0001) and nicotine (38% vs 14%,p = 0.004) prescriptions. Homeless patients exhibited significantly lower Glasgow Coma Scores and significantly more bacterial respiratory cultures. Longer durations of antibiotics, vasopressors/inotropes, ventilation, ICU and hospital lengths of stay were not statistically different, but homeless patients had higher hospital mortality (29% vs 8%,p = 0.005). Review of all deaths disclosed that withdrawal of life-sustaining therapy occurred in similar clinical circumstances and proportions in both groups, regardless of family involvement. Using multivariable logistic regression, homelessness did not appear to be an independent predictor of hospital mortality.ConclusionsHomeless patients, admitted to ICU matched to non-homeless patients by age and sex (characteristics most commonly used by clinicians), have higher hospital mortality despite similar comorbidities and illness severity. Trends to longer durations of life supports may have contributed to the higher mortality. Additional research is required to validate this higher mortality and develop strategies to improve outcomes in this vulnerable population.
Highlights
Homelessness is a serious social and public health problem
Compared to matched non-homeless, homeless patients had similar comorbidities and illness severity except for increased alcohol (70% vs 17%, p
Intensity of intensive care units (ICUs) interventions was similar except for higher thiamine (71% vs 21%,p
Summary
Homelessness is a serious social and public health problem. Prevalence estimates indicate that at least 150,000 people were homeless in Canada in 2009 [1] and 1.5 million people were homeless in the United States in 2012 [2]. The course of illness and use of health care resources for people who are homeless admitted to the intensive care unit (ICU) are largely unknown. In a subsequently published propensitymatched cohort from France, homelessness was not associated with ICU or hospital mortality but was associated with significantly longer ICU and hospital stays [12]. Given this higher use of hospital and intensive care resources and that intensive care is a limited and costly resource, a better understanding of the needs and outcomes of homeless critically ill patients would be useful for health system planning and improvement. Little is known about homeless patients in intensive care units (ICUs)
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