Abstract
PurposeTo estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients.MethodsWe performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt admissions (within 4 h of assessment) were compared to a ‘watchful waiting’ cohort. We used critical care strain (bed occupancy) as a natural randomisation event that would predict prompt transfer to critical care. Strain was classified as low, medium or high (2+, 1 or 0 empty beds). This instrumental variable (IV) analysis was repeated for the subgroup of referrals with a recommendation for critical care once assessed. Risk-adjusted 90-day survival models were also constructed.ResultsA total of 12,380 patients from 48 hospitals were available for analysis. There were 2411 (19%) prompt admissions (median delay 1 h, IQR 1–2) and 9969 (81%) controls; 1990 (20%) controls were admitted later (median delay 11 h, IQR 6–26). Prompt admissions were less frequent (p < 0.0001) as strain increased from low (22%), to medium (15%) to high (9%); the median delay to admission was 3, 4 and 5 h respectively. In the IV analysis, prompt admission reduced 90-day mortality by 7.4% (95% CI 1.7–18.5%, p = 0.117) overall, and 16.2% (95% CI 1.1–31.3%, p = 0.036) for those recommended for critical care. In the risk-adjust survival model, 90-day mortality was similar.ConclusionAfter allowing for unobserved prognostic differences between the groups, we find that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.
Highlights
Recent policy stresses the importance of identifying and responding to the deteriorating ward patient [1]
We explore whether delays to admission engendered by high strain allow us to estimate the effect of effect of delay on patient outcome
Repeat visits and re-admissions were excluded as were patients where intensive care units (ICU) admission was either a priori refused or inevitable
Summary
Recent policy stresses the importance of identifying and responding to the deteriorating ward patient [1]. Current guidelines recommend that critical care admission. Supporting evidence is limited because randomised evaluation of prompt admission to critical care is deemed unethical. Without quantification of the benefits, it is difficult to assess the magnitude and importance of this problem. Non-randomised evaluations are primarily confounded by treatment allocation bias [3]. Patients are prioritised on the basis of clinical severity so prompt admissions tend to have poorer prognoses. Risk adjustment will help remove this bias, but depends heavily on adequate measurement of all factors driving the decision about how to treat. Measured severity is an incomplete description, and often there are other end of the bed factors prompting clinicians to recommend prompt admission to critical care
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