Intensive Care Unit Consultants Research Articles

ICU physicians\u2019 and internists\u2019 survival predictions for patients evaluated for admission to the intensive care unit

BackgroundA higher chance of survival is a key justification for admission to the intensive care unit (ICU). This implies that physicians should be able to accurately estimate a patient’s prognosis, whether cared for on the ward or in the ICU. We aimed to determine whether physicians’ survival predictions correlate with the admission decisions and with patients’ observed survival. Consecutive ICU consultations for internal medicine patients were included. The ICU physician and the internist were asked to predict patient survival with intensive care and with care on the ward using 5 categories of probabilities (< 10%, 10–40%, 41–60%, 61–90%, > 90%). Patient mortality at 28 days was recorded.ResultsThirty ICU physicians and 97 internists assessed 201 patients for intensive care. Among the patients, 140 (69.7%) were admitted to the ICU. Fifty-eight (28.9%) died within 28 days. Admission to intensive care was associated with predicted survival gain in the ICU, particularly for survival estimates made by ICU physicians. Observed survival was associated with predicted survival, for both groups of physicians. The discrimination of the predictions for survival with intensive care, measured by the area under the ROC curve, was 0.63 for ICU physicians and 0.76 for internists; for survival on the ward the areas under the ROC curves were 0.69 and 0.74, respectively.ConclusionsPhysicians are able to predict survival probabilities when they assess patients for intensive care, albeit imperfectly. Internists are more accurate than ICU physicians. However, ICU physicians’ estimates more strongly influence the admission decision. Closer collaboration between ICU physicians and internists is needed.

The impact of the patient post-intensive care syndrome components upon caregiver burden

ObjectiveTo evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden. DesignA prospective observational study was conducted over 26 months (January 2013–February 2015). SettingMedical-surgical ICU and follow-up consultation in Portugal. Patients or participantsPatients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study. Main variables of interestIn ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder). ResultsA total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden.Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008).When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden. ConclusionsThe presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

Early in-hospital clinical deterioration is not predicted by severity of illness, functional status, or comorbidity.

BackgroundPrior studies concentrated on unplanned intensive care unit (ICU) transfer to gauge deterioration occurring shortly following hospital admission. However, examining only ICU transfers is not ideal since patients could stabilize with treatment, refuse ICU admission, or not require ICU evaluation. To further explore etiologies of early clinical deterioration, we used rapid response team (RRT) activation within 48 hours of admission as an index of early clinical worsening.MethodsA retrospective analysis of prospectively gathered admissions from the emergency department in an academic medical center was done. Data were reviewed independently by two physicians. We assessed severity of illness, functional status, comorbidity, the frequency of ICU and palliative care consultations, and changes in advance health care directives.ResultsOf 655 rapid responses (RRs) within the study period, 24.6% occurred within 48 hours of admission. Disease trajectory was the most frequent perceived reason for RRs (55.6% and 58.9%, reviewer 1 and 2, respectively) followed by medical error (15.6% and 15.2%). Acute physiology and chronic health evaluation II (APACHE-II) and modified early warning scores (MEWS) were higher at the time of RR compared to admission (p<0.0001). However, admission APACHE-II, MEWS, functional status, and comorbidity scores did not predict early RRs. One third of RRs resulted in ICU consultation and 95% were accepted. Palliative care consults were requested for 15%, the majority (65%) after RR and all resulting in advance directive change.ConclusionDisease trajectory accounted for most clinical deterioration and medical error contributed to 15%. Our data suggest that it is difficult to predict early clinical deterioration as none of the measured parameters were associated with RRT activation.

The impact of the patient post-intensive care syndrome components upon caregiver burden

ObjectiveTo evaluate patient post-intensive care syndrome (PICS-P) and caregiver burden 3 months after discharge from the Intensive Care Unit (ICU) and determine the impact of different components of PICS-P upon caregiver burden. DesignA prospective observational study was conducted over 26 months (January 2013–February 2015). SettingMedical-surgical ICU and follow-up consultation in Portugal. Patients or participantsPatients discharged after a minimum of 2 days in the ICU. Caregiver inclusion criteria: not paid, written and spoken Portuguese, and agreement to participate in the study. Main variables of interestIn ICU: Patient gender, age, severity of illness (SAPS II) and length of ICU stay. At 3 months caregiver burden, physical (reduced mobility, weakness acquired in the ICU) and psychological components of PICS (anxiety, depression, post-traumatic stress disorder). ResultsA total of 168 caregivers completed the survey (response rate of 69%). A low degree of overburden was reported by 34.5% of caregivers, while 15.5% showed moderate to high levels of overburden.Patient anxiety and depression 3 months after ICU discharge significantly influenced the presence of caregiver burden (p=0.030 vs p=0.008).When physical components of PICS-P were evaluated, no influence on caregiver burden was observed. Patient demographics, severity of illness and length of stay also failed to influence caregiver burden. ConclusionsThe presence of psychological components of PICS-P 3 months after ICU seems to have a negative impact upon caregiver burden. On the other hand, physical problems showed no important impact upon caregiver overburden.

Improving clinical handover: Development of a web-based intensive care unit consultation system with structured reply generation

Clinical handover is a process of transferring a patient's clinical information from one team to another. Poor quality of handover of critically ill patients associates with misunderstanding, delay in treatment,...

Treatment of ventilator-associated pneumonia and ventilator-associated tracheobronchitis in the intensive care unit. A national survey of clinicians and pharmacists in Saudi Arabia.

Objectives:To assess current practices of different healthcare providers for treating extensively drug-resistant (XDR) Acinetobacter baumannii (AB) infections in tertiary-care centers in Saudi Arabia.Methods:This cross-sectional study was performed in tertiary-care centers of Saudi Arabia between March and June 2014. A questionnaire consisting of 3 parts (respondent characteristics; case scenarios on ventilator-associated pneumonia [VAP] and tracheobronchitis [VAT], and antibiotic choices in each scenario) was developed and sent electronically to participants in 34 centers across Saudi Arabia.Results:One-hundred and eighty-three respondents completed the survey. Most of the respondents (54.6%) preferred to use colistin-based combination therapy to treat VAP caused by XDR AB, and 62.8% chose to continue treatment for 2 weeks. Most of the participants (80%) chose to treat VAT caused by XDR AB with intravenous antibiotics. A significant percentage of intensive care unit (ICU) fellows (41.3%) and clinical pharmacists (35%) opted for 2 million units (mu) of colistin every 8 hours without a loading dose, whereas 60% of infectious disease consultants, 45.8% of ICU consultants, and 44.4% of infectious disease fellows preferred a 9 mu loading dose followed by 9 mu daily in divided doses. The responses for the scenarios were different among healthcare providers (p<0.0001).Conclusion:Most of the respondents in our survey preferred to use colistin-based combination therapy and intravenous antibiotics to treat VAP and VAT caused by XDR AB. However, colistin dose and duration varied among the healthcare providers.

Advance Care Planning in palliative care: A qualitative investigation into the perspective of Paediatric Intensive Care Unit staff

Background: The majority of children and young people who die in the United Kingdom have pre-existing life-limiting illness. Currently, most such deaths occur in hospital, most frequently within the intensive care environment. Aim: To explore the experiences of senior medical and nursing staff regarding the challenges associated with Advance Care Planning in relation to children and young people with life-limiting illnesses in the Paediatric Intensive Care Unit environment and opportunities for improvement. Design: Qualitative one-to-one, semi-structured interviews were conducted with Paediatric Intensive Care Unit consultants and senior nurses, to gain rich, contextual data. Thematic content analysis was carried out. Setting/participants: UK tertiary referral centre Paediatric Intensive Care Unit. Eight Paediatric Intensive Care Unit consultants and six senior nurses participated. Findings: Four main themes emerged: recognition of an illness as ‘life-limiting’; Advance Care Planning as a multi-disciplinary, structured process; the value of Advance Care Planning and adverse consequences of inadequate Advance Care Planning. Potential benefits of Advance Care Planning include providing the opportunity to make decisions regarding end-of-life care in a timely fashion and in partnership with patients, where possible, and their families. Barriers to the process include the recognition of the life-limiting nature of an illness and gaining consensus of medical opinion. Organisational improvements towards earlier recognition of life-limiting illness and subsequent Advance Care Planning were recommended, including education and training, as well as the need for wider societal debate. Conclusions: Advance Care Planning for children and young people with life-limiting conditions has the potential to improve care for patients and their families, providing the opportunity to make decisions based on clear information at an appropriate time, and avoid potentially harmful intensive clinical interventions at the end of life.

Pediatric patients who receive antibiotics for fever and neutropenia in less than 60 min have decreased intensive care needs.

BackgroundAntibiotic delivery to patients with fever and neutropenia (F&N) in <60 min is an increasingly important quality measure for oncology centers, but several published reports indicate that a time to antibiotic delivery (TTA) of <60 min is quite difficult to achieve. Here we report a quality improvement (QI) effort that sought to decrease TTA and assess associated clinical outcomes in pediatric patients with cancer and F&N.ProcedureWe used Lean-Methodology and a Plan-Do-Study-Act approach to direct QI efforts and prospectively tracked TTA measures and associated clinical outcomes (length of stay, duration of fever, use of imaging studies to search for occult infection, bacteremia, intensive care unit (ICU) consultation or admission, and mortality). We then performed statistical analysis to determine the impact of our QI interventions on total TTA, sub-process times, and clinical outcomes.ResultsOur QI interventions significantly improved TTA such that we are now able to deliver antibiotics in <60 min nearly 100% of the time. All TTA sub-process times also improved. Moreover, achieving TTA <60 min significantly reduced the need for ICU consultation or admission (P = 0.003) in this population.ConclusionHere we describe our QI effort along with a detailed assessment of several associated clinical outcomes. These data indicate that decreasing TTA to <60 min is achievable and associated with improved outcomes in pediatric patients with cancer and F&N.

Medical intensive care unit consults occurring within 48 hours of admission: A prospective study

RationaleCritical care consults requested shortly after admission could represent a triage error. This consult process has not been adequately assessed, and data are retrospective relying on discharge diagnoses. ObjectivesThe aims of this study were to identify reasons for medical Intensive care unit (MICU) consultations within 48 hours of admission and to detect differences between those accepted and those denied MICU admission. MethodsData were prospectively collected including demographics, reason for consultation, Acute Physiology and Chronic Health Evaluation II score, Elixhauser comorbidity measure, functional status, need for assisted ventilation or vasopressor, presence of do-not-resuscitate (DNR) order, and whether a DNR order was obtained after MICU consultation. ResultsNinety-four percent of patients consulted were not initially evaluated in the emergency department, half of whom were accepted. Respiratory failure, sepsis, and alcohol withdrawal were the most frequent reasons for MICU transfers. Factors predicting MICU admission included respiratory illness, better baseline functional status, and less comorbidity, whereas DNR predicted rejection. We did not find differences in hospital mortality; but hospital length of stay was longer. ConclusionsProspective examination of the consult process suggests that disease progression rather than triage error accounted for most unplanned transfers. Functional status and comorbidity predicted MICU admission rather than illness severity. Goals of care were not being discussed adequately. We did not detect differences in mortality although hospital length of stay was increased.

The Impact of a Structured Clinical Pathway on the Application of Management Standards in Patients with Diabetic Ketoacidosis and Its Acceptability by Medical Residents

Diabetic Ketoacidosis (DKA) is a serious and potentially a fatal complication of diabetes mellitus. Tools to guarantee proper, evidence-based, guideline implementation are of paramount importance and an essential element for quality patient care. Clinical pathways represent one such tool that clearly promotes the implementation of guidelines and research evidence into clinical practice. The aims of this study were to measure quantitatively and qualitatively the impact of a specially structured Resident-friendly, DKA clinical pathway on the application of evidence-based management standards and its acceptability by the treating resident physicians. A retrospective chart review of patients who were admitted prior to and after the launching of the clinical pathway and a questionnaire assessment of resident’s acceptance of the pathway format were undertaken. Eighty one episodes of DKA in a total of 58 patients fulfilled the criteria for inclusion in the study. Thirty seven admissions were on the pathway (45.7%) and 44 were not (54.3%). Documentation of severity indices of patients who were admitted under the pathway were significantly improved with a trend for a shorter hospital stay. The duration of intravenous insulin therapy, intensive care unit consultation and diabetes educator involvement in patient care were not different between the two groups. Residents found the pathway user-friendly, educationally very valuable, reduced their workload and had a positive effect on their DKA management skills. Conclusions: Use of specially structured, resident-friendly pathway led to significant improvement in documentation of DKA severity indices and empowered our residents with evidence-based knowledge and skills to deal with this serious diabetic complication.

Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward

Guidelines recommend documentation of care preferences for patients with advanced cancer upon hospital admission.We assessed end-of-life outcomes for patients who did or did not have code status (CS) documented within 48 h of admission. This was a retrospective cohort study of patients who died on an inpatient oncology ward between January 2004 and February 2009. Primary end-of-life outcomes were "code blues" and cardiopulmonary resuscitation (CPR) attempts; secondary outcomes included unsuccessful CPR attempts, intensive care unit (ICU), consultations, and ICU admissions. Using logistic regression, outcomes were compared between those with and without CS documentation ≤ 48 h from admission (full code or do-not-resuscitate), controlling for significant confounders. The 336 patients had a median age of 61 years; 97 % had advanced cancer. The median time from admission to death was 12 days (range <1-197 days); 151 patients (45 %) had CS documentation ≤ 48 h from admission. Controlling for confounders of reason for admission and marital status, patients with CS documentation ≤ 48 h from admission had fewer "code blues" (2 vs. 15 %; adjusted odds ratio(AOR) 0.12, 95% confidence interval (CI) 0.02-0.43), CPR attempts (1 vs. 11 %; AOR 0.12, 95 % CI 0.01-0.51), unsuccessful CPR attempts (0 vs. 11 %), ICU consultations (9 vs. 30 %; AOR 0.19, 95 % CI 0.08-0.40) and ICU admissions (2 vs. 5 %; AOR 0.18, 95 %CI 0.02-0.85). In patients who died on an oncology ward, CS documentation within 48 h of admission was associated with less aggressive end-of-life care, regardless of the reason for admission.

Recombinant activated protein C usage in Scotland: a comparison with published guidelines and a survey of attitudes*

Severe sepsis is a common cause of admission to the intensive care unit and is associated with a high hospital mortality. This audit explored the current use of, and attitudes towards, recombinant activated protein C therapy across Scotland, and compared these with current guidance. Patients with severe sepsis were followed for three days. Consideration and/or usage of recombinant activated protein C were compared with two different guidelines. Ninety-seven patients were admitted to the intensive care unit over the audit period. Recombinant activated protein C was used in nine of these patients. Depending on the criteria used, between 50% and 81% of the patients who qualified for recombinant activated protein C therapy did not receive it. Subsequent to the audit, a survey was performed to study intensive care unit consultants' attitudes to recombinant activated protein C therapy. A total of 125 consultants responded to the survey (77%). Of these, 104 (83%) stated that they used recombinant activated protein C in their clinical practice, 56 (52%) of whom prescribed it to patients with two-organ failures and an Acute Physiology and Chronic Health Evaluation II score of ≥ 25. Thirty-nine respondents (38%) stated that two-organ failures alone would be an adequate trigger for therapy. We conclude that recombinant activated protein C is potentially under-used to treat severe sepsis. Many consultants seem to reserve the drug for the most severely ill sub group of patients.

Movement Disorders Emergencies Part 2

Although movement disorders do not usually present as neurologic emergencies, there are times when the abrupt onset of an unusual movement abnormality results in emergency department or intensive care unit consultations. Part 1 of this review discussed hypokinetic movement disorders emergencies. Part 2 provides a diagnostic approach to the recognition and treatment of hyperkinetic movement disorders emergencies by identifying phenomenology and reviewing common etiologies.

Analysis of Consistency in Intensive Care Unit Consultants' Decision Making in Clinical Practice

This study examined whether there was significant variation in the rate at which different intensive care unit (ICU) consultants accept unplanned referrals to critical care. Over 2.75 years, 1,292 unplanned referrals were admitted to the ICU at Glan Clwyd Hospital, representing an average rate of one unplanned admission every 18.6 hours. There was significant variation in the rate at which consultants accepted unplanned referrals, ranging from 0.99 to 1.83 admissions per 24 hours (p = 0.0039). There was also a significant difference between the rate of acceptance during normal working hours and outside these hours (p <0.001). Some of this variation was associated with differences in severity of illness, whether the patient was accepted in or out of hours and the number of beds used each day. Using rates of acceptance of unplanned admissions could be a useful measure of an ICU consultant’s performance.

Effect of early achievement of physiologic resuscitation goals in septic patients admitted from the ward on the kidneys

Purpose The aim of the study was to evaluate if early achievement of physiologic goals of resuscitation in critically ill septic patients admitted from the ward may prevent acute kidney injury (AKI). Materials and Methods Patients admitted to the intensive care unit (ICU) with a diagnosis of sepsis were retrospectively identified. Mean arterial pressure greater than 65 mm Hg, central venous pressure greater than 8 mm Hg, and central venous oxygenation greater than 70% achieved within 6 hours after ICU consultation at the ward was considered early achievement. Acute kidney injury was defined by the RIFLE criteria. Results Of 85 patients, 29% achieved all goals within 6 hours, 42% had late or no achievement of goals, and 28% had incomplete documentation of goals. Of these, 52% developed AKI. Patients who eventually developed AKI had a significantly higher creatinine level at ICU consultation before resuscitation. Delay in achievement of goals results in a 3.4% creatinine level rise per hour in multivariate analysis ( P = .03). The development of AKI was significantly influenced by delayed achievement of physiologic goals on the ICU ( P = .02). Conclusions Although most of AKI occurred before ICU consultation, early physiologic resuscitation and achievement of hemodynamic goals on the ICU is associated with a decrease in development of AKI of septic patients admitted from the ward.

Timeliness of code status documentation in terminally ill cancer patients admitted to a general oncology ward.

e19519 Background: Code status (CS) discussions are important to avoid unwanted or futile invasive interventions. This study assessed CS documentation and timeliness thereof in terminally-ill patients on a general oncology ward. Methods: A retrospective chart review was performed of consecutive patients who died on the general oncology ward of the Princess Margaret Hospital, Toronto, Canada (admission January 2007-February 2009). Data retrieved included details of admission, CS, consults to the intensive care unit (ICU) and death. CS was classified as timely (documentation ≤24 hours of admission) or not timely (documentation >24h of admission). Outcomes of ICU consultations, attempts at CPR and ICU admission were compared between these two groups. Fisher's exact test and Wilcoxon test were used for statistical analysis. Results: The 150 patients (71 males, 79 females) had a mean age of 62 years (SD 13). All patients had recurrent or spread disease (lymph nodes or distant), with exception of 7 locally advanced (1 esophageal, 3 head & neck, 3 gynecologic) and 4 intracranial primaries. The mean time to death was 16 days (SD 21). Of 150 patients, 68 (45%) did and 82 (65%) did not have timely CS documentation. The 68 timely CS were initially 6 full codes and 62 do-not-resuscitate (DNR). CS was eventually documented in 70 of the 82 without timely CS (1 full code and 69 DNR); in 12 patients, CS was never documented. Compared to patients with a timely CS, those without timely CS had significantly more ICU consults (32 vs. 4, p<0.00001) and more attempts at CPR (11 vs. 1, p = 0.006); all 11 attempts in the patients without timely CS were futile. There were 4 ICU stays in the group without timely CS, compared to one stay in the timely CS group (11 vs. 4 days in ICU, p = 0.26). Conclusions: In this study of general oncology ward deaths, the majority of patients had CS documentation more than 24 hours after admission. The group without timely CS had more ICU consults and more futile attempts at CPR. Better knowledge with respect to CS documentation may help guide policy and improve patient care. No significant financial relationships to disclose.

Patient outcomes after noninvasive mechanical ventilation at a high dependency unit of an emergency department

To describe the outcome of patients after noninvasive ventilation in a high dependency unit (HDU) of an emergency department (ED). Secondary aims were to define the role of intensive care consultation and to identify variables associated with mortality. Observational, prospective 6-month study. Two hundred and nine cases were analysed. Thirty-four patients were initially rejected by the intensive care unit (ICU). Physicians in the ED did not request ICU consultation in the remaining 175 (83%) because of 'belief of improvable medical condition in the ED in patients without therapeutic limits' in 93 (group 1) and to 'preset therapeutic limits' or 'comfort measures only' in 82 (groups 2 and 3). Ten out of these 175 were subsequently admitted to the ICU. The global in-hospital mortality rate was 22% (3.3% in the high dependency unit), but only 10% in group 1. Place of referral for ventilation (P<0.001), absence of subsequent ventilation on the general ward (P<0.001), group of assignation (P=0.004), intensive care initial rejection (P=0.022), no previous home ventilation (P=0.028), older age (P=0.03) and longer duration on ventilation (P=0.047) were significantly associated with mortality. In the multivariate regression model, ventilating patients from general wards (odds ratio=7.1; 2.3-25, 95% confidence interval) and ventilation under preset limits (odds ratio=3.57; 1.42-8.98, 95% confidence interval) remained significantly associated with mortality. Noninvasive ventilation is a relatively safe and effective treatment in the ED when performed in carefully controlled settings. ICU consultation may be securely deferred in this setting.

The use of cuffed tracheal tubes for paediatric tracheal intubation, a survey of specialist practice in the United Kingdom

For more than 50 yr, uncuffed tracheal tubes have been the gold standard for intubation in children under the age of 8 yr. However, recently there has been interest in the use of cuffed tubes in paediatric practice. This survey aimed to benchmark UK practice with regard to tracheal intubation within specialist paediatric centres, exploring current cuffed tracheal tube use in children. A questionnaire was e-mailed to the paediatric intensive care unit and anaesthetic department clinical leads in all UK specialist paediatric hospitals with a paediatric intensive care unit (n = 30). Information was requested on the use of tracheal tubes across all paediatric age groups, as well as the reasons for non-use and the incidence of complications attributed to cuffed tubes. A total of 20 paediatric intensive care unit and 15 anaesthetic questionnaires were returned, equating to a response rate of 67% and 50%, respectively. Only 5% of the paediatric intensive care unit and 7% of the anaesthetic respondents routinely use a cuffed tube in children under the age of 8 yr. The commonest reason cited in both groups for non-cuff use was that there is minimal benefit to be gained over using an uncuffed tracheal tube. The most frequent specific indication for use of a cuffed tube was a reduced lung compliance (60% respondents both groups). In all, 45% of the paediatric intensive care unit respondents and 100% of the anaesthetists reported that they did not routinely monitor the intracuff pressure when using a cuffed tube. The incidence of observed complications attributed to the use of cuffed tubes was far higher amongst paediatric intensive care unit consultants (65% vs. 7% anaesthetists); however, the majority in both groups stated that such complications were no more common than when using an uncuffed tube (60% paediatric intensive care unit and 53% anaesthetists). Cuffed tracheal tubes are rarely routinely used in children, particularly in the under 8 yr age group, in specialist paediatric centres in the UK. When used, it is predominantly for a specific indication, and the monitoring of intracuff pressure is not routine. Current expert consensus is that complications are equally as common when using a cuffed as an uncuffed tube.

Enforcing treatment with clozapine: survey of views and practice

Aim and methodThe aim of the study was to survey strategies for dealing with patients who refuse clozapine blood tests or tablets. One hundred and twenty-five psychiatric intensive care unit consultants were sent a questionnaire.ResultsThirty-nine (31%) questionnaires were returned. Opinions and practices were diverse ranging from uncertainty around the legal right to enforce venepuncture, to the practice of slipping clozapine into a patient's drink without their knowledge.Clinical implicationsThere is need for an open debate of the relevant legal and ethical issues.

Preoperative intensive care unit consultations

To determine if a structured preoperative ICU consultation would correctly assign patients to preoperative invasive monitoring, postoperative ICU care, or recovery room care, and to compare morbidity, mortality, and resource utilization among all groups. Prospective, observational study. A university hospital. A total of 475 patients who were referred preoperatively by surgeons for ICU consultation and were evaluated by ICU physicians. Patients assessed to have clinical evidence of cardiovascular compromise were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization. Patients without such evidence, but who were to undergo major operations or had anticipated major fluid replacement were independently selected for invasive monitoring by anesthesiologists. Patients who developed physiologic instability or became unstable due to hemorrhage also underwent invasive monitoring. Nonmonitored patients who remained stable were given postoperative ICU care or went to the recovery room based on an assessment by the surgeon and anesthesiologist at the end of the operation. Of 8,916 elective surgical cases, ICU physicians were consulted in 475 (5.3%) patients preoperatively. Sixty-seven patients were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization; 60 patients had surgery (0.7% of elective cases, 12.6% of ICU consultations). Patients selected for ICU preoperative monitoring were older than non-monitored patients and had higher numbers of cardiovascular and total risk factors than any other group. They had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores, higher Therapeutic Intervention Scoring System (TISS) points, a higher number of complications, and longer ICU stays than non-monitored postoperative ICU patients. In addition, they had a higher number of complications than nonmonitored recovery room patients. APACHE II scores, TISS points, number of complications, and ICU days in the preoperative ICU admission group were not increased when compared with all other monitored patients. Neither hospital days nor total hospital charges were increased when compared with the other elective ICU patients. Patients selected for ICU preoperative monitoring who underwent surgery had an 11.7% mortality rate and accounted for four of five cardiovascular-related deaths. A small number of high-risk patients can be selected for preoperative monitoring on the basis of clinical assessment without increasing ICU stay or hospital bills. A structured preoperative consultation correctly identifies those patients who need monitoring and ICU care, but does not overutilize scarce and expensive ICU beds.