Late Intensive Care Unit Research Articles

Early vs late ICU admission in patients with COVID-19 pneumonia.

The type of admission to the Intensive Care Unit (ICU) influences the prognosis of patients with severe pneumonia and, in the case of patients with COVID-19 pneumonia, this is still unexplored. The objective of this study was to determine the differences between early and late ICU admission. A retrospective cohort study of patients with COVID-19 pneumonia at two high-complexity hospitals in Colombia. Early ICU admission (EICUA) was defined as direct admission from the emergency department or within the first 24 hours of admission. Late ICU admission (LICUA) was defined as admission from the hospitalization service after 24 hours of arrival. A robust Cox regression was performed for the variable recovery time, to determine the impact of the ICU admission type in the hazard rate. 68.2% were EICUA patients and 31.8% were LICUA patients. Recovery and duration of hospital stay were significantly lower in EICUA than in LICUA (9 vs 15 days, p = 0.0001, and 10 vs 15.5 days, p < 0.0001, respectively). However, the duration of ICU stay (7 vs 9 days, p = 0.131) and the invasive mechanical ventilation requirement (48.9% vs 54.9%, p = 0.374) were not statistically significant. The 30-day follow-up showed no difference between the EICUA and LICUA (alive 97% vs 94.6%, p = 0.705). Mortality between EICUA and LICUA patients with COVID-19 pneumonia showed no statistically significant differences. However, the recovery time, the probability intensity of instant recovery, and the duration of hospital stay were better in EICUA than in LICUA. Neither EICUA nor LICUA affects the final status (death) of patients.

Does Timing Matter? The Effect of Intensive Care Unit Arrival Timing on Elective Cardiac Surgery

BackgroundDue to staffing changes at scheduled intervals and decreases in essential staff in the evenings, late intensive care unit (ICU) arrivals may be at risk for suboptimal outcomes. Utilizing a regional collaborative, we sought to determine the effect of ICU arrival timing on outcomes in elective isolated coronary artery bypass. MethodsAdults undergoing elective, isolated coronary artery bypass from 17 hospitals between 2013 and 2023 were identified. Patients with missing predicted risk of mortality or missing ICU arrival time were excluded. Late ICU arrival time was defined as between 6:00 pm and 6:00 am. Hierarchical logistic regression with appropriate predicted risk scores was utilized for outcome risk adjustment. ResultsWe identified 11,638 patients, with 972 (8.4%) experiencing late ICU arrival. Late ICU arrival patients had higher predicted risk of morbidity or mortality (8.2%; [interquartile range {IQR}, 5.6%, 12.0%] vs 7.7% [IQR, 5.5%, 11.5%], P = .048) compared with early ICU arrival patients with longer median cardiopulmonary bypass times (96 minutes [IQR, 78, 119] vs 93 [IQR, 73, 116], P < .001). Late ICU arrival patients experienced more unadjusted complications including prolonged ventilation (7.7% vs 4.2%, P < .001) and operative mortality (2.0% vs 1.1%, P = .02), although no difference in failure-to-rescue (11.0% vs 10.4%, P = .84). Logistic regression with risk adjustment demonstrated late ICU arrival as a predictor of prolonged ventilation (odds ratio, 1.49 [95% CI, 1.12-1.99], P = .006). ConclusionsAfter adjustment, late ICU arrivals experienced higher rates of prolonged ventilation, although this did not translate to failure-to-rescue.

Association of Early Oseltamivir With Improved Outcomes in Hospitalized Children With Influenza, 2007-2020

Oseltamivir is recommended for all children hospitalized with influenza, despite limited evidence supporting its use in the inpatient setting. To determine whether early oseltamivir use is associated with improved outcomes in children hospitalized with influenza. This multicenter retrospective study included 55 799 children younger than 18 years who were hospitalized with influenza from October 1, 2007, to March 31, 2020, in 36 tertiary care pediatric hospitals who participate in the Pediatric Health Information System database. Data were analyzed from January 2021 to March 2022. Early oseltamivir treatment, defined as use of oseltamivir on hospital day 0 or 1. The primary outcome was hospital length of stay (LOS) in calendar days. Secondary outcomes included 7-day hospital readmission, late (hospital day 2 or later) intensive care unit (ICU) transfer, and a composite outcome of in-hospital death or use of extracorporeal membrane oxygenation (ECMO). Inverse probability treatment weighting (IPTW) based on propensity scoring was used to address confounding by indication. Mixed-effects models were used to compare outcomes between children who did and did not receive early oseltamivir treatment. Outcomes were also compared within high-risk subgroups based on age, presence of a complex chronic condition, early critical illness, and history of asthma. The analysis included 55 799 encounters from 36 hospitals. The median (IQR) age of the cohort was 3.61 years (1.03-8.27); 56% were male, and 44% were female. A total of 33 207 patients (59.5%) received early oseltamivir. In propensity score-weighted models, we found that children treated with early oseltamivir had shorter LOS (median 3 vs 4 days; IPTW model ratio, 0.52; 95% CI, 0.52-0.53) and lower odds of all-cause 7-day hospital readmission (3.5% vs 4.8%; adjusted odds ratio [aOR], 0.72; 95% CI, 0.66-0.77), late ICU transfer (2.4% vs 5.5%; aOR, 0.41; 95% CI, 0.37-0.46), and the composite outcome of death or ECMO use (0.9% vs 1.4%; aOR, 0.63; 95% CI, 0.54-0.73). Early use of oseltamivir in hospitalized children was associated with shorter hospital stay and lower odds of 7-day readmission, ICU transfer, ECMO use, and death. These findings support the current recommendations for oseltamivir use in children hospitalized with influenza.

Bacterial coinfection in influenza pneumonia: Rates, pathogens, and outcomes.

Evidence from pandemics suggests that influenza is often associated with bacterial coinfection. Among patients hospitalized for influenza pneumonia, we report the rate of coinfection and distribution of pathogens, and we compare outcomes of patients with and without bacterial coinfection. We included adults admitted with community-acquired pneumonia (CAP) and tested for influenza from 2010 to 2015 at 179 US hospitals participating in the Premier database. Pneumonia was identified using an International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) algorithm. We used multiple logistic and gamma-generalized linear mixed models to assess the relationships between coinfection and inpatient mortality, intensive care unit (ICU) admission, length of stay, and cost. Among 38,665 patients hospitalized with CAP and tested for influenza, 4,313 (11.2%) were positive. In the first 3 hospital days, patients with influenza were less likely than those without to have a positive culture (10.3% vs 16.2%; P < .001), and cultures were more likely to contain Staphylococcus aureus (34.2% vs 28.2%; P = .007) and less likely to contain Streptococcus pneumoniae (24.9% vs 31.0%; P = .008). Of S. aureus isolates, 42.8% were methicillin resistant among influenza patients versus 53.2% among those without influenza (P = .01). After hospital day 3, pathogens for both groups were similar. Bacterial coinfection was associated with increased odds of in-hospital mortality (aOR, 3.00; 95% CI, 2.17-4.16), late ICU transfer (aOR, 2.83; 95% CI, 1.98-4.04), and higher cost (risk-adjusted mean multiplier, 1.77; 95% CI, 1.59-1.96). In a large US inpatient sample hospitalized with influenza and CAP, S. aureus was the most frequent cause of bacterial coinfection. Coinfection was associated with worse outcomes and higher costs.

Bacterial and fungal co-infections among COVID-19 patients in intensive care unit

This study aimed to investigate the frequency and characteristics of respiratory co-infections in COVID-19 patients in the intensive care unit (ICU). In this retrospective observational study, pathogens responsible for potential co-infections were detected by the bacterial culture, real-time polymerase chain reaction (RT-PCR), or serological fungal antigen tests. Demographic and clinical characteristics, as well as microbial results, were analyzed. Bacterial culture identified 56 (58.3%) positive samples for respiratory pathogens, with the most common bacteria being Burkholderia cepacia (18, 18.8%). RT-PCR detected 38 (76.0%) and 58 (87.9%) positive results in the severe and critical groups, respectively. Most common pathogens detected were Stenotrophomonas maltophilia (28.0%) and Pseudomonas aeruginosa (28.0%) in the severe group and S. maltophilia (45.5%) in the critical group. P. aeruginosa was detected more during the early stage after ICU admission. Acinetobacter baumannii and Staphylococcus aureus were more frequently identified during late ICU admission. Fungal serum antigens were more frequently positive in the critical group than in the severe group, and the positive rate of fungal serum antigens frequency increased with prolonged ICU stay. A high frequency of respiratory co-infections presented in ICU COVID-19 patients. Careful examinations and necessary tests should be performed to exclude these co-infections.

Impact of early ICU admission for critically ill cancer patients: Post-hoc analysis of a prospective multicenter multinational dataset.

Early intensive care unit (ICU) admission, in Critically Ill Cancer Patients (CICP), is believed to have contributed to the prognostic improvement of critically ill cancer patients. The primary objective of this study was to assess the association between early ICU admission and hospital mortality in CICP. Retrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU<24h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching. Of the 1011patients in our cohort, 1005 had data available regarding ICU admission timing and were included. Overall, early ICU admission occurred in 455 patients (45.3%). Crude hospital mortality in patients with early and delayed ICU admission was 33.6% (n=153) vs. 43.1% (n=237), respectively (P=0.02). After adjustment for confounders, early compared to late ICU admission was not associated with hospital mortality (HR 0.92; 95%CI 0.76-1.11). After propensity score matching, hospital mortality did not differ between patients with early (35.2%) and late (40.6%) ICU admission (P=0.13). In the matched cohort, early ICU admission was not associated with mortality after adjustment on SOFA score (HR 0.89; 95%CI 0.71-1.12). Similar results were obtained after adjustment for center effect. In this cohort, early ICU admission was not associated with a better outcome after adjustment for confounder and center effect. The uncertainty with regard to the beneficial effect of early ICU on hospital mortality suggests the need for an interventional study.

Reduce Mortality and Morbidity in Acute Myeloid Leukemia With Hyperleukocytosis With Early Admission in Intensive Care Unit: A Retrospective Analysis

BackgroundPatients presenting with acute myeloid leukemia (AML) at diagnosis are at high risk of severe complications and death, particularly with high white blood cell (WBC) count. In this retrospective study, we evaluate interest of early and systematic support in the intensive care unit (ICU) for AML with hyperleukocytosis (AML-HL) at diagnosis.MethodsPatients with AML-HL, defined by WBC > 50 × 109/L, primary referred in ICU (“Early ICU”) without organ failure and before initiating chemotherapy induction were compared to patients first admitted in the Hematology Department who required a secondary transfer in ICU (“Late ICU”) or not (“No ICU”). Primary end point was mortality during the first month, and secondary end points were the use of life-sustaining therapies in ICU and risk factors for ICU transfer and mortality.ResultsOne hundred fifty-four patients were included: 77 (50%) to the group “No ICU”, 18 (12%) to “Late ICU” and 59 (38%) to “Early ICU”. Mortality at day 30 was higher in “Late ICU” than in “Early ICU” and “No ICU”, with 27.8%; 16.9% and 2.6% respectively (P < 0.001). “Late ICU” patients had an increased use of life-sustaining therapy comparing to “Early ICU” patients (56% vs. 29%, P = 0.04).ConclusionsEarly referral to ICU reduces morbidity and seems an effective strategy to reduce short-term mortality in AML-HL at diagnosis.

Patterns and predictors of end-of-life care in older patients with pancreatic cancer.

BackgroundLittle is known about end‐of‐life care among patients with pancreatic adenocarcinoma (PDAC). We used the Surveillance, Epidemiology, and End Results‐Medicare linked database to analyze patterns of hospice use and end‐of‐life treatment in patients with PDAC.MethodsWe included patients diagnosed with PDAC between 2000‐2011 and who had died by December 31, 2012. We assessed patterns of hospice use, chemotherapy receipt, and intensive care unit (ICU) admissions at end‐of‐life. We used multivariable logistic regression to investigate predictors of end‐of‐life care.ResultsIn our cohort of 16 309 patients, 70.5% enrolled in hospice, of which 29.1% enrolled in the last 7 days of life. Use of hospice increased over time, from 61.6% in 2000 to 77.5% in 2012 (P‐value for trend <0.0001). Among the entire cohort, 6.4% received chemotherapy within the last 14 days of life and 13.1% were admitted to the ICU within the last 30 days of life. Late ICU admissions increased over time, while chemotherapy receipt at the end‐of‐life decreased. Patients who were older, female, with higher SES, or from the South or Midwest were more likely to enroll in hospice. Those who were younger or male were more likely to receive chemotherapy or have an ICU admission at the end‐of‐life.ConclusionAlthough hospice enrollment has increased among patients with PDAC, late enrollment still occurs in a substantial proportion of patients. While chemotherapy at the end‐of‐life has decreased slightly, ICU admissions at the end‐of‐life have continued to increase. Further research is needed to determine effective ways of enhancing end‐of‐life care for patients with PDAC.

Hospice use and end-of-life care among older patients with esophageal cancer.

BackgroundHospice and end‐of‐life health care utilization among patients with esophageal cancer are understudied. We used the Surveillance, Epidemiology, and End Results (SEER)‐Medicare linked database to analyze hospice use and end‐of‐life treatment patterns.MethodsWe included patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2000 and 2011 and who had died by December 31, 2013. We evaluated patterns of hospice enrollment, chemotherapy receipt, radiation receipt, acute care hospitalizations, and intensive care unit (ICU) admissions at end of life. We used multivariate logistic regression to evaluate possible associations with hospice use, late ICU admission, and late chemotherapy receipt.ResultsOur study included 6449 patients; 3597 (55.8%) enrolled in hospice. Among hospice enrolled patients, 31.4% enrolled in the last 7 days of life. Hospice enrollment increased over time, from 43.2% in 2000 to 59.6% in 2013. Patients who were older, female, with stage IV disease, or those with higher socioeconomic status were more likely to enroll in hospice. Among all patients, 19.1% had an ICU admission within the last 30 days and 4.6% received chemotherapy within the last 14 days of life. Those who were Black or Asian (compared to White), married, or had a comorbidity score >1 were more likely to have a late ICU admission. Males and younger patients were more likely to receive chemotherapy at end of life.ConclusionHospice enrollment rates among patients with esophageal cancer have increased over time; however, a significant percentage of patients enrolls near the end of life. Further research is needed to improve understanding of how end‐of‐life care decisions for these patients are made.

Effect of a Pediatric Early Warning System on All-Cause Mortality in Hospitalized Pediatric Patients

There is limited evidence that the use of severity of illness scores in pediatric patients can facilitate timely admission to the intensive care unit or improve patient outcomes. To determine the effect of the Bedside Paediatric Early Warning System (BedsidePEWS) on all-cause hospital mortality and late admission to the intensive care unit (ICU), cardiac arrest, and ICU resource use. A multicenter cluster randomized trial of 21 hospitals located in 7 countries (Belgium, Canada, England, Ireland, Italy, New Zealand, and the Netherlands) that provided inpatient pediatric care for infants (gestational age ≥37 weeks) to teenagers (aged ≤18 years). Participating hospitals had continuous physician staffing and subspecialized pediatric services. Patient enrollment began on February 28, 2011, and ended on June 21, 2015. Follow-up ended on July 19, 2015. The BedsidePEWS intervention (10 hospitals) was compared with usual care (no severity of illness score; 11 hospitals). The primary outcome was all-cause hospital mortality. The secondary outcome was a significant clinical deterioration event, which was defined as a composite outcome reflecting late ICU admission. Regression analyses accounted for hospital-level clustering and baseline rates. Among 144 539 patient discharges at 21 randomized hospitals, there were 559 443 patient-days and 144 539 patients (100%) completed the trial. All-cause hospital mortality was 1.93 per 1000 patient discharges at hospitals with BedsidePEWS and 1.56 per 1000 patient discharges at hospitals with usual care (adjusted between-group rate difference, 0.01 [95% CI, -0.80 to 0.81 per 1000 patient discharges]; adjusted odds ratio, 1.01 [95% CI, 0.61 to 1.69]; P = .96). Significant clinical deterioration events occurred during 0.50 per 1000 patient-days at hospitals with BedsidePEWS vs 0.84 per 1000 patient-days at hospitals with usual care (adjusted between-group rate difference, -0.34 [95% CI, -0.73 to 0.05 per 1000 patient-days]; adjusted rate ratio, 0.77 [95% CI, 0.61 to 0.97]; P = .03). Implementation of the Bedside Paediatric Early Warning System compared with usual care did not significantly decrease all-cause mortality among hospitalized pediatric patients. These findings do not support the use of this system to reduce mortality. clinicaltrials.gov Identifier: NCT01260831.

Abstract 13175: Outcomes of Heart Failure (HF) Patients Admitted to the Intensive Care Unit (ICU): Impact of Early or Late ICU Admission

Background: Little is known about the outcomes of HF patients who are admitted to an ICU. We examined the outcomes of HF patients who were admitted to directly to the ICU (early) or admitted to the ICU after initial ward admission (late), compared to non-ICU admitted patients. Methods: We examined 118,595 HF patients (ICD-10 code I50) in Ontario, Canada, who were hospitalized from 2003-2012 using the Canadian Institute for Health Information Discharge Abstract Database. We examined the association of ICU admission and timing with: a) 30-day mortality using multiple Cox regression with time-varying covariates, and b) 30-day hospital readmissions using repeated events analysis approach of Prentice, Williams and Peterson. Results: Of the cohort, 24,119 (20%) were admitted to an ICU during the hospital stay, of whom 84% were admitted early (median age 76 years, 54% men) and 16% were admitted later (age 77 years, 53% men). 30-day mortality was higher in early and late ICU compared to no ICU: 13%, 27%, 10.5% (p &lt;.001). Multivariable-adjusted hazard ratios (HR) were: 1.65 (95%CI; 1.58-1.73) for early ICU (p&lt;.001) and 4.59 (95%CI; 4.31-4.89) for late ICU (p&lt;.001) vs. no ICU (referent). All-cause 30-day readmissions were also highest among late ICU, followed by early ICU, and lowest in non-ICU patients: 24.3, 22.9, 21.7 readmissions per 100 person-months (all p &lt;.001). Multivariable-adjusted repeated events analysis demonstrated a progressively increasing HRs for all-cause readmission: 1.07 (95%CI; 1.04-1.11) for early ICU (p&lt;.001) and 1.13 (95%CI; 1.04-1.22) for late ICU (p&lt;.01) vs. no ICU (referent). Median in-hospital costs were $16,553 for late ICU, $8587 for early ICU, and $7296 for non-ICU admitted patients (p &lt;.001). Conclusions: HF patients who are admitted to the ICU are sicker and experience increased risk of 30-day readmissions and death. Late ICU admissions were associated with the highest risk of death and readmission, and incurred substantially higher costs of care.

SAPS 3 score as a predictive factor for postoperative referral to intensive care unit.

BackgroundPatients undergoing intermediate-risk surgery are typically taken to the ward postoperatively. However, some may develop complications requiring intensive care later. We aimed to evaluate the characteristics of patients undergoing intermediate-risk surgery who required late postoperative admission to the intensive care unit (ICU) and determine the predictors for this.MethodsThe study included patients undergoing intermediate-risk surgery with preoperative indication for ICU but who were taken to the ward postoperatively, because they appeared to be responding well. However, they required late ICU admission. ICU care and preoperative SAPS 3 score were evaluated. Palliative surgeries and patients readmitted to ICU were excluded.ResultsThe study included 100 patients, 27 % of whom had late postoperative admission to the ICU. The preoperative SAPS 3 score was higher (45.4 ± 7.8 vs. 35.9 ± 7.4, P < 0.001) in patients who required delayed admission to the ICU postoperatively. Furthermore, they had undergone longer surgery (4.2 ± 1.9 vs. 2.7 ± 1.5 h, P < 0.001), and a greater proportion were gastrointestinal surgeries (14.8 vs. 5.5 %, P = 0.03) and intraoperative transfusion (18.5 vs. 5.5 % P = 0.04). In multivariate analysis, preoperative SAPS 3 and surgery duration independently predicted postoperative ICU admission, respectively (OR 1.25; 95 % CI 1.1–1.4 and OR 3.33; 95 % CI 1.7–6.3).ConclusionThe identification of high-risk surgical patients is essential for proper treatment; time of surgery and preoperative SAPS 3 seem to provide a useful indication of risk and may help better to characterize patients undergoing intermediate-risk surgery that demand ICU care.

Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock.

IntroductionSeptic shock is one of the most frequent causes of admission to the intensive care unit (ICU) and is associated with a poor prognosis. Early and late death in septic shock should be distinguished because they may involve different underlying mechanisms. In various conditions, the neutrophil-to-lymphocyte count ratio (NLCR) has been described as an easily measurable parameter to express injury severity. In the present study, we investigated whether the timing of death was related to a particular NLCR.MethodsWe conducted a prospective, single-center, observational study that included consecutive septic shock patients. Severity scores, early (before day 5) or late (on or after day 5 of septic shock onset) ICU mortality, and daily leukocyte counts were collected during the ICU stay. We assessed the association between leukocyte counts at admission and their evolution during the first 5 days with early or late death. The association between patient characteristics (including cell counts) and prognosis was estimated using Cox proportional cause-specific hazards models.ResultsThe study included 130 patients who were diagnosed with abdominal (n = 99) or extra-abdominal (n = 31) septic shock. The median (interquartile range) NLCR was 12.5 (6.5–21.2) in survivors and 6.2 (3.7–12.6) in nonsurvivors (p = 0.001). The NLCR at admission was significantly lower in patients who died before day 5 than in survivors (5 [3.5–11.6] versus 12.5 [6.5–21.2], respectively; p = 0.01). From day 1 to day 5, an increased NLCR related to an increase in neutrophil count and a decrease in lymphocyte count was associated with late death (+34.8 % [−8.2 to 305.4] versus −20 % [−57.4 to 45.9]; p = 0.003). Those results were present in patients with abdominal origin sepsis as well as in those with extra-abdominal sepsis, who were analyzed separately.ConclusionsIn the present study, a reversed NLCR evolution was observed according to the timing of death. Septic shock patients at risk of early death had a low NLCR at admission, although late death was associated with an increased NLCR during the first 5 days.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-015-1144-x) contains supplementary material, which is available to authorized users.

Update on management options in the treatment of nosocomial and ventilator assisted pneumonia: review of actual guidelines and economic aspects of therapy

ObjectiveNosocomial or more exactly, hospital-acquired (HAP) and ventilator-associated pneumonia (VAP) are frequent conditions when treating intensive care unit (ICU) patients that are only exceeded by central line-associated bloodstream infections. In Germany, approximately 18,900 patients per year suffer from a VAP and another 4,200 from HAP. We therefore reviewed the current guidelines about HAP and VAP, from different sources, regarding the strategies to address individual patient risks and medication strategies for initial intravenous antibiotic treatment (IIAT).Material and methodsWe conducted an analysis of the recent guidelines for the treatment of HAP. The current guidelines of the American Thoracic Society, the treatment recommendations of the Paul-Ehrlich-Gesellschaft (PEG), the guidelines from the British Society for Antimicrobial Chemotherapy, the VAP guideline of the Canadian Critical Care trials group, as well as the new German S3-guideline for HAP were examined.ResultsAll guidelines are based on grading systems that assess the evidence underlying the recommendations. However, each guideline uses different grading systems. One common aspect of these guidelines is the risk assessment of the patients for decision making regarding IIAT. Most guidelines have different recommendations depending on the risk of the presence of multidrug resistant (MDR) bacteria. In guidelines using risk assessment, for low-risk patients (early onset, no MDR risk) aminopenicillins with beta-lactamase inhibitors (BLI), second or third generation cephalosporins, quinolones, or ertapenem are recommended. For patients with higher risk, imipenem, meropenem, fourth generation cephalosporins, ceftazidime or piperacillin/tazobactam are recommended. The PEG recommendations include a combination therapy in cases of very high risk (late onset, MDR risk, ICU, and organ failure) of either piperacillin/tazobactam, dori-, imi- or meropenem or cefepime or ceftazidime with ciprofloxacin, levofloxacin, fosfomycin or an aminoglycoside. For the treatment of HAP caused by methicillin-resistant Staphylococcus aureus (MRSA), either linezolid or vancomycin is recommended. With regard to the ZEPHyR-trial, linezolid has shown higher cure rates but, no difference in overall survival. Economic analyses show the relevance of guideline-adherent IIAT (GA-IIAT). Besides significantly better clinical outcomes, patients with GA-IIAT cause significantly lower costs (€28,033 versus (vs) €36,139) (P=0.006) and have a shorter length of stay in hospital (23.9 vs 28.3 days) (P=0.022).ConclusionWe conclude that most current treatment guidelines take into account the individual patient risk and that the correct choice of IIAT affects clinical as well as economical outcomes.

Determinants and outcomes associated with decisions to deny or to delay intensive care unit admission in Morocco

To report determinants and outcomes associated with decisions to deny or to delay intensive care unit (ICU) admission in critically ill patients. An observational prospective study over a 6-month period. All adult patients triaged for admission to a medical ICU were included prospectively. Age, gender, reasons for requesting ICU admission, severity of underlying disease, severity of acute illness, mortality and ICU characteristics were recorded. Multinomial logistic regression analysis was used for evaluating predicting factors of refused ICU admission. ICU admission was requested for 398 patients: 110 were immediately admitted (27.8%), 142 were never admitted (35.6%), and 146 were admitted at a later time (36.6%). The reasons for refusal were: too sick to benefit (31, 10.8%), too well to benefit (55, 19.1%), unit full (117, 40.6%), and more data about the patient were needed to make a decision (85, 29.5%). Multivariate analysis revealed that late ICU admission was associated with the lack of available ICU beds (OR 1.91; 95% CI 1.46-2.50; p=0.003), cardiac disease (OR 7.77; 95% CI 2.41-25.04; p<0.001), neurological disease (OR 3.78; 95% CI 1.40-10.26; p=0.009), shock and sepsis (OR 2.55; 95% CI 1.06-6.13; p=0.03), and metabolic disease (OR 2.84; 95% CI 1.11-7.30; p=0.02). Factors for ICU refusal for never admitted patients were: severity of acute illness (OR 4.83; 95% CI 1.11-21.01; p=0.03), cardiac disease (OR 14.26; 95% CI 3.95-51.44; p<0.001), neurological disease (OR 4.05; 95% CI 1.33-12.28; p=0.01) and lack of available ICU beds (OR 6.26; 95% CI 4.14-9.46; p<0.001). Hospital mortality was 33.3% (37/110) for immediately admitted patients, 43.8% (64/146) for patients admitted later and 49.3% (70/142) for never admitted patients. Refusal of ICU admission was correlated with the severity of acute illness, lack of ICU beds and reasons for admission request. Further efforts are needed to define which patients are most likely to benefit from ICU admission and to improve the accuracy of data on ICU refusal rates.

Outcomes of Early, Late, and No Admission to the Intensive Care Unit for Patients Hospitalized with Community‐acquired Pneumonia

The objective was to compare outcomes associated with early, late, and no admission to the intensive care unit (ICU) for patients hospitalized with community-acquired pneumonia (CAP). This was a post hoc analysis of the original data from the Emergency Department Community-Acquired Pneumonia (EDCAP) and Pneumocom-1 prospective multicenter cohort studies of adult patients hospitalized with CAP. Propensity score-adjusted analysis was used to compare 28-day mortality and hospital length of stay (LOS) for 199, 144, and 2,215 patients with early (i.e., ICU admission on the day of emergency department [ED] presentation), late, and no ICU admission. Unadjusted 28-day mortality rates were 13.1, 19.4, and 5.7% for early, late, and no ICU admissions, respectively (p < 0.001). After adjusting for quintile of propensity score, the odds of 28-day mortality were higher for late ICU admissions relative to early ICU admissions (odds ratio [OR] = 2.63; 95% confidence interval [CI] = 1.42 to 4.90), and no ICU admissions (OR = 3.40; 95% CI = 2.11 to 5.48), but did not differ between early and no ICU admissions (OR = 1.29; 95% CI = 0.79 to 2.09). The median hospital LOS was 10 days for early (interquartile range [IQR] = 7 to 18), 15 days for late (IQR 9 to 23), and 6 days (IQR 4 to 9) for no ICU admissions (p < 0.001). This study suggests that late but not early admission to the ICU is associated with higher 28-day mortality for patients hospitalized with CAP. Patients admitted to the ICU have longer hospital LOS in comparison to those managed on the wards, particularly if they are admitted late to the ICU.

Early Admission to the Intensive Care Unit In High Risk Acute Myeloid Leukemia Patients

AbstractAbstract 4364 INTRODUCTION:Acute Myeloblastic Leukemia (AML) is considered as an oncology emergency as a proportion of patients experience life threatening complications within the first hours or days after diagnosis. Early death had been demonstrated to be statistically related to high white blood cell (WBC) and monoblastic leukemia, with leukostasis and lysis syndrome as the most deadful events. OBJECTIVES:To evaluate the relationship between timing of admission to the Intensive Care Unit (ICU) and outcomes in high risk AML patients at the earliest phase of the malignancy (before any chemotherapy) METHODS:Retrospective study in a tertiary care center teaching hospital between 1998 and 2008. Adult patients with newly diagnosed AML were included. Patients admitted for an immediate life sustaining therapy (ventilation, vasopressors or renal replacement therapy) were excluded. 42 patients admitted directly to the ICU (Early admission) were matched for age, WBC and FAB subtype with 42 patients primarily admitted in hematology ward. Medical charts were reviewed and datasets extracted. RESULTS:Overall 84 patients were included in the study (42 patients early admitted to the ICU and 42 patients admitted first to the wards). Median follow up was 10,3 months. Median age was 46,5 years (36-57). FAB M4 or M5 was retrieved in 58% of the patients. According to MRC, karyotype was favorable for 30% and poor for 19%. Median WBC was 103×109.L-1. No statistical difference was seen for demographic and hematological parameters between early admitted patients and matched controls. Among the 42 patients admitted first to the wards (controls), 20 were subsequently admitted to the ICU (Lately admitted) and 22 remained in ward during the entire treatment course (Never admitted). The median time between diagnostic and ICU admission of this last group was 4 (1-9) days. Strikingly, patients lately admitted had more frequently dyspnea, oxygen requirement, high respiratory rate, low diastolic arterial pressure and lower first 24h urine output (p<0,05 for each). Lately admitted patients were less likely to receive the complete dose of induction chemotherapy than early admitted patients (68% vs. 88%,p<0,05) Furthermore, Late admission resulted in increased use of invasive mechanical ventilation (60 vs. 33%) and vaso-active drugs (60 vs. 16%,p<0,05) These differences resulted in longer stay in ICU and decreased survival. CONCLUSIONS:Patients at the earliest phase of High risk AML who are lately admitted to the ICU experience worse outcomes, with increased use of life-sustaining therapies and higher mortality, compared to patients early admitted to the ICU. Physiologic parameters at the time of AML diagnosis such as respiratory rate, diastolic blood pressure, SpO2, or oxygen need are likely to help clinicians distinguish those patients at risk of late ICU admission and subsequent adverse outcomes. Studies are needed to assess the right place for newly diagnosed AML with physiological abnormalities but no organ dysfunction. Disclosures:No relevant conflicts of interest to declare.

The effect of comorbidities on risk of intensive care readmission during the same hospitalization: A linked data cohort study ,

Purpose The aim of this study is to assess the effect of comorbidities on risk of readmission to an intensive care unit (ICU) and the excess hospital mortality associated with ICU readmissions. Materials and Methods A cohort study used clinical data from a 22-bed multidisciplinary ICU in a university hospital and comorbidity data from the Western Australian hospital morbidity database. Results From 16 926 consecutive ICU admissions between 1987 and 2002, and 654 (3.9%) of these patients were readmitted to ICU readmissions within the same hospitalization. Patients with readmission were older, more likely to be originally admitted from the operating theatre or hospital ward, had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-predicted mortality, and had more comorbidities when compared with patients without readmission. The number of Charlson comorbidities was significantly associated with late readmission (>72 hours) but not early readmission (≤72 hours) in the multivariate analysis. Both early and late ICU readmissions were associated with an increased risk of hospital mortality (odds ratio, 1.68; 95% confidence interval, 1.18-2.39; P = .004; odds ratio, 1.45; 95% confidence interval, 1.05-1.99; P = .022, respectively) after adjusting for age, admission source, type of admission, the APACHE-predicted mortality, and the number of Charlson comorbidities and APACHE chronic health conditions. Conclusions Comorbidity was a risk factor for late ICU readmission. Comorbidities could not account for the excess mortality associated with ICU readmissions.