Intensive Care Unit Readmission Research Articles

Perioperative Management of Gastric Cancer Patients Treated With (Sub)Total Gastrectomy, Cytoreductive Surgery, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): Lessons Learned.

The PERISCOPE I study was designed to assess the safety and feasibility of (sub)total gastrectomy, cytoreductive surgery (CRS), and hyperthermic intraperitoneal chemotherapy (HIPEC) with oxaliplatin and docetaxel for gastric cancer patients who have limited peritoneal dissemination. The current analysis investigated changes in perioperative management together with their impact on postoperative outcomes. Patients with resectable gastric cancer and limited peritoneal dissemination were administered (sub)total gastrectomy, CRS, and HIPEC with oxaliplatin (460mg/m2) and docetaxel (escalating scheme: 0, 50, 75mg/m2). Of the 25 patients who completed the study protocol, 14 were treated in the dose-escalation cohort and 11 were treated in the expansion cohort (to optimize perioperative management). A significant proportion of the patients in the dose-escalation cohort (n = 7, 50%) had ileus-related complications. In this cohort, enteral nutrition was started immediately after surgery at 20ml/h, which was increased on day 1 to meet nutritional needs. In the expansion cohort, enteral nutrition was administered at 10ml/h until day 3, then restricted to 20ml/h until day 6, supplemented with total parenteral nutrition to meet nutritional needs. Ileus-related complications occurred for two patients (18%) of the expansion cohort. The intensive care unit (ICU) readmission rate decreased from 50 (n = 7) to 9% (n = 1; p = 0.04). The implementation of a strict nutritional protocol during the PERISCOPE I study was associated with a decrease in postoperative complications. Based on these results, a perioperative care path was described for the gastric cancer HIPEC patients in the PERISCOPE II study.

Decreased Complications After Total Laryngectomy Using a Clinical Care Pathway.

Background: Complications following total laryngectomy can lead to increased hospital length of stay (LOS) and increased health care costs. Our objective was to determine the efficacy of a clinical care pathway for improving outcomes for patients following total laryngectomy.Methods: This quality improvement study included all adult patients undergoing total laryngectomy—either primary or salvage—at a tertiary referral center between January 2013 and December 2018. The primary outcome was hospital LOS measured in postoperative days. The total and specific postoperative complication frequencies were evaluated, as well as 30-day readmission rates and intensive care unit (ICU) LOS.Results: Sixty-three patients were included in the study: 29 (46.0%) patients before the pathway implementation and 34 (54.0%) patients after pathway implementation. Demographic characteristics between the groups were similar. The prepathway cohort had a higher rate of total complications compared to the postpathway group (relative risk=0.5; 95% CI 0.3-1.0), although the differences in individual complications were similar. The median LOS of 10 days was the same for the 2 cohorts. The median ICU LOS was 1 day greater in the postpathway cohort, but no difference was seen in rates of ICU readmission in the 2 groups. The 30-day readmission rate also was not significant between the 2 groups.Conclusion: Implementation of a postoperative order set pathway for patients undergoing laryngectomy is associated with decreased overall complication rates. Use of a clinical care pathway may improve outcomes in patients undergoing total laryngectomy.

HFS‐LightGBM: A machine learning model based on hybrid feature selection for classifying ICU patient readmissions

AbstractCompared to patients readmitted to general wards, readmitted patients in the intensive care unit (ICU) are exposed to higher mortality rates and prolonged hospital stays. Moreover, the readmission of ICU patients brings pressing challenges for ICU management. Most models are devoted to identifying the risk factors and developing classification models that can predict whether ICU patients will be readmitted. Though these models are prominent, they do not provide estimates for the frequency of readmissions. This paper establishes a prediction model, hybrid feature selection‐LightGBM (HFS‐LightGBM), to evaluate the probability and frequency of ICU patient readmissions empirically. In terms of feature selection, a hybrid feature selection (HFS) algorithm for LightGBM combines the filter and wrapper methods. Pearson's correlation coefficient is employed in the filter procedure. Then we adopt the targeted LightGBM classifier along with the recursive feature elimination and cross‐validated (RFECV) to produce the optimal feature subset. Additionally, the hyperparameters of the HFS‐LightGBM are optimized. The HFS‐LightGBM is employed on the real‐world ICU dataset containing 1722 patients' electronic health records. This model outperforms the current prevailing readmission models. The identified frequency can assist doctors in making specific interventions for patients to reduce the ICU readmission rate.

Anemia at Intensive Care Unit Admission and Hospital Mortality Among Patients at a Referral Hospital in Malawi.

Anemia is associated with intensive care unit (ICU) outcomes, but data describing this association in sub-Saharan Africa are scarce. Patients in this region are at risk for anemia due to endemic conditions like malaria and because transfusion services are limited. This was a prospective cohort study of ICU patients at Kamuzu Central Hospital (KCH) in Malawi. Exclusion criteria included age <5years, pregnancy, ICU readmission, or admission for head injury. Cumulative incidence functions and Fine-Gray competing risk models were used to evaluate hemoglobin (Hgb) at ICU admission and hospital mortality. Of 499 patients admitted to ICU, 359 were included. The median age was 28years (interquartile ranges (IQRs) 20-40) and 37.5% were men. Median Hgb at ICU admission was 9.9g/dL (IQR 7.5-11.4g/dL; range 1.8-18.1g/dL). There were 61 (19%) patients with Hgb < 7.0g/dL, 59 (19%) with Hgb 7.0-8.9g/dL, and 195 (62%) with Hgb ≥ 9.0g/dL. Hospital mortality was 51%, 59%, and 54%, respectively. In adjusted analyses, anemia was associated with hospital mortality but was not statistically significant. This study provides preliminary evidence that anemia at ICU admission may be an independent predictor of hospital mortality in Malawi. Larger studies are needed to confirm this association.

EARLY PALLIATIVE CARE INTERVENTION REDUCES ICU READMISSIONS IN HIGH-RISK PATIENTS

SESSION TITLE: Palliative Care and End-of-Life Issues Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To determine whether a process of early palliative care intervention prompted by a patient-specific estimate of poor prognosis leads to improved patient outcomes in the medical intensive care unit (ICU). METHODS: We conducted a prospective two-phase study including usual care (UC) (N=53) and usual care plus targeted pro-active palliative care intervention (PC) (N=51) (either by consulting supportive care services or shared decision making discussion by the intensivists), each lasting four months on consecutive patients admitted to the ICU who survived ≥48 hours. For both phases, patients predicted to be at high risk (≥40% 6-month mortality) were identified using our validated integrated prognostic model1 [Surprise question “No” response-Would you be surprised if this patient died in the next six months?-, APACHE IV score, and Charlson Comorbidity Index (CCI) score]. RESULTS: Compared to UC, the pro-active PC intervention phase showed significant reduction in ICU readmissions (35.8% vs 16%, p=0.022) and increased identification of the patient’s legal decision maker (98% vs 83%, p=0.009). There were no differences in means between groups (UC vs PC) for age (67.9 vs 68.1 years, p=.938), CCI score (6.6 vs 6.1, p=.489), and mortality prediction model score (51.6 vs 54.3, p=.141). Intervention-arm patients had higher BMI (34.0 vs 28.3 kg/m2, p=0.005) and APACHE IV scores (65.3 vs 55.8, p=0.019), suggestive of a sicker critically ill patient population. There was no significant difference between groups (UC vs PC) in mean length of stay in ICU (5.5 vs 6.2 days, p=.454) or in hospital (13.0 vs 14.7 days, p=.466). There was no difference between groups (UC vs PC) in death at hospital discharge (60% vs 48%, p=.208). CONCLUSIONS: This pilot study demonstrates feasibility and improved patient-specific outcomes of end-of-life care. CLINICAL IMPLICATIONS: Systematic identification of high-risk ICU patients using the integrated mortality prediction model and pro-active primary palliative care intervention improves shared-decision making with the appropriate legal decision-maker and ICU readmission rates. This study promotes the role of family engagement and empowerment which is in compliance with Society of Critical Care Medicine (SCCM) ICU liberation bundle (A-F). These findings provide support for a large, multisite trial to see if they can be confirmed and if this approach represents a way to improve ICU patient care. DISCLOSURES: No relevant relationships by Lori Constantine, source=Web Response No relevant relationships by Stacey Culp, source=Web Response No relevant relationships by Sarah Hadique, source=Web Response No relevant relationships by Erica Mokaya, source=Web Response No relevant relationships by Alvin Moss, source=Web Response No relevant relationships by Hassan Mujahid, source=Web Response No relevant relationships by Rahul Sangani, source=Web Response

IMPACT OF SERUM EOSINOPHIL COUNTS ON HOSPITAL LENGTH OF STAY, READMISSION RATES, AND IN-HOSPITAL OUTCOMES IN PATIENTS WITH ACUTE EXACERBATION OF COPD

SESSION TITLE: Obstructive Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: To assess whether serum eosinophilia increases hospital lengths of stay, readmission rates, intubation rates, and intensive care unit (ICU) admission. METHODS: This was an observational retrospective study design. We analyzed data of patients admitted for acute exacerbation of COPD (AE-COPD) between January 2011 and December 2018. Patients were stratified into high eosinophil group if the blood eosinophil count at admission was ≥2% of the total white blood cells or ≥150cells/µL. Inclusion criteria included spirometry showing FEV1/FVC ratios less than 70%, age over 40 years, and smoking history. The study was approved by the University of Missouri Institutional Review Board. RESULTS: A total of 87 patients were included in the analysis. The average age was 62 years (SD 8.95) and 57% of patients were female. The average length of stay was 4 days (SD 3.94 days). There were 16 (18%) patients with eosinophils greater than 2% and 25 (29%) patients with eosinophils greater than 150 cells/µL. The average FEV1 was 1.42L (SD 0.55L). There were 15 patients (17%) who were readmitted within 1 year. There was no difference in readmission rates between the low eosinophil group compared to the high eosinophil group (OR, 0.582; 95% CI, 0.118–2.86; P =0.725). There was also no statistically significant difference in lengths of stay between the two groups (4.23 days vs 2.56, p =0.128). There was no difference in the intubation rates (OR 0.88; 95% CI 0.096-8.09; p=.91) or ICU admission rates (OR 0.85; 95% CI 0.245-2.95 p=.798). Serum eosinophil counts decreased from admission to discharge. Inhaled corticosteroid (ICS) use prior to admission did not influence eosinophil levels. CONCLUSIONS: Peripheral eosinophilia (>2% of total white cell count) at time of admission in patients presenting with AE-COPD does not appear to have a significant impact on ICU admission, intubation, hospital LOS, or readmission. Our data is limited by a small sample size. CLINICAL IMPLICATIONS: More clinical research is required to determine the accuracy and usefulness of eosinophils as a biomarker for outcomes in patients with acute exacerbations of COPD. There is continued need to search for other biomarkers to help us better define the risk of COPD exacerbation. This is especially important in determining patients who may be at higher risk for intubation and ICU admission. DISCLOSURES: No relevant relationships by Trent Bailey, source=Web Response No relevant relationships by karthik Gangu, source=Web Response No relevant relationships by Armin Krvavac, source=Web Response No relevant relationships by Tinashe Maduke, source=Web Response No relevant relationships by Pooja Nair, source=Web Response No relevant relationships by Sara Tepe, source=Web Response

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

Journal-related Activities and Other Special Activities at the 2020 American Society of Anesthesiologists Meeting.

Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia.

Background Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR). Materials and Method s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol ( n = 188) and nonmannitol ( n = 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at p < 0.05. Results Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%; p = 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours; p = 0.021), higher reintubation rate (11.3 vs. 2.7%; p = 0.009), ICU readmission (12.7 vs. 4.8%; p = 0.026), prolonged ICU (112 vs. 70 hours; p = 0.040), and hospital stay (17.8 vs. 12.6 days; p < 0.001), leading to higher expenses (19,349 € vs. 16,606 €, p < 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7; p < 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89; p = 0.02). Conclusion Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.

Feasibility of diaphragmatic interventions in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis: A 20-year experience

IntroductionComplete cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is an effective treatment for improving prognosis of selected patients with peritoneal carcinomatosis. The addiction of diaphragmatic procedures may increase the incidence of postoperative respiratory complications. Our goal was to evaluate the early postoperative results following diaphragmatic surgery. MethodsProspectively collected data of patients undergoing diaphragmatic surgery between January 2000 and January 2020 were retrospectively analyzed. Chest drains were routinely placed in all cases. Demographics, clinical and perioperative features were evaluated. ResultsThe study included 222 patients. Peritoneal stripping and full-thickness resections were performed in 165 and 57 cases, respectively. Women and ovarian tumours represented the vast majority of cases. Overall postoperative mortality and morbidity rates were 1.3% (3 patients) and 43.2% (96 patients), respectively. Specific diaphragmatic surgery-related complications was 9.4% (21 patients). No pleural effusion and pneumothotrax occurred. The incidence of pneumonia was 1.8% (4 patients), each due to systemic bacterial origin, 2 (0.9%) of which required Intensive Care Unit-readmission. Postoperative bleeding was observed in 15 (6.7%) cases, 12 (5.4%) of which required reoperation. A comparison with 105 patients who operated during the same period without diaphragmatic surgery was performed and by multivariate analysis, Peritoneal Cancer Index, histology and overall morbidity resulted significantly associated with diaphragmatic surgery. ConclusionDiaphragmatic surgery during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is often required in order to obtain complete resection. It may be associated with higher postoperative morbidity, especially bleeding, but routine placement of chest drains may reduce the incidence of adverse respiratory events.

A Tool to Predict Readmission to the Intensive Care Unit in Surgical Critical Care Patients-The RISC Score.

Readmission to the Intensive Care Unit (ICU) is associated with a high risk of in-hospital mortality and higher health care costs. Previously published tools to predict ICU readmission in surgical ICU patients have important limitations that restrict their clinical implementation. We sought to develop a clinically intuitive score that can be implemented to predict readmission to the ICU after surgery or trauma. We designed the score to emphasize modifiable predictors. In this retrospective cohort study, we included surgical patients requiring critical care between June 2015 and January 2019 at Beth Israel Deaconess Medical Center, Harvard Medical School, MA, USA. We used logistic regression to fit a prognostic model for ICU readmission from a priori defined, widely available candidate predictors. The score performance was compared with existing prediction instruments. Of 7,126 patients, 168 (2.4%) were readmitted to the ICU during the same hospitalization. The final score included 8 variables addressing demographical factors, surgical factors, physiological parameters, ICU treatment and the acuity of illness. The maximum score achievable was 13 points. Potentially modifiable predictors included the inability to ambulate at ICU discharge, substantial positive fluid balance (>5 liters), severe anemia (hemoglobin <7 mg/dl), hyperglycemia (>180 mg/dl), and long ICU length of stay (>5 days). The score yielded an area under the receiver operating characteristic curve of 0.78 (95% CI 0.74-0.82) and significantly outperformed previously published scores. The performance of the underlying model was confirmed by leave-one-out cross-validation. The RISC-score is a clinically intuitive prediction instrument that helps identify surgical ICU patients at high risk for ICU readmission. The simplicity of the score facilitates its clinical implementation across surgical divisions.

Antibiotic Resistance Is Associated With Morbidity and Mortality After Decortication for Empyema

Previous studies of decortication for empyema demonstrated that patient characteristics are associated with mortality, but the relationship of infectious pathogen to outcome has not been described. Our objective was to analyze the association of microbiology and antibiotic resistance with postoperative mortality after decortication for empyema. We hypothesized that bacterial pathogens, antibiotic resistance, and patient characteristics would all contribute to perioperative morbidity and mortality. Patients undergoing pulmonary decortication for empyema from January 1, 2010 to October 1, 2017 were reviewed retrospectively. Cases were matched with microbiology cultures. Outcomes of interest were a composite of death, tracheostomy, initial ventilator support greater than 48 hours, or unexpected intensive care unit readmission. Antibiotic resistance was categorized as present or absent, and the number of antibiotics with resistance was counted for each patient. We describe the relationship of patient characteristics, antibiotic resistance, and microbiology to mortality. During the study period, 185 patients underwent decortication, 118 of whom had a diagnosis of primary empyema (63.8%). Positive culture results were present in 79 of 185 patients (43%). The most common isolate was Streptococcus, which was present in 29 of 79 (37%), followed by Staphylococcus in 19 of 79 (24%). Of 79 patients, 11 had fungal infections (13.9%). In addition, 16 of 79 patients had polymicrobial empyema (20%). Of 185 patients, 30 experienced the composite adverse outcome (16.2%). In multivariable regression, the composite adverse outcome was associated with emphysema, Candida in pleural culture, and antibiotic resistance count. Perioperative mortality and morbidity after decortication for empyema is considerable. In this cohort, infections with increasing antibiotic resistance are associated with morbidity and mortality among patients with empyema.

The Impact of Mechanical Ventilation Duration on the Readmission to Intensive Care Unit: A Population-Based Observational Study.

BackgroundIf the duration of mechanical ventilation (MV) is related with the intensive care unit (ICU) readmission must be clarified. The purpose of this study was to elucidate if prolonged MV duration increases ICU readmission rate.MethodsThe present observational cohort study analyzed national healthcare claims data from 2006 to 2015. Critically ill patients who received MV in the ICU were classified into five groups according to the MV duration: MV for <7 days, 7–13 days, 14–20 days, 21–27 days, and ≥28 days. The rate and risk of the ICU readmission were estimated according to the MV duration using the unadjusted and adjusted analyses.ResultsWe found that 12,929 patients had at least one episode of MV in the ICU. There was a significant linear relationship between the MV duration and the ICU readmission (R2=0.85, p=0.025). The total readmission rate was significantly higher as the MV duration is prolonged (MV for <7 days, 13.9%; for 7–13 days, 16.7%; for 14–20 days, 19.4%; for 21–27 days, 20.4%; for ≥28 days, 35.7%; p<0.001). The analyses adjusted by covariables and weighted with the multinomial propensity scores showed similar results. In the adjusted regression analysis with a Cox proportional hazards model, the MV duration was significantly related to the ICU readmission (hazard ratio, 1.058 [95% confidence interval, 1.047–1.069], p<0.001).ConclusionThe rate of readmission to the ICU was significantly higher in patients who received longer durations of the MV in the ICU. In the clinical setting, closer observation of patients discharged from the ICU after prolonged periods of MV is required.

Predictive factors for sepsis by carbapenem resistant Gram-negative bacilli in adult critical patients in Rio de Janeiro: a case-case-control design in a prospective cohort study

BackgroundStudies have investigated risk factors for infections by specific species of carbapenem-resistant Gram-negative bacilli (CR-GNB), but few considered the group of GNB species and most of them were performed in the setting of bacteremia or hospital infection. This study was implemented to identify risk factors for sepsis by CR- and carbapenem-susceptible (CS) GNB in intensive care unit (ICU) patients to improve management strategies for CR-GNB sepsis.MethodsWe developed a case-case-control study from a prospective cohort of patients with systemic inflammatory response syndrome (SIRS), sepsis-2 or sepsis-3 criteria in which blood and other sample cultures were collected and antimicrobial therapy was instituted, in an adult clinical-surgical ICU, at tertiary public hospital in Rio de Janeiro, from August 2015 through March 2017.ResultsAmong the total of 629 ICU admissions followed by 7797 patient-days, after applying inclusion and exclusion criteria we identified 184 patients who developed recurrent or single hospital-acquired sepsis. More than 90% of all evaluable cases of sepsis and 87% of control group fulfilled the modified sepsis-3 definition. Non-fermenting bacilli and ventilator-associated pneumonia predominated as etiology and source of CR-GNB sepsis. While Enterobacteriaceae and intra-abdominal surgical site plus urinary-tract infections prevailed in CS-GNB than CR-GNB sepsis. Carbapenemase production was estimated in 76% of CR-GNB isolates. Multivariate logistic regression analysis revealed previous infection (mostly hospital-acquired bacterial infection or sepsis) (OR = 4.28; 95% CI 1.77–10.35), mechanical ventilation (OR = 4.21; 95% CI 1.17–15.18), carbapenem use (OR = 3.42; 95% CI 1.37–8.52) and length of hospital stay (OR = 1.03; 95% CI 1.01–1.05) as independent risk factors for sepsis by CR-GNB. While ICU readmission (OR = 6.92; 95% CI 1.72–27.78) and nosocomial diarrhea (OR = 5.32; 95% CI 1.07–26.45) were factors associated with CS-GNB sepsis.ConclusionsThe investigation of recurrent and not only bacteremic episodes of sepsis was the differential of this study. The results are in agreement with the basic information in the literature. This may help improve management strategies and future studies on sepsis by CR-GNB.

Comorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure.

Chronic obstructive pulmonary disease (COPD) is defined by chronic airflow obstruction, but is presently considered as a complex, heterogeneous, and multicomponent disease in which comorbidities and extrapulmonary manifestations make important contributions to disease expression. COPD-related hospital readmission. In particular frequent intensive care unit (ICU) readmissions for exacerbations represent a major challenge and place a high burden on patient outcomes and health-related quality of life, as well as on the healthcare system.In this narrative review, we first address major and often undiagnosed comorbidities associated with COPD that could have an impact on hospital readmission after an index ICU admission for acute hypercapnic respiratory failure. Some guidance for treatment is discussed. Second, we present predictors of hospital and ICU readmission and discuss various strategies to reduce such events.There is a strong rationale to detect and treat major comorbidities early after index ICU admission for acute hypercapnic respiratory failure. It still remains unclear, however, if a comprehensive and holistic approach to comorbidities in frail patients surviving hypercapnic respiratory failure can efficiently reduce the readmission rate.

Impact of previous percutaneous coronary intervention on cardiovascular outcomes and mortality after lung cancer surgery: A nationwide study in Korea.

BackgroundThe number of patients with operable lung cancer with a history of percutaneous coronary intervention (PCI) has increased. However, cardiovascular outcomes and mortality, according to the time from PCI to surgery, and the follow‐up time after surgery are largely unknown. Here, we aimed to compare the cardiovascular outcomes and mortality of these patients with a history of PCI to those of patients without a history of PCI.MethodsUsing the Korean National Health Insurance Service Database, we selected 30 750 patients who underwent surgery for lung cancer between 2006 and 2014. Study outcome variables were all‐cause mortality, revascularization, intensive care unit (ICU) readmission, and stroke incidence. Patients were followed‐up until 2016.ResultsOf the 30 750 patients, 513 (1.7%) underwent PCI before surgery. The PCI group did not show an increased risk of death, ICU readmission, or stroke within one year of surgery, despite an increased risk of revascularization. However, one year after surgery, they showed a higher risk of death and revascularization than the non‐PCI group. The risk of revascularization was highest when the interval between PCI and surgery was <1 year and remained high when the interval was >3 years.ConclusionsPatients who underwent PCI before surgery for lung cancer were at a higher risk of death than those in the non‐PCI group at one year after surgery. In addition, they showed higher short‐ and long‐term risks of revascularization than patients in the non‐PCI group. Careful long‐term management of cardiovascular risk is necessary for this population.

Accuracy of Clinicians’ Ability to Predict the Need for Intensive Care Unit Readmission

Rationale: Determining when an intensive care unit (ICU) patient is ready for discharge to the ward is a complex daily challenge for any ICU care team. Patients who experience unplanned readmissions to the ICU have increased mortality, length of stay, and cost compared with those not readmitted during their hospital stay. The accuracy of clinician prediction for ICU readmission is unknown.Objectives: To determine the accuracy of ICU physicians and nurses for predicting ICU readmissionsMethods: We conducted a prospective study in the medical ICU of an academic hospital from October 2015 to September 2017. After daily rounding for patients being transferred to the ward, ICU clinicians (nurses, residents, fellows, and attendings) were asked to report the likelihood of readmission within 48 hours (using a 1-10 scale, with 10 being "extremely likely"). The accuracy of the clinician prediction score (1-10) was assessed for all clinicians and by clinician type using sensitivity, specificity, and area under the curve (AUC) for the receiver operating characteristic curve for predicting the primary outcome, which was ICU readmission within 48 hours of ICU discharge.Results: A total of 2,833 surveys was collected for 938 ICU-to-ward transfers, of which 40 (4%) were readmitted to the ICU within 48 hours of transfer. The median clinician likelihood of readmission score was 3 (interquartile range, 2-4). When physician and nurse likelihood scores were combined, the median clinician likelihood score had an AUC of 0.70 (95% confidence interval [CI], 0.62-0.78) for predicting ICU readmission within 48 hours. Nurses were significantly more accurate than interns at predicting 48-hour ICU readmission (AUC, 0.73 [95% CI, 0.64-0.82] vs. AUC, 0.60 [95% CI, 0.49-0.71]; P = 0.03). All other pairwise comparisons were not significantly different for predicting ICU readmission within 48 hours (P > 0.05 for all comparisons).Conclusions: We found that all clinicians surveyed in our ICU, regardless of the level of experience or clinician type, had only fair accuracy for predicting ICU readmission. Further research is needed to determine if clinical decision support tools would provide prognostic value above and beyond clinical judgment for determining who is ready for ICU discharge.

An Innovative Individual-Level Socioeconomic Measure Predicts Critical Care Outcomes in Older Adults: A Population-Based Study.

Little is known about the impact of socioeconomic status (SES) as a key element of social determinants of health on intensive care unit (ICU) outcomes for adults. We assessed whether a validated individual SES index termed HOUSES (HOUsing-based SocioEconomic status index) derived from housing features was associated with short-term outcomes of critical illness including ICU mortality, ICU-free days, hospital-free days, and ICU readmission. We performed a population-based cohort study of adult patients living in Olmsted County, Minnesota, admitted to 7 intensive care units at Mayo Clinic from 2011 to 2014. We compared outcomes between the lowest SES group (HOUSES quartile 1 [Q1]) and the higher SES group (HOUSES Q2-4). We stratified the cohort based on age (<50 years old and ≥50 years old). Among 4134 eligible patients, 3378 (82%) patients had SES successfully measured by the HOUSES index. Baseline characteristics, severity of illness, and reason for ICU admission were similar among the different SES groups as measured by HOUSES except for larger number of intoxications and overdoses in younger patients from the lowest SES. In all adult patients, there were no overall differences in mortality, ICU-free days, hospital-free days, or ICU readmissions in patients with higher SES compared to lower SES. Among older patients (>50 years), those with higher SES (HOUSES Q2-4) compared to those with lower SES (HOUSES Q1) had lower mortality rates (hazard ratio = 0.72; 95% CI: 0.56-0.93; adjusted P = .01), increased ICU-free days (mean 1.08 days; 95% CI: 0.34-1.84; adjusted P = .004), and increased hospital-free days (mean 1.20 days; 95% CI: 0.45-1.96; adjusted P = .002). There were no differences in ICU readmission rates (OR = 0.74; 95% CI: 0.55-1.00; P = .051). Individual-level SES may be an important determinant or predictor of critical care outcomes in older adults. Housing-based socioeconomic status may be a useful tool for enhancing critical care research and practice.

Randomized trial of a perioperative geriatric intervention for older adults with cancer.

12012 Background: Older adults with gastrointestinal (GI) cancers undergoing surgery often experience poor outcomes, such as prolonged postoperative (post-op) length of stay (LOS), intensive care unit (ICU) use, and readmissions. Involvement of geriatricians in the care of older adults with cancer can improve outcomes. We conducted a randomized trial of a perioperative geriatric intervention in older adults with GI cancers undergoing surgery. Methods: We randomly assigned patients age ≥65 with GI cancers planning to undergo surgical resection to receive a perioperative geriatric intervention or usual care. Intervention patients met with a geriatrician preoperatively in the outpatient setting and post-op as an inpatient consultant. The geriatrician conducted a geriatric assessment and made recommendations to the surgical/oncology teams. The primary end point was post-op LOS. Secondary end points included post-op ICU use, readmission risk, and patient-reported symptom burden (Edmonton Symptom Assessment System [ESAS]) and depression symptoms (Geriatric Depression Scale). We conducted both intention-to-treat (ITT) and per protocol (PP) analyses. Results: From 9/13/16-4/30/19, we randomized 160 patients (72.4% enrollment rate; median age = 72 [65-92]). The ITT analyses included 137/160 patients who underwent surgery (usual care = 68/78, intervention = 69/82). The PP analyses included the 68 usual care patients and the 30/69 intervention patients who received both pre- and post-op intervention components. In ITT analyses, we found no significant differences between intervention and usual care in post-op LOS (7.2 v 8.2 days, P = .37), ICU use (23.3% v 32.4%, p = .23), and readmission rates within 90 days of surgery (21.7% v 25.0%, p = .65). Intervention patients reported lower depression symptoms (B = -1.39, P &lt; .01) at post-op day 5 and fewer moderate/severe ESAS symptoms at post-op day 60 (B = -1.09, P = .02). In PP analyses, intervention patients had significantly shorter post-op LOS (5.9 v 8.2 days, P = .02) and lower rates of post-op ICU use (13.3% v 32.4%, p &lt; .05), but readmission rates were not significantly different (16.7% v 25.0%, p = .36). Conclusions: Although this perioperative geriatric intervention did not have a significant impact on the primary end point in ITT analysis, we found encouraging results in several secondary outcomes and for the subgroup of patients who received the planned intervention. Future studies of this perioperative geriatric intervention should include efforts, such as telehealth visits, to ensure the intervention is delivered as planned. Clinical trial information: NCT02810652 .

The ICU Liberation Bundle and Strategies for Implementation in Pediatrics.

Purpose of ReviewWe briefly review post-intensive care syndrome (PICS) and the morbidities associated with critical illness that led to the intensive care unit (ICU) liberation movement. We review each element of the ICU liberation bundle, including pediatric support data, as well as tips and strategies for implementation in a pediatric ICU (PICU) setting.Recent FindingsNumerous studies have found children have cognitive, physical, and psychiatric deficits after a PICU stay. The effects of the full ICU liberation bundle in children have not been published, but in adults, bundle implementation (even partial) resulted in significant improvement in survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.SummaryAlthough initially described in adults, children also suffer from PICS. The ICU liberation bundle is feasible in children and may ameliorate the effects of a PICU stay. Further studies are needed to characterize the benefits of the ICU liberation bundle in children.

Impact of Intensive Care Unit Readmissions on Patient Outcomes and the Evaluation of the National Early Warning Score to Prevent Readmissions: Literature Review

BackgroundIntensive care unit (ICU) readmissions have been shown to increase a patient’s in-hospital mortality and length of stay (LOS). Despite this, no methods have been set in place to prevent readmissions from occurring.ObjectiveThe aim of this literature review was to evaluate the impact of ICU readmission on patient outcomes and to evaluate the effect of using a risk stratification tool, the National Early Warning Score (NEWS), on ICU readmissions.MethodsA database search was performed on PubMed, Cumulative Index of Nursing and Allied Health Literature, Google Scholar, and ProQuest. In the initial search, 2028 articles were retrieved; after inclusion and exclusion criteria were applied, 12 articles were ultimately used in this literature review.ResultsThis literature review found that patients readmitted to the ICU have an increased mortality rate and LOS at the hospital. The sample sizes in the reviewed studies ranged from 158 to 745,187 patients. Readmissions were most commonly associated with respiratory issues about 18% to 59% of the time. The NEWS has been shown to detect early clinical deterioration in a patient within 24 hours of transfer, with a 95% CI of 0.89 to 0.94 (P<.001), a sensitivity of 93.6% , and a specificity of 82.2%.ConclusionsICU readmissions are associated with worse patient outcomes, including hospital mortality and increased LOS. Without the use of an objective screening tool, the provider has been solely responsible for the decision of patient transfer. Assessment with the NEWS could be helpful in decreasing the frequency of inappropriate transfers and ultimately ICU readmission.