Shortage Of Intensive Care Unit Beds Research Articles

Factors contributing to delay intensive care unit admission of critically ill patients from the adult emergency Department in Tikur Anbessa Specialized Hospital

BackgroundThe transfer time for critically ill patients from the emergency department (ED) to the Intensive care unit (ICU) must be minimal; however, some factors prolong the transfer time, which may delay intensive care treatment and adversely affect the patient’s outcome.PurposeTo identify factors affecting intensive care unit admission of critically ill patients from the emergency department.Patients and methodsA cross-sectional study design was conducted from January 13 to April 12, 2020, at the emergency department of Tikur Anbesa Specialized Hospital. All critically ill patients who need intensive care unit admission during the study period were included in the study. A pretested structured questionnaire was adapted from similar studies. The data were collected by chart review and observation. Then checked data were entered into Epi-data version 4.1 and cleaned data was exported to SPSS Version 25 for analysis. Descriptive statistics, bivariate and multivariate logistic regression were used to analyze the data.ResultFrom the total of 102 critically ill patients who need ICU admission 84.3% of them had prolonged lengths of ED stay. The median length of ED stay was 13.5 h with an IQR of 7–25.5 h. The most common reasons for delayed ICU admission were shortage of ICU beds 56 (65.1%) and delays in radiological examination results 13(15.1%). On multivariate logistic regression p < 0.05 male gender (AOR = 0.175, 95% CI: (0.044, 0.693)) and shortage of ICU bed (AOR = 0.022, 95% CI: (0.002, 0.201)) were found to have a significant association with delayed intensive care unit admission.Conclusionthere was a delay in ICU admission of critically ill patients from the ED. Shortage of ICU bed and delay in radiological investigation results were the reasons for the prolonged ED stay.

Savable but Lost Lives when ICU Is Overloaded: a Model from 733 Patients in Epicenter Wuhan, China

Coronavirus Disease 2019 (COVID-19) causes a sudden turnover to bad at some checkpoints and thus needs the intervention of intensive care unit (ICU). This resulted in urgent and large needs of ICUs posed great risks to the medical system. Estimating the mortality of critical in-patients who were not admitted into the ICU will be valuable to optimize the management and assignment of ICU. Retrospective, 733 in-patients diagnosed with COVID-19 at a local hospital (Wuhan, China), as of March 18, 2020. Demographic, clinical and laboratory results were collected and analyzed using machine learning to build a predictive model. Considering the shortage of ICU beds at the beginning of disease emergence, we defined the mortality for those patients who were predicted to be in needing ICU care yet they did not as Missing-ICU (MI)-mortality. To estimate MI-mortality, a prognostic classification model was built to identify the in-patients who may need ICU care. Its predictive accuracy was 0.8288, with an AUC of 0.9119. On our cohort of 733 patients, 25 in-patients who have been predicted by our model that they should need ICU, yet they did not enter ICU due to lack of shorting ICU wards. Our analysis had shown that the MI-mortality is 41%, yet the mortality of ICU is 32%, implying that enough bed of ICU in treating patients in critical conditions.

Anesthesiology and Critical Care Response to COVID-19 in Resource-Limited Settings: Experiences from Nepal.

It is difficult to predict the future course and length of the ongoing COVID-19 pandemic, which has devastated health care systems in low- and middle-income countries. Anesthesiology and critical care services are hard hit because many hospitals have stopped performing elective surgeries, staff and scarce hospital resources have been diverted to manage COVID-19 patients, and several makeshift COVID-19 units had to be set up. Intensive care units are overwhelmed with critically ill patients. In these difficult times, low- and middle-income countries need to improvise, perform indigenous research, adapt international guidelines to suit local needs, and target attainable clinical goals.

The mortality of critically ill patients was not associated with inter-hospital transfer due to a shortage of ICU beds - a single-centre retrospective analysis

BackgroundPatients in the intensive care unit (ICU) are increasingly being transferred between ICUs due to a shortage of ICU beds, although this practice is potentially harmful. However, in tertiary units, the transfer of patients who are not in need of highly specialized care is often necessary. The aim of this study was to assess the association between a 90-day mortality and inter-hospital transfer due to a shortage of ICU beds in a tertiary centre.MethodsData were retrieved from the local ICU database from December 2011 to September 2019. The primary analysis was a risk-adjusted logistic regression model. Secondary analyses comprised case/control (transfer/non-transfer) matching.ResultsA total of 573 patients were transferred due to a shortage of ICU beds, and 8106 patients were not transferred. Crude 90-day mortality was higher in patients transferred due to a shortage of beds (189 patients (33%) vs 2188 patients (27%), p = 0.002). In the primary, risk-adjusted analysis, the risk of death at 90 days was similar between the groups (odds ratio 0.923, 95% confidence interval 0.75–1.14, p = 0.461). In the secondary analyses, a 90-day mortality was similar in transferred and non-transferred patients matched according to SAPS 3-score, age, days in the ICU and ICU diagnosis (p = 0.407); SOFA score on the day of discharge, ICU diagnosis and age (p = 0.634); or in a propensity score model (p = 0.229).ConclusionMortality at 90 days in critically ill patients treated in a tertiary centre was not affected by transfer to another intensive care units due to a shortage of beds. We found this conclusion to be valid under the assumption that patients are carefully selected and that the transports are safely performed.

Donación de órganos y trasplante en la era COVID-19: ¿Realmente se deben parar los programas?

Durante los primeros meses de la pandemia por SARS-CoV2 (Coronavirus 2 del Síndrome Respiratorio Agudo y Grave), el agente etiológico de la Enfermedad Infecciosa por Coronavirus de 2019 (COVID-19), la actividad de donación y trasplante de órganos en todo el mundo se ha visto claramente afectada. Las principales razones que en este momento motivan el cese parcial o total de los trasplantes son: 1) la carga asistencial que genera el manejo de un potencial donante en la Unidad de Cuidado Intensivo (UCI), 2) el alto riesgo de contagio entre donante y receptor, 3) el riesgo de inmunosuprimir a un paciente en medio de la pandemia y 4) la escases de camas de UCI. A pesar de que el mundo está enfrentando a una enfermedad emergente que merece especial atención, al mismo tiempo continúan prevaleciendo las complicaciones asociadas a las demás enfermedades incluyendo las complicaciones de patologías crónicas en estado terminal. La decisión de continuar con los programas de trasplante se debe basar en el comportamiento local del virus y en la capacidad asistencial de cada una de las instituciones. En Colombia, el comportamiento epidemiológico del SARS-CoV2 varía significativamente entre las diferentes regionales, permitiendo a las instituciones que hasta el momento, presentan poca carga de atención del COVID-19 retomar sus actividades de trasplante. De esta manera se propone un balance entre mantener las medidas de prevención y atención del COVID-19 y continuar ofreciendo los servicios de trasplante, principalmente a los pacientes con alto riesgo de morbi-mortalidad en lista de espera.

Factors related to delayed intensive care unit admission from emergency department—A retrospective cohort study

The delays in transferring patients from emergency department (ED) to intensive care unit (ICU) are known to be linked with several adverse events, including prolonged ICU stay and increased hospital mortality. The factors associated with delayed ICU admission include shortage of ICU beds, organizational factors, ED overcrowding, and patient-related factors, including sepsis as admission diagnosis. The aim of this study was to examine ED-related factors associated with prolonged ED stay. The study population consisted of adult patients admitted (n=479) from ED to ICU between 31 May 2016 and 19 March 2017 in Oulu University Hospital. A patient's ED length of stay (LOS) exceeding 180minutes was considered delayed. Most of the patients (380, 79.3%) were admitted to the ICU within 3hours of hospital admission. In a logistic regression analysis, odds ratios (ORs) for ED LOS>180minutes were as follows: for Glasgow Coma Scale score>9, 2.73 (1.39-5.32); for thrombocytes<100×109 /mmol, 6.69 (2.32-19.26); for absence of pre-arrival notification, 5.27 (3.04-9.14); and for radiological examination, 3.95 (1.72-9.10). Trauma and intoxicated patients had shorter ED LOS while patients with medical conditions had more often prolonged admissions. The delays in ICU admissions were linked to therapeutic and diagnostic procedures and absence of pre-arrival notification. Patients were admitted to the ICU on the basis of diagnosis instead of clinical risk. However, the delays were not associated with worsening outcome, which indicates that sufficient care can be provided at the ED while the ICU admission is pending.

388

Introduction: Shortage of ICU beds, increased life expectancy, and future reduction of resources allocated to health care will soon lead to an increasing need to ration beds and expenses in the intensive care unit (ICU). Methods: The electronic medical record and order sets for mechanical ventilation (MV) were used to identify all newly mechanically ventilated patients on the GMF. Demographic and clinical data included age, gender, race, living arrangements, Charlson-comorbidity index (CCI), Karnofsky performance status scale (KPSS), diagnosis on admission, APACHE II score, clinical evaluations, days on MV, and palliative care intervention. Outcomes included all cause mortality, rate of self-extubation, weaning trials and successful extubation, tracheostomies, and hospital length of stay (LOS). Results: Over a 7-month period 68 patients met inclusion criteria. Patients were mostly male (56%), Caucasian (47.1%), elderly (80+/-16years), admitted from a nursing home (68%), with high CCI (8.1+/-2.5) and low functional status (KPSS 10–30% in 86% of patients). Patients were intubated 4+/-6.6 days after admission; the APACHE II score at the time was 23+/-10 and the most common admitting diagnosis was severe sepsis (72%). The ICU team evaluated 79% of patients and frequent reasons for non-admission were poor functional status (47%) and irreversible disease processes (25%). The average duration of days on MV was 11+/-11.7 days and hospital LOS was 19+/-14.4 days. 35 patients had weaning trials, but only 5 patients were successfully extubated; 8 patients underwent tracheostomies. Self-extubation occurred in 9 patients and decision for comfort measures was made in 5 of them. Palliative care evaluated 50% percent of patients; overall, 43% of patients were transitioned to comfort care and 72% of patients were made DNR. The majority of patients (60%) died during hospital stay, 31% were transferred to chronic ventilator centers and 1.5% were transferred to hospice. Conclusions: In our institution patients with multiple co-morbidities, poor functional status, and with an irreversible disease process, are managed on the GMF after MV. Early intervention by the palliative care team helps with transition to comfort measures and discussions of advance directives in the majority of these patients. Admitting these patients to the ICU is unlikely to change outcomes or improve quality of life, and will increase health care costs. Larger multi-center trials to evaluate these results are urgently needed as the health care system continues to use costly and aggressive measures for a terminally ill population in times of financial crisis.

HIV/AIDS and admission to intensive care units: A comparison of India, Brazil and South Africa

In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners’ knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU) admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the ‘availability, and the knowledge and the experience’ of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIV-infected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status. S Afr J HIV Med 2013;14(1):15-16. DOI:10.7196/SAJHIVMED.887

HIV/AIDS and admission to intensive care units: A comparison of India, Brazil and South Africa

In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners’ knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU) admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the ‘availability, and the knowledge and the experience’ of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIV-infected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status.&#x0D; &#x0D; S Afr J HIV Med 2013;14(1):15-16. DOI:10.7196/SAJHIVMED.887

Maternal near miss and quality of maternal health care in Baghdad, Iraq

BackgroundThe maternal near-miss concept has been developed as an instrument for assisting health systems to evaluate and improve their quality of care. Our study aimed at studying the characteristics and quality of care provided to women with severe complications in Baghdad through the use of the World Health Organization (WHO) near-miss approach for maternal health.MethodsThis is a facility-based, cross-sectional study conducted in 6 public hospitals in Baghdad between March 1, 2010 and the June 30, 2010. WHO near-miss approach was utilized to analyze the data in terms of indicators of maternal near miss and access to and quality of maternal care.ResultsThe maternal near-miss rate was low at 5.06 per 1,000 live births, while the overall maternal near miss: mortality ratio was 9:1. One third of the near-miss cases were referred from other facilities and the mortality index was the same for referred women and for in-hospital women (11%). The intensive care unit (ICU) admission rate was 37% for women with severe maternal outcomes (SMO), while the overall admission rate was 0.28%. Anemia (55%) and previous cesarean section (45%) were the most common associated conditions with severe maternal morbidity. The use of magnesium sulfate for treatment of eclampsia, oxytocin for prevention and treatment of postpartum hemorrhage, prophylactic antibiotics during caesarean section, and corticosteroids for inducing fetal lung maturation in preterm birth is suboptimum.ConclusionsThe WHO near-miss approach allowed systematic identification of the roadblocks to improve quality of care and then monitoring the progress. Critical evidence-based practices, relevant to the management of women experiencing life-threatening conditions, are underused. In addition, possible limitations in the referral system result in a very high proportion of women presenting at the hospital already in a severe health condition (i.e. with organ dysfunction). A shortage of ICU beds leading to women taken care of without admission to ICU may also contribute to a high proportion of maternal deaths and organ dysfunction.

Mechanical ventilation of patients hospitalized in medical wards vs the intensive care unit—an observational, comparative study

Background In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds. Objective The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU. Design This was a prospective, observational, noninterventional study over a 6-month period. Setting The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital. Patients Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study. Results Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 ( P < .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 ± 7 vs 27 ± 7 in group 2 ( P < .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 ± 25 years in group 1 vs 69 ± 13 years in group 2 ( P = NS). Mean number of ventilatory changes in group 1 was 7.5 ± 1.4 per day per patient, whereas it was 1.3 ± 1.0 in group 2 ( P < .001). The number of arterial blood gas analyses in group 1 was 7.7 ± 1.2 per day per patient compared with 2.3 ± 1.3 in group 2 ( P < .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube–related inadvertent events compared with 62% of the patients in group 2 ( P < .05). Conclusions We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube–related complications and more active ventilatory management.

Preoperative calculation of risk for prolonged intensive care unit stay following coronary artery bypass grafting

ObjectivePatients who have prolonged stay in intensive care unit (ICU) are associated with adverse outcomes. Such patients have cost implications and can lead to shortage of ICU beds. We aimed to develop a preoperative risk prediction tool for prolonged ICU stay following coronary artery surgery (CABG).Methods5,186 patients who underwent CABG between 1st April 1997 and 31st March 2002 were analysed in a development dataset. Logistic regression was used with forward stepwise technique to identify preoperative risk factors for prolonged ICU stay; defined as patients staying longer than 3 days on ICU. Variables examined included presentation history, co-morbidities, catheter and demographic details. The use of cardiopulmonary bypass (CPB) was also recorded. The prediction tool was tested on validation dataset (1197 CABG patients between 1st April 2003 and 31st March 2004). The area under the receiver operating characteristic (ROC) curve was calculated to assess the performance of the prediction tool.Results475(9.2%) patients had a prolonged ICU stay in the development dataset. Variables identified as risk factors for a prolonged ICU stay included renal dysfunction, unstable angina, poor ejection fraction, peripheral vascular disease, obesity, increasing age, smoking, diabetes, priority, hypercholesterolaemia, hypertension, and use of CPB. In the validation dataset, 8.1% patients had a prolonged ICU stay compared to 8.7% expected. The ROC curve for the development and validation datasets was 0.72 and 0.74 respectively.ConclusionA prediction tool has been developed which is reliable and valid. The tool is being piloted at our institution to aid resource management.

Verification of the Acute Physiology and Chronic Health Evaluation scoring system in a Hong Kong intensive care unit.

To validate the Acute Physiology and Chronic Health Evaluation (APACHE II) severity of illness scoring system in Chinese patients in a multidisciplinary intensive care unit (ICU) in Hong Kong. To audit the service and utilization of an ICU with a low ICU to hospital bed ratio. Prospective data collection and review. A 12-bed multidisciplinary ICU within a 1,430-bed tertiary care university hospital. Data from 1,573 of 1,814 consecutive patients admitted to the ICU from May 1988 to November 1990 were studied. The patients were all Chinese. None. The patients' clinical details and APACHE II scores were recorded on day 2 of admission and reviewed at hospital discharge or after death. The APACHE II scores, risk of death values, age, and length of ICU stay between survivors and nonsurvivors were compared by two-sample t-tests. Relationships between mortality and APACHE II score, risk of death, and results from previous studies were investigated using the Pearson product-moment coefficient and regression analysis. Predictive capacity of risk of death was assessed by receiver operating characteristic curve analysis. The hospital mortality rate for study patients was 36%. Survivors were younger, had shorter ICU stays, lower APACHE scores, and lower risk of death values than nonsurvivors (p < .001). There was close correlation (r2 = .81, .77, and .76 for all patients, operative group, nonoperative group, respectively) between APACHE II scores and predicted risk of death values. Risk of death was an accurate group predictor of death in all patients and in separate operative and nonoperative groups. Areas under the receiver operating characteristic curves were 0.89 (all patients), 0.85 (operative), and 0.88 (nonoperative). Neither the Apache II scores nor risk of death scores were sufficiently accurate to predict outcome of individual patients. There was close concordance between observed and predicted mortality of patient groups. Mortality ratio was 0.97 (all patients), 0.89 (operative group), and 1.02 (nonoperative group). Chronological age, per se, was not a good predictor of mortality. The audit of the ICU service showed a short length (4.2 days) of ICU stay and high bed occupancy (80%). Subgroups of low-risk, postoperative patients with good outcomes and poor-risk patients admitted after cardiopulmonary arrest with a high mortality rate were identified. The APACHE II scoring system was an accurate predictor of group outcome in a Chinese population, making it suitable for comparisons between countries. Application of the APACHE II scoring system in a clinical audit facilitates critical appraisal of an ICU service. Problems identified by the study were a shortage of ICU beds and delayed referrals of patients.