Ward Mortality Research Articles

Efecto del momento de ingreso sobre el pronóstico de los pacientes en la Unidad de Cuidados Intensivos: on-hours vs. off-hours

ObjectiveTo assess the repercussion of the timing of admission to the ICU upon patient prognosis. DesignA prospective, observational, non-interventional cohort study was carried out. ScopeA second level hospital with 210 operational beds and a general ICU with 8 operational beds. Patients or participantsThe study comprised all patients admitted to the ICU during 3 years (January 2010 to December 2012), excluding those subjects admitted from the operating room after scheduled surgery. The patients were divided into 2 groups according to the timing of admission (on-hours or off-hours). InterventionsNon-interventional study. Variables of interestAn analysis was made of demographic variables (age, sex), origin (emergency room, hospital ward, operating room), comorbidities and SAPS 3 as severity score upon admission, length of stay in the ICU and hospital ward, and ICU and hospital mortality. ResultsA total of 504 patients were included in the on-hours group, versus 602 in the off-hours group. Multivariate analysis showed the factors independently associated to hospital mortality to be SAPS 3 (OR 1.10; 95% CI 1.08-1.12), and off-hours admission (OR 2.00; 95% CI 1.20-3.33). In a subgroup analysis of the off-hours group, the admission of patients on weekends or non-working days compared to daily night shifts was found to be independently associated to hospital mortality (OR 2.30; 95% CI 1.23-4.30). ConclusionsAdmission to the ICU in off-hours is independently associated to patient mortality, which is also higher in patients admitted on weekends and non-working days compared to the daily night shifts.

Implementation of an acute surgical admission ward.

The aim of the study was to assess the impact of an acute surgical admission ward on admission and discharge processes. This prospective cohort study was conducted in a university tertiary referral centre. All acute surgical patients were clustered in the acute surgical unit (ASU) in February and March 2012, and discharged or transferred to specialized departments within 48 h. The primary outcome was length of hospital stay (LOS). Secondary outcomes were impact on emergency department waiting times, discharge home within 48 h, incorrect ward admissions, readmissions and mortality. Outcomes of the study group were compared with those of a historical reference group admitted during the same interval the year before. Some 249 patients were admitted to the ASU during the study interval. The reference group consisted of 211 patients. The total LOS decreased significantly from a median of 4·0 to 2·0 days (P = 0·004). The percentage of patients who were discharged within 48 h increased from 30·3 to 43·4 per cent (P = 0·004). The rate of incorrect ward admission decreased from 9·5 to 0 per cent. Emergency department waiting time, readmission rate and 30-day mortality did not change. Introduction of an acute surgical unit-shortened length of hospital stay without comprising readmission and mortality rates.

Traqueotomía percutánea por dilatación con el método Ciaglia Blue Dolphin®

ObjectiveTo describe the perioperative and postoperative complications in critically ill patients requiring percutaneous tracheostomy using the Ciaglia Blue Dolphin® technique. DesignA prospective, observational, cohort study was carried out. ScopeTwo medical-surgical Intensive Care Units. PatientsAdult patients subjected to prolonged mechanical ventilation. InterventionPercutaneous tracheostomy using Ciaglia Blue Dolphin® with an endoscopic guide. VariablesDemographic variables, intraoperative and postoperative complications, and Intensive Care Unit and ward mortality were recorded. ResultsSeventy patients were included. Age: 68.6±12 years (68.6% males). APACHE II score: 23.5±8.7. Duration of mechanical ventilation prior to percutaneous tracheostomy: 14.3±5.5 days. Perioperative complications were recorded in 25 patients. In 23 of them the complications were mild: difficulty inserting the tracheostomy cannula (n=10), mild bleeding (n=7), partial atelectasis (n=3), cuff leak (n=2), and technical inability to complete the procedure (switch to Ciaglia Blue Rhino®) (n=1). Severe complications were recorded in 2 patients: severe bleeding that forced completion of the procedure via surgical tracheostomy (n=1), and false passage with desaturation (n=1). None of the complications proved life-threatening. Eleven complications occurred in the learning curve. As postoperative complications, mild peri-cannula bleeding was seen in 2 patients. ConclusionsPercutaneous tracheostomy using the Ciaglia Blue Dolphin® technique with an endoscopic guide is a safe procedure. As with other procedures, the learning curve contributes to increase the incidence of complications. Potential benefits versus other percutaneous tracheostomy techniques should be explored by randomized trials.

Intensive care unit discharge to the ward with a tracheostomy cannula as a risk factor for mortality: A prospective, multicenter propensity analysis*

To analyze the impact of decannulation before intensive care unit discharge on ward survival in nonexperimental conditions. Prospective, observational survey. Thirty-one intensive care units throughout Spain. All patients admitted from March 1, 2008 to May 31, 2008. None. At intensive care unit discharge, we recorded demographic variables, severity score, and intensive care unit treatments, with special attention to tracheostomy. After intensive care unit discharge, we recorded intensive care unit readmission and hospital survival. Multivariate analyses for ward mortality, with Cox proportional hazard ratio adjusted for propensity score for intensive care unit decannulation. We included 4,132 patients, 1,996 of whom needed mechanical ventilation. Of these, 260 (13%) were tracheostomized and 59 (23%) died in the intensive care unit. Of the 201 intensive care unit tracheostomized survivors, 60 were decannulated in the intensive care unit and 141 were discharged to the ward with cannulae in place. Variables associated with intensive care unit decannulation (non-neurologic disease [85% vs. 64%], vasoactive drugs [90% vs. 76%], parenteral nutrition [55% vs. 33%], acute renal failure [37% vs. 23%], and good prognosis at intensive care unit discharge [40% vs. 18%]) were included in a propensity score model for decannulation. Crude ward mortality was similar in decannulated and nondecannulated patients (22% vs. 23%); however, after adjustment for the propensity score and Sabadell Score, the presence of a tracheostomy cannula was not associated with any survival disadvantage with an odds ratio of 0.6 [0.3-1.2] (p=.1). In our multicenter setting, intensive care unit discharge before decannulation is not a risk factor.

Ward mortality after ICU discharge: a multicenter validation of the Sabadell score

Tools for predicting post-ICU patients' outcomes are scarce. A single-center study showed that the Sabadell score classified patients into four groups with clear-cut differences in ward mortality. To validate the Sabadell score using a prospective multicenter approach. Thirty-one ICUs in Spain. All patients admitted in the 3-month study period. We recorded variables at ICU admission (age, sex, severity of illness, and do-not-resuscitate orders), during the ICU stay (ICU-specific treatments, ICU-acquired infection, and acute renal failure), and at ICU discharge (Sabadell score). Statistical analyses included one-way ANOVA and multiple regression analysis with ward mortality as the dependent variable. We admitted 4,132 patients (mean age 61.5 +/- 16.7 years) with mean predicted mortality of 23.8 +/- 22.7%; 545 patients (13%) died in the ICU and 3,587 (87%) were discharged to the ward. Overall ward mortality was 6.7%; ward mortality was 1.5% (36/2,422) in patients with score 0 (good prognosis), 9% (64/725) in patients with score 1 (long-term poor prognosis), 23% (79/341) in patients with score 2 (short-term poor prognosis), and 64% (63/99) in patients with score 3 (expected hospital death). Variables associated with ward mortality in the multivariate analysis were predicted risk of death (OR 1.016), ICU readmission (OR 5.9), Sabadell score 1 (OR 4.7), Sabadell score 2 (OR 15.7), and Sabadell score 3 (OR 107.2). We confirm the ability of the Sabadell score at ICU discharge to define four groups of patients with very different likelihoods of hospital survival.

Withdrawal of life support in critically ill neurosurgical patients and in-hospital death after discharge from the neurosurgical intensive care unit

The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI). Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI. One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate. The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

Ward mortality in patients discharged from the ICU with tracheostomy may depend on patient’s vulnerability

To determine the effect of discharge from the ICU with a tracheostomy tube on ward mortality and its relation to patient vulnerability. Retrospective single-center cohort study. Database (2003-2006) review of patients undergoing mechanical ventilation (MV) > 24 h and discharged from the ICU with or without tracheostomy tube in place and followed up to hospital discharge or death. We recorded clinical characteristics, complications, major ICU procedures, subjective prognosis at ICU discharge (Sabadell score), and hospital outcome. Factors associated with ward mortality were analyzed by multiple logistic regression. From 3,065 patients admitted to the ICU, 1,502 needed MV > 24 h. Only 936 patients (62%) survived the ICU and were transferred to the ward; of these, 130 (13.9%) had a tracheostomy tube in place. Ward mortality was higher in patients with a tracheostomy tube in place than in those without (26 vs. 7%, P < 0.001). Increased ward mortality among cannulated patients was seen only in those with intermediate Sabadell score (24 vs. 9% in score 1, P = 0.02, and 38 vs. 24% in score 2, P = 0.06), but not in the "good prognosis" (2 vs. 2%, score 0) and "expected to die in hospital" (80 vs. 75%, score 3) groups. Multivariate analysis found three factors associated with ward mortality: age, tracheostomy tube in place, and Sabadell score. Lack of tracheostomy decannulation in the ICU appears to be associated with ward mortality, but only in the group with a Sabadell score of 1.

First-Ever Ischemic Stroke in Very Old Asians: Clinical Features, Stroke Subtypes, Risk Factors and Outcome

Background: Prior studies have been conducted in very old white and black patients. However, stroke in very old Asians has not been studied. Methods: This study retrospectively reviewed the records of first-ever ischemic stroke patients admitted to the Chiayi Chang Gung Memorial Hospital in the middle part of Taiwan from January 2002 to December 2005. Clinical features, stroke subtypes, risk factors, acute ward mortality, length of acute ward stay, medical complications and medication for secondary stroke prevention at discharge were compared in 2 groups of first-ever ischemic stroke patients (one ≧80 and the other <80 years old). Results: Aged patients (≧80 years old) had a higher proportion of conscious impairment at admission, a longer acute ward stay, a higher incidence of total anterior circulation infarct and a lower frequency of lacunar infarct, more frequent atrial fibrillation and less frequent diabetes mellitus, hyperlipidemia and smoking habits, and a higher incidence of pneumonia, urinary tract infection and upper gastrointestinal bleeding. Conclusions: Understanding the risk factors and medical complications in very old stroke patients may help improve the stroke prevention strategy and the quality of stroke patient management.

A modified McCabe score for stratification of patients after intensive care unit discharge: the Sabadell score

IntroductionMortality in the ward after an intensive care unit (ICU) stay is considered a quality parameter, and is described as a source of avoidable mortality. Additionally, the attending intensivist frequently anticipates fatal outcome after ICU discharge. Our objective was to test the ability of a new score to stratify patients according to ward mortality after ICU discharge.MethodsA prospective cohort study was performed in the general ICU of a university-affiliated hospital. In 2003 and 2004 we prospectively recorded the attending intensivist's subjective prognosis at ICU discharge about the hospital outcome for each patient admitted to the ICU (the Sabadell score), which was later compared with the real hospital outcome.ResultsWe studied 1,521 patients with a mean age of 60.2 ± 17.8 years. The median (25–75% percentile) ICU stay was five (three to nine) days. The ICU mortality was 23.8%, with 1,156 patients being discharged to the ward. Post-ICU ward mortality was 9.6%, mainly observed in patients with a Sabadell score of 3 (81.3%) or a score of 2 (41.1%), whereas lower mortality was observed in patients scoring 1 (17.2%) and scoring 0 (1.7%). Multivariate analysis selected age and the Sabadell score as the only variables associated with ward mortality, with an area under the receiver operating curve of 0.88 (95% CI 0.84–0.93) for the Sabadell score.ConclusionThe Sabadell score at ICU discharge works effectively to stratify patients according to hospital outcome.

The Ghost of Christmas Past: health effects of poverty in London in 1896 and 1991

Objectives: To compare the extent to which late 20th century patterns of mortality in London are predicted by contemporary patterns of poverty and by late 19th century patterns of poverty....

Deprivation and excess winter mortality.

OBJECTIVE: To investigate the effect of material deprivation on the winter rise in mortality and temperature dependent variations in mortality. DESIGN: Ecological comparison of seasonal mortality at electoral ward level....

Utilization Strategies for Intensive Care Units

To the Editor.— The article Utilization Strategies for Intensive Care Units by Drs Kalb and Miller' fails to address the important question of how to evaluate the effects of rationing critical care resources in a hospital. This entails collecting data on the impact of the intensive care unit (ICU) on the pool of patients both inside and outside the ICU when attendant bed shortages occur. Studying only patients in the ICU, the common methodology cited in the article by Drs Kalb and Miller, introduces selection bias into ICU research and neglects a basic tenet of epidemiology. As an example, take a hypothetical 100-bed hospital with a single 10-bed ICU. This system will generate descriptive data such as case mix and severity for ICU and non-ICU patients. Outcome data (including ICU, ward, and hospital mortality; occupancy rates; and lengths of stay) can be collected that will be unique to this particular

Electoral ward mortality analysis in Newcastle upon Tyne

All deaths of residents of Newcastle upon Tyne aged from 15 to 64 years of age, occurring during 1978, 1979 or 1980 were analysed to calculate standardized mortality ratios for each electoral ward. This method of constructing a geographical profile of health within a district is economical, but limits on accuracy and reliability must be accepted.