Intensive care unit occupancy and premature discharge rates: A cohort study assessing the reporting of quality indicators

This paper by Blayney and colleagues was first published online in the Journal of Critical Care during October 2019.
Purpose:  ICU occupancy fluctuates. High levels may disadvantage patients. Currently, occupancy is benchmarked annually which may inaccurately reflect strained units. Outcomes potentially sensitive to occupancy include premature (early) ICU discharge and non-clinical transfer (NCT). This study assesses the association between daily occupancy and these outcomes, and evaluates benchmarking care across Scotland using daily occupancy.
Materials and methods:  Population: all Scottish ICU patients, 2006–2014. Exposure: bed occupancy per unit-day; Outcomes: proportion of early discharges and NCTs. Design: Retrospective cohort study. Outcome rates were calculated above various occupancy thresholds. Polynomial regression visualised associations, and inflection points between occupancy and outcomes. Spearman’s rho correlations between occupancy measures and outcomes were reported.
Results:  65,472 discharges occurred over 57,812 unit-days. 1954(3.0%) discharges were early; 429 (0.7%) were NCTs. Early discharge rates above 70%, 80% and 90% occupancy were 3.9%, 5.0% and 7.5% respectively. Occupancies at which outcome rates greatly increased were near 80% for early discharge, and 90% for NCT. Mean annual occupancy was not correlated with outcomes; annual proportion of days ≥90% occupancy correlated most strongly (early discharge rho = 0.46,p < .001; NCT rho = 0.31, p < .001).
Conclusions:  We demonstrate a clear association between daily ICU occupancy and early discharge/NCT. Daily occupancy may better benchmark care quality than mean annual occupancy.
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Association between acute kidney injury and neurological outcome or death at 6 months in out-of-hospital cardiac arrest: A prospective, multicenter, observational cohort study

This paper by Oh and colleagues was first published online in the Journal of Critical Care during August 2019.
Purpose:  This study aimed to evaluate the association between acute kidney injury (AKI) and 6 months neurological outcome after out-of-hospital cardiac arrest (OHCA).
Materials and methods:  Prospective multi-center observational cohort included adult OHCA patients treated with targeted temperature management (TTM) across 20 hospitals in the South Korea between October 2015 and October 2017. The diagnosis of AKI was made using the Kidney Disease: Improving Global Outcomes criteria. The outcome was neurological outcome at 6 months evaluated using the modified Rankin scale (MRS).
Results:  Among 5676 patients with OHCA, 583 patients were enrolled. AKI developed in 348 (60%) patients. Significantly more non-AKI patients had good neurological outcome at 6 months (MRS 0–3) than AKI patients (134/235 [57%] vs. 69/348 [20%], P < .001). AKI was associated with poor neurological outcome at six months in multivariate logistic regression analysis (adjusted odds ratio: 0.206 [95% confidence interval: 0.099–0.426], P < .001]). Cox regression analysis with time-varying covariate of AKI showed that patients with AKI had a higher risk of death than those without AKI (hazard ratio: 2.223; 95% confidence interval: 1.630–3.030, P < .001).
Conclusions:  AKI is associated with poor neurological outcome (MRS 4–6) at 6 months in OHCA patients treated with TTM.

The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study.

This research by Valley and others was published in the BMJ in June 2019.
Objective:  To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).
Design:  Retrospective cohort study.
Setting: 1727 acute care hospitals in the United States. Participants:  Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015.
Main Outcome Measure:  30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI.
Results:  The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points).
Conclusions:  ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.
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Time of admission to intensive care unit, strained capacity, and mortality: A retrospective cohort study

This research by Cardoso and colleagues was published online in June 2019 in the Journal of Critical Care.
Purpose:  We sought to study the association between afterhours ICU admission and ICU mortality considering measures of strained ICU capacity.
Materials and methods:  Retrospective analysis of 4141 admissions to 2 ICUs in Lisbon, Portugal (06/2016–06/2018). Primary exposure was ICU admission on 20:00 h–07:59 h. Primary outcome was ICU mortality. Measures of strained ICU capacity were: bed occupancy rate ≥ 90% and cluster of ICU admissions 2 h before or following index admission.
Results:  There were 1581 (38.2%) afterhours ICU admissions. Median APACHE II score (19 vs. 20) was similar between patients admitted afterhours and others (P = .27). Patients admitted afterhours had higher crude ICU mortality (15.4% vs. 21.9%; P < .001), but similar adjusted ICU mortality (aOR [95%CI] = 1.15 [0.97–1.38]; P = .12). While bed occupancy rate ≥ 90% was more frequent in patients admitted afterhours (23.1% vs. 29.1%) or deceased in ICU (23.6% vs. 33.7%), cluster of ICU admissions was more frequent in patients admitted during daytime hours (75.2% vs. 58.9%) or that survived the ICU stay (70.1% vs. 63.9%; P ≤ .001 for all). These measures of strained ICU capacity were not associated with adjusted ICU mortality (P ≥ .10 for both).
Conclusions:  Afterhours ICU admission and measures of strained ICU capacity were associated with crude but not adjusted ICU mortality.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Outcomes of emergency laparotomy in patients on extracorporeal membrane oxygenation for severe respiratory failure: A retrospective, observational cohort study

This research by McCann and others was first issued on line during late June 2019 in the Journal of Critical Care.
Purpose:  There is a paucity of literature to support undertaking emergency laparotomy when indicated in patients supported on ECMO. Our study aims to identify the prevalence, outcomes and complications of this high risk surgery at a large ECMO centre.
Materials and methods:  A single centre, retrospective, observational cohort study of 355 patients admitted to a university teaching hospital Severe Respiratory Failure service between December 2011 and January 2017.
Results:  The prevalence of emergency laparotomy in patients on ECMO was 3.7%. These patients had significantly higher SOFA and APACHEII scores compared to similar patients not requiring laparotomy. There was no difference in the duration of ECMO or intensive care unit (ICU) stay post decannulation between the two groups. 31% of laparotomy patients survived to hospital discharge. Major haemorrhage was uncommon, however emergency change of ECMO oxygenator was commonly required.
Conclusion:  Survival to hospital discharge is possible following emergency laparotomy on ECMO, however the mortality is higher than for those patients not requiring laparotomy, this likely reflects the severity of underlying organ failure rather than the surgery itself. Our service’s collocation with a general surgical service has made this development in care possible. ECMO service planning should consider general surgical provision.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Differences in 90-day mortality of delirium subtypes in the intensive care unit: A retrospective cohort study

This article by Rood and colleagues was published online in the “Journal of Critical Care” during June 2019
Introduction:  Many intensive care unit (ICU) patients suffer from delirium which is associated with deleterious short-term and long-term effects, including mortality. We determined the association between different delirium subtypes and 90-day mortality.
Materials and methods:  Retrospective cohort study in ICU patients admitted in 2015–2017. Delirium, including its subtypes, was determined using the confusion assessment method-ICU (CAM-ICU) and Richmond agitation sedation scale (RASS). Exclusion criteria were insufficient assessments and persistent coma. Cox-regression analysis was used to determine associations of delirium subtypes with 90-day mortality, including relevant covariates (APACHE-IV, length of ICU stay and mechanical ventilation).
Results:  7362 ICU patients were eligible of whom 6323 (86%) were included. Delirium occurred in 1600 (25%) patients (stratified for delirium subtype: N = 571–36% mixed, N = 485–30% rapidly reversible, N = 433–27% hypoactive, N = 111–7% hyperactive). The crude hazard ratio (HR) for overall prevalent delirium with 90-day mortality was 2.84 (95%CI: 2.32–3.49), and the adjusted HR 1.29 (95%CI: 1.01–1.65). The adjusted HR for 90-day mortality was 1.57 (95%CI: 1.51–2.14) for the mixed subtype, 1.40 (95%CI: 0.71–2.73) for hyperactive, 1.31 (95%CI: 0.93–1.84) for hypoactive and 0.95 (95%CI: 0.64–1.42) for rapidly reversible delirium.
Conclusion:  After adjusting for covariates, including competing risk factors, only the mixed delirium subtype was significantly associated with 90-day mortality.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting

This research by Smith and colleagues was published online in “Intensive and Critical Care Nursing” in April 2019.
Objective:  Determine the incidence and risk factors for pressure ulcers in a paediatric intensive care unit. Use the information gathered to develop preventive pressure ulcer care bundles.
Research methodology:  Prospective cohort study using Braden Q Scale for Predicting Pressure Sore Risk and European Pressure Ulcer Advisory Panel Pressure Ulcer Staging tool.
Setting:  General paediatric intensive care unit in a tertiary level hospital between May and October 2017.
Results:  Seventy-seven children were recruited. Most children were male (n = 42, 54.5%) and all nine children (11.7%) that developed a pressure ulcer were male. The main risk factor for developing a pressure ulcer was lack of physical activity. None of the children assessed as high or severe risk developed a pressure ulcer. Eight (89%) pressure ulcers were assessed as grade one. Seven pressure ulcers (77.8%) were on the facial and scalp area and all seven children were receiving airway support at the time the pressure ulcers developed.
Conclusion:  Incidence of pressure ulcers was 11.7%, with the facial and scalp area the most common anatomical areas affected. Medical devices appeared to be the prime causative factor. Based on our data we have modified and launched the SSKIN care bundle for the paediatric intensive care unit setting.
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