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ICU Admission (icu + admission)

Distribution by Scientific Domains

Medical Sciences	100%

Distribution within Medical Sciences

Anesthesia & Pain Management	18%
General & Internal Medicine	9%

Selected Abstracts

Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2006
Y-C Chen
Summary The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1-year period. Twenty-five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child,Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness-of-fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver,operating characteristic curve (0.917 ± 0.028 and 0.912 ± 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r2 = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child,Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified. [source]

Haematological parameters in severe acute respiratory syndrome

INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY, Issue 1 2005
W. J. CHNG
Summary Clinical presentation of severe acute respiratory syndrome (SARS) is non-specific and isolation of all suspected patients is difficult because of the limited availability of isolation facilities. We studied changes in haematological parameters in SARS patients using median values analysed according to the day of symptom onset. White cell (WCC), absolute neutrophil, absolute lymphocyte (ALC) and platelet counts followed a v-shaped trend with the nadir at day 6 or 7 after symptom onset except for ALC in the ICU group that had not reached the nadir by day 12. None of our patients had a platelet count < 80 × 109/l and WCC < 2 × 109/l in the first 5 days of symptoms and these parameters may allow early stratification of febrile patients into likely and unlikely SARS cases to allow effective utilization of isolation facilities. On multivariate analysis, age is the only independent predictor for ICU admission. [source]

Factual memories of ICU: recall at two years post-discharge and comparison with delirium status during ICU admission , a multicentre cohort study

JOURNAL OF CLINICAL NURSING, Issue 9 2007
Brigit L Roberts RN, IC Cert
Aims and objective., To examine the relationship between observed delirium in ICU and patients' recall of factual events up to two years after discharge. Background., People, the environment, and procedures are frequently cited memories of actual events encountered in ICU. These are often perceived as stressors to the patients and the presence of several such stressors has been associated with the development of reduced health-related quality of life or post-traumatic stress syndrome. Design., Prospective cohort study using interview technique. Method., The cohort was assembled from 152 patients who participated in a previously conducted multi-centre study of delirium incidence in Australian ICUs. The interviews involved a mixture of closed- and open-ended questions. Qualitative responses regarding factual memories were analysed using thematic analysis. A five-point Likert scale with answers from ,always' to ,never' was used to ask about current experiences of dream, anxiety, sleep problems, fears, irritability and/or mood swings. Scoring ranged from 6 to 30 with a mid-point value of 18 indicating a threshold value for the diagnosis of post-traumatic stress syndrome. A P -value of <0·05 was considered significant for all analyses. Results., Forty-one (40%) out of 103 potential participants consented to take part in the follow-up interview; 18 patients (44%) had been delirious and 23 patients (56%) non-delirious during the ICU admission. The non-participants (n = 62) formed a control group to ensure a representative sample; 83% (n = 34) reported factual memories either with or without recall of dreaming. Factual memories were significantly less common (66% cf. 96%) in delirious patients (OR 0·09, 95%CI 0·01,0·85, p = 0·035). Five topics emerged from the thematic analysis: ,procedures', ,staff', ,comfort', ,visitors', and ,events'. Based on the current experiences, five patients (12%, four non-delirious and one delirious) scored ,18 indicative of symptoms of post-traumatic stress syndrome; this did not reach statistical significance. Memory of transfer out of ICU was less frequent among the delirious patients (56%, n = 10) than among the non-delirious patients (87%, n = 20) (p = 0·036). Conclusion., Most patients have factual memories of their ICU stay. However, delirious patients had significantly less factual recall than non-delirious patients. Adverse psychological sequelae expressed as post-traumatic stress syndrome was uncommon in our study. Every attempt must be made to ensure that the ICU environment is as hospitable as possible to decrease the stress of critical illness. Post-ICU follow-up should include filling in the ,missing gaps', particularly for delirious patients. Ongoing explanations and a caring environment may assist the patient in making a complete recovery both physically and mentally. Relevance to clinical practice., This study highlights the need for continued patient information, re-assurance and optimized comfort. While health care professionals cannot remove the stressors of the ICU treatments, we must minimize the impact of the stay. It must be remembered that most patients are aware of their surroundings while they are in the ICU and it should, therefore, be part of ICU education to include issues regarding all aspects of patient care in this particularly vulnerable subset of patients to optimize their feelings of security, comfort and self-respect. [source]

Prognostic factors and outcome after drowning in an adult population

ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 7 2009
M. Á. BALLESTEROS
Background: Drowning remains an actual problem. Although medical assistance has improved, it still has high rates of morbidity and mortality. We set out to explore the clinical characteristics and outcome of drowning patients admitted to the intensive care unit (ICU) of tertiary-care university hospital. Methods: We designed a retrospective observational study to analyse all drowning patients admitted to our ICU after successful cardiopulmonary resuscitation. The study was conducted during 1 January 1992,31 December 2005. There was no exclusion. We used a univariate analysis to evaluate the effect on patient and management characteristics on survival. Results: There were 43 patients (five children and 38 adults), with male predominance. Fifteen patients, all adults (34.9%), died. Submersion time, age, Glasgow Coma Score (GCS), pupillary reactivity and acute physiology and chronic health evaluation (APACHE II) at ICU admission were related to mortality. Non-survivors presented a higher glycaemia level at ICU admission than survivors (P=0.005). Conclusions: The outcome is closely related to the patient's clinical status on arrival to the hospital. We have found that submersion time, age, GCS, pupillary reactivity and APACHE II at ICU admission were related to mortality. Further research in prospective studies is needed. [source]

Long-term physical outcome in patients with septic shock

ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 6 2009
J. B. POULSEN
Background: Limited information is available on physical function after septic shock. The aim of the present study was to assess the physical outcome in survivors 1 year after septic shock. Methods: The outcome status of all 174 adult patients admitted to a mixed ICU with the diagnosis septic shock in a 1-year period was registered. Survivors were interviewed about physical function and socioeconomic status using a questionnaire including the Short Form-36 survey. The pre-ICU-admission Functional Comorbidity Index (FCI) was also registered. Results: Of the 80 survivors, two were still hospitalised; thus, 78 were invited to participate and 70 replied (inclusion-rate 88%). Patients were followed up at median 351 days after hospital discharge. At follow-up the patients had a markedly reduced physical component summary score (PCS) compared with age- and sex-adjusted general population controls (36 vs. 47, P<0.0001). This was also observed in patients with no comorbidity before ICU admission (34 vs. 47, P<0.001). There was a negative correlation (r=,0.27, P=0.03) between pre-ICU-admission FCI values and the PCS at follow-up. According to 81% of the patients, loss of muscle mass was the main cause of decreased physical function. Only 43% (10 vs. 23, P=0.01) of the previously employed had returned to work, and the number of patients in need of home-based personal assistance had doubled (10/20, P=0.04). Conclusion: Physical function is substantially reduced in survivors of septic shock 1 year after discharge. [source]

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 2 2010
S. J. Thomson
Aliment Pharmacol Ther 2010; 32: 233,243 Summary Background, Hospital admissions for cirrhosis have been increasing in the United Kingdom, leading to increased pressure on intensive care (ICU) services. Outcome data for patients admitted to ICU are currently limited to transplant centre reports, with mortality rates exceeding 70%. These tertiary reports could fuel a negative bias when patients with cirrhosis are reviewed for ICU admission in secondary care. Aims, To determine whether disease severity and mortality rates in non-transplant general ICU are less severe than those reported by tertiary datasets. Methods, A prospective dual-centre non-transplant ICU study. Admissions were screened for cirrhosis and physiological and biochemical data were collected. Disease-specific and critical illness scoring systems were evaluated. Results, Cirrhosis was present in 137/4198 (3.3%) of ICU admissions. ICU and hospital mortality were 38% and 47%, respectively; median age 50 [43,59] years, 68% men, 72% alcoholic cirrhosis, median Child Pugh Score (CPS) 10 [8,11], Model for End-Stage Liver Disease (MELD) 18 [12,24], Acute Physiology and Chronic Health Evaluation II score (APACHE II) 16 [13,22]. Conclusions, Mortality rates and disease staging were notably lower than in the published literature, suggesting that patients have a more favourable outlook than previously considered. Transplant centre data should therefore be interpreted with caution when evaluating the merits of intensive care admission for patients in general secondary care ICUs. [source]

Serum osmolality and outcome in intensive care unit patients

ACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2006
B. Holtfreter
Background:, The aim of the present study was to compare 16 routine clinical and laboratory parameters, acute physiologic and chronic health evaluation (APACHE) and sequential organ failure assessment (SOFA) score for their value in predicting mortality during hospital stay in patients admitted to a general intensive care unit (ICU). Methods:, A retrospective observational clinical study was carried out in a 15-bed ICU in a university hospital. Nine hundred and thirty-three consecutive patients with ICU stay > 24 h (36.2% surgical, 29.1% medical and 34.7% trauma) were observed. Blood sampling, patient surveillance and data collection were performed. The primary outcome was mortality in the hospital. We used receiver operating characteristic (ROC) analyses and logistic regression to compare the 16 relevant parameters, APACHE II and SOFA scores. Results:, Two hundred and thirty-three out of the 933 patients died (mortality 25.0%). One laboratory parameter, serum osmolality [area under the curve (AUC) 0.732] had a predictive value for mortality which lay between that of APACHE II (AUC 0.784) and SOFA (AUC 0.720) scores. When outcome prediction was restricted to long-term patients (ICU stay > 5 days), serum osmolality (AUC 0.711) performed better than either of the standard scores (APACHE AUC 0.655, SOFA AUC 0.636). Using logistic regression analysis, the association of clinical parameters, age and diagnosis group with mortality was determined. Conclusion:, Elevated serum osmolality at ICU admission is associated with an increased mortality risk in critically ill patients. Serum osmolality is cheaper and more rapid to determine than the scoring systems. However, further studies are needed to evaluate the predictive value of serum osmolality in different patient populations. [source]

Mechanical ventilation in children with severe asthma

PEDIATRIC PULMONOLOGY, Issue 6 2001
DMSc, Kristiina Malmström MD
Abstract Hospital admissions for childhood asthma have increased during the past few decades. The aim of this study was to describe the need for mechanical ventilation for severe asthma exacerbation in children in Finland from 1976 to 1995. We reviewed medical records and collected data retrospectively from all 5 university hospitals in Finland, thus covering the entire population of about 5 million. The endpoints selected were the number of admissions and readmissions leading to mechanical ventilation, duration of stay in the hospital, and mortality. Moreover, asthma medications prescribed prior to admission and administered in the intensive care unit (ICU), as well as the etiology of the exacerbation associated with mechanical ventilation were examined. Mechanical ventilation was required in 66 ICU admissions (59 patients). This constituted approximately 10% of all 632 admissions for acute asthma to an ICU. The number of admissions decreased from 1976 to 1995: 41 admissions between 1976 and 1985 vs. 25 admissions during the next 10-year period. The mean age at admission to the ICU was 3.6 years, and 46% of the patients were boys. Prior to the index admission, 70% of the patients had used asthma medication such as oral bronchodilator (50%), inhaled bronchodilator (20%), theophylline (38%), inhaled glucocorticoid (18%), oral glucocorticoid (5%), and cromoglycate (7%). Respiratory infection was by far the most common cause of all the exacerbations (61%), followed by food allergy (8%) and gastroesophageal reflux (3%). In 28% of cases the cause of the severe asthma exacerbation could not be identified. In the mechanically ventilated patients readmissions occurred 38 times between 1976 and 1985 vs. 5 times between 1986 and 1995. Five of the patients who received mechanical ventilation died, and in 3 of these patients asthma was the event causing death. In conclusion, there has been decrease in the number of first and repeat ICU admission for asthma requiring mechanical ventilation between 1970 and 1995. This trend occurred despite a simultaneous 5% yearly increase in hospital admissions for childhood asthma during these 2 decades. Pediatr Pulmonol. 2001; 31:405,411. © 2001 Wiley-Liss, Inc. [source]

Progression of Organ Failure in Patients Approaching Brain Stem Death

AMERICAN JOURNAL OF TRANSPLANTATION, Issue 6 2009
F. T. Lytle
We performed a retrospective cohort study to document the progression of organ dysfunction in 182 critically ill adult patients who subsequently met criteria for brain stem death (BSD). Patients were admitted to intensive care units (ICUs) of Mayo Medical Center, Rochester, MN, between January 1996 and December 2006. Daily sequential organ failure assessment (SOFA) scores were used to assess the degree of organ dysfunction. Serial SOFA scores were analyzed using analysis of variance (ANOVA). Mean (standard deviation, SD) SOFA score on the first ICU day was 8.9 (3.2). SOFA scores did not significantly change over the course of ICU stay. 67.6% of patients donated one or more organs after BSD was declared. The median time from ICU admission to declaration of BSD was 18.8 h (interquartile range 10.3,45.0), and in those who donated organs, the time from declaration of BSD to organ retrieval was 11.8 h (9.5,17.6). The fact that mean SOFA scores did not change significantly over time, even after BSD occurred, has implications for the timing of retrieval of organs for transplantation. [source]

A comparison of severely injured trauma patients admitted to level 1 trauma centres in Queensland and Germany

ANZ JOURNAL OF SURGERY, Issue 3 2010
Johanna M. M. Nijboer
Abstract Background:, The allocation of a trauma network in Queensland is still in the developmental phase. In a search for indicators to improve trauma care both locally as state-wide, a study was carried out comparing trauma patients in Queensland to trauma patients in Germany, a country with 82.4 million inhabitants and a well-established trauma system. Methods:, Trauma patients ,15 years of age, with an Injury Severity Score (ISS) , 16 admitted to the Princess Alexandra Hospital (PAH) and to the 59 German hospitals participating in the Trauma Registry of the German Society for Trauma Surgery (DGU-G) during the year 2005 were retrospectively identified and analysed. Results:, Both cohorts are comparable when it comes to demographics and injury mechanism, but differ significantly in other important aspects. Striking is the low number of primary admitted patients in the PAH cohort: 58% versus 83% in the DGU-G cohort. PAH patients were less physiologically deranged and less severely injured: ISS 25.2 ± 9.9 versus 29.9 ± 13.1 (P < 0.001). Subsequently, they less often needed surgery (61% versus 79%), ICU admission (49% versus 92%) and had a lower mortality: 9.8% versus 17.9% of the DGU-G cohort. Conclusions:, Relevant differences were the low number of primary admissions, the lesser severity of injuries, and the low mortality of the patients treated at the PAH. These differences are likely to be interrelated and Queensland's size and suboptimal organization of trauma care may have played an important role. [source]

Fijian seasonal scourge of mango tree falls

ANZ JOURNAL OF SURGERY, Issue 12 2009
Anuj Gupta
Abstract Background:, Mango tree falls are a frequent presentation at any health facility in the South Pacific. This study aims to identify (i) the number of admissions because of falls from mango trees; (ii) epidemiology; (iii) seasonal trend; (iv) injury profile; and (v) hospital care provided. Methods:, Retrospective case review on all mango tree falls related injuries resulting in admissions at the Lautoka Hospital, Fiji during a 1-year period (2007). Patient records were analysed to identify specific injury patterns such as upper/lower limb fractures, spinal cord injury and head injury, caused by mango tree falls. Results:, Thirty-nine cases were identified. Eighty-two percent (n= 32) of the falls occurred in the mango season (June,November). Seventy-two percent (n= 28) of the patients were males and 28% (n= 11) were females. Seventy-six percent were aged 5,13 and only 21% were adults. Also, 77% (n= 30) of the patients were ethnic Fijians and 23% (n= 9) were Fijian-Indians. Sixty-four percent (n= 25) had closed fractures and 17% (n= 7) had open fractures. Fifty-six percent (n= 22) of the fractures were of the fore arm. There were two cases of spinal cord injury, four cases of head injury, one ICU admission and one death. Average hospital stay was 7.56 days. Conclusion:, All these injuries were recreational and the majority in the urban setting. They were all avoidable. [source]

Epidemiology of post-injury multiple organ failure in an Australian trauma system

ANZ JOURNAL OF SURGERY, Issue 6 2009
David C. Dewar
Abstract Background:, The epidemiology of post-injury multiple organ failure (MOF) is reported internationally to have gone through changes over the last 15 years. The purpose of this study is to describe the epidemiology of post-injury MOF in Australia. Methods:, A 12-month prospective epidemiological study was performed at the John Hunter Hospital (Level-1 Trauma Centre). Demographics, injury severity (ISS), physiological parameters, MOF status and outcome data were prospectively collected on all trauma patients who met inclusion criteria (ICU admission; ISS > 15; age > 18, head Abbreviated Injury Scale (AIS) <3 and survival >48 h). MOF was prospectively defined by the Denver MOF score greater than 3 points. Data are presented as % or Mean+/,SEM. Univariate statistical comparison was performed (Student t -test, X2 test), P < 0.05 was considered significant. Results:, Twenty-nine patients met inclusion criteria (Age 40+/,4, ISS 29+/,3, Male 62%), five patients developed MOF. The incidence of MOF among trauma patients admitted to ICU was 2% (5/204) and 17% (5/29) in the high-risk cohort. The maximum average MOF score was 6.3 +/,1, with the average duration of MOF 5+/,2 days. Two patients had respiratory and cardiac failure, two patients had failure of respiratory, cardiac and hepatic systems, while one patient had failure of respiratory, hepatic and renal systems. One MOF patient died, all non MOF patients survived. MOF patients had longer ICU stays (20+/,4 versus 7+/,0.8 P= 0.01), tended to be older (60+/,11 versus 35+/,4 p=0.07). None of the previously described independent predictors (ISS, base deficit, lactate, transfusions) were different when the MOF patients were compared with the non-MOF patients. Conclusion:, The incidence of MOF in Australia is consistent with the international data. In Australia MOF continues to cause significant late mortality and morbidity in trauma patients. MOF patients have longer ICU stay than high-risk non MOF patients, and use significant resources. Our preliminary data challenges the timeliness of the 10-year-old independent predictors of post-injury MOF. The epidemiology, the clinical presentation and the independent predictors of post-injury MOF require larger scale reassessment for the Australian context. [source]

Prospective Multicenter Bronchiolitis Study: Predicting Intensive Care Unit Admissions

ACADEMIC EMERGENCY MEDICINE, Issue 10 2008
Dorothy Damore MD
Abstract Objectives:, The authors sought to identify predictors of intensive care unit (ICU) admission among children hospitalized with bronchiolitis for ,24 hours. Methods:, The authors conducted a prospective cohort study during two consecutive bronchiolitis seasons, 2004 through 2006, in 30 U.S. emergency departments (EDs). All included patients were aged <2 years and had a final diagnosis of bronchiolitis. Regular floor versus ICU admissions were compared. Results:, Of 1,456 enrolled patients, 533 (37%) were admitted to the regular floor and 50 (3%) to the ICU. Comparing floor and ICU admissions, multivariate ED predictors of ICU admission were age <2 months (26% vs. 53%; odds ratio [OR] = 4.1; 95% confidence interval [CI] = 2.1 to 8.3), an ED visit the past week (25% vs. 40%; OR = 2.2; 95% CI = 1.1 to 4.4), moderate/severe retractions (31% vs. 48%; OR = 2.6; 95% CI = 1.3 to 5.2), and inadequate oral intake (31% vs. 53%; OR = 3.3; 95% CI = 1.6 to 7.1). Unlike previous studies, no association with male gender, socioeconomic factors, insurance status, breast-feeding, or parental asthma was found with ICU admission. Conclusions:, In this prospective multicenter ED-based study of children admitted for bronchiolitis, four independent predictors of ICU admission were identified. The authors did not confirm many putative risk factors, but cannot rule out modest associations. [source]

Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003

BJOG : AN INTERNATIONAL JOURNAL OF OBSTETRICS & GYNAECOLOGY, Issue 7 2005
D.J. Tuffnell
Objective To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions. Design A five-year prospective study. Setting Sixteen maternity units in Yorkshire. Population All women managed with severe pre-eclampsia and eclampsia. Methods A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data. Main outcome measure Incidence of the conditions and serious complication rates. Results A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug. Conclusion A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications. [source]

Survival and predictors of outcome in patients with acute leukemia admitted to the intensive care unit

CANCER, Issue 10 2008
Snehal G. Thakkar MD
Abstract BACKGROUND. Predictors of outcome and rates of successful discharge have not been defined for patients with acute leukemia admitted to intensive care units (ICUs) in the US. METHODS. This is a retrospective analysis of 90 patients with acute leukemia (no history of bone marrow transplant) admitted to an ICU from 2001,2004. The primary endpoints were improvement and subsequent discharge from the ICU, discharge from the hospital, and 2-month survival after hospital discharge. Secondary endpoints were 6- and 12-month survival. Univariate and multivariate logistic regression analyses were performed to identify factors predicting outcome. RESULTS. The median age of patients was 54 years and 48 (53%) were male. The most common reason for ICU transfer for all patients was respiratory compromise. The majority of all patients (68%) were eventually placed on ventilator support and approximately half required pressors. During the ICU course, 29 patients (32%) improved and subsequently resumed aggressive leukemia management, and 24 patients (27%) survived to be discharged from the hospital. The 2-, 6-, and 12-month overall survival was 24 (27%), 16 (18%), and 14 (16%), respectively. Higher APACHE II score, use of pressors, undergoing bone marrow transplantation preparative regimen, and adverse cytogenetics predicted worse outcome. Newly diagnosed leukemia, type of leukemia, or age did not. CONCLUSIONS. One of 4 patients with acute leukemia survived an ICU admission to be discharged from the hospital and were alive 2 months later. A diagnosis of acute leukemia should not disqualify patients from an ICU admission. Cancer 2008. © 2008 American Cancer Society. [source]

Trends in Inpatient Treatment Intensity among Medicare Beneficiaries at the End of Life

HEALTH SERVICES RESEARCH, Issue 2 2004
Amber E. Barnato
Objective. Although an increasing fraction of Medicare beneficiaries die outside the hospital, the proportion of total Medicare expenditures attributable to care in the last year of life has not dropped. We sought to determine whether disproportionate increases in hospital treatment intensity over time among decedents are responsible for the persistent growth in end-of-life expenditures. Data Source. The 1985,1999 Medicare Medical Provider Analysis and Review (MedPAR) and Denominator files. Study Design. We sampled inpatient claims for 20 percent of all elderly fee-for-service Medicare decedents and 5 percent of all survivors between 1985 and 1999 and calculated age-, race-, and gender-adjusted per-capita inpatient expenditures and rates of intensive care unit (ICU) and intensive procedure use. We used the decedent-to-survivor expenditure ratio to determine whether growth rates among decedents outpaced growth relative to survivors, using the growth rate among survivors to control for secular trends in treatment intensity. Data Collection. The data were collected by the Centers for Medicare and Medicaid Services. Principal Findings. Real inpatient expenditures for the Medicare fee-for-service population increased by 60 percent, from $58 billion in 1985 to $90 billion in 1999, one-quarter of which were accrued by decedents. Between 1985 and 1999 the proportion of beneficiaries with one or more intensive care unit (ICU) admission increased from 30.5 percent to 35.0 percent among decedents and from 5.0 percent to 7.1 percent among survivors; those undergoing one or more intensive procedure increased from 20.9 percent to 31.0 percent among decedents and from 5.8 percent to 8.5 percent among survivors. The majority of intensive procedures in the United States were performed in the more numerous survivors, although in 1999 50 percent of feeding tube placements, 60 percent of intubations/tracheostomies, and 75 percent of cardiopulmonary resuscitations were in decedents. The proportion of beneficiaries dying in a hospital decreased from 44.4 percent to 39.3 percent, but the likelihood of being admitted to an ICU or undergoing an intensive procedure during the terminal hospitalization increased from 38.0 percent to 39.8 percent and from 17.8 percent to 30.3 percent, respectively. One in five Medicare beneficiaries who died in the hospital in 1999 received mechanical ventilation during their terminal admission. Conclusions. Inpatient treatment intensity for all fee-for-service beneficiaries increased between 1985 and 1999 regardless of survivorship status. Absolute changes in per-capita hospital expenditures, ICU admissions, and intensive inpatient procedure use were much higher among decedents. Relative changes were similar except for ICU admissions, which grew faster among survivors. The secular decline in in-hospital deaths has not resulted in decreased per capita utilization of expensive inpatient services in the last year of life. This could imply that net hospital expenditures for the dying might have been even higher over this time period if the shift toward hospice had not occurred. [source]

Effects of rapid response systems on clinical outcomes: Systematic review and meta-analysis

JOURNAL OF HOSPITAL MEDICINE, Issue 6 2007
Sumant R. Ranji MD
Abstract BACKGROUND A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial. PURPOSE To evaluate the effects of RRSs on clinical outcomes through a systematic literature review. DATA SOURCES MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies. STUDY SELECTION Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions. DATA EXTRACTION Two authors independently determined study eligibility, abstracted data, and classified study quality. DATA SYNTHESIS Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies. CONCLUSIONS Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven. Journal of Hospital Medicine 2007;2:422,432. © 2007 Society of Hospital Medicine. [source]

Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting

Mechanical ventilation in children with severe asthma

Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery

ANAESTHESIA, Issue 1 2008
S. M. Abbas
Summary The use of intra-operative Doppler oesophageal probes provides continuous monitoring of cardiac output. This enables optimisation of intravascular volume and tissue perfusion in major abdominal surgery, which is thought to reduce postoperative complications and shorten hospital stay. Medline and EMBASE were searched using the standard methodology of the Cochrane collaboration for trials that compared oesophageal Doppler monitoring with conventional clinical parameters for fluid replacement in patients undergoing major elective abdominal surgery. Data from randomised controlled trials were entered and analysed in Meta-view in Rev -Man 4.2 (Nordic, Denmark). We included five studies that recruited 420 patients undergoing major abdominal surgery who were randomly allocated to receive either intravenous fluid treatment guided by monitoring ventricular filling using oesophageal Doppler monitor or fluid administration according to conventional parameters. Pooled analysis showed a reduced hospital stay in the intervention group. Overall, there were fewer complications and ICU admissions, and less requirement for inotropes in the intervention group. Return of normal gastro-intestinal function was also significantly faster in the intervention group. Oesophageal Doppler use for monitoring and optimisation of flow-related haemodynamic variables improves short-term outcome in patients undergoing major abdominal surgery. [source]