To evaluate the relationship between pre-intensive care length of stay and outcomes of patients transferred to the Intensive Care Unit (ICU).
Data was obtained from the Project Impact database. Patients without a previous ICU admission transferred to the Medical-Surgical ICU (MSICU) between October 2002 and November 2004 were reviewed. Medical patients came from general care and telemetry floors. Surgical patients came from these areas, the operating room (OR), and the post anesthesia care unit. Patients were classified as surgical if surgery was performed in the OR within 7 days prior to ICU admission. Patients were grouped by hospital length of stay (HLOS) prior to ICU admission: medical patients HLOS ≤5 days (Group M1) or HLOS ≥6 days (Group M2); surgical patients HLOS ≤5 but >1 day (Group S1) or HLOS ≥6 days (Group S2). Variables analyzed included age, SAPS II survival probability, ICU and hospital LOS, and mortality.
Groups were demographically similar. Group M2 was sicker than M1. Acuity was similar between S1 and S2. Mortality was higher among patients with pre-ICU LOS ≥6 days versus those with pre-ICU LOS ≤5 days. HLOS was longer in groups M2 vs. M1 and S2 vs. S1. ICU LOS did not differ based on pre-ICU LOS. Observed deaths exceeded predicted in group S2.
ICU admission from a general care floor after ≥6 days is associated with poor outcome as compared to earlier admission. Previous studies have invoked suboptimal care prior to ICU admission as the reason for poorer outcomes. This idea is supported by the higher acuity of patients in Group M2. Poor organization, insufficient knowledge, failure to appreciate clinical urgency, inadequate supervision and failure to seek advice have been previousely suggested as factors in this suboptimal care.
Improving outcomes in patients transferred to the ICU may require institutional changes. Prompt recognition of deteriorations in patient condition and earlier interventions, such as the institution of a rapid response team may result in securing better outcomes.
Table 1Medical PatientsM 1M 2p ValueNumber18149Mean ICU LOS (SD)5.4 (7.1)5.6 (6.3)0.85Mean Hosp LOS (SD)20.3 (24.5)34.4 (23.6)0.0004Survival Probability- SAPS II (SD)0.70 (0.29)0.57 (0.32)0.0082Expected Mortality- SAPS II30.00%43%Actual Mortality32%53%0.0115Surgical PatientsS 1S 2p ValueNumber96103Mean Hosp LOS (SD)15.2 (8.9)28.3 (23.6)0.0001Survival Probability- SAPS II (SD)0.87 (0.180)0.84 (0.21)0.28Expected Mortality- SAPS II13.00%16%Actual Mortality8.30%24%0.0037Table 2—
Differences Between Actual and Predicted Survival (%)Predicted SurvivalActual survivalpM 170680.55M 257470.15S 18791.70.17S 284760.02
Raquel Nahra, None.