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The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying.

ABSTRACT: OBJECTIVE:Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidable complications and 2) high-acuity ICUs may focus attention toward the many sicker patients and away from the fewer low-risk patients. DESIGN:Retrospective cohort study. SETTING:Three hundred twenty-two ICUs in 199 hospitals in the Philips eICU database between 2010 and 2015. PATIENTS:Adult ICU patients at low risk of dying, defined as an Acute Physiology and Chronic Health Evaluation-IVa-predicted mortality of 3% or less. EXPOSURE:ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. MEASUREMENTS AND MAIN RESULTS:We used generalized estimating equations to test whether ICU acuity is independently associated with a primary outcome of ICU length of stay and secondary outcomes of hospital length of stay, hospital mortality, and discharge destination. The study included 381,997 low-risk patients. Mean ICU and hospital length of stay were 1.8?±?2.1 and 5.2?±?5.0 days, respectively. Mean Acute Physiology and Chronic Health Evaluation IVa-predicted hospital mortality was 1.6% ± 0.8%; actual hospital mortality was 0.7%. In adjusted analyses, admission to low-acuity ICUs was associated with worse outcomes compared with higher-acuity ICUs. Specifically, compared with the highest-acuity quartile, ICU length of stay in low-acuity ICUs was increased by 0.24 days; in medium-acuity ICUs by 0.16 days; and in high-acuity ICUs by 0.09 days (all p < 0.001). Similar patterns existed for hospital length of stay. Patients in lower-acuity ICUs had significantly higher hospital mortality (odds ratio, 1.28 [95% CI, 1.10-1.49] for low-; 1.24 [95% CI, 1.07-1.42] for medium-, and 1.14 [95% CI, 0.99-1.31] for high-acuity ICUs) and lower likelihood of discharge home (odds ratio, 0.86 [95% CI, 0.82-0.90] for low-, 0.88 [95% CI, 0.85-0.92] for medium-, and 0.95 [95% CI, 0.92-0.99] for high-acuity ICUs). CONCLUSIONS:Admission to high-acuity ICUs is associated with better outcomes among low mortality-risk patients. Future research should aim to understand factors that confer benefit to patients with different risk profiles.

SUBMITTER: Vranas KC

PROVIDER: S-EPMC5828025 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying.

Vranas Kelly C KC Jopling Jeffrey K JK Scott Jennifer Y JY Badawi Omar O Harhay Michael O MO Slatore Christopher G CG Ramsey Meghan C MC Breslow Michael J MJ Milstein Arnold S AS Kerlin Meeta Prasad MP

Critical care medicine 20180301 3

<h4>Objective</h4>Many ICU patients do not require critical care interventions. Whether aggressive care environments increase risks to low-acuity patients is unknown. We evaluated whether ICU acuity was associated with outcomes of low mortality-risk patients. We hypothesized that admission to high-acuity ICUs would be associated with worse outcomes. This hypothesis was based on two possibilities: 1) high-acuity ICUs may have a culture of aggressive therapy that could lead to potentially avoidabl ...[more]

PMID: 29474319

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Project description:ImportanceThere is substantial socioeconomic and individual burden from uncorrected refractive error (URE) and chronic ocular disease. Understanding the association of visual acuity (VA) reduction with URE and the adults most likely to benefit from refraction may help support clinical decision-making in ophthalmologic care and maximize patient outcomes.ObjectivesTo assess the magnitude of VA improvement associated with URE among adults under ophthalmic care who obtain low vision rehabilitation (LVR) services and identify the characteristics of the patients who are most likely to experience improvement.Design, setting, and participantsThis retrospective case series assessed patients 20 years or older who were new to the LVR clinics from August 1, 2013, to December 31, 2015, and who had habitual VA between 20/40 and counting fingers (not including) and underwent refraction. Data analysis was performed from April 4, 2018, to December 20, 2019.ExposuresPatient demographics and clinical data, including habitual and refraction VA, refraction, and disease diagnosis. Habitual VA was categorized as mild (VA worse than 20/40 and at least 20/60), moderate (VA worse than 20/60 and better than 20/200), severe (VA 20/200 or worse and better than 20/500), and profound (VA 20/500 or worse) vision impairment (VI).Main outcomes and measuresAt least 2-line VA improvement and any VA improvement (≥1-line) by refraction.ResultsAmong the 2923 patients new to LVR clinics, 1773 (mean [SD] age, 70 [18.2] years; 1069 [60.3%] female) were included in these analyses. The mean habitual VA was 20/100 (mean [SD], 0.67 [0.36] logMAR). At least 2-line improvement was observed in 493 patients (27.8%), and any VA improvement was seen in 1023 patients (57.7%). At least 2-line improvement was observed in 54 patients (34.8%) with corneal disorders and was more likely seen among patients aged 40 to <65 years compared with those aged 20 to <40 years (odds ratio [OR], 1.57; 95% CI, 1.02-2.41), African American patients compared with white patients (OR, 1.41; 95% CI, 1.08-1.85), or patients with moderate VI compared with mild VI (OR, 1.36; 95% CI, 1.07-1.72).Conclusions and relevanceThe findings suggest that URE is prevalent among patients with ocular disease and accessing LVR and that refractive evaluation should be considered for patients with ocular disease and reduced VA, especially working-age adults aged 40 to <65 years, African American patients, and those with moderate VI.

Project description:ImportancePrognostication following ICU admission can often be determined based on known risk factors, including demographics and illness severity; however, little is known about outcomes of patients deemed to be "low-risk" at the time of hospital admission who subsequently are admitted to the ICU.ObjectivesThe objectives of this study were to determine the characteristics, outcomes, and costs for patients requiring ICU admission despite having lower predicted mortality when they were admitted to the hospital.Design setting and participantsIn this historical cohort study, we used a prospectively maintained ICU registry that included all ICU admissions to The Ottawa Hospital for patients 18 years or older from January 2011 to December 2016. We classified patients as low-risk using the Hospital-patient 1-year Mortality Risk at admission score, a hospital admission score validated to predict 1-year mortality.Main outcomes and measuresThe primary outcome was inhospital mortality. Secondary outcomes included adverse events, resource utilization, and costs.ResultsOf the 17,173 total ICU patients, 3,445 (20.1%) were classified as low-risk at hospital admission. Low-risk patients were younger (48.7 vs 67.5 yr; p < 0.001) and had a lower Multiple Organ Dysfunction Score (2.37 vs 4.14; p < 0.001). Mortality for low-risk patients was significantly lower than for non-low-risk patients (4.1% vs 25.4%; p < 0.001). For low-risk patients, multivariable logistic regression showed mortality was independently associated with older age (odds ratio, 1.02 per 1 yr; 95% CI, 1.00-1.03 per 1 yr), Multiple Organ Dysfunction Score (odds ratio, 1.42 per 1 point; 95% CI, 1.31-1.54 per 1 point), fluid management adverse events (odds ratio, 2.84; 95% CI, 1.29-6.25), hospital-acquired infections (odds ratio, 1.60; 95% CI, 1.02-2.51), and mechanical ventilation (odds ratio, 1.98; 95% CI, 1.20-3.26).Conclusions and relevanceDespite their robust premorbid status, low-risk patients admitted to the ICU had significant inhospital mortality. Fluid management adverse events, hospital-associated infections, multiple organ dysfunction, and mechanical ventilation are important prognostic factors for low-risk patients.

Project description:ImportancePostoperative complications are increasing, risking patients' health and health care sustainability. High-acuity postoperative units may benefit outcomes, but existing data are very limited.ObjectiveTo evaluate whether a new high-acuity postoperative unit, advanced recovery room care (ARRC), reduces complications and health care utilization compared with usual ward care (UC).Design, setting, and participantsIn this observational cohort study, adults who were undergoing noncardiac surgery at a single-center tertiary adult hospital, anticipated to stay in hospital for 2 or more nights, were scheduled for postoperative ward care, and at medium risk (defined as predicted 30-day mortality of 0.7% to 5% by the National Safety Quality Improvement Program risk calculator) were included. Allocation to ARRC was based on bed availability. From 2405 patients assessed for eligibility with National Safety Quality Improvement Program risk scoring, 452 went to ARRC and 419 to UC, with 8 lost to 30-day follow-up. Propensity scoring identified 696 patients with matched pairs. Patients were treated between March and November 2021, and data were analyzed from January to September 2022.InterventionsARRC is an extended postanesthesia care unit (PACU), staffed by anesthesiologists and nurses (1 nurse to 2 patients) collaboratively with surgeons, with capacity for invasive monitoring and vasoactive infusions. ARRC patients were treated until the morning after surgery, then transferred to surgical wards. UC patients were transferred to surgical wards after usual PACU care.Main outcome and measuresThe primary end point was days at home at 30 days. Secondary end points were health facility utilization, medical emergency response (MER)-level complications, and mortality. Analyses compared groups before and after propensity scoring matching.ResultsOf 854 included patients, 457 (53.5%) were male, and the mean (SD) age was 70.0 (14.4) years. Days at home at 30 days was greater with ARRC compared with UC (mean [SD] time, 17 [11] vs 15 [11] days; P = .04). During the first 24 hours, more patients were identified with MER-level complications in ARRC (43 [12.4%] vs 13 [3.7%]; P < .001), but after return to the ward, these were less frequent from days 2 to 9 (9 [2.6%] vs 22 [6.3%]; P = .03). Length of hospital stay, hospital readmissions, emergency department visits, and mortality were similar.Conclusions and relevanceFor medium-risk patients, brief high-acuity care with ARRC allowed enhanced detection and management of early MER-level complications, which was followed by a decreased incidence of subsequent MER-level complications after discharge to the ward and by increased days at home at 30 days.

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The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying.

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The Association of ICU Acuity With Outcomes of Patients at Low Risk of Dying.

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