The association between ICU admission and emergency hospital readmission following emergency general surgery.
ABSTRACT: Background:The relationship between postoperative intensive care (ICU) admission following emergency general surgery (EGS) and emergency hospital readmission has not been widely investigated. Methods:Retrospective analysis of registry data for patients undergoing EGS in Scotland, 2005-2007. Exposure of interest was ICU admission status (direct from theatre; indirect after initial care on ward; no ICU admission). The primary outcome was emergency hospital readmission within 30 days of discharge. Results:Thirty-seven thousand one hundred seventy-three patients were included in the analysis. Overall emergency readmission rate was 8% (n = 2983): 2756 (7.8%) in patients without postoperative ICU admission; 155 (12.1%) with direct ICU admission and 65 (14.7%) with indirect ICU admission. Indirect ICU admission was associated with increased hospital readmission rates (HR 1.24 [1.03, 1.49]; p = 0.024) compared with direct ICU admission. ICU admission was associated with increased three-year readmission rates (p = 0.006) and costs (p < 0.001) compared with initial ward care. Conclusion:Indirect ICU admission is associated with increased emergency hospital readmission and healthcare costs for patients undergoing EGS.
Project description:To describe the case mix, activity, and outcome for admissions to intensive care units (ICUs) from emergency departments (EDs).An observational study using data from a high quality clinical database, the Case Mix Programme Database, of intensive care admissions, coordinated at the Intensive Care National Audit & Research Centre (ICNARC).91 adult ICUs in England, Wales, and Northern Ireland, 1996-99.46,587 intensive care admissions.Ultimate hospital mortality.Admissions from EDs constituted 26% of total admissions to ICU, 77% of which were direct admissions to ICU from EDs. Direct admissions from EDs, indirect admissions from EDs, and non-ED admissions presented to ICU with different conditions and severity of illness. Indirect admissions from EDs presented in the ICU with the more severe case mix (older age, more acute severity of illness, more likely to have a chronic illness) compared with direct admissions to ICU from EDs. Compared with ICU admissions not originating in EDs, unit and hospital mortality were higher for admissions from EDs, with indirect admissions experiencing the highest hospital (46.4%) mortality. For ICU survivors, indirect admissions stayed longest in the ICU.A large proportion of admissions to ICU (26%) originate in EDs, and differ from those not originating in EDs in terms of both case mix and outcome. Additionally, those admitted directly to ICU from EDs differ from those admitted indirectly via a ward. The observed differences in outcome between different admission routes require further investigation and explanation.
Project description:BACKGROUND:Unplanned readmissions to hospital are used in many healthcare systems as a quality indicator of care. Identifying patients at risk of readmission is difficult; existing prediction tools are only moderately sensitive. Correlations exist between certain medicines and emergency readmission, but it is not known whether the association is direct or indirect. OBJECTIVES:To determine whether person-centred pharmaceutical care bundles, comprising individualised medicines information, risk management and/or support in taking medicines, might prevent unplanned readmissions by improving adherence and reducing avoidable harm from prescribed medications. METHODS:We designed and implemented person-centred pharmaceutical care bundles for patients who were socially isolated and/or on high-risk medicines on one older people's medical ward for 1?year from February 2013. Another ward with similar patient demographics, service characteristics and a standard clinical pharmacy service was used as a comparator in a prospective cohort study. Readmission rates were retrospectively studied for 12?months before the intervention and during the 12-month intervention period. RESULTS:The readmission rates for the intervention and control wards in the 12?months before the intervention were not significantly different. During the intervention period, the readmission rate was significantly lower on the intervention ward (69/418) than on the control ward (107/490; 17% vs 22%, p<0.05, z=2.05, two-sample z test for difference in proportions of unrelated samples). CONCLUSIONS:Person-centred pharmaceutical care bundles were significantly associated with reduced risk of emergency hospital readmission in this study. Further evaluation of the model is warranted.
Project description:Although most intensive care unit (ICU) admissions originate in the emergency department (ED), a substantial number of admissions arrive from hospital wards. Patients transferred from the hospital ward often share clinical characteristics with those admitted from the ED, but family expectations may differ. An understanding of the impact of ICU admission source on family perceptions of end-of-life care may help improve patient and family outcomes by identifying those at risk for poor outcomes.This was a cohort study of patients with chronic illness and acute respiratory failure requiring mechanical ventilation who died after admission to an ICU in any of the 14 participating hospitals in the Seattle-Tacoma area between 2003 and 2008 (n = 1,500).Using regression models adjusted for hospital site and patient-, nurse- and family-level characteristics, we examined associations between ICU admission source (hospital ward vs. ED) and (1) family ratings of satisfaction with ICU care; (2) family and nurse ratings of quality of dying; (3) chart-based indicators of palliative care.Admission from the hospital ward was associated with lower family ratings of quality of dying [? -0.90, 95% confidence interval (CI) -1.54, -0.26, p = 0.006] and satisfaction (total score ? -3.97, 95% CI -7.89, -0.05, p = 0.047; satisfaction with care domain score ? -5.40, 95% CI -9.44, -1.36, p = 0.009). Nurses did not report differences in quality of dying. Patients from hospital wards were less likely to have family conferences [odds ratio (OR) 0.68, 95% CI 0.52, 0.88, p = 0.004] or discussion of prognosis in the first 72 h after ICU admission (OR 0.72, 95% CI 0.56, 0.91, p = 0.007) but were more likely to receive spiritual care (OR 1.48, 95% CI 1.14, 1.93, p = 0.003) or have life support withdrawn (OR 1.38, 95% CI 1.04, 1.82, p = 0.025).Admission from the hospital ward is associated with family perceptions of a lower quality of dying and less satisfaction with ICU care. Differences in receipt of palliative care suggest that family of patients from the hospital ward receive less communication. Nurse ratings of quality of dying did not significantly differ by ICU admission source, suggesting dissimilarities between family and nurse perspectives. This study identifies a patient population at risk for poor quality palliative and end-of-life care. Future studies are needed to identify interventions to improve care for patients who deteriorate on the wards following hospital admission.
Project description:Importance:The safety of discharging adult patients recovering from critical illness directly home from the intensive care unit (ICU) is unknown. Objective:To compare the health care utilization and clinical outcomes for ICU patients discharged directly home from the ICU with those of patients discharged home via the hospital ward. Design, Setting, and Participants:Retrospective population-based cohort study of adult patients admitted to the ICU of 9 medical-surgical hospitals from January 1, 2014, to January 1, 2016, with 1-year follow-up after hospital discharge. All adult ICU patients were discharged home alive from hospital, and the propensity score matched cohort (1:1) was based on patient characteristics, therapies received in the ICU, and hospital characteristics. Exposures:Patient disposition on discharge from the ICU: directly home vs home via the hospital ward. Main Outcomes and Measures:The primary outcome was readmission to the hospital within 30 days of hospital discharge. The secondary outcomes were emergency department visit within 30 days and death within 1 year. Results:Among the 6732 patients included in the study, 2826 (42%) were female; median age, 56 years (interquartile range, 41-67 years); 922 (14%) were discharged directly home, with significant variation found between hospitals (range, 4.4%-44.0%). Compared with patients discharged home via the hospital ward, patients discharged directly home were younger (median age 47 vs 57 years; P < .001), more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma (32%  vs 10% ; P < .001), to have a lower severity of acute illness on ICU admission (median APACHE II score 15 vs 18; P < .001), and receive less than 48 hours of invasive mechanical ventilation (42%  vs 34% ; P < .001). In the propensity score matched cohort (n = 1632), patients discharged directly home had similar length of ICU stay (median, 3.1 days vs 3.0 days; P = .42) but significantly shorter length of hospital stay (median, 3.3 days vs 9.2 days; P < .001) compared with patients discharged home via the hospital ward. There were no significant differences between patients discharged directly home or home via the hospital ward for readmission to the hospital (10% [n = 81] vs 11% [n = 92]; hazard ratio [HR], 0.88; 95% CI, 0.64-1.20) or emergency department visit (25% [n = 200] vs 26% [n = 212]; HR, 0.94; 95% CI, 0.81-1.09) within 30 days of hospital discharge. Four percent of patients in both groups died within 1 year of hospital discharge (n = 31 and n = 34 in the discharged directly home and discharged home via the hospital ward groups, respectively) (HR, 0.90; 95% CI, 0.60-1.35). Conclusions and Relevance:The discharge of select adult patients directly home from the ICU is common, and it is not associated with increased health care utilization or increased mortality.
Project description:Following emergency department (ED) assessment, patients with infection may be directly admitted to the intensive care unit (ICU) or alternatively admitted to hospital wards or sent home. Those admitted to the hospital wards or sent home may experience future deterioration necessitating ICU admission.We used a prospectively collected registry from two hospitals within a single tertiary care hospital network between 2011 and 2014. Patient information, outcomes, and costs were stored in the hospital data warehouse. Patients were categorized into three groups: (1) admitted directly from the ED to the ICU; (2) initially admitted to the hospital wards, with ICU admission within 72 hours of initial presentation; or (3) sent home from the ED, with ICU admission within 72 hours of initial presentation. Using multivariable logistic regression, we sought to compare outcomes and total costs between groups. Total costs were evaluated using a generalized linear model.A total of 657 patients were included; of these, 338 (51.4%) were admitted directly from the ED to the ICU, 246 (37.4%) were initially admitted to the wards and then to the ICU, and 73 (11.1%) were initially sent home and then admitted to the ICU. In-hospital mortality was lowest among patients admitted directly to the ICU (29.5%), as compared with patients admitted to the ICU from wards (42.7%) or home (61.6%) (P?<?0.001). As compared with direct ICU admission, disposition to the ward was associated with an adjusted OR of 1.75 (95% CI, 1.22-2.50; P?<?0.01) for mortality, and disposition home was associated with an adjusted OR of 4.02 (95% CI, 2.32-6.98). Mean total costs were lowest among patients directly admitted to the ICU ($26,748), as compared with those admitted from the wards ($107,315) and those initially sent home ($71,492) (P?<?0.001). Cost per survivor was lower among patients directly admitted to the ICU ($37,986) than either those initially admitted to the wards ($187,230) or those sent home ($186,390) (P?<?0.001).In comparison with direct admission to the ICU, patients with suspected infection admitted to the ICU who have previously been discharged home or admitted to the ward are associated with higher in-hospital mortality and costs.
Project description:OBJECTIVES:The National Early Warning Score (NEWS) was originally developed to assess hospitalised patients in the UK. We examined whether the NEWS could be applied to patients transported by ambulance in Japan. DESIGN:This retrospective study assessed patients and calculated the NEWS from paramedic records. Emergency department (ED) disposition data were categorised into the following groups: discharged from the ED, admitted to the ward, admitted to the intensive care unit (ICU) or died in the ED. The predictive performance of NEWS for patient disposition was assessed using receiver operating characteristic curve analysis. Patient dispositions were compared among NEWS-based categories after adjusting for age, sex and presence of traumatic injury. SETTING:A tertiary hospital in Japan. PARTICIPANTS:Overall, 2847 patients transported by ambulance between April 2017 and March 2018 were included. RESULTS:The mean (±SD) NEWS differed significantly among patients discharged from the ED (n=1330, 3.7±2.9), admitted to the ward (n=1263, 60.3±3.8), admitted to the ICU (n=232, 9.4±4.0) and died in the ED (n=22, 110.7±2.9) (p<0.001). The prehospital NEWS C-statistics (95% CI) for admission to the ward, admission to the ICU or death in the ED; admission to the ICU or death in the ED; and death in the ED were 0.73 (0.72-0.75), 0.81 (0.78-0.83) and 0.90 (0.87-0.93), respectively. After adjusting for age, sex and trauma, the OR (95% CI) of admission to the ICU or death in the ED for the high-risk (NEWS ?7) and medium-risk (NEWS 5-6) categories was 13.8 (8.9-21.6) and 4.2 (2.5-7.1), respectively. CONCLUSION:The findings from this Japanese tertiary hospital setting showed that prehospital NEWS could be used to identify patients at a risk of adverse outcomes. NEWS stratification was strongly correlated with patient disposition.
Project description:Patients with heart failure (HF) presenting to the emergency department (ED) can be admitted to care settings of different intensity, where the intensive care unit (ICU) is the highest intensity, ward admission is intermediate intensity, and those discharged home are of lowest intensity. Despite the costs associated with higher-intensity care, little is known about disposition decisions and outcomes of HF patients treated in different care settings.We identified predictors of ICU or ward admission and determined whether survival differs in patients admitted to higher-intensity versus lower-intensity care settings (ie, ICU vs ward, or ward vs ED-discharged). Among 9054 patients (median, 78 years; 51% men) presenting to an ED in Ontario, Canada, 1163 were ICU-admitted, 5240 ward-admitted, and 2651 were ED-discharged. Predictors of ICU (vs ward) admission included: use of noninvasive positive pressure ventilation (adjusted odds ratio [OR], 2.01; 95% CI, 1.36-2.98), higher respiratory rate (OR, 1.10 per 5 breaths/min; 95% CI, 1.05-1.15), and lower oxygen saturation (OR, 0.90 per 5%; 95% CI, 0.86-0.94; all P<0.001). Predictors of ward-admitted versus ED-discharged were similar. Propensity-matched analysis comparing lower-risk ICU to ward-admitted patients demonstrated a nonsignificant trend at 100 days (relative risk [RR], 0.69; 95% CI, 0.43-1.10; P=0.148). At 1 year, however, survival was higher among those initially admitted to ICU (RR, 0.68; 95% CI, 0.49-0.94; P=0.022). There was no survival difference among low-risk ward-admitted versus ED-discharged patients.Respiratory factors were associated with admission to higher-intensity settings. There was no difference in early survival between some lower-risk patients admitted to higher-intensity units compared to those treated in lower-intensity settings.
Project description:Objectives:To examine whether and how step-down unit admission after ICU discharge affects patient outcomes. Design:Retrospective study using an instrumental variable approach to remove potential biases from unobserved differences in illness severity for patients admitted to the step-down unit after ICU discharge. Setting:Ten hospitals in an integrated healthcare delivery system in Northern California. Patients:Eleven-thousand fifty-eight episodes involving patients who were admitted via emergency departments to a medical service from July 2010 to June 2011, were admitted to the ICU at least once during their hospitalization, and were discharged from the ICU to the step-down unit or the ward. Interventions:None. Measurements and Main Results:Using congestion in the step-down unit as an instrumental variable, we quantified the impact of step-down unit care in terms of clinical and operational outcomes. On average, for ICU patients with lower illness severity, we found that availability of step-down unit care was associated with an absolute decrease in the likelihood of hospital readmission within 30 days of 3.9% (95% CI, 3.6-4.1%). We did not find statistically significant effects on other outcomes. For ICU patients with higher illness severity, we found that availability of step-down unit care was associated with an absolute decrease in in-hospital mortality of 2.5% (95% CI, 2.3-2.6%), a decrease in remaining hospital length-of-stay of 1.1 days (95% CI, 1.0-1.2 d), and a decrease in the likelihood of ICU readmission within 5 days of 3.6% (95% CI, 3.3-3.8%). Conclusions:This study shows that there exists a subset of patients discharged from the ICU who may benefit from care in an step-down unit relative to that in the ward. We found that step-down unit care was associated with statistically significant improvements in patient outcomes especially for high-risk patients. Our results suggest that step-down units can provide effective transitional care for ICU patients.
Project description:OBJECTIVES:ICU admission delays can negatively affect patient outcomes, but emergency department volume and boarding times may also affect these decisions and associated patient outcomes. We sought to investigate the effect of emergency department and ICU capacity strain on ICU admission decisions and to examine the effect of emergency department boarding time of critically ill patients on in-hospital mortality. DESIGN:A retrospective cohort study. SETTING:Single academic tertiary care hospital. PATIENTS:Adult critically ill emergency department patients for whom a consult for medical ICU admission was requested, over a 21-month period. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Patient data, including severity of illness (Mortality Probability Model III on Admission), outcomes of mortality and persistent organ dysfunction, and hourly census reports for the emergency department, for all ICUs and all adult wards were compiled. A total of 854 emergency department requests for ICU admission were logged, with 455 (53.3%) as "accept" and 399 (46.7%) as "deny" cases, with median emergency department boarding times 4.2 hours (interquartile range, 2.8-6.3?hr) and 11.7 hours (3.2-20.3?hr) and similar rates of persistent organ dysfunction and/or death 41.5% and 44.6%, respectively. Those accepted were younger (mean ± SD, 61?±?17 vs 65?±?18 yr) and more severely ill (median Mortality Probability Model III on Admission score, 15.3% [7.0-29.5%] vs 13.4% [6.3-25.2%]) than those denied admission. In the multivariable model, a full medical ICU was the only hospital-level factor significantly associated with a lower probability of ICU acceptance (odds ratio, 0.55 [95% CI, 0.37-0.81]). Using propensity score analysis to account for imbalances in baseline characteristics between those accepted or denied for ICU admission, longer emergency department boarding time after consult was associated with higher odds of mortality and persistent organ dysfunction (odds ratio, 1.77 [1.07-2.95]/log10 hour increase). CONCLUSIONS:ICU admission decisions for critically ill emergency department patients are affected by medical ICU bed availability, though higher emergency department volume and other ICU occupancy did not play a role. Prolonged emergency department boarding times were associated with worse patient outcomes, suggesting a need for improved throughput and targeted care for patients awaiting ICU admission.
Project description:Objective:In the emergency department (ED), the severity assessment of shock is a fundamental step prior to the admission in the intensive care unit (ICU). As biomarkers are time consuming to evaluate the severity of micro- and macro-circulation alteration, capillary refill time and skin mottling score are two simple, available clinical criteria validated to predict mortality in the ICU. The aim of the present study is to provide clinical evidence that capillary refill time and skin mottling score assessed in the ED also predict ICU admission of patients with septic or haemorrhagic shock. Methods:This trial is an observational, non-randomised controlled study. A total of 1500 patients admitted to the ED for septic or haemorrhagic shock will be enrolled into the study. The primary outcome is the admission to the ICU. Results:The study will not impact the treatments provided to each patient. Capillary refill time and skin mottling score will not be taken into account to decide patient's treatments and/or ICU admission. Patients will be followed up during their hospital stay to determine their precise destination after the ED (home, ICU or ward) and the 28- and 90-day mortality after hospital admission. Conclusion:The results from the present study will provide clinical evidence on the correlation between the ICU admission and the capillary refill time and the skin mottling score in septic or haemorrhagic shock admitted to the ED. The aim of the present study is to provide two simple, reliable and non-invasive tools for the triage and early orientation of these patients.