Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study

Abstract

IntroductionThe aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU.MethodsAn observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days).ResultsOne hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002).ConclusionsThe presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment.Trial registrationClinicaltrials.gov NCT01422070. Registered 19 August 2011.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0551-8) contains supplementary material, which is available to authorized users.

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“…61,62 This significant finding necessitates that care coordination for complex critically ill patients incorporate methods that include stringent practices for medication reconciliation. Vital to the development of medication reconciliation initiatives is the inclusion of both the patient's baseline preadmission home medications and an ongoing assessment of the need for continuing medications.…”

“…Vital to the development of medication reconciliation initiatives is the inclusion of both the patient's baseline preadmission home medications and an ongoing assessment of the need for continuing medications. 61,63 Implementation of 1 measure by Pronovost et al 63 demonstrated that use of a simple safety check system comparing patient's current medications, home (preadmission) medications, and transfer medications revealed that initially more than 94% of ICU patients were leaving the unit with potential medication errors. Following implementation of the medication reconciliation process, this rate decreased to almost zero.…”

“…61,62 Vital to the implementation of medication reconciliation practices is the development of systems that are easily incorporated within the care plan and diminish the care burden of the critical care bedside nurse who is completing the reconciliation tool. 61,63,64 Computerized charting systems and patient data management systems have also been identified as effective and innovative methods to streamline medication reconciliation practices during transitions of care within the acute care setting and facilitate improved institutional compliance. 39,63 Conclusions Based on the Evidence…”

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“…Additionally, having an intermediate-care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in-hospital mortality. 3 A study by Ghaferi et al showed that survival after in-hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse-to-patient ratios, and high-level hospital technology. 4 Therefore, there are many factors that could have had an impact on in-hospital mortality in this study.…”

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“…Critical illness is different from other illness as it is often unexpected, sudden and a life-threatening condition which requires a high level of treatment especially in the initial phase of management of patients admitted to the intensive care units (ICUs). 1,2 It is indeed associated with long term impact on functional status and their quality of life. The primary goal of an ICU is to save the life of critically ill patients by detecting and treating their functional derangements, thereby decreasing the inhospital mortality rate.…”