Influence of the Admission Pattern on the Outcome of Patients Admitted to a Respiratory Intensive Care Unit: Does a Step-Down Admission Differ From a Step-Up One?

Abstract

BACKGROUND:The outcomes of patients admitted to a respiratory ICU (RICU) have been evaluated in the past, but no study has considered the influence of location prior to RICU admission. METHODS: We analyzed prospectively collected data from 326 consecutive patients admitted to a 7-bed RICU. The primary end points were survival and severity of morbidity-related complications, evaluated according to the patient's location prior to RICU admission. Three admission pathways were considered: step-down for patients transferred from the ICUs of our hospital; step-up for patients coming from our respiratory wards or other medical wards; and directly for patients coming from the emergency department. The secondary end point was the potential influence of several risk factors for morbidity and mortality. RESULTS: Of the 326 subjects, 92 (28%) died. Overall, subjects admitted in a step-up process had a significantly higher mortality (P < .001) than subjects in the other groups. The mortality rate was 64% for subjects admitted from respiratory ward, 43% for those from medical wards, and 18% for subjects from both ICU and emergency department (respiratory ward vs medical ward P ‫؍‬ .04, respiratory ward vs emergency department P < .001, respiratory ward vs ICU P < .001, medical ward vs emergency department P < .001, and medical ward vs ICU P < .001). Subjects admitted from a respiratory ward had a lower albumin level, and Simplified Acute Physiology Score II was significantly higher in subjects following a step-up admission. About 30% of the subjects admitted from a respiratory ward received noninvasive ventilation as a "ceiling treatment." The highest odds ratios related to survival were subject location prior to RICU admission and female sex. Lack of use of noninvasive ventilation, younger age, female sex, higher albumin level, lower Simplified Acute Physiology Score II, higher Barthel score, and absence of chronic heart failure were also statistically associated with a lower risk of death. CONCLUSIONS: The pathway of admission to a RICU is a determinant of outcome. Patients following a step-up pattern are more likely to die. Other major determinants of survival are age, nutritional status and female sex.

Outcomes of Prolonged Mechanical Ventilation Before and After Implementation of a Respiratory ICU

“…21 It may be classified as follows: step-down pathway, which corresponds to an admission from an ICU; step-up pathway, which corresponds to an admission from a hospital ward; or direct pathway, which corresponds to an admission from the emergency department. 22 These patterns differed in our hospital according to the pre-RICU period or RICU period in that the 3 previously described patterns were possible during the pre-RICU period, whereas the step-down pattern was the one authorized by the Regional Health Agency. Patients admitted in a RICU according to a step-up pattern usually have a poorer prognosis than those admitted according to the step-down pattern.…”

Intermediate care to intensive care triage: A quality improvement project to reduce mortality

“…Patients who may worsen and need ICU care will be better served in an ICU than patients awaiting ICU downgrade [36]. …”

New Surviving Sepsis Campaign guidelines: back to the art of medicine

“…factor in RHDUs, accounting for 36% of the causes of death in severe acute respiratory failure (ARF) [15]. In the clinical setting of a tremendously increasing burden of critically ill respiratory patients, RHDUs provide a specialised quality of care for ARF patients who require an intermediate level of care between ICU and wards, with health resources optimisation in Europe [16].…”

“…A recent Spanish multicentre study [29] demonstrated that although the incidence of sepsis/septic shock remained unchanged during a 10-year period, implementation of SSC guidelines decreased the severity of illness and overall mortality. Mortality of sepsis has been shown to be correlated with pre-ICU/RHDCU admission site [13,15]. Patients with sepsis/septic shock identified in emergency departments, general wards and ICUs in Europe were more severely ill than those in the USA with similar mortality if adjusted for severity of illness and organ dysfunction.…”

“…Similarly, survival is greater in patients admitted to RHDCU as a "step down" from the ICU or emergency department than in those admitted as a "step up" from the wards. This discrepancy could be explained by the fact that the latter patients were more severely ill than the former because they developed a progressive worsening of their conditions while being outside a protected environment [15]. This risk is greater for septic patients whose prognosis is strongly dependent on the prompt application of SSC bundles.…”