Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI / Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU

Detectar posibles razones de la mortalidad de los pacientes críticos trasladados desde la UCI a las plantas del hospital y analizar las potenciales causas atribuibles de esta mortalidad. Diseño Estudio observacional de datos prospectivos analizados retrospectivamente. Muestra Cohorte de 5.328 pacientes ingresados consecutivamente en nuestro SMI cuya evolución se sigue hasta el fallecimiento o el alta hospitalaria. Período Desde enero de 2006 a diciembre de 2009. Método Análisis de significación diferencial de datos epidemiológicos, clínico-asistenciales, de estimación de riesgo de muerte, de coincidencia de diagnóstico de causa de ingreso en UCI y de causa de fallecimiento y de incidencia de limitación de esfuerzo asistencial. Se consideró alta inadecuada de UCI si la muerte acontecía antes de las 48h del traslado, sin limitación de esfuerzo asistencial.ResultadosFallecieron 907 pacientes (tasa estandarizada de 0,9; IC del 95%, 0,87-0,93) de los que 202 fallecieron tras el alta del SMI (el 3,8% de la población total y el 22,3% de los fallecidos); la estancia en planta post-UCI fue de 12,4±17,9 días. No se detectaron diferencias significativas entre los fallecidos en UCI o tras la estancia en UCI respecto a complicaciones infectivas aparecidas tras el ingreso. Tampoco los reingresados en UCI tras el pase a planta presentaron una mayor mortalidad. Se comprueba que la causa de muerte en planta no es significativamente coincidente con la causa de ingreso en UCI. Discusión Cierta mortalidad de pacientes críticos tras el traslado desde UCI es un hecho habitual. Nuestros datos no permiten atribuir esta mortalidad a deficiencias asistenciales (altas inadecuadas o disminución de asistencia en planta). Las razones para esta mortalidad tienen una explicación variada y variable, y en su mayoría corresponden a evolución del paciente diferente de la previsible tras el traslado desde el SMI (AU)

Objective: To detect possible reasons for mortality of critical patients transferred from the ICUto the hospital wards and to analyze the possible attributable causes for such mortality.Design: An observational study of prospectively collected data, analyzed retrospectively.Population: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolutionwas followed up to hospital discharge or death. Period: From January 2006 to December 2009. Method: An analysis was made of differential significance of epidemiological, clinical-care,death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, withoutlimitation of care effort. Results: A total of 907 patients died (SMR = 0.9; 95% CI, 0.87-0.93), 202 of whom died afterICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of staybeing 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greatermortality was also not found in those re-admitted to the ICU after having been transferred tothe ward. It was verified that the cause of death in the ward did not significantly coincide withthe cause of admission to the ICU.Discussion: Some mortality after ICU discharge is to be expected. Our data do not allow usto attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceasedcare in the wards). The reasons for this mortality have a varied and variable explanation. Itmostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU (AU)

[Study of post-ICU mortality during 4 years (2006-2009). Analysis of the factors related to death in the ward after discharge from the ICU]. / Estudio de la mortalidad post-UCI durante 4 años (2006-2009). Análisis de factores en relación con el fallecimiento en planta tras el alta de UCI.

OBJECTIVE: To detect possible reasons for mortality of critical patients transferred from the ICU to the hospital wards and to analyze the possible attributable causes for such mortality. DESIGN: An observational study of prospectively collected data, analyzed retrospectively. POPULATION: Cohort analysis of 5328 with consecutive admissions to our ICU, whose evolution was followed up to hospital discharge or death. PERIOD: From January 2006 to December 2009. METHOD: An analysis was made of differential significance of epidemiological, clinical-care, death risk estimate, coincidence between ICU admissions reasons and causes of death after ICU discharge, as well as limitation of health care effort incidence. Inappropriate ICU discharge was considered to exist if the death occurred during the first 48 hours after ICU transfer, without limitation of care effort. RESULTS: A total of 907 patients died (SMR=0.9; 95% CI, 0.87-0.93), 202 of whom died after ICU discharge (3.8% of total sample and 22.3% of all deceased patients), ward length of stay being 12.4±17.9 days. No significant differences were found between deaths in the ICU or post-ICU deaths regarding infective complications appearing after admission to the ICU. Greater mortality was also not found in those re-admitted to the ICU after having been transferred to the ward. It was verified that the cause of death in the ward did not significantly coincide with the cause of admission to the ICU. DISCUSSION: Some mortality after ICU discharge is to be expected. Our data do not allow us to attribute this mortality rate to care deficiencies (inappropriate ICU discharges or deceased care in the wards). The reasons for this mortality have a varied and variable explanation. It mostly corresponds to an evolution of the patients differing from that expected when they were discharged from ICU.

[Bias in time delay in ICU admission as a mortality risk factor or "lead time bias"]. / Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias.

OBJECTIVE: To assess if delay in admission to the Intensive Care Unit (ICU), measured according to the prognostic estimation of survival in critical patients (EPEC) system, influences the final outcome of patients admitted to our ICU. DESIGN: Retrospective and systematic analysis of data collected during six months in 2003. SETTING: Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital. PATIENTS: Four hundred and eighty one patients consecutively admitted to our ICU and followedup to hospital discharge. MAIN INTEREST VARIABLES: Risk of death was estimated with the EPEC, SAPS II and MPM II 0. Variables collected were gender, age, origin of admission, risk of death by means of the 3 methods mentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead). RESULTS: A total of 44 out of 481 patients died during the hospital stay, overall admission delay being 0.7 +/- 1.98 hours (2.96 +/- 3.28, range 0.25-20 hours, for those with delay > 0). No differences were found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0). CONCLUSIONS: Our study does not make it possible to relate lead time bias with patient survival. Due to the EPEC design, it is possible to differentiate "physiopathological delay" (inappropriate detection of the critical situation) and "logistic delay" (conditioned by factors such as lack of available beds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias.

Sesgo de retraso en el ingreso en la Unidad de Cuidados Intensivos como causa de mal pronóstico o lead time bias / Bias in time delay in ICU admission as a mortality risk factor or “lead time bias”

Objetivo. Comprobar cómo el tiempo de retraso en el ingreso, cuantificado conforme al sistema EPEC, influye en el resultado final de los pacientes ingresados en nuestro Servicio de Medicina Intensiva.Diseño. Análisis retrospectivo de datos recogidosde forma sistemática y prospectiva durante un período de 6 meses del año 2003.Ámbito. Servicio de Medicina Intensiva de 19 camas (15 de la Unidad de Cuidados Intensivos convencional y 4 de Cuidados Intermedios) en un hospital docente de referencia.Pacientes. Cuatrocientos ochenta y un pacientesingresados en nuestro Servicio y seguidos hasta su alta hospitalaria. Principales variables de interés. El riesgo de muerte de los pacientes fue estimado por mediode EPEC, SAPS 2 y MPM II 0. Las variables recogidasfueron sexo, edad, procedencia, tipo de paciente,riesgo de muerte por los tres sistemas mencionados, retraso en el ingreso en horas (conforme EPEC) y estado vital (vivo o muerto) tanto a la salida de la Unidad de Cuidados Intensivos como al abandonar el hospital.Resultados. Fallecieron 44 pacientes de los 481ingresados, siendo el retraso global en el ingresode 0,7 ± 1,98 horas (2,96 ± 3,28, límites 0,25-20 horas,para aquellos con retraso > 0). No se enconencontrarondiferencias en el retraso de ingreso entre vivosy fallecidos, y existió una correlación muy malaentre el pronóstico realizado con consideracióndel tiempo de retraso en el ingreso y el que se estableció sin considerarlo (SAPS 2 y MPM II 0).Conclusiones. Nuestro estudio no permite relacionarel sesgo temporal (retraso en el ingreso)con la supervivencia o no de los pacientes. Por eldiseño de EPEC se distingue entre el «retraso fisiopatológico » (detección inapropiada de la situaciónde gravedad) y el «retraso logístico» (condicionadopor factores tales como falta de camas disponibles). Nuestro estudio y EPEC sólo consideran este último. No puede descartarse que el incremento de mortalidad respecto al pronóstico esté relacionado directamente con el primer tipo de retraso y no con el sesgo temporal globalmente considerado

Objective. To assess if delay in admission to theIntensive Care Unit (ICU), measured according tothe prognostic estimation of survival in critical patients (EPEC) system, influences the final outcomeof patients admitted to our ICU.Design. Retrospective and systematic analysis of data collected during six months in 2003. Setting. Nineteen-bed ICU (15 from Standard intensive care and 4 from intermediate care) in a referral teaching hospital.Patients. Four hundred and eighty one patientsconsecutively admitted to our ICU and followedup to hospital discharge Main interest variables. Risk of death was estimated with the EPEC, SAPS II and MPM II 0.Variables collected were gender, age, origin ofadmission, risk of death by means of the 3 methodsmentioned, admission time delay (lead time bias) as measured by EPEC and life status on ICU and hospital discharge (alive or dead).Results. A total of 44 out of 481 patients diedduring the hospital stay, overall admission delaybeing 0.7 ± 1.98 hours (2.96 ± 3.28, range 0.25-20hours, for those with delay > 0). No differenceswere found when comparing delay in admission among those surviving and the deceased, and there was very bad correlation between the prognosis made considering delay time for admission and that established without considering it (SAPS II or MPM II 0).Conclusions. Our study does not make it possibleto relate lead time bias with patient survival.Due to the EPEC design, it is possible to differentiate“physiopathological delay” (inappropriate detection of the critical situation) and “logistic delay”(conditioned by factors such as lack of availablebeds). Our study as well as the EPEC only considers the latter. It cannot be ruled out that the increase in mortality regarding prognosis is directly related with first type of delay and not with the overall lead time bias