Comparison of patient characteristics and long-term mortality between transferred and non-transferred COVID-19 patients in Dutch intensive care units: A national cohort study.

BACKGROUND: COVID-19 patients were often transferred to other intensive care units (ICUs) to prevent that ICUs would reach their maximum capacity. However, transferring ICU patients is not free of risk. We aim to compare the characteristics and outcomes of transferred versus non-transferred COVID-19 ICU patients in the Netherlands. METHODS: We included adult COVID-19 patients admitted to Dutch ICUs between March 1, 2020 and July 1, 2021. We compared the patient characteristics and outcomes of non-transferred and transferred patients and used a Directed Acyclic Graph to identify potential confounders in the relationship between transfer and mortality. We used these confounders in a Cox regression model with left truncation at the day of transfer to analyze the effect of transfers on mortality during the 180 days after ICU admission. RESULTS: We included 10,209 patients: 7395 non-transferred and 2814 (27.6%) transferred patients. In both groups, the median age was 64 years. Transferred patients were mostly ventilated at ICU admission (83.7% vs. 56.2%) and included a larger proportion of low-risk patients (70.3% vs. 66.5% with mortality risk <30%). After adjusting for age, APACHE IV mortality probability, BMI, mechanical ventilation, and vasoactive medication use, the hazard of mortality during the first 180 days was similar for transferred patients compared to non-transferred patients (HR [95% CI] = 0.99 [0.91-1.08]). CONCLUSIONS: Transferred COVID-19 patients are more often mechanically ventilated and are less severely ill compared to non-transferred patients. Furthermore, transferring critically ill COVID-19 patients in the Netherlands is not associated with mortality during the first 180 days after ICU admission.

Comparing continuous versus categorical measures to assess and benchmark intensive care unit performance.

PURPOSE: To compare categorical and continuous combinations of the standardized mortality ratio (SMR) and the standardized resource use (SRU) to evaluate ICU performance. MATERIALS AND METHODS: We analysed data from adult patients admitted to 128 ICUs in Brazil and Uruguay (BR/UY) and 83 ICUs in The Netherlands between 2016 and 2018. SMR and SRU were calculated using SAPS-3 (BR/UY) or APACHE-IV (The Netherlands). Performance was defined as a combination of metrics. The categorical combination was the efficiency matrix, whereas the continuous combination was the average SMR and SRU (average standardized ratio, ASER). Association among metrics in each dataset was evaluated using Spearman's rho and R2. RESULTS: We included 277,459 BR/UY and 164,399 Dutch admissions. Median [interquartile range] ASER = 0.99[0.83-1.21] in BR/UY and 0.99[0.92-1.09] in Dutch datasets. The SMR and SRU were more correlated in BR/UY ICUs than in Dutch ICUs (Spearman's Rho: 0.54vs.0.24). The highest and lowest ASER values were concentrated in the least and most efficient groups. An expert focus group listed potential advantages and limitations of both combinations. CONCLUSIONS: The categorical combination of metrics is easy to interpret but limits statistical inference for benchmarking. The continuous combination offers appropriate statistical properties for evaluating performance when metrics are positively correlated.

Number of intensivists per bed is associated with efficiency of Dutch intensive care units.

PURPOSE: To measure efficiency in Intensive Care Units (ICUs) and to determine which organizational factors are associated with ICU efficiency, taking confounding factors into account. MATERIALS AND METHODS: We used data of all consecutive admissions to Dutch ICUs between January 1, 2016 and January 1, 2019 and recorded ICU organizational factors. We calculated efficiency for each ICU by averaging the Standardized Mortality Ratio (SMR) and Standardized Resource Use (SRU) and examined the relationship between various organizational factors and ICU efficiency. We thereby compared the results of linear regression models before and after covariate adjustment using propensity scores. RESULTS: We included 164,399 admissions from 83 ICUs. ICU efficiency ranged from 0.51-1.42 (average 0.99, 0.15 SD). The unadjusted model as well as the propensity score adjusted model showed a significant association between the ratio of employed intensivists per ICU bed and ICU efficiency. Other organizational factors had no statistically significant association with ICU efficiency after adjustment. CONCLUSIONS: We found marked variability in efficiency in Dutch ICUs. After applying covariate adjustment using propensity scores, we identified one organizational factor, ratio intensivists per bed, having an association with ICU efficiency.