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

INTRODUCTION: The 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. METHODS: An 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). RESULTS: One 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). CONCLUSIONS: The 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 REGISTRATION: Clinicaltrials.gov NCT01422070. Registered 19 August 2011.

Predicting resource utilization of elderly burn patients in the baby boomer era.

BACKGROUND: Census predictions for Florida suggest a 3-fold increase in the 65 and older population within 20 years. We predict resource utilization for burn patients in this age group. METHODS: Using the Florida Agency for Healthcare Administration admission dataset, we evaluated the effect of age on length of stay, hospital charges, and discharge disposition while adjusting for clinical and demographic factors. Using US Census Bureau data and burn incidence rates from this dataset, we estimated future resource use. RESULTS: Elderly patients were discharged to home less often and were discharged to short-term general hospitals, intermediate-care facilities, and skilled nursing facilities more often than the other age groups (P < .05). They also required home health care and intravenous medications significantly more often (P < .05). Their length of stay was longer, and total hospital charges were greater (P < .05) after adjusting for sex, race, Charleson comorbidity index, payer, total body surface area burned, and burn center treatment. CONCLUSIONS: Our data show an age-dependent increase in the use of posthospitalization resources, the length of stay, and the total charges for elderly burn patients.

Results of a retrospective observational study of intermediate care staffed by hospitalists: impact on mortality, co-management, and teaching.

BACKGROUND: Hospitalized patients are complex and institutions have to face the high cost of critical care and the limited resources of the ward. Intermediate care appears as an attractive strategy to provide rational care according to patient needs. It is an interesting scenario to expand co-management and teaching. STUDY DESIGN: Retrospective observational study. SETTING: Intermediate care unit (ImCU) of a single academic hospital. PATIENTS AND METHODS: 456 patients admitted from April 2006 to April 2010 were included in the study. Demographics, admission physiologic parameters and in-hospital mortality were recorded. We used the Simplified Acute Physiology Score II (SAPS II) as prognostic score system. Co-management with medical and surgical teams, and the number of training residents were evaluated. RESULTS: In-hospital mortality was 20.6%, whereas the expected mortality was 23.2% based on SAPS II score. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, p < 0.001). Co-management was performed with several medical and surgical teams, with an increase in perioperative comanagement of 22.7% (p = 0.014). The number of training residents in ImCU increased from 4.3% to 30.4% (p = 0.002) CONCLUSIONS: An ImCU led by hospitalists showed encouraging results regarding patient survival and SAPS II is an useful tool for prognostic evaluation in this population. Intermediate care serves as an expansion of role for hospitalists; and clinicians, trainees and patients may benefit from co-management and teaching opportunities at this unique level of care.

Intermediate care--a challenge to specialty of geriatric medicine or its renaissance?

The specialism of geriatric medicine has developed considerably in the last half of the twentieth century. In Great Britain it has emerged from its sombre beginnings in Victorian poor law institutions to become one of the largest specialities in medicine encompassing a wide range of disciplines and interests. More recently, there has been a parallel development in "intermediate care" a sweeping phrase that encompasses a wide diversity of practices in a plethora of venues. Although there is considerable attraction in minimising the duration of hospital stay by older people, there is a real risk of intermediate care being used as a euphemism for indeterminate neglect. For older people to benefit from appropriate treatment and care, the lessons learnt by earlier generations of geriatricians, and supported by the international evidence base should not be disregarded. Elderly people need a full multi-disciplinary assessment (comprehensive geriatric assessment) and continued involvement of skilled and trained personnel in their continuing care (geriatric evaluation and management). The recommendations of the British Geriatrics Society on intermediate care are commended and should be adhered to by all planners and providers of intermediate care. There is considerable logic in developing ways in which the two developments can be integrated to build upon the best features of both.

Prediccion de la evolucion postoperatoria en una unidad de cuidados intermedios

Se ha correlacionado la evaluacion post-operatoria inmediata y mediata de 65 pacientes mayores de 60 años con diagnosticos pre-operatorios de abdomen agudo quirurgico y oclusion arterial aguda de miembros inferiores. Todos los pacientes fueron sometidos a cirugia mayor, en malas condiciones la mayoria de ellos. Hemos utilizado una escala de evaluacion que la hemos denominado P.O.T.O.S.I. (Pronostico organico del trauma operatorio en sala de cuidados intermedios). Dicha escala nos ayudo a predecir, segun puntuacion correspondiente la mortalidad y morbilidad de dichos pacientes y lo mas importante, que corrigiendo ciertos valores organicos en franca alteracion, mejoramos el pronostico. De 65 pacientes 22 presentaron complicaciones postoperatorias, 8 fallecieron y los restantes evolucionaron favorablemente.

Changes in psychotropic drug use in long-term residents of an ICF/MR facility.

Psychotropic drug use of 139 persons residing continuously over a 10-year period in an ICF/MR was monitored. Results indicate an ongoing decrease in psychotropic drug use, primarily antipsychotic agents, as well as the benefits of ongoing monitoring of individual drug usage. This monitoring can be utilized to minimize side effects of medication. Information obtained can be organized and utilized to improve care. Drug histories, when used with other data pertinent to targeted benefit to risk of medication.

Assessment of needs of adults with developmental disabilities in skilled nursing and intermediate care facilities in Illinois.

Findings are reported from a statewide assessment of the habilitation, medical, and behavioral training needs of adults with developmental disabilities in Illinois general nursing homes. Only 10% were determined to be appropriately placed in medical settings, and only 27% were enrolled in developmental training programs. A large proportion of those recommended for alternative residential settings had significantly more intense medical, adaptive behavior, self-care, and self-preservation needs than did residents who typically reside in residential facilities for persons with developmental disabilities. Historical barriers to addressing the residential and active treatment needs of the assessed residents were discussed as were recent program developments in Illinois and implications of this study for other states.

Psychotropic drug patterns in a large ICF/MR facility: a ten-year experience.

Psychotropic drug-prescribing patterns for a stable cohort of 474 persons in continuous residence at an ICF/MR facility for a 10-year period were recorded and classified by drug type. Results indicated a progressive, marked decrease in total psychotropic drug usage and changes in the type of drugs prescribed. The findings indicate the importance of physician awareness of drug side-effects and alternate treatment possibilities.