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2.
Intensive Care Med ; 46(8): 1567-1575, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32500182

RESUMO

PURPOSE: Patients with persistent critical illness may account for up to half of all intensive care unit (ICU) bed-days. It is unknown if there is hospital variation in the development of persistent critical illness and if hospital performance affects the incidence of persistent critical illness. METHODS: This is a retrospective analysis of Veterans admitted to the Veterans Administration (VA) ICUs from 2015 to 2017. Hospital performance was defined by the risk- and reliability-adjusted 30-day mortality. Persistent critical illness was defined as an ICU length of stay of at least 11 days. We used 2-level multilevel logistic regression models to assess variation in risk- and reliability-adjusted probabilities in the development of persistent critical illness. RESULTS: In the analysis of 100 hospitals which encompassed 153,512 hospitalizations, 4.9% (N = 7640/153,512) developed persistent critical illness. There was variation in the development of persistent critical illness despite controlling for patient characteristics (intraclass correlation: 0.067, 95% CI 0.049-0.091). Hospitals with higher risk- and reliability-adjusted 30-day mortality had higher probabilities of developing persistent critical illness (predicted probability: 0.057, 95% CI 0.051-0.063, p < 0.01) compared to those with lower risk- and reliability-adjusted 30-day mortality (predicted probability: 0.046, 95% CI 0.041-0.051, p < 0.01). The median odds ratio was 1.4 (95% CI 1.33-1.49) implying that, for two patients with the same physiology on admission at two different VA hospitals, the patient admitted to the hospital with higher adjusted mortality would have 40% greater odds of developing persistent critical illness. CONCLUSION: Hospitals with higher risk- and reliability-adjusted 30-day mortality have a higher probability of developing persistent critical illness. Understanding the drivers of this variation may identify modifiable factors contributing to the development of persistent critical illness.

3.
Crit Care Explor ; 2(4): e0102, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32426744

RESUMO

We aimed to understand the prevalence, timing of onset, resource use, and long-term outcomes of patients who developed persistent critical illness in a national dataset. Design: Retrospective cohort. Using a physiologic risk adjustment model from ICU admission, we examined the relative ability of acute (related to reason for ICU presentation) and antecedent (demographics, comorbidities) characteristics to discriminate hospital mortality models. Persistent critical illness was defined as the point during an ICU stay when, at the population-level, patients' acute diagnoses and physiologic disturbance are no longer more accurate at discriminating who survives than are baseline demographics and comorbidity. We examined the change across ICU stay in the relative discrimination of those characteristics, and short-term (in-hospital and 30 d after admission) and medium-term (90 d after admission) survival. Finally, we analyzed the changes in the population definition of persistent critical illness over time. Setting: Patients admitted as level 3 to Scottish ICUs between 2005 and 2014. Patients: Seventy-two-thousand two-hundred fifty-three adult level 3 ICU admissions in 23 ICUs across Scotland. Interventions: None. Measurements and Main Results: The onset of persistent critical illness, occurs at an average of 5.0 days (95% CI, 3.9-6.4 d) across this dataset. The crossing point increased across the decade, by an average of 0.36 days (95% CI, 0.22-0.50 d) per year. In this dataset, 24,425 (33.8%) remained in the ICU long enough to meet this greater than 5-day definition of persistent critical illness. The care of such patients involved 72.3% ICU days used by any level 3 patient; 46.5% of all Scottish ICU bed-days were after day 5. Although rates of 30 days after admission survival rose dramatically during the decade under study, these rates were similar for those with shorter or longer ICU stays, as were the rates of 90-day survival among those who survived at least 30 days. Conclusions: Persistent critical illness occurred in one in three ICU patients in Scotland. These minority of patients accounted for disproportionate hospital resources but did not have worse 30- or 90-day postadmission survival.

4.
Chest ; 158(2): 571-578, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32278780

RESUMO

BACKGROUND: Little is known about the prevalence, predictors, and outcomes of late vasopressor administration which evolves after admission to the ICU. RESEARCH QUESTION: What is the epidemiology of late vasopressor administration in the ICU? STUDY DESIGN AND METHODS: We retrospectively studied a cohort of veterans admitted to the Veterans Administration ICUs for ≥ 4 days from 2014 to 2017. The timing of vasopressor administration was categorized as early (only within the initial 3 days), late (on day 4 or later and none on day 3), and continuous (within the initial 2 days through at least day 4). Regressions were performed to identify patient factors associated with late vasopressor administration and the timing of vasopressor administration with posthospitalization discharge mortality. RESULTS: Among the 62,206 hospitalizations with at least 4 ICU days, late vasopressor administration occurred in 5.5% (3,429 of 62,206). Patients with more comorbidities (adjusted OR [aOR], 1.02 per van Walraven point; 95% CI, 1.02-1.03) and worse severity of illness on admission (aOR, 1.01 per percentage point risk of death; 95% CI, 1.01-1.02) were more likely to receive late vasopressor therapy. Nearly 50% of patients started a new antibiotic within 24 h of receiving late vasopressor therapy. One-year mortality after survival to discharge was higher for patients with continuous (adjusted hazard ratio [aHR], 1.48; 95% CI, 1.33-1.65) and late vasopressor administration (aHR, 1.26; 95% CI, 1.15-1.38) compared with only early vasopressor administration. INTERPRETATION: Late vasopressor administration was modestly associated with comorbidities and admission illness severity. One-year mortality was higher among those who received late vasopressor administration compared with only early vasopressor administration. Research to understand optimization of late vasopressor therapy administration may improve long-term mortality.

7.
BMC Med Res Methodol ; 19(1): 94, 2019 05 08.
Artigo em Inglês | MEDLINE | ID: mdl-31068135

RESUMO

BACKGROUND: To study patient physiology throughout a period of acute hospitalization, we sought to create accessible, standardized nationwide data at the level of the individual patient-facility-day. This methodology paper summarizes the development, organization, and characteristics of the Veterans Affairs Patient Database 2014-2017 (VAPD 2014-2017). The VAPD 2014-2017 contains acute hospitalizations from all parts of the nationwide VA healthcare system with daily physiology including clinical data (labs, vitals, medications, risk scores, etc.), intensive care unit (ICU) indicators, facility, patient, and hospitalization characteristics. METHODS: The VA data structure and database organization represents a complex multi-hospital system. We define a single-site hospitalization as one or more consecutive stays with an acute treating specialty at a single facility. The VAPD 2014-2017 is structured at the patient-facility-day level, where every patient-day in a hospital is a row with separate identification variables for facility, patient, and hospitalization. The VAPD 2014-2017 includes daily laboratory, vital signs, and inpatient medication. Such data were validated and verified through lab value range and comparison with patient charts. Sepsis, risk scores, and organ dysfunction definitions were standardized and calculated. RESULTS: We identified 565,242 single-site hospitalizations (SSHs) in 2014; 558,060 SSHs in 2015; 553,961 SSHs in 2016; and 550,236 SSHs in 2017 at 141 VA hospitals. The average length of stay was four days for all study years. In-hospital mortality decreased from 2014 to 2017 (1.7 to 1.4%), 30-day readmission rates increased from 15.3% in 2014 to 15.6% in 2017; 30-day mortality also decreased from 4.4% in 2014 to 4.1% in 2017. From 2014 to 2017, there were 107,512 (4.8%) of SSHs that met the Center for Disease Control and Prevention's Electronic Health Record-based retrospective definition of sepsis. CONCLUSION: The VAPD 2014-2017 represents a large, standardized collection of granular data from a heterogeneous nationwide healthcare system. It is also a direct resource for studying the evolution of inpatient physiology during both acute and critical illness.


Assuntos
Bases de Dados Factuais , Registros Eletrônicos de Saúde/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Idoso , Feminino , Mortalidade Hospitalar , Hospitais/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Sepse , Índice de Gravidade de Doença , Estados Unidos , United States Department of Veterans Affairs
8.
Crit Care Resusc ; 21(1): 39-44, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30857511

RESUMO

OBJECTIVE: The purpose of this study was to evaluate if vitamin D deficiency is associated with increased rates of persistent critical illness, and whether repletion of vitamin D among patients with this deficiency leads to decreased persistent critical illness. DESIGN: Retrospective cohort analysis. SETTING: Seven intensive care units (ICUs) at the University Medical Center of Graz, Austria, with participants recruited between July 2008 and April 2010. The VITdAL-ICU trial cohort included five ICUs at the University Medical Center of Graz, Austria, with patients recruited between May 2010 through September 2012. PARTICIPANTS: There were 628 patients aged ≥ 18 years admitted to the ICU and who had their 25-hydroxyvitamin D (25(OH)D) level measured at least once. The VITdAL-ICU cohort included 475 patients aged ≥ 18 years who were expected to stay in the ICU for greater than 48 hours and found to have a 25(OH)D level of ≤ 20 ng/mL. MAIN OUTCOME MEASURES: Development of persistent critical illness. RESULTS: In the retrospective cohort, vitamin D level on admission was not significantly associated with the development of persistent critical illness compared with patients who were discharged alive earlier (relative risk ratio [RRR], 1.02; 95% CI, 1.00-1.04) or who died (RRR, 1.02; 95% CI, 0.99-1.05). In the VITdAL-ICU trial, supplementation with vitamin D3 did not lead to less persistent illness relative to patients who were discharged alive earlier (RRR, 1.19; 95% CI, 0.79-1.80) or who died (RRR, 1.34; 95% CI, 0.72-2.52). CONCLUSION: Vitamin D deficiency was not associated with persistent critical illness, nor did supplementation with vitamin D3 mitigate the development of persistent critical illness.


Assuntos
Estado Terminal/terapia , Deficiência de Vitamina D/terapia , Vitamina D/administração & dosagem , Vitamina D/uso terapêutico , Vitaminas/administração & dosagem , Adolescente , Adulto , Estudos de Coortes , Humanos , Unidades de Terapia Intensiva , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Vitamina D/sangue , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/tratamento farmacológico , Vitaminas/uso terapêutico
9.
Clin Pulm Med ; 26(5): 141-145, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32454571

RESUMO

Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty as well as uncertainty regarding patients' goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to employ a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient's progress according to previously-established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal timeframes for TLTs, and interventional trials to determine if TLTs ultimately improve the delivery of goal-concordant care in the ICU.

11.
Crit Care Clin ; 34(4): 493-500, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30223989

RESUMO

The differential diagnosis of prolonged intensive care unit (ICU) stays includes intrinsic patient and admitting diagnostic characteristics, occurrences during the course of critical illness, and system failures. Existing data suggest that the most common cause of prolonged ICU stay is the development of new cascading problems, which is now more related to ongoing critical illness than the original reason for ICU admission. Accepting the dynamism inherent in such a clinical course has implications for contemporary clinical care.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Unidades de Terapia Intensiva/organização & administração , Tempo de Internação , Estado Terminal/epidemiologia , Diagnóstico Diferencial , Humanos , Fatores de Tempo
12.
Intensive Care Med ; 44(9): 1512-1520, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30105600

RESUMO

PURPOSE: Frail patients are known to experience poor outcomes. Nevertheless, we know less about how frailty manifests itself in patients' physiology during critical illness and how it affects resource use in intensive care units (ICU). We aimed to assess the association of frailty with short-term outcomes and organ support used by critically ill patients. METHODS: Retrospective analysis of prospective collected data from 93 ICUs in Brazil from 2014 to 2015. We assessed frailty using the modified frailty index (MFI). The primary outcome was in-hospital mortality. Secondary outcomes were discharge home without need for nursing care, ICU and hospital length of stay (LOS), and utilization of ICU organ support and transfusion. We used mixed logistic regression and competing risk models accounting for relevant confounders in outcome analyses. RESULTS: The analysis consisted of 129,680 eligible patients. There were 40,779 (31.4%) non-frail (MFI = 0), 64,407 (49.7%) pre-frail (MFI = 1-2) and 24,494 (18.9%) frail (MFI ≥ 3) patients. After adjusted analysis, frailty was associated with higher in-hospital mortality (OR 2.42, 95% CI 1.89-3.08), particularly in patients admitted with lower SOFA scores. Frail patients were less likely to be discharged home (OR 0.36, 95% CI 0.54-0.79) and had higher hospital and ICU LOS than non-frail patients. Use of all forms of organ support (mechanical ventilation, non-invasive ventilation, vasopressors, dialysis and transfusions) were more common in frail patients and increased as MFI increased. CONCLUSIONS: Frailty, as assessed by MFI, was associated with several patient-centered endpoints including not only survival, but also ICU LOS and organ support.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Fragilidade/terapia , Idoso , Transfusão de Sangue/estatística & dados numéricos , Brasil/epidemiologia , Estado Terminal/mortalidade , Utilização de Instalações e Serviços , Idoso Fragilizado/estatística & dados numéricos , Recursos em Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença
14.
J Crit Care ; 46: 55-57, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29684773

RESUMO

PURPOSE: The purpose of this study was to characterize the organ failures that develop among patients with prolonged ICU stays, defined as those who spent a minimum of 14 days in an ICU. METHODS: We retrospectively studied a cohort of consecutive patients from a university hospital who were in an ICU for a minimum of 14 days during 2014-2016. We calculated daily Sequential Organ Failure Assessment (SOFA) scores from admission to ICU day 14. The primary outcome was the number of new late organ failures, defined as occurring on ICU day 4 through 14. RESULTS: In a retrospective cohort of 3777 consecutive patients in six ICUs, 50 patients had prolonged ICU stays. Of those 50, new cardiovascular failure occurred in 24 (62%) on day 4 or later; persistent mechanical ventilation was present in only 28 (56%). CONCLUSIONS: Strategies aiming to reduce the development of new late organ failures may be a novel target for preventing persistent critical illness.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , Tempo de Internação , Insuficiência de Múltiplos Órgãos/complicações , Idoso , Comorbidade , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Insuficiência de Múltiplos Órgãos/epidemiologia , Alta do Paciente , Respiração Artificial/estatística & dados numéricos , Insuficiência Respiratória , Estudos Retrospectivos
16.
Medicine (Baltimore) ; 96(31): e7695, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28767603

RESUMO

Little is known about variation in patterns of recovery among patients discharged alive from hospitalizations for pneumonia.The aim of the is observational cohort study was to characterize the variation in patterns of hospital readmission and survival in the year after discharge for pneumonia in 3 different health systems.The 3 cohorts consisted of (1) the Health and Retirement Study participants enrolled in Fee-for-service Medicare (FFS), (2) Veterans Administration (VA) Healthcare system, and (3) Kaiser Permanente of Northern California (KPNC). The 365-day survival and re-hospitalizations were determined for each cohort. Multinomial logistic regression was used to identify potential contributors to the different patterns.We identified 2731, 23,536, and 39,147 hospitalizations for pneumonia in FFS Medicare, VA, and KPNC, respectively, of whom 88.1%, 92.8%, and 89.7% survived to hospital discharge. The median patient survived to 1 year and was rehospitalized twice in FFS (9.0%), once in VA (14.1%) and KPNC (9.1%). Of the patients who survived the hospitalization, 33.3% (FFS), 30.2% (VA), and 26.8% (KPNC) died during the subsequent year. Of those who survived, 29.8% (FFS), 35.9% (VA), and 46.1% (KPNC) were never rehospitalized. 11.9% (FFS), 11.9% (VA), and 11.7% (KPNC) had greater than 3 hospitalizations. Age, race, gender, comorbidity, ICU use, and hospital length stay collectively explained little (5-7%) of the variation in the recovery pattern.There is significant variation in the year after the hospitalization for pneumonia across individuals, but less so across health systems. There may be important opportunities to better classify these heterogeneous individual-level pathways.


Assuntos
Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/epidemiologia , Pneumonia/terapia , Idoso , California , Planos de Pagamento por Serviço Prestado , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Medicare , Alta do Paciente , Pneumonia/economia , Estudos Prospectivos , Estados Unidos , United States Department of Veterans Affairs
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