Caring for critically ill patients outside intensive care units due to full units: a cohort study. Marcos T. Tanita II. Lucienne T. Cardoso III.
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Caring for critically ill patients outside intensive care units due to full units: a cohort study. Marcos T. Tanita II. Lucienne T.
Cardoso III. Cintia M. This study sought to analyze the clinical and epidemiologic characteristics of critically ill patients who were denied intensive care unit admission due to the unavailability of beds and to estimate the direct costs of treatment.
A prospective cohort study was performed with critically ill patients treated in a university hospital. All consecutive patients denied intensive care unit beds due to a full unit from February to February were included. The data collected included clinical data, calculation of costs, prognostic scores, and outcomes. The patients were followed for data collection until intensive care unit admission or cancellation of the request for the intensive care unit bed.
Vital status at hospital discharge was noted, and patients were classified as survivors or non-survivors considering this endpoint. Four hundred and fifty-four patients were analyzed. Patients were predominantly male Invasive mechanical ventilation was used in patients The median time of follow-up was 3 days ITQ: 2 - 6 ; after this time, patients were admitted to the intensive care unit and had the intensive care unit bed request canceled.
Patients presented a high severity in terms of disease scores, had multiple organ dysfunction and needed multiple invasive therapeutic interventions. The study patients received intensive care with specialized consultation during their stay in the hospital wards and presented high costs of treatment. The intensive care unit ICU provides a continuous monitoring system for critically ill patients who have the potential for recovery or are in a life-threatening situation.
In recent decades, this sector has observed a significant increase in the demand for beds associated with the reduced mortality among patients admitted. Additionally, an increase in the complexity of diseases and number of chronic health conditions has been reported 1. A patient who may not benefit from treatment due to either a very good or very poor prognosis may be rejected from the ICU. Some patients, however, may be denied admission to the ICU due to a lack of available beds 2 , and this delay in admission has been associated with increased mortality 3.
The concept of rapid and early care has been established in various fields of medicine 4 - 6. Considering that most acute illnesses develop in stages of physiological and organ dysfunction, the logical step would certainly be to provide specialized care for any critically ill patient within the hospital, regardless of the location.
In an attempt to provide intensive care outside the ICU environment, rapid response teams RRTs have been created with the goal of early identification of the signs and symptoms of physiological worsening in patients, thereby reducing the risk of adverse events in inpatient units. This strategy consists of a bedside intensive therapy system formed usually by a doctor, nurse and physiotherapist 8. The benefits that this system have provided to hospitalized patients have been described by several authors 9 - However, there are few studies describing the care costs of critically ill patients outside of the intensive care environment.
Research in this area is important for the financial planning of actions in health care. The aim of the present study was to analyze the clinical and epidemiological characteristics of critically ill patients who were denied ICU admission due to the unavailability of beds and to estimate the direct costs of treatment during this period.
This was a prospective cohort study of critically ill patients who were treated outside the ICU due to a full unit and attended by the RRT in a university hospital from February to February The RRT in this hospital is composed of an intensivist physician and a physiotherapist who are assigned exclusively to the tasks of this team.
The RRT responds to yellow and blue codes, assists in the care of all critically ill patients denied ICU beds and evaluates patients post-discharge from the ICU to prevent early readmissions.
For a yellow or blue code, the nurse caring for the patient on the ward triggers a call for RRT consultation and participates in the care of the patient together with the two members of the RRT. During this evaluation, if there is a need to transfer the patient to the ICU, the RRT accompanies this intra-hospital transportation.
In these cases, the RRT performs two scheduled daily evaluations of these patients to assist with medical prescriptions, clinical decisions, therapeutic interventions, and checking of laboratory and other exam results. If additional evaluations are needed, the local staff calls the RRT. The ICU request is performed in the electronic hospital system that provides the diagnostic and clinical data of the patient.
If there is no ICU bed immediately available, the intensivist on duty with the RRT evaluates the request and classifies the patient according to the prioritization model A convenience sample was obtained from all adult patients admitted in the study period who presented with a critical condition requiring admission to a monitored ICU bed and who were refused admission due to lack of availability.
Patients under the age of 18 years and those who had a waiting time for admission to the ICU of less than 24 hours were excluded.
The data collected consisted of demographic data age and sex and clinical data, including the diagnosis of a critical condition, presence of comorbidities, length of stay before ICU admission, data for the calculation of costs and prognostic scores and outcomes. Each patient was followed until one of the following primary outcomes occurred: ICU admission, cancellation of the request for the ICU due to clinical improvement or limitation of therapeutic support, transfer to another hospital or death.
Data collection began on the day of refusal of admission to the ICU and continued until a primary outcome occurred. Patients were classified as survivors and non-survivors considering their vital status at hospital discharge. Each of these scores was calculated according to their original descriptions 17 - In an interim analysis, a smaller sample of patients estimated to be representative was used to perform a cost analysis.
For this purpose, data were collected from patients included in the study period from February to July The model adopted to collect costs applied the "bottom-up" approach, a methodology considered the gold standard, in which the goal is to estimate costs by individual patient or by a group of patients The measurement of direct costs is then generated, and the sum of the costs can provide a conservative estimate of the true value of treating a health problem For the present study, the direct costs generated for the treatment of patients were divided into four categories: clinical support, consumer items, human resources and hospital fees.
Clinical support: costs related to pharmacy needs ointments, body oil, strips for verification of blood sugar and items for pressure ulcer prevention , renal support, laboratory, laboratory tests, imaging and complementary examinations. Items from the clinical support category were analyzed according to the medical prescription. For the calculation of medication costs, a standard dose was considered, calculated as the mean daily prescription for a patient of 70 kg body weight.
In the category of human resources, values were attributed to medical procedures performed as well as the physiotherapy service, which was divided into motor and respiratory therapy, as noted in the medical record. In the category of hospital fees, the values of the daily hospital fees and intensivist doctor on duty with the RRT were computed.
Costs related to the use of equipment, infrastructure, electricity, security systems, information technology, and non-clinical support and indirect costs lost productivity, etc. After data collection, a value was assigned to all items.
The values were obtained from standard tables and index values for medical procedures outlined by the Brazilian Medical Association BMA Comorbidities were defined according to the criteria published in the Charlson comorbidity index The need for ICU admission was classified as one of the following: respiratory failure; hemodynamic instability; metabolic disorder, postoperative; cardiac monitoring; neurological monitoring; or other.
The diagnosis of infection was based on clinical, microbiological and imaging results, and the source of infection was classified as lung, urinary tract, bloodstream, abdominal, surgical site or other. The diagnosis and classification of sepsis used the Third International Consensus Definitions for sepsis and septic shock Sepsis was defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock was defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities were associated with a greater risk of mortality than with sepsis alone.
Data were analyzed using SPSS version Continuous quantitative variables were described after the normality of the distribution was verified with the Shapiro-Wilk test. For variables that presented a normal distribution, the mean and standard deviation were calculated; otherwise, the median and interquartile range ITQ 25 th percentile - 75 th percentile were calculated. The areas under the ROC curve of the indices were compared in pairs using a non-parametric approach, based on the difference between the areas and standard error.
The ethics committee waived the need for informed consent. During the study period, critically ill patients had ICU bed requests denied and were cared for in the hospital wards with intensivist consultation by the RRT.
There were patients excluded as follows: 60 patients were under 18 years of age, patients spent less than 24 hours waiting for the ICU bed, and 59 patients were considered losses due to a lack of sufficient information in the medical records to complete the case report form.
In total, patients were evaluated. Among the patients studied, data collection on direct costs was performed for during the period from February to July Of the patients included in the study, Organ dysfunction measured by the SOFA score at study entry presented a median of 8 4 - 10 , and the SOFA score at the time of primary outcome was 8 4 - The median score for therapeutic interventions TISS at study entry was 27 21 - A diagnosis of infection was present in Regarding the classification of infections, patients presented septic shock, had sepsis, and 10 had a localized infection.
The most frequent comorbidities were hypertension Mechanical ventilation was required in patients When mechanical ventilation was initiated, an intensivist physiotherapist was assigned to care for the patient and consult in cases of any difficulties regarding this intervention. The need for therapeutic interventions was associated with higher mortality Table 1.
In relation to the treatment of hemodynamic instability, On the other hand, 5. Of the therapeutic interventions in these patients, 51 patients required procedures that are usually performed in an ICU but needed to be carried out in the hospital wards, such as tracheal intubation, insertion of a transvenous pacemaker, hemodialysis, and insertion of a chest tube.
In addition, patients required intra- or inter-hospital transportation for the performance of diagnostic or therapeutic procedures. Of the patients analyzed, Two patients 0. While waiting for an ICU bed, patients The demographic characteristics and prognostic scores of the group of patients whose data were collected for the calculation of direct costs were no different from those of the other patients in the study. Patients not included in the cost analysis stayed longer in the hospital, but the period of cost analysis was similar.
Patients included in cost analysis also required vasoactive drugs more frequently Table 2. To compare the day-by-day costs between survivors and non-survivors, the results for the first seven days of observation are presented in Figure 1. The results showed that the median daily cost was higher in non-survivors. The present study describes the care of critically ill patients outside the ICU in the hospital wards, which is becoming a common reality for hospitals around the world.
Caring for these patients with daily intensivist consultations and the aid of an RRT was a local solution to increase safety for these hospitalized patients. These patients required mechanical ventilation, vasoactive drugs and invasive procedures, and they received such assistance outside of a monitored ICU bed. This situation is associated with high costs of care and possibly with an increase in adverse events.
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