Effects of time and day of admission on the outcome of critically ill patients admitted to ICU.

BACKGROUND: Studies have shown that patients admitted to hospitals on weekends and after-hours experience worse outcome than those admitted on weekdays and daytime hours. Although admissions of patients to intensive care units (ICUs) occur 24 hours a day, not all critical care units maintain the same level of staffing during nighttime, weekends, and holidays. This raises concerns in view of evidence showing that the organizational structure of an ICU influences the outcome of critically ill patients. The objective of this study is to evaluate the effects of day and time of admission to ICU on patients' outcome. METHODS: A single-center, prospective, observational study was conducted among all consecutive admissions to ICU in a community teaching hospital during a 4-month period. RESULTS: A total of 282 patients were admitted during the study period. Their mean age was 59.5 years (median 59, range 17-96), and the majority were male (157, 55.7%). Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 18.9 (median 33, range 1-45), and mean ICU length of stay was 3.1 days (median 2, range 1-19). Of the patients, 104 patients (36.9%) were admitted during weekends and 178 (63.1%) during weekdays. A total of 122 patients (43.3%) were admitted after-hours, constituting 68.5% of all admissions during weekdays. Fifty-six patients (19.9%) were admitted during daytime hours, representing 31.5% of all weekday admissions. Forty-five patients (15.9%) died in ICU. Compared to patients admitted on weekends, those admitted on weekdays had increased ICU mortality (operating room (OR)=0.437; 95% confidence interval=0.2054-0.9196; p=0.0293). CONCLUSION: Admissions to ICU during weekends were not independently associated with increased mortality. A linear relationship between weekdays and after-hours admissions to ICU with mortality was observed at our institution.

Etiology and Outcome of Patients with HIV Infection and Respiratory Failure Admitted to the Intensive Care Unit.

Background. Although access to HAART has prolonged survival and improved quality of life, HIV-infected patients with severe immunosuppression or comorbidities may develop complications that require critical care support. Our objective is to evaluate the etiology of respiratory failure in patients with HIV infection admitted to the ICU, its relationship with the T-lymphocytes cell count as well as the use of HAART, and its impact on outcome. Methods. A single-center, prospective, and observational study among all patients with HIV-infection and respiratory failure admitted to the ICU from December 1, 2011, to February 28, 2013, was conducted. Results. A total of 42 patients were admitted during the study period. Their median CD4 cell count was 123 cells/ µ L (mean 205.7, range 2.0-694.0), with a median HIV viral load of 203.5 copies/mL (mean 58,676, range <20-367,649). At the time of admission, 23 patients (54.8%) were receiving HAART. Use of antiretroviral therapy at ICU admission was not associated with survival, but it was associated with higher CD4 cell counts and lower HIV viral loads. Twenty-five patients (59.5%) had respiratory failure secondary to non-HIV-related diseases. Mechanical ventilation was required in 36 patients (85.1%). Thirteen patients (31.0%) died. Conclusions. Noninfectious etiologies of respiratory failure account for majority of HIV-infected patients admitted to ICU. Increased mortality was observed among patients with sepsis as etiology of respiratory failure (HIV related and non-AIDS related), in those receiving mechanical ventilation, and in patients with decreased CD4 cell count. Survival was not associated with the use of HAART. Complementary studies are warranted to address the impact of HAART on outcomes of HIV-infected patients with respiratory failure admitted to ICU.

Factors influencing triage decisions in patients referred for ICU admission.

BACKGROUND: Few data is available on triage of critically ill patients. Because the demand for ICU beds often exceeds their availability, frequently intensivists need to triage these patients in order to equally and efficiently distribute the available resources based on the concept of potential benefit and reasonable chance of recovery. The objective of this study is to evaluate factors influencing triage decisions among patients referred for ICU admission and to assess its impact in outcome. METHODS: A single-center, prospective, observational study of 165 consecutive triage evaluations was conducted in patients referred for ICU admission that were either accepted, or refused and treated on the medical or surgical wards as well as the step-down and telemetry units. RESULTS: Seventy-one patients (43.0%) were accepted for ICU admission. Mean Acute Physiology and Chronic Health Evaluation (APACHE)-II score was 15.3 (0 - 36) and 13.9 (0 - 30) for accepted and refused patients, respectively. Three patients (4.2%) had active advance directives on admission to ICU. Age, gender, and number of ICU beds available at the time of evaluation were not associated with triage decisions. Thirteen patients (18.3%) died in ICU, while the in-hospital mortality for refused patients was 12.8%. CONCLUSION: Refusal of admission to ICU is common, although patients in which ICU admission is granted have higher mortality. Presence of active advance directives seems to play an important role in the triage decision process. Further efforts are needed to define which patients are most likely to benefit from ICU admission. Triage protocols or guidelines to promote efficient critical care beds use are warranted.

The use of an early alert system to improve compliance with sepsis bundles and to assess impact on mortality.

Introduction. Diagnostic and therapeutic guidelines, organized as sepsis bundles, have been shown to improve mortality, but timely and consistent implementation of these can be challenging. Our study examined the use of a screening tool and an early alert system to improve bundle compliance and mortality. Methods. A screening tool was used to identify patients with severe sepsis or septic shock and an overhead alert system known as Code SMART (Sepsis Management Alert Response Team) was activated at the physician's discretion. Data was collected for 6 months and compliance with bundle completion and mortality were compared between the Code SMART and non-Code SMART groups. Results. Fifty eight patients were enrolled -34 Code SMART and 24 non-Code SMART. The Code SMART group achieved greater compliance with timely antibiotic administration (P < 0.001), lactate draw (P < 0.001), and steroid use (P = 0.02). Raw survival and survival adjusted for age, leucopenia, and severity of illness scores, were greater in the Code SMART group (P < 0.05, P = 0.03, and P = 0.01). Conclusions. A screening tool and an alert system can improve compliance with sepsis bundle elements and improve survival from severe sepsis and septic shock.