ICU admissions after actual or planned hospital discharge: incidence, clinical characteristics, and outcomes in patients with cancer.

BACKGROUND: Unexpected ICU admissions may result from early or premature discharge from the hospital. We sought to determine the incidence, clinical characteristics, and outcomes of patients admitted to the ICU after actual or planned hospital discharge and to analyze whether the need for ICU admission was related or unrelated to the associated hospitalization. METHODS: We retrospectively reviewed all adult ICU admissions between January 2004 and December 2006 at a tertiary care cancer center and identified the following two groups of patients: those patients admitted directly to the ICU within 48 h of actual hospital discharge (group A); and those patients admitted to the ICU within 48 h of planned hospital discharge (group B). RESULTS: Of 60,462 patients discharged from the hospital during the study period, 826 patients (1.4%) required readmission to the hospital within 48 h of discharge; of these, 13 patients (1.5%) were admitted directly to the ICU (group A). An additional 12 patients were admitted to the ICU within 48 h of a planned hospital discharge (group B). The majority of these 25 patients (68%) [groups A and B] required ICU admission for a condition that was related to the previous or current hospitalization. The overall hospital mortality rate for both groups was 16%. CONCLUSIONS: A small, but unique group of patients is admitted to the ICU within 48 h of actual or planned hospital discharge. Worsening of the underlying condition that necessitated the previous or current hospitalization often is the reason for ICU admission. Whether ICU admission could have been prevented by continued hospital care or improved diagnostic evaluation during the prior or current hospitalization requires further study.

Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients.

INTRODUCTION: Limited data are available regarding the relationship of premortem clinical diagnoses and postmortem autopsy findings in cancer patients who die in an oncologic intensive care unit (ICU). The purposes of this study were to compare the premortem clinical and postmortem diagnoses of cancer patients who died in the ICU and to analyze any discrepancies between them. METHODS: This is a retrospective review of medical records and autopsy reports of all cancer patients who died in a medical-surgical ICU and had an autopsy performed between 1 January 1999 and 30 September 2005 at a tertiary care cancer center. Premortem clinical diagnoses were compared with the postmortem findings. Major missed diagnoses were identified and classified, according to the Goldman criteria, into class I and class II discrepancies. RESULTS: Of 658 deaths in the ICU during the study period, 86 (13%) autopsies were performed. Of the 86 patients, 22 (26%) had 25 major missed diagnoses, 12 (54%) patients had class I discrepancies, 7 (32%) had class II discrepancies, and 3 (14%) had both class I and class II discrepancies. Class I discrepancies were due to opportunistic infections (67%) and cardiac complications (33%), whereas class II discrepancies were due to cardiopulmonary complications (70%) and opportunistic infections (30%). CONCLUSION: There was a discrepancy rate of 26% between premortem clinical diagnoses and postmortem findings in cancer patients who died in a medical-surgical ICU at a tertiary care cancer center. Our findings underscore the need for enhanced surveillance, monitoring, and treatment of infections and cardiopulmonary disorders in critically ill cancer patients.

Computerized ICU Orders Versus Handwritten ICU Orders: A Prospective, Pharmacy-Based Analysis.

OBJECTIVE: To compare computerized ICU order writing with handwritten ICU physician orders. DESIGN: Prospective study. SETTING: Medical and surgical Intensive Care Units and pharmacy of a Department of Veterans Affairs Medical Center. PATIENTS: Two hundred sixty-four individual sets of orders. INTERVENTIONS: A time study and problem analysis were performed in the pharmacy as orders were received and processed. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty-four sets of orders were evaluated; MICU (handwritten; n = 133) and SICU (computerized; n = 131). Physician length of training are similar in both units. The patient age and number of major diagnoses per patient in the two ICU groups were similar. Significantly less time (min) (MICU 2.5 ± 0.3 versus SICU 1.84 ± 0.1, p < 0.05) is required to review SICU orders. The SICU had significantly fewer order problems (MICU 45 versus SICU 12, p < 0.05). Computerized SICU orders were corrected more rapidly. The majority of order problems in both groups were resolved by telephone. CONCLUSIONS: ICU orders by computer program are processed more rapidly, have fewer errors, and are corrected more rapidly than standard handwritten orders. We conclude that a dedicated ICU computerized order-writing system permits orders to be written with fewer errors and the pharmacy to process them more efficiently than handwritten orders.