Associations of Government-issued ICU Admission Criteria with Clinical Practices, Outcomes, and ICU Bed Occupancy

Introduction The COVID-19 pandemic required careful management of intensive care unit (ICU) admissions, to reduce ICU overload while facing limitations in resources. We implemented a standardized, physiology-based, ICU admission criteria and analyzed the mortality rate of patients refused from the ICU. Materials and methods In this retrospective observational study, COVID-19 patients proposed for ICU admission were consecutively analyzed; Do-Not-Resuscitate patients were excluded. Patients presenting an oxygen peripheral saturation (SpO2) lower than 85% and/or dyspnea and/or mental confusion resulted eligible for ICU admission; patients not presenting these criteria remained in the ward with an intensive monitoring protocol. Primary outcome was both groups’ survival rate. Secondary outcome was a sub analysis correlating SpO2 cutoff with ICU admission. Results From March 2020 to January 2021, 1623 patients were admitted to our Center; 208 DNR patients were excluded; 97 patients were evaluated. The ICU-admitted group (n = 63) mortality rate resulted 15.9% at 28 days and 27% at 40 days; the ICU-refused group (n = 34) mortality rate resulted 0% at both intervals (p < 0.001). With a SpO2 cut-off of 85%, a significant correlation was found (p = 0.009), but with a 92% a cut-off there was no correlation with ICU admission (p = 0.26). A similar correlation was also found with dyspnea (p = 0.0002). Conclusion In COVID-19 patients, standardized ICU admission criteria appeared to safely reduce ICU overload. In the absence of dyspnea and/or confusion, a SpO2 cutoff up to 85% for ICU admission was not burdened by negative outcomes. In a pandemic context, the SpO2 cutoff of 92%, as a threshold for ICU admission, needs critical re-evaluation.

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Designing and Evaluating the Establishment of Admission Criteria for Patients in an Intensive Care Unit: A Descriptive Study in Iran

Evidence Based Health Policy Management and Economics ◽

10.18502/jebhpme.v5i2.6554 ◽

2021 ◽

Author(s):

Fariba Hosseinpour ◽

Mahyar Sedighi ◽

Fariba Hashemi ◽

Sima Rafiei

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Statistical Tests ◽

P Value ◽

Admission Criteria ◽

Total Cost ◽

Icu Admission ◽

Study Results ◽

Significant Difference

Background: A few studies have reviewed and revised ICU admission criteria based on specific circumstances and local conditions. The aim was to develop ICU admission criteria and compare the cost, mortality, and length of stay among identified admission priorities. Methods: This was a cross-sectional study conducted in an intensive care unit of a training hospital in Qazvin, Iran. The study was conducted among 127 patients admitted to ICU from July to September 2019. The data collection tool was a self-designed checklist, which included items regarding patients' clinical data and their billing, type of diagnosis, level of consciousness at the time of hospitalization based on GCS scale or Glasgow Coma Scale, length of stay, and patient status at the time of discharge. Descriptive statistical tests were used to describe study variables, and in order to determine the relationship between study variables, ANOVA and Chi-square test were used. Results: A set of criteria were designed to prioritize patient admissions in ICU. Based on the defined criteria, patients were categorized into four groups based on patient's stability, hemodynamic, and respiration. Study findings revealed that a significant percentage of patients were admitted to the ward while in the second and third priorities of hospitalization (26.8 % and 32.3 %, respectively). There was a statistically significant difference in the four groups in terms of patients' age, total cost, and insurance share of the total cost (P-value < 0.05). Conclusion: Study results emphasize the necessity to classify patients based on defined criteria to efficiently use available resources.

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1709. Epidemiology of Invasive Fungal Infection (IFI) after Severe Influenza Requiring Intensive Care Unit (ICU) Admission: 10-Year Experience at a Tertiary Care Center in the United States

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1572 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S627-S627

Author(s):

J Alex Viehman ◽

Penny Sappington ◽

Erin K McCreary ◽

Rachel V Marini ◽

Ryan K Shields ◽

...

Keyword(s):

United States ◽

Influenza A ◽

Care Center ◽

Tertiary Care ◽

The United States ◽

Fungal Colonization ◽

Clinical Practices ◽

Icu Admission ◽

Severe Influenza ◽

Colonization Rates

Abstract Background Despite increasing recognition of aspergillosis complicating severe influenza and its associated high fatality in Europe, incidence and features of the disease in the United States are unknown. Methods We reviewed all influenza cases requiring ICU admission from 2009 to 2019 at our center. Results 262 patients with influenza required ICU admission. 4% (10) developed IFI at median 2d after influenza diagnosis. 80% (8/10) of patients with IFI were infected with influenza A vs. 88% (221/252) without IFI. 20% were on steroids at the time of IFI diagnosis. 70% of IFI required mechanical ventilation. Types of IFI were pneumonia (70%, 6 Aspergillus and 1 Wangiella), endobronchial IFI (20%, 1 each with Aspergillus and Lictheimia), and Coccidioides fungemia (10%). 4% (10) of patients were fungal colonized, but did not have IFI (5 A. fumigatus, 1 A. terreus, 4 Penicillium). CT findings of IFI included nodules (4), cavitation (3), and ground-glass opacities (2). Serum galactomannan (GM) was positive in 3 (43%). Median time to antifungal therapy (AF) was 2 days. Triazoles were prescribed to all 7 patients with aspergillosis. Posaconazole and amphotericin B were AF for patients with Wangiellaand Lichteimia, respectively. Patients with C. immitis fungemia died before AF. Median duration of AF was 60 days among survivors. Patients with IFI required acute hemodialysis more frequently than colonized patients (60% vs. 0%, P = 0.01). 30-day mortality was 60% (6/10) and 20% 92/10) in patients with IFI and colonization, respectively (P = 0.2). Patients with IFI had significantly higher in-hospital and 60-day mortality than those without IFI (Fig 1, P = 0.009). Conclusion Our rate of post-influenza IFI (4%) was lower than reported in Europe (~15%), which might stem from a lack of systematic BAL GM testing at our center, over-reliance on GM to make diagnoses in Europe, and/or differences in pt populations and clinical practices in treating severe influenza. IFI and fungal colonization rates were similar at our center, highlighting the importance of using well-defined criteria to define disease. Given the high mortality of post-influenza IFI, priority should be given to defining risk factors that might identify patients for targeted AF prophylaxis. In using AF, it is important to recognize that Aspergillus is not the only cause of IFI. Disclosures All authors: No reported disclosures.

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ICU deaths in patients with advanced cancer: Criteria to decrease potentially inappropriate admissions and analysis of advance planning discussions.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.26_suppl.47 ◽

2016 ◽

Vol 34 (26_suppl) ◽

pp. 47-47

Author(s):

Syed Sameer Nasir ◽

Alva B Weir

Keyword(s):

Life Expectancy ◽

Cancer Patients ◽

Advanced Cancer ◽

Performance Status ◽

Admission Criteria ◽

Advanced Cancer Patients ◽

Icu Admission ◽

Post Procedure ◽

Inappropriate Admissions ◽

Advance Planning

47 Background: A significant number of advanced cancer admissions to intensive care unit (ICU) are inappropriate, as they do not prolonged survival. No clear consensus criteria for reasonable admissions of advanced cancer patients have been developed. Methods: We established four criteria for ICU admissions in advanced cancer patients: post procedure complication, recent cancer diagnosis, good performance status and life expectancy of > 6 months. We reviewed charts of all patients who died in the ICU at a university-affiliated hospital between 2005-2010. We then identified advanced cancer patients and looked for presence or absence of these criteria. We also reviewed evidence of advance planning discussions (APDs), prior to ICU admission to evaluate their benefit in preventing inappropriate admissions. Results: 421 deaths occurred in ICU between 2005-2010. 52 patients had advanced cancer. 27% were diagnosed with cancer one month or less prior to admission. 40% had ECOG performance status of 0-1. 27% had life expectancy of more than 6 months and 15% were admitted for post procedure complications. Overall, 37% did not satisfy any of our reasonable criteria at the time of ICU admission. In our chart review for evidence of APDs, 31% had completed APDs prior to ICU admission. 47% of patients who did not satisfy any of our reasonable admission criteria had APDs indicating desire for limited medical intervention. Patients lacking both reasonable admission criteria and APDs were 15%. Conclusions: Incorporating proposed admission criteria in ICU admission guidelines may prevent significant number of inappropriate, advanced cancer admissions to the ICU, thus avoiding ineffective, aggressive interventions and delay in timely access to high-quality hospice and palliative care. Our data confirms other data in suggesting that a simple increase in numbers of APDs would not likely change significantly the numbers of inappropriate ICU admissions. [Table: see text]

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Admission criteria in critically ill COVID-19 patients: a physiology-based approach.

10.1101/2021.05.30.21257382 ◽

2021 ◽

Author(s):

Samuele Ceruti ◽

Andrea Glotta ◽

Maira Biggiogero ◽

PierAndrea Maida ◽

Martino Marzano ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Survival Rate ◽

Mortality Rate ◽

Primary Outcome ◽

Secondary Outcome ◽

Admission Criteria ◽

Do Not Resuscitate ◽

Icu Admission ◽

Careful Management

Introduction: The COVID-19 pandemic required a careful management of intensive care unit (ICU) admissions, to reduce ICU overload while facing resources' limitations. We implemented standardized, physiology-based, ICU admission criteria and analyzed the mortality rate of patients refused from the ICU. Materials and Methods: COVID-19 patients proposed for ICU admission were consecutively analyzed; Do-not-resuscitate patients were excluded. Patients presenting a SpO2 lower than 85% and/or dyspnea and/or mental confusion resulted eligible for ICU admission; patients not presenting these criteria remained in the ward. Primary outcome was both groups' survival rate. Secondary outcome was a sub analysis correlating SpO2 cutoff with ICU admission. Results: From March 2020 to January 2021, 1623 patients were admitted to our Center; 208 DNR patients were excluded; 97 patients underwent intensivist evaluation. The ICU-admitted group mortality rate resulted 15.9% at 28 days and 27% at 40 days; the ICU-refused group mortality rate resulted 0% at both intervals (p < 0.001). With a SpO2 cut-off of 92%, the hypoxia rate distribution did not correlate with ICU admission (p = 0.26); with a SpO2 cut-off of 85%, a correlation was found (p = 0.009). A similar correlation was also found with dyspnea (p =0.0002). Conclusion: In COVID-19 patients, standardized ICU admission criteria appeared to reduce safely ICU overload. In the absence of dyspnea and/or confusion, a SpO2 cutoff up to 85% for ICU admission was not burdened by negative outcomes. In a pandemic context, the SpO2 cutoff of 92%, as a threshold for ICU admission, needs critical re-evaluation.

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