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At the boundaries of the ICU: Triage and Post-ICU Mortality Elie AZOULAY, MD, PhD Medical ICU, Saint-Louis Hospital Paris, France, Europe The patient’s journey … Mortality / Morbidity / Sequelae / QOL ... Triage Admission Discharge ICU stay Hospital stay PIM End-Of-Life DFLST Withdrawing/Withholding Short-term outcome One-year mortality Morbidity Neurocognitive disorders Psychiatric symptoms Long-term sequelae Quality of life The spectrum of triage... Patients/ families Selftriage ER Pre-ICU triage ICU ICU triage Hospital Post-ICU triage Home Levin PD, Intensive Care Med 2001 Triage to the ICU When evaluating a patient with a severe acute illness, the ICU physician must assess: (i) the diagnosis, prognosis, and treatment: reversibility, time from treatment onset ... (ii) whether or not ICU admission is warranted (iii) and if it is, whether the patient, if competent, consents to ICU admission. Wanzer SH. N Engl J Med 1984. Triage to the ICU The answer to the second question is a daily dilemma for ICU physicians. Its determinants have been reported as related to: (i) the number of beds available in the ICU (ii) patient characteristics and comorbidities (iii) and the characteristics of the acute illness (severity, reversibility, and predicted residuals and quality of life after ICU discharge) (“ reasonable prospect of substantial recovery ”) SCCM. Crit Care Med 1999 Evaluating prognosis is difficult Poor prediction of individual outcomes with statistical models Chang, Lancet 1989;2:143-146 Doctors need help to critically appraise studies on prognostic information. Randolph Crit Care Med 1998;26:767-72 Prognostic judgements depend on the experience of the doctors. Poses Arch Intern Med 1990; 150: 1874-1878 Doctors are often not completely honest with their patients. Vincent, Intensive Care Med 1998;24:1237-8 Discriminating ability of the APACHE II and SAPS II AUC APACHE II AUC SAPSII 0.60 0.67 Sculier et al. Crit Care Med 2000;28:2786-2792 North American and European recommendations - Because the decision to recommend ICU admission is based on complex criteria, and in order to ensure appropriate utilization of ICU resources -To avoid depriving patients of a chance to recover Recommendations for ICU admission, triage, and discharge have been established for: - cardiac and trauma patients, - patients with gastrointestinal hemorrhage - patients with any critical disorder Crit Care Med 1999;27:1073-79 Priorities for ICU admission Priority 1: critically ill patients requiring invasive treatments or monitoring (MV, vasopressors, dialysis …) Priority 2: intensive monitoring for unstable patients Priority 3: critically ill or unstable patients with little chance of recovery (comorbidities, nature of the acute medical disease) Priority 4: patients with little benefit expected from the ICU management without ICU admission: not severe enough for the ICU dying patients Alternatives to ICU admission Transfer to the ward SCCM. Crit Care Med 1999 Management by the ER Rausch PG. Ann Emerg Med 1991 Pavey B. Ann Emerg Med 1992 Palliative care Alleviate symptoms Adequate use of technology Improvement in communication skills Management of family needs, respect for religious values Sedation, analgesia, oxygen, tracheal aspiration Ethical consultation Caregivers available Adam J. BMJ 1997 Falk S. BMJ 1997 In practice …prevalence of refusal 38% Hong Kong Joynt GM, Intensive Care Med 2001 28% Israel Sprung CL, Crit Care Med 1999 26% United Kingdom Metcalfe MA, Lancet 1997 22% France Azoulay E, Crit Care Med 2001 Determinants of ICU refusal ISRAEL FRANCE * age * severity scores * bed availability * surgical status * admission diagnosis * age * chronic health status * comorbidities (cancer, COPD, CHF) * admission diagnosis Hong Kong * age * severity scores * cardiac arrest * neuro-surgical status * comorbidities (cancer) Sprung CL, Crit Care Med 1999 27:1073-9 Azoulay, Crit Care Med 2001;29:2132-6 Joynt GM, Intensive Care Med 2001 Cumulative survival estimates of triaged patients who were admitted, admitted later, and never admitted (controlling for APACHE II scores) RR = 2.5; p < .01 Sprung CL et al. Crit Care Med 1999;27(6):1073-1079 Recommendations Patient’s opinion Expected cost of treatment i f patient admitted Family’s opinion Bed available in another ICU General practitioner’s opinion Severity of underlying disease QOL as evaluated by the fa mily Reversibility of underlying disease QOL as evaluated by the patient Reversibility of acute condition QOL as evaluated by the intensi vist Ti me to optimal treatment Religious values o f the patient Potential handicap ICU admission for an iatrogenic event Expected chance of sur vival i f patient admitted Burdens and a dvantages o f a new treatment Consequences for the fa mily Investigations might better explain the event Social context JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62 SCCM pejorative diagnoses Does the patient have any of the following? Refractory leukemia associated with multiple organ failure I__I Persistent vegetative status or brain death without possibility of organ donation I__I Acute respiratory failure associated with refractory leukemia I__I Chronic respiratory or cardiac failure, or metastatic cancer without therapeutic resource I__I JAMA 1994;271:1200-1203 Crit Care Med 1994;22:358-62 The example of cancer patients Carlon GC. Just say no … Schuster D.P. Everything that should be done-not everything that can be done. G.D. Rubenfeld Withdrawing life support from MV recipients of BMT Brunet F. Is ICU justified for hematological patients? Crit Care Med. 1989;17:106-7 Ann Intern Med 1996;125;625-30 Am Rev Respir Dis 1992;145:508-9 Intensive Care Medicine 1990;16:291-7 Autologous PBSCT Patients Variables 1991 - 1993 1993 - 1995 1995 - 1997 1997 - 1999 Patients Hosp. survival 7 (9) 0 (0) 13 (17) 2 (15) 25 (33) 7 (27) 32 (42) 11 (35) No or 1-organ failure Patients 7 (100) Hosp. Survival 0 (0) 11 (85) 2 (18) 18 (72) 7 (39) 24 (75) 10 (42) Two-organ failure Patients 0 (0) Hosp. Survival 0 (0) 2 (15) 0 (0) 7 (28) 0 (0) 8 (25) 1 (13) Khassawneh et al. Chest 2002;121:185-188 Critically Ill Cancer Patients % deaths Number of patients 100 1 80 0.8 60 0.6 40 0.4 20 0.2 0 0 1990 1991 1992 1993 1994 1995 1996 Year of ICU admission 1997 1998 1999 Patient selection (1) 1992-1995 1996-1998 n=41 (%) n=34 (%) Knaus scale C or D 26 (66.5) 13 (38.2) 0.02 Stage III disease 34 (83) 21 (62) 0.03 SAPS II score at admission 54 (38-70) 64 (43-82) 0.05 Dialysis 9 (22) 15 (44) 0.04 NIMV 2 (5) 7 (20.6) 0.03 31 (75.6) 12 (35) 0.0008 Myeloma patients P Need for : 30-day mortality Changing use of ICU … Azoulay et al. Intensive Care Medicine 1999;25:1395-1401 Patient selection (2) 1991-1995 n=132 (%) 1996-1998 n=105 (%) Complete remission 28 (21.2) 34 (32.3) 0.04 17 (12.8) 48 (36.6) 25 (23.8) 43 (40.9) 0.02 0.50 SAPS II score at admission 55 (38-70) 62 (43-82) 0.005 Need for : Vasopressors Dialysis NIMV Conventional MV End-of-life decision 63 (47.7) 25 (18.9) 19 (14.4) 113 (85.6) 25 (18.9) 55 (52.4) 29 (27.7) 29 (27.6) 76 (72.4) 17 (16.2) 0.59 0.11 0.01 0.01 0.58 30-day mortality 108 (81.8) 64 (60.9) 0.0003 P MV patients BMT Neutropenia Azoulay et al. Crit Care Med 2001;29:519-525 Patient selection (3) 1995 - 1997 1998 -2000 (n=34) (n=54) 21 (61.8) 31 (57.4) 0.79 Poor chronic health status (Knaus scale C or D) 11 (32.3) 9 (16.6) 0.05 Hospitalization >48h before ICU admission 31 (91.1) 40 (74) 0. 03 LOD Day 1 8 (6-11) 7 (4-9) 0.49 DLOD 0 (-0.25-0.25) 0 (-0.75-0.25) 0.20 SAPSII score at ICU admission 72 (53-86) 65 (45-93) 0.33 Mechanical ventilation 31 (93.9%) 37 (68.5%) 0. 005 Noninvasive ventilation 4 (11.8) 8 (14.8) 0.12 Volume of crystalloid infused on day 1 (ml) 141 (0-500) 444 (0-1200) 0. 03 End-of-life decisions 6 (17.6) 11 (20) 0.54 30-day mortality 27 (79.4) 30 (55.5) 0. 01 Remission of the malignancy P value Larché J, Azoulay E. Submitted Compliance with Triage-to-ICU Recommendations (1) Number of recommendations observed 20 16 P=0.0003 12 Admission denied after patient examination 8 Admission denied over the phone 4 0 Compliance with Triage-to-ICU Recommendations (2) Number of recommendations observed 20 16 P<0.0001 12 8 4 0 Beds available Full unit Who needs recommendations ? Patients/ families Selftriage ER Pre-ICU triage ICU ICU triage Hospital Post-ICU triage Home Levin PD, Intensive Care Med 2001 The patient’s journey … Mortality / Morbidity / Sequelae / QOL ... Triage Admission Discharge ICU stay Hospital stay PIM End-Of-Life DFLST Withdrawing/Withholding Post ICU Mortality Mortality after discharge from intensive care has been reported to range from 6.1 to 27%. Latour J, Intensive Care Med 1990; 16:125-7. Goldhill DR, CritCareMed1998;26:1337-45. Rowan KM, Bmj 1993; 307:972-7. Munn J, Anaesthesia 1995; 50:1017-21. Death after ICU discharge can be related to factors occurring: before Bion J. Bmj 1995; 310:682-3. Ryan DW. Bmj 1996; 312:654. or after the ICU stay Wallis CB, Anaesthesia 1997; 52:9-14. Dragsted L, Eur J Anaesthesiol 1989; 6:385-96. Post ICU Mortality In-hospital mortality was higher among patients discharged at night. Goldfrad C, Rowan K. Lancet 2000; 355:1138-42. Keeping at-risk patients in the ICU for another 48 hours may reduce mortality after ICU discharge by 39%. Daly K. Bmj 2001; 322:1274-6. Determinants of Post-Intensive-Care-Unit Mortality (PIM) The OUTCOMEREA Study Group http//www.outcomerea.org Patients and Methods Prospective multicenter study to report determinants of PIM, with particular attention to EOL decisions in the ICU. OUTCOMEREA DATABASE® – 2-year study period in 6 medical and surgical ICUs – All adult patients consecutively hospitalized for longer than 48 hours were enrolled starting in January 1997. – Variables were collected daily on standardized forms. All patients were screened for end-of-life decisions, ICU discharge, or death. After ICU discharge, all patients were screened on the wards for hospital length of stay and for death or hospital discharge. Patient management and end-of-life decisions Management policies were identical in the 6 ICUs. Transferred patients were discharged to the source wards. When ICU admission occurred directly (emergency room or mobile emergency medical system), discharge was to a same-hospital ward. The EOL decision procedure included at least 2 deliberations and involvement of more than 2 ICU physicians and the patient’s nurse or of all caregivers Patient characteristics 1385 patients were discharged alive DFLST implemented in 80 patients P I M = 10.8% 47 died 1235 were discharged alive from the Hospital 150 died during their post-ICU hospital stay Comparison between post-ICU decedents and post-ICU survivors Discharged from the ward n=1235 (89.2%) Age (years) 63 (47-73) Female gender, n (%) 458 (37) Transfer from the ward, n (%) 548 (44.4) Type of patients, n (%) Medical 791 (64.1) Surgical 130 (10.4) Scheduled surgery 314 (25.4) Died in the ward n=150 (10.8%) 72 (61-79) 47 (31.3) 99 (66) Chronic Disease, n (%) 485 (39.3) 94 (62.7) <0.0001 Mc Cabe 1, n (%) 734 (59.4) 41 (27.3) <0.0001 116 (77.3) 7 (4.6) 27 (17.8) P value <0.0001 0.05 <0.0001 0.11 P Discharged Died in the value from the ward ward n=1235 (89.2%) n=150 10.8%) Severity and organ failure scores At admission SAPS II LOD SOFA At discharge SAPS II LOD SOFA Omega Score of Workload Omega 1 Omega 3 Patients discharged Fri-Sunday Patients with end-of-life decisions 35 (25-47) 4 (3-5) 3 (1-5) 42 (34-56) 5 (3-6) 5 (3-8) 0.0001 0.0001 <0.0001 22.5 (18-27) 1.5 (1-2) 1.5 (1-2) 35 (28-42) 3 (2-5) 3 (1-5) <0.0001 0.0005 <0.0001 9 (1-18) 48 (24-115) 12 (6-24) 126 (28-370) 0.001 <0.0001 308 (24.9) 29 (19.3) 0.13 33 (2.6) 47 (31.3) <0.0001 Multivariate analysis: Independent predictors of Post-ICU-mortality Odds ratio 95% CI Mc Cabe class 1 0.388 [0.258-0.583] Transfer from the ward 1.89 [1.27-2.80] SAPS II score at admission > 36 1.57 [1.60-2.33] SOFA score at discharge 1.11 [1.03-1.18] per point End-of-life orders 9.64 [5.75-16.16] Determinants of Post-Intensive-Care-Unit Mortality in Critically Ill Septic Patients: An International study For the European Sepsis Group Flow-chart of patients 14 364 ICU admissions 3 034 patients infected at ICU admission 11 330 patients not infected at ICU admission 868 patients with ICUacquired infection P I M = 10.4% 3902 patients with first infection 1913 removed 1989 alive at ICU discharge 1782 alive at hospital discharge 207 dead at hospital discharge 1301 dead at ICU discharge 311 alive at ICU discharge but LOS > 28 d 301 alive at ICU discharge with no hospital follow-up Comparison between post-ICU decedents and survivors (1) Variable All N (% Death) OR [95 CI] p-value Surgical scheduled 231 19 (8.2%) 1 Medical 1248 143 (11.5%) 1.44 [0.87 ; 2.38] 0.15 Surgical emergency 352 39 (11.1%) 1.39 [0.78 ; 2.47] 0.26 Trauma 158 6 (3.8%) 0.44 [0.17 ; 1.12] 0.09 Chronic pulmonary failure 108 18 (16.7%) 1.79 [1.06 ; 3.04] 0.03 Chronic heart failure 175 32 (18.29%) 2.10 [1.39 ; 3.17] 0.0005 Chronic renal failure 168 37 (22.02%) 2.74 [1.84 ; 4.09] < 0.0001 Cirrhosis 98 20 (20.4%) 2.34 [1.40 ; 3.91] Immunossupression 494 82 (16.6%) 2.18 [1.62 ; 2.94] < 0.0001 Chronic Obstructive Pulmonary Disease 349 45 (12.89%) 1.35 [0.95 ; 1.92] Admission categories Comorbidities 0.001 0.09 Comparison between post-ICU decedents and survivors (2) Variable All N OR (%deaths) [95% CI] 1 P value Mac Cabe 1 1345 106 (7.88%) 2 521 73 (14.01%) 1.90 [1.38 ; 2.62] < 0.0001 3 123 28 (22.76%) 3.45 [2.16 ; 5.50] < 0.0001 Renal 142 25 (17.61%) 1.96 [1.24 ; 3.09] 0.004 Shock 397 52 (13.10%) 1.40 [1.00 ; 1.96] 0.05 Inotropic or vasopressor use 747 103 (13.79%) 1.74 [1.31 ; 2.33] Ventilation support 1455 162 (11.13%) 1.36 [0.96 ; 1.92] 0.08 Renal support 213 0.11 Reason of ICU admission 29 (13.62%) 1.41 [0.92 ; 2.15] 0.0002 Comparison between post-ICU decedents and survivors (3) Variable Age Survivors Non survivors p values 60 (43 - 71) 67 (55 - 75) < 0.0001 3.5 (2.5 - 4.4) 4.2 (3.5 - 5.3) < 0.0001 LOS in ICU 2 (1 – 3) 3 (2 – 4) 0.05 LOD at ICU-discharge 2 (1 – 4) 4 (2 – 6) < 0.0001 SAPS II at the first day of infection Comparison between post-ICU decedents and survivors Variable All N (% Death) 629 98 (15.58%) 2,32 [1,68 ; 3,20] < 0,0001 Microbiologically documented 1242 155 (12.5%) 1.91 [1.37 ; 2.65] 0.0001 Site of infection Pulmonary Digestive Urinary Primary bacteremia Unknown Other 1197 262 208 202 44 327 107 (8.94%) 32 (12.21%) 26 (12.50%) 32 (15.84%) 3 (6.82%) 34 (10.40%) 0.68 [0.51 ; 0.91] 1.23 [0.83 ; 1.84] 1.26 [0.81 ; 1.96] 1.73 [1.15 ; 2.61] 0.62 [0.19 ; 2.03] 0.99 [0.67 ; 1.47] 0.01 0.31 0.30 0.01 0.43 0.99 Origin of infection Hospital-acquired OR [95 CI] p-value Documentation of infection Ho sp PS ita II t l-ac he qu ir f ir s t ed in d Cl fe LO ay in ct ic D o io al f at n in ly do ICU f ec c t Re um -dis ion sp c e ira nte har d ge to in ry f e Su s ite c tio n rg ic inf e al ct sc e he d du Im m le un d os A s Ch up g ro re e ni s s c pu C ion lm irrh In on ot os ro ar is pi y c f a or il v a Ma ure s c o Le Ca ng S a pre s s be ur th eu or of IC s in us U fe e Di s sh Su tay c tio ar ns ge rgic >1 4 a du d l rin em ay s er g ge th e n Re Fu We c y ek s p ng ira al i -en n d to ry f ec tio d y Re n na s f u s l d nc y s tio n M f un M ec ed ct ha ic a ion ni c a l pa t Pr im l v e ient nt ar IC ila y Utio ac ba c qu te n r Co ire em d cc ia in ig fe ra c tio m n po s i Dia t l Sh y if oc inf s is ec k at ti ad ons m is si on Co m a SA Bootstrap for variables selection Results of the bootstrap technique: % selected from the 500 samples 100 90 80 70 60 50 40 30 20 10 0 Multivariate analysis: Independent predictors of Post-ICU-mortality variable OR adjusted 95 IC p value Age 1.02 [1.01 ; 1.03] 0.001 Immunossupression 1.92 [1.37 ; 2.68] 0.0002 Cirrhosis 1.75 [1.00 ; 3.06] 0.05 Chronic Pulmonary failure 2.05 [1.16 ; 3.63] 0.01 Medical 1.86 [1.08 ; 3.23] 0.02 SAPS II at the first day of infection 1.17 [1.04 ; 1.32] 0.01 LOD at ICU discharge 1.23 [1.15 ; 1.31] < 0.0001 Hospital-acquired 1.72 [1.21 ; 2.45] 0.002 ICU-acquired 1.54 [0.96 ; 2.49] 0.07 Infection of the respiratory site 0.69 [0.50 ; 0.95] 0.02 Microbiologically documented 1.77 [1.23 ; 2.55] 0.001 Admission categories Origin of infection Discussion (1) Patients at risk of dying after ICU discharge were those with poorer chronic health status, more severe acute disease at ICU admission, and prolonged severity of illness and organ failure. The most powerful predictors of PIM were implementation of end-of-life decisions during the ICU stay and the importance of severity at ICU discharge. DFLST Decisions to withhold/withdraw treatment have been recorded in half the patients who died in the ICU Ferrand, Lancet 2001, Pochard, Crit care Medicine 2001 Patients for whom end-of-life decisions were made in the ICU had lower ICU and hospital mortality rates in the late 1980s than ten years earlier. Jayes RL, Jama 1993; 270:2213-7 However, no studies have been specifically designed to evaluate the impact of end-of-life decisions made in the ICU on mortality between ICU discharge and hospital discharge (post-ICU mortality). Discussion (2) The 10% PIM rate reported in these studies is in agreement with previous reports. Moreover, patients who died in the hospital after ICU discharge had significantly higher severity-ofillness scores on the day of discharge than those who survived. This suggests that patients at risk for PIM may have been discharged from the ICU with incomplete resolution of their acute medical condition. Discussion (3) The appropriateness of established discharge criteria depends on whether a decision to limit therapy was taken in the ICU. The incidence of end-of-life decisions taken on the ward was not determined in this study. Discussion (4) A growing proportion of patients are discharged alive from the ICU despite previous implementation of end-of-life decisions. In the present study, 58.8% of patients who were discharged alive from the ICU after an end-of-life decision died before hospital discharge. In these patients, ICU discharge was an appropriate response to an awareness that further intensive care would be futile. Conclusion Identifying patients at risk for premature ICU discharge may help physicians to solve the clinical dilemma of whom to discharge to make room for a patient requiring urgent admission to the unit. However, the appropriateness of discharge criteria should be evaluated in the light of the patient’s end-oflife decision status. Further studies are needed to assess risk factors for PIM according to whether end-of-life decisions are implemented in the ward. Need to focus on long-term outcomes Post-ICU mortality One-year mortality Morbidity Neurocognitive disorders Psychiatric symptoms (depression +++) Intensive feeding and malnutrition Long-term sequelae Quality of life