Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission

274 Introduction of a Floating Emergency Critical Care Team Into an Academic Emergency Department

To assess the impact of delay in emergency department (ED) on outcome of critically ill patients admitted to the medical intensive care unit (MICU). Outcome was defined as hospital mortality and as health-related quality of life (HRQoL) at 6 months after intensive care assessed by the 15D measure. The 15D is a generic, 15-dimensional, standardized measure of HRQoL. We hypothesized that prolonged stay in the ED is related to worse outcome. A prospective follow-up cohort study in university hospital. All consecutive 1675 patients admitted to the MICU between July 2002 and June 2004. The 15D questionnaire was mailed to all patients alive at 6 months after admission. Of all MICU patients, 64% were admitted from ED. The mean length of stay in the ED was 6.2 h (95%CI 5.9-6.5 h). The hospital mortality rate was 24.4% (20.0% in the ED vs. 33.0% in the non-ED cohort, P < 0.001) and it was associated with higher age and degree of physiological derangement at admission. Neither the length of ED stay was associated with hospital mortality (P = 0.82) nor with HRQoL at 6 months after MICU admission (P = 0.34). Altogether, HRQoL at 6 months was significantly lower compared with the age- and sex-matched general population (P < 0.001). In a university hospital, the length of ED stay was not associated with the outcome of critically ill medical patients. However, we feel that the effect of ED treatment and delay on outcome and outcome prediction in the critically ill patients deserves further evaluation.

Recent medical advances mean that more people survive critical illnesses and intensive care unit (ICU) admissions. This has led to an uptick in reported physical, cognitive and mental health issues post-ICU (Hiser SL, Fatima A, Ali M et al. Post-intensive care syndrome (PICS): recent updates. J Intensive Care 2023; 11: 23). Despite existing research, dermatological symptoms post-ICU care have been overlooked. This study aims to assess the prevalence and extent of such symptoms in patients 1 month after ICU admission. Local approval was obtained for the study. We enrolled ICU patients admitted for 5 days or longer, or with advanced respiratory issues, from 1 August to 30 November 2023. Telephone interviews were conducted with patients 1 month after ICU admission to assess previous and new dermatological diagnoses or symptoms. If new disease was present, patients were asked about the impact on their quality of life, and if they had sought treatment. Of 148 ICU admissions in a 4-month period, 70 met the study’s criteria. Exclusions were made for patients with primary skin issues (n = 1), deceased or on an end-of-life pathway (n = 25), or still under specialist care (n = 10). Three patients could not be reached. In total, data from 31 patients were included; their ages ranged from 18 to 89 years (mean 61.8, SD 16.9) and 48% were female. Twenty-three patients (74%) experienced dermatological issues post-ICU, including xerosis (n = 8), nonspecific pruritic erythematous rash (n = 5), mouth ulcers (n = 3), hair loss (n = 3), brittle nails (n = 3), cellulitis (n = 2), seborrhoeic dermatitis (n = 2) and pruritus (n = 2). Six patients reported that these caused a significant impact on their daily life (causing low mood, or interrupting sleep or daily activities), while nine reported a moderate impact (causing irritation but not halting usual activities). Nine sought healthcare advice to treat their symptoms, while 10 self-managed with over-the-counter products. Among those with post-ICU dermatological issues, six had a formal chronic dermatology diagnosis, and a further nine reported previous skin problems. The eight patients without post-ICU dermatological symptoms had no formal skin disease diagnoses. Our findings indicate that a notable portion of ICU patients experience skin impairments, and a potential predictor is identified, as 65% of affected patients have a history of chronic skin disorders or symptoms. Dermatological symptoms post-ICU significantly or moderately affected daily life for most individuals, leading them to seek treatment following hospital discharge. Further research is warranted to explore the risk of cutaneous impairment post-ICU, and we propose preventive measures such as prescribing prophylactic emollients to mitigate this risk.

In the UK, mortality from liver disease has increased by 400% between 1970 and 2010 with death rates for those under 65 having risen by almost 500% (1). Up to 75% of deaths related to chronic liver disease have an underlying aetiology of alcohol and are preventable (1, 2). Advanced chronic liver disease leads to multi-system clinical manifestations, many of which will require critical care. Evidence supporting this claim is seen in the increase in admissions to critical care for those patients with cirrhosis (3). These patients have higher rates of readmission to ICU (Intensive Care Unit), longer length of ICU stay and have an increased requirement for organ support (4). Despite this, both ICU and hospital mortality in those with cirrhosis have improved since the 1980s where mortality was reported to be up to 100% (5-7). With fewer beds compared to the USA or other European countries the existing demand on critical care capacity in the UK is increasing. There remains a need for a greater number of centres offering both critical care and hepatology input, with a significant number of hospitals nationwide lacking any hepatology input (8). Assessment of critically ill patients with cirrhosis is challenging, with many prognostic scoring systems in use. To date, no scoring system has been demonstrated to be superior in stratifying which patients would benefit from ICU admission. With the existing pressure on limited critical care beds within the UK and the increased demand to support critically ill patients, identifying those patients who merit admission to critical care will become an increasingly important challenge. This thesis focuses on the factors used in the decision to admit a patient with advanced chronic liver disease or cirrhosis to critical care, their long-term survival and quality of life. Attention is given to the utility of the Child-Pugh score and when it should be assessed. As the majority of deaths due to chronic liver disease have an underlying aetiology of alcohol, this thesis will also address how an alcohol use disorder can be assessed in the critically ill. The first investigation of this thesis explores the criteria used in the decision to escalate a patient to intensive care. This is explored through 2 Scottish surveys of consultant gastroenterologists and intensivists. Results highlighted agreement by both specialities on the importance of Child-Pugh score measured when a patient was clinically stable. Inconsistencies were evident in the escalation of therapy with intensivists more likely to offer intensive care and multi-organ support as compared to gastroenterologists. In response to these findings, the timing and utility of Child-Pugh score was investigated. This observational cohort study compared Child-Pugh score measured on ICU admission with the score when a patient was clinically stable and short-term mortality. Only Child-Pugh score measured at time of ICU admission was associated with hospital mortality, which contradicted the findings of the previous chapter. The degree of change in Child-Pugh score between these time points was associated with mortality. Given that the majority of deaths due to chronic liver disease in the UK are primarily caused by alcohol, challenges exist in identifying alcohol use disorders in the critically ill. A prospective study examined the use of a proxy to report an alcohol use disorder in critically ill patients and suggested that a proxy could be used as a reliable historian. Whilst short-term survival of critically ill cirrhotics has improved, there is a paucity of studies reporting long-term outcomes. An observational cohort study investigated survival at 12 months for cirrhotic patients admitted to a general ICU in the UK. Long-term survival following an ICU stay has improved, in keeping with other studies. When measured on admission to ICU, Child-Pugh class was demonstrated to stratify patients into 3 distinct groups for long-term survival. With the improvement in survival, the sequelae of an ICU stay were investigated. A prospective observational cohort study explored the long-term quality of life and prevalence of sleep disturbance. A number of survivors reported that their quality of life was worse than, or equal to death. Quality of life and sleep disturbance were influenced by pre-existing comorbidity and events during their ICU. In this study, there was no association found between QOL and insomnia in those with liver cirrhosis. This thesis addresses the decision to admit a patient with advanced chronic liver disease or cirrhosis to critical care, reports their long-term survival and quality of life and explores how one preventable cause of chronic liver disease can be assessed in the critically ill by use of a proxy.

Older Adults With Isolated Rib Fractures Do Not Require Routine Intensive Care Unit Admission

AimTo test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome ‘mortality’ (hospital or 30 day) and secondary outcomes ‘intensive care unit (ICU) admission’ and ‘critical care in ED’ and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. MethodsRegister-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. Results1586 patients were included. NEWS2 showed poor prediction of ‘mortality’ (AUC 0.686, CI 0.633–0.739) and adequate prediction of ‘ICU admission’ (AUC 0.716, CI 0.690–0.742) and ‘critical care in ED’ (AUC 0.756, CI 0.732–0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with ‘mortality’ (OR 1.688, CI 1.052–2.708, p<0.05) and ‘critical care in ED’ (OR 3.267, CI 2.490–4.286, p<0.001). NEWS2 > 4 had the strongest association with ‘ICU admission’ (OR 2.339, CI 1.742–3.141, p<0.001). ConclusionFor identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.

This study examined records of 2566 consecutive COVID-19 patients at five Massachusetts hospitals and sought to predict level-of-care requirements based on clinical and laboratory data. Several classification methods were applied and compared against standard pneumonia severity scores. The need for hospitalization, ICU care, and mechanical ventilation were predicted with a validation accuracy of 88%, 87%, and 86%, respectively. Pneumonia severity scores achieve respective accuracies of 73% and 74% for ICU care and ventilation. When predictions are limited to patients with more complex disease, the accuracy of the ICU and ventilation prediction models achieved accuracy of 83% and 82%, respectively. Vital signs, age, BMI, dyspnea, and comorbidities were the most important predictors of hospitalization. Opacities on chest imaging, age, admission vital signs and symptoms, male gender, admission laboratory results, and diabetes were the most important risk factors for ICU admission and mechanical ventilation. The factors identified collectively form a signature of the novel COVID-19 disease.

ICU Admission Rate Among Patients With Acute Exacerbation of COPD: What Are Predictors for Ventilator Support?

Burnout Syndrome in ICU Caregivers: Time to Extinguish!

An internally validated prediction model for critical COVID-19 infection and intensive care unit admission in symptomatic pregnant women

All types of healthcare professionals can develop burnout syndrome (BOS), while those who serve in critical care and emergency units are more susceptible to it. The emergence of BOS is linked to an imbalance between a team member's personal traits and problems at work or with other organisational elements. BOS is linked to a number of negative effects, including as higher rates of employee turnover, lower patient satisfaction, and lower levels of care quality. BOS also has a direct impact on the mental and physical health of the many physicians and other healthcare workers that work in emergency and critical care settings around the world. Critical care medical professionals and other psychological illnesses went mostly undetected until recently. The current paper examines the burnout prevalence among doctors in critical care (CC) unit and emergency unit physicians, the risk factors (RF) of burnout and their consequences, prevention and treatment measures of BOS and intensive and non-ICU healthcare workers' burnout prevalence comparison were also studied. It finally concludes from the study that the physicians from the Critical Care Unit and emergency department unit are more stressed and prone to high burnout levels than others.

Objective This study aimed to evaluate the impact of Intensive Care Unit (ICU) admission on patients with malignant liver tumors after elective major hepatectomy, and to analyze the relevant factors relating to ICU admission. Method 1 044 liver cancer patients who underwent elective hepatectomy were included into this study. Using the length of extubation time (>5 h) and/or treatment time (>24 h) in ICU, the patients were divided into the ICU group and the general group. The age, gender, underlying disease and operative time, intraoperative blood loss, blood transfusion, as well as postoperative complications, mortality, hospital stay and hospitalization costs were compared between the two groups. The relative factors of the ICU group were evaluated using univariate and multivariate analysis. Results Compared to the general group, the mean age (57.4±3.7 vs. 53.2±3.2), and the proportions of patients with associated lung diseases (33.7% vs. 10.0%), chronic kidney diseases (9.6% vs 2.0%), anemia (50.6% vs. 5.3%), as well as the amounts of intraoperative blood loss (816 ml vs. 635 ml) and blood transfusion (4.3 U vs. 1.4 U) in the ICU group were significantly higher. The differences were significant (P<0.05). Furthermore, the ICU group of patients had a significantly longer hospital stay (21.6 days vs. 10.1 days, P<0.05) and more hospital costs (76 751 yuan vs. 42 069 yuan, P<0.05). Multivariate analysis showed that age, blood loss and transfusion were associated with ICU admission. Conclusions It is not necessary to admit every patient with malignant liver tumors to ICU after elective major hepatectomy. ICU admission resulted in prolonged hospital stay and elevated hospital costs. Age (OR=1.077, 95%CI: 1.030~1.127), amount of blood loss (OR=3.211, 95%CI: 1.038~9.929) and blood transfusion (OR=1.330, 95%CI: 1.113~1.589) were associated with ICU admission. There are still many potentially influencing factors which need further studies to determine. Key words: Liver neoplasms; Hepatectomy; ICU; Risk factors

Pancreaticoduodenectomy (PD) is standard for patients with resectable pancreatic ductal adenocarcinoma (PDAC) in the pancreatic head, neck, and uncinate process, but it is associated with a relatively high morbidity. This study aimed to identify risk factors for extended postoperative intensive care unit (ICU) admission and assess the impact of ICU treatment on patient survival. Between October 2001 and June 2008, patients that underwent PD for PDAC in the pancreatic head were identified from a prospective database. Patients admitted to the ICU after an initial recovery period were compared to those not admitted regarding comorbidities, intraoperative parameters, resection size, and tumor biology. Five hundred and forty patients were included. Of these, 17.8% required extended postoperative ICU admission (immediate, 9.3%; delayed, 7.6%). Immediate ICU admission was most frequently required for increased intraoperative blood loss and fluid management. Delayed ICU treatment was most frequently required for hemorrhage, respiratory insufficiency, or pancreatic fistula. Morbidity and 30-day mortality rates were 54.2% and 2.6%, respectively. ICU admission correlated with significantly lower survival rates compared to no ICU admission (P = 0.0155). Multivariate risk factors for ICU admission included a history of diabetes mellitus and heart failure (NYHA I-III), an intraoperative blood transfusion, and a longer operating time. The need for extended ICU admission is associated with higher in-hospital mortality and reduced long-term outcome. The highest mortality was observed after delayed ICU admission. Preoperative diabetes, heart failure and long operations, and intraoperative blood transfusions substantially increased the risk for ICU requirement.

Towards Consensus in Timing of Kidney Replacement Therapy for Acute Kidney Injury?

To determine how medical intensive care unit (MICU) admission decisions are made at U.S. academic MICUs and to learn how these practices compare with the recommendations of the Society of Critical Care Medicine and the American Thoracic Society. A 22-question Web-based survey. University health sciences centers. MICU directors at academic U.S. medical centers offering fellowship programs in pulmonary/critical care or critical care medicine. The survey was sent by E-mail to 146 academic MICU directors. Survey response rate was 83% (121/146). MICU attendings were the primary decision-maker for patient admission to the intensive care unit (ICU) in 40% of the MICUs during daytime hours, in 36% on weekends, and in 27% overnight. Critical care fellows and resident house staff were often responsible for making MICU admission decisions, particularly overnight and on weekends. Of the MICUs surveyed, 88% had written admission guidelines, although only 25% used them on a regular basis. Written restriction guidelines were present in only 21% of these ICUs, although 53% of MICU directors believed that MICUs should have standardized criteria for restricting admission to the ICU. Finally, 29% of MICUs surveyed did not authorize MICU attendings to deny ICU admission on a case-by-case basis for futile or inadvisable care, thereby maintaining an open door policy for ICU admission. Significant practice variability exists across U.S. academic MICUs regarding how decisions are made to admit patients to the ICU. The majority of academic MICUs in the United States do not strictly employ ICU admission and restriction guidelines, as recommended by the Society of Critical Care Medicine and the American Thoracic Society.