Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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HDUs, not more ICU beds
- Stephen Stott (25 May 2001)
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ICU Follow up team is the next logical extension
- Milind P Sovani (27 May 2001)
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Re; Mortality after discharge from intensive care
- Andrew Inglis, Richard Price (11 June 2001)
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Reduction in mortality after discharge from ICU
- William Konarzewski (14 June 2001)
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Hospital mortality prediction at ICU discharge
- Nicolás Serrano, Maria-Luisa Mora (15 June 2001)
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The role of high dependency unit care
- D L Crosby (6 July 2001)
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Stephen Stott, Consultant In Anaesthesia and Intensive Care Aberdeen Royal Infirmary
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Editor, The paper by Daley et al presents a model to help us decide if patients should be discharged from the Intensive Care Unit. The discussion, however does not address the most important issue of the standard of care after discharge. To call for an increase in the provision of ICU beds so that patients can stay up to 48 hours longer is missing the fact that if the standard of care post discharge is low then the mortality will always be unacceptably high. None of the units used in their paper had a High Dependancy Unit as a step down facility from ICU. The inability to provide good step down care will always influence the ICU discharge mortality rate and it is here that resource shold be concentrated, not in more ICU beds. In terms of cost benefits the answer is not to continue to expand already vastly expensive ICUs but to fund, equip and staff proper step down facilites. |
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Milind P Sovani, clinical fellow ICU Manchester Royal Infirmary
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Dear Editor I feel that the model proposed by Daly et al will be of limited help in deciding who will be suitable for disharge from ICU.The model may not be appropriate for most of the ICU setups at District general Hospitals as they hardly ever look after cardiac surgery patients. To obtain the score for each patient everyday may be difficult in most of the ICUs.I agree with Dr. Stott that we need more HDU beds. Moreover in my opinion we also need ICU follow-up team to establish continuity of care and a smooth transition from highly monitored environment to a general ward with minimum facilities. All it needs is something like an extra litre of fluid to upset these critically balanced patients. Follow-up team can provide the necessary expertise and continuity of care and easily prevent the potential disaster. |
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Andrew Inglis, Consultant Intensivist, SHO Anaesthesia Southern General Hospital, Glasgow G51 4TF, Richard Price
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Dear Sir, The triage model described in the BMJ of 26.05.2001(1) to identify patients at higher risk of death following discharge from intensive care (ICU) seeks to address a number of important issues. The authors used five variables (patient's age, chronic health points, length of ICU stay, acute physiology score and 'cardiothoracic surgery') to produce a predictive model which gave a relative risk of death of 9.44 in the developmental group (mortality 14% in those 'at risk', 1.5% in those 'not at risk' by this model) and 6.76 in the validation group (mortality 28% in those 'at risk on day of discharge', 4% in those 'not at risk in the 48 hours prior to discharge'). This adds further statistical background to previous studies which had highlighted four of these variables as risk factors at ICU discharge (2,3). The fifth variable 'cardiothoracic surgery' (57% of the developmental model) makes this group atypical of most UK intensive care units although this point is acknowledged in the internet version of the paper. Unfortunately the authors then proceed to claim that if patients 'at risk on day of discharge' stay an extra 48 hours in ICU the mortality post discharge may be reduced by 39%. This piece of statistical fast footwork is given despite no prospective component to the study demonstrating that an extra 48 hours in ICU will reduce the risk of (any / most / all) patients. Indeed of the five factors in the model only 'normalisation of physiology' will reduce the risk of mortality after discharge (as is noted in the internet version of the paper). It may be either a) not possible or b) take much more than 48 hours, to reduce the risk in an individual paitent, thus the extrapolation from a 'predicitive triage model' to conclusions regarding reduction in mortality and resource requirements for 48 hours longer stay is invalid. This may be what the accompanying editorial alluded to (4). No consideration of the relative timing of deaths after discharge was made. 'Early' deaths, within say 48 hours may reflect precipitate discharge or communication problems whereas late deaths may reflect more the standard of ward care. It is of note that none of the 20 intensive care units in this study were in hospitals with high dependency units (at that time). The advantages of such step down care have been long and widely recognised (5) Further consideration is also merited of the cause of death of patients after ICU discharge. Whilst this paper excluded discharges deemed 'not for resuscitation' no numbers are given. Previous studies have found 25% of post ICU deaths were 'expected' at discharge (2). Yours sincerely, Andrew Inglis
Richard Price
Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF References 1) Daly K, Beale R, Chang RWS. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model. BMJ 2001; 322: 1274-1276. 2) Wallis CB, Davies HTO, Shearer AJ. Why do patients die on general wards after discharge from intensive care units? Anaesthesia 1997; 52: 9- 14 3) Ridley S, Purdie J. Cause of death after critical illness. Anaesthesia 1992; 47:116-119 4) McPherson K. Safer discharge from intensive care to hospital wards (editorial). BMJ 2001; 322: 1261-1262. 5) The High Dependency Unit. London: Association of Anaesthetists of Great Britain and Ireland, 1991 |
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William Konarzewski, Consultant anaesthetist Colchester General Hospital
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Dear Sir Safer discharge from intensive care to hospital wards I read with interest the recent paper by Kathleen Daly et al and the editorial by Klim McPherson. (1, 2) Whilst I agree that premature discharge from intensive care is hazardous, particularly if the patients are discharged in an unstable condition, I disagree with the conclusions that we should keep patients an extra 48 hours on intensive care and that we should increase by 16% the number of intensive care beds. What I believe would be a more appropriate response to the problem would be, first, to question how efficiently we are using our existing intensive care beds. Are we still admitting to intensive care units patients who have negligible chances of survival? Are we treating aggressively for prolonged periods patients who are obviously dying? Are we taking steps, in the rest of the hospital, to treat seriously ill patients in the hope of preventing them becoming intensive care patients? Are our surgical emergency facilities sufficient to ensure that surgical patients with a perforated viscus are receiving surgery before they develop septic shock? Are we discharging unstable intensive care patients to understaffed general wards? Or to high dependency units where they can be properly monitored? My impression is that we are still allocating intensive care beds to dying patients who do not benefit from intensive care, and to patients who might not have needed intensive care had they been managed differently prior to admission. Also we are discharging our patients to inadequately staffed wards. If we merely ask for more intensive care beds, we are only masking deficiences in our decision making processes and the resources in the rest of the hospital. It should also be remembered that many patients probably would not welcome an extra 48 hours on intensive care units since intensive care units are stressful places where good quality sleep is nearly impossible. More intensive care beds would be expensive and it would be difficult recruit enough nursing staff for them. They might well not be the best way of using our resources to save patients’ lives. Yours sincerely, William Konarzewski
(1) Daly K, Beale R, Chang RWS. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model BMJ 2001; 322: 1274-6 (2) Klim McPherson. Safer discharge from intensive care to hospital wards. BMJ 2001; 322: 1261-2 |
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Nicolás Serrano, Consultant in Intensive Care Hospital Universitario de Canarias, Intensive Care Department, E-38320 La Laguna, Tenerife, Spain, Maria-Luisa Mora
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Dear Sir, We have read with interest the excellent article of Daly, Beale and Chang [1] addressed to develop a predictive model of hospital mortality after discharge from the intensive care unit (ICU). We would like to congratulate to the authors and to validate their results with those of our recent work. It has been accepted as an oral presentation in the next meeting of the National Intensive Care Society from Spain, after submitting our abstract several months ago [2]. In our work we developed and validated a logistic regression model on a cohort of consecutive patients discharged alive from our ICU in order to predict hospital mortality after ICU discharge. We prospectively studied 962 consecutive patients discharged from the 20 bed general intensive care unit at Hospital Universitario de Canarias, Tenerife, Canary Islands, Spain. Cardiac surgery patients (more than 50% of our case-mix) were not included. We measured severity of illness with the acute physiology and chronic health evaluation II and III (APACHE II and APACHE III) systems [3;4], the mortality probability model II at admission and at 24 hours (MPM II-0 and MPM II-24) [5], and the simplified acute physiology score II (SAPS II) [6]. Demographic data and hospital outcome were also recorded. Severity scores APACHE II, III and SAPS II were also calculated at ICU discharge. The first 481 patients were assigned for the development of the model, and the next 481 for validation. The main outcome measure was hospital mortality after ICU discharge. The hospital mortality rate after discharge from intensive care was found to be 8.6%. Predictive variables were identified by univariate analysis, and a stepwise forward logistic regression procedure was used to derive the following model: logit = ß0 + ß1 (age) + ß2 (MPM II-24) + ß3 (length of ICU stay) + ß4 (DAPS III) where the coefficient values are ß0 = -5.1835; ß1 = 0.0352; ß2 = 3.0190; ß3 = 0.0182; ß4 = 0.0295, and the variables in the model are in parenthesis. The variable DAPS III means the difference between the acute physiology score of APACHE III (APS III) measured at ICU discharge minus the APS III value at ICU admission. Hospital mortality probability after ICU discharge, as calculated by Pr = e(logit)/1+e(logit) was obtained for the next 481 patients of the validation sample. Calibration of the model was assessed by means of the C and the H Hosmer-Lemeshow goodness of fit tests, with significance (p>0.05). We also assessed discrimination with receiver operating curve (ROC) analysis, and the area under the curve (AUC) was 0.703 (95% confidence interval: 0.618-0.789). After comparing our set of selected variables with those proposed by Daly and co-workers in their model, we would strongly agree with them that variables like patient's age, chronic health points, acute physiology points at discharge from unit, and length of ICU stay would be the main variables defining the probability of survival after ICU discharge. We had the opportunity of including cardiothoracic surgery patients in our model, but we refused to do it by several reasons. First of all, in previous studies performed in our setting we have shown that these patients have an excellent prognosis once they are discharged from the ICU [7]. Second, in our opinion this subgroup of ICU patients should not be included in a model based in severity measures such as APACHE II and III, SAPS II or MPM II, because these systems did not consider cardiothoracic surgery patients in their development [3-6]. And last, but not least, a vast majority of ICUs does not include cardiothoracic surgery patients in its case-mix, an important aspect in order to reach an easier utilization and a more widespread validation of the model. Although our findings may need confirmation in a multicenter study, such it has been done by Daly and co-workers, they are consistent with mortality risk estimation after ICU discharge as an useful parameter to calculate the "risk adjusted after-ICU discharge mortality rate". Undoubtedly, this could be used as another measure of efficiency in intensive care. Yours sincerely, Nicolás Serrano, MD, PhD
Maria-Luisa Mora, MD, PhD
Hospital Universitario de Canarias, Intensive Care Department, E-38320 La Laguna, Tenerife, Canary Islands, Spain References: 1. Daly K, Beale R, Chang RW. Reduction in mortality after inappropriate early discharge from intensive care unit: logistic regression triage model. BMJ 2001; 322:1274. 2. Serrano N, Jiménez J, Málaga J, Galván R, García C, Mora M. Hospital mortality prediction among survivors at ICU discharge. Oral Communication at XXXVI Congress of the Spanish Society of Intensive Care [Abstract 093] June 2001, 20-23. Published in Medicina Intensiva 2001: Suppl 1. 3. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13:818-829. 4. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, Sirio CA, Murphy DJ, Lotring T, Damiano A. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991; 100:1619-1636. 5. Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA 1993; 270:2478-2486. 6. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270:2957-2963. 7. Martinez-Alario J, Tuesta ID, Plasencia E, Santana M, Mora ML. Mortality prediction in cardiac surgery patients: comparative performance of Parsonnet and general severity systems. Circulation 1999; 99:2378-2382. |
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D L Crosby, Honourary Consultant Surgeon Retired
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EDITOR RE: “Reduction in mortality after inappropriate early discharge from intensive care units: Logistic Regression Triage Model”. Daly K et al. BMJ 2001. 7297: 1274-1276 The Role of High Dependency Unit Care The increased risk of death reported by Daly et al (1) in patients discharged prematurely from intensive care units (ICU’s) must surely come as no surprise. The transfer of those who have been critically ill from an area where continuous observations of vital signs are routine, to an area where only peripheral observations are made from time to time (and less frequently at night) is asking for trouble. Neither does it take any leap of imagination to appreciate how this can happen when a seriously expensive facility is under remorseless pressure to improve its throughput. What is surprising is that no mention is made of the role of High Dependency Units (HDU’s) in this scenario. Such units, preferably in the vicinity of ICU’s are specifically equipped and staffed to provide the intermediate level of care that such patients often require after discharge from ICU’s. When necessary, the need for re-admission to intensive care can then be more swiftly identified. Moreover, when compared to ICU’s, HDU’s are also intermediate in the consumption of valuable resources, thereby rationalising the use of the more expensive facilities. Daly et al have calculated that an increase of 16% in the UK provision of intensive care beds is needed in order to reduce the excess mortality that they have identified. However, it is unclear whether their calculations include the increased provision of HDU beds. If not, they should re-calculate, since the reduced resource implications are considerable. It is incidentally worth noting that the most recent report of the National Confidential Enquiry into Peri-operative Deaths concludes that “High dependency unit care should now be at the top of the list of priorities for any hospital that does not already have one.”(2,3) D.L.CROSBY Hon Consultant Surgeon G.A.D. REES Hon Consultant Anaesthetist University Hospital of Wales, CARDIFF 1. Reduction in mortality after inappropriate early discharge from intensive care unit: Logistic regression triage Model (DALY K, Beale R, Chang RSW). BMJ 2001.7297.1274-1276 2. Department of Health (2000a). The 2000 report of the National Confidential Enquiry into Peri operative deaths. The Stationary Office London. 3. Mython M, Grocott M, and Goldhill D. Hospital Medicine 2001 Vol 62, No 5 |
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