Long stay in ICU Audit of hospitals in North Wales

Mohammad Abdul Rahim, Usman Al-Sheik, Yvonne Soon, Louisa Brock

22nd June 2012

Introduction:

No Clear Consensus: Long Stay in ICU (1)

Concerns regarding bed occupation, higher mortality, functional disability and subsequent cost implications.

Evidence from the literature:

• Laupland et al :Large Canadian Study in 2006 involving > 4000 patients showed:

One in 25 ICU patients will have a prolonged admission.

These patients have a higher mortality rate during the acute phase 25%.

If they survived, the long term mortality was not high (2) .

• O Friedrich J et al 2005:

Another Canadian Study

182 patients

Patients that stayed more than 30 days on ICU

ICU mortality %32

Concluded that these patients had reasonably good outcome despite LOS.Therefore cost implications were justified (2).

•Crozier et al looked at the Australian/NZ ICU database over the periodbetween 2000 - 2004 :

Data from more than 5000 patients.

Long stay patients accounted for 22.5% of total ICU bed-hour usage.

Patients who stayed > 21 days had significant resource uptake but had good rateof survival to hospital discharge. ICU mortality was 28% (1).

• Williams et al (2010):

Most powerful study

Retrospective Cohort.

Looking at patients who stayed in ICU > 10 days

More than 20000 patients over 23 year period

Concluded that LOS was not independently associated with an increased riskof in-hospital mortality.

Small Effect on long term mortality (4).

Main aims of the Audit::

• To Audit the number of long term admissions (>30 days)

• To identify the primary reason(s) for admission

• To identify ICU mortality, mortality after six months and after one year

• Data collected from three hospitals across North Wales.

• Covering a two year period between 02/2008 to 02/2010

• Data extracted from ICNARC and complemented with data from patients’ notes and GPs.

• Data collected included:•Sex•Age•Median ICU stay in days•Primary reason for admission to ICU•Secodary reason for admission to ICU•Cause for long stay in ICU•Need for home ventilation•ICU mortality•Mortality after six months•Mortality after one year

Methods

Results

Total number of patients: 79

16%

28%56%

Wrexham

YGC

YG

Age

Age Range Median

All hospitals

21-86 67

Wrexham 21-83 66

YGC 45-82 69.5

YG 24-86 67

Reason for ICU Admission

Secondary Primary

Medical: Infective Non Infective

Post operative Emergency Post operative Elective Trauma Pancreatitis

Surgical

Primary reason for admission to ICUSurgical Admissions

17%

50%

20%

13%Post-opElective

Post-opEmergency

Trauma

Pancreatitis

Total number of patients: 30 Percentage from total: %37.97

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wrexham YGC YG

Post-opElectivePost-opEmergencyTrauma

Pancreatitis

Primary Reasons for Surgical Admissions to ICU Breakdown

Primary Reasons for Admission to ICUMedical Admissions Total number of patients: 51

Percentage from total: 64.55%

54.90%45.10% Infective

Non Infective

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Wrexham YGC YG

Infective

Non-infective

Primary Reasons for Medical Admissions to ICU Breakdown

0 10 20 30 40 50 60 70Tot

alW

rexh

am

YGC

YG

Mean Stay onICU (days)

Mean Stay on ICU in days:

Cause for long stay in ICU

36.70%

18.98%

30.37%

77.21%

20.25%

18.98%

7.59%

2.53%

2.53%

7.59%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100

%

Peripheral Motor Weakness (Suspected

CIN/ CIM)

Central Motor Weakness

Severe Cardiovascular disease

Severe respiratory disease

Ventilator Associated Pneumonia

Acute Kidney Injury/ Failure

Multiple Surgeries

Long term Nursing Care

Obesity

Unknown

All Three Hospitals

(6)

(2)

(2)

(6)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

(15)

(29)

(24)

(15)

(29)

(61)

(24)

(15)

(29)

(16)

(61)

(24)

(15)

(29)

(15)

(16)

(61)

(24)

(15)

(29)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

(6)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

(2)

(6)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

(2)

(2)

(6)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

(6)

(2)

(2)

(6)

(25)

(15)

(16)

(61)

(24)

(15)

(29)

Mortality: ICU Outcome, After Six Months, After One Year

0%10%20%30%40%50%60%70%80%90%

100%

ICUOutcome

Six months One Year

41.77%40.5%

18.98%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ICU Six Months One Year

Wrexham YGC YG

Comparing Mortality between different hospitals

Conclusions

1- The ICU Mortality despite LOS was not high for each individual hospital and all three hospitals collectively.

2- This significantly elevated to a much higher level after six months ( doubled) and sustained after one year.

3- These findings are consistent with the literature.

4- Mortality not high. Functionality? Role of Follow Up Clinics?

5- Main cause for long stay on ICU was severe respiratory or cardiovascular disease.

6- Number of patients not enough to conclude statistically significant conclusionsregarding difference in mortality between hospitals.

7- Concerns regarding documentation and data feeding into ICNARC.

References:1- Crozier T et al. Long-stay Patients In Australian/New ZealandIcu’s: Demographics And Outcomes. Anaesth Intensive Care 2007; 35: 132-137.

2- Laupland K et al. Long-term Mortality Outcome Associated With Prolonged Admission To the ICU. Chest 2006; 129:954–959.

3- O Friedrich et al. Long-term outcomes and clinical predictors of hospital mortalityin very long stay intensive care unit patients: a cohort study. Critical Care Vol 10 No 2

4- Williams T A et al. Effect of length of stay in intensive care unit on hospital andlong-term mortality of critically ill adult patients. British Journal of Anaesthesia 104(4): 459–64 (2010).

Thank You

Any Questions?