Association between pre-intensive care unit (ICU) hospital length of stay and ICU outcomes in a resource- limited setting

Abstract

Background. Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings. Objectives. The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality. Methods. This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS. Results. The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source. Conclusions. Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes.

An analysis of referrals to a level 3 intensive care unit in a resource-limited setting in South Africa

“…When comparing our patient cohort with another ICU in the same province, 36.2% of our patients had a qSOFA score ≥2 v. 60.6% in a study by Khan et al [10] This trend continued when looking at a study done in Botswana, where their mean APACHE II score was 25 v. 18 in our study. [14] However, when comparing the mean APACHE II score in our study group with high-income countries such as Japan and the USA, no difference was seen, with similar mean APACHE II scores of 18 noted across all three studies.…”

“…Although trauma comprised a large proportion of ICU admissions, this is lower than reported in another large South African ICU. [2 , 10 , 13] Despite the young median age, the incidence of comorbidities was high at 63.4%. The impact of the HIV epidemic is apparent in this regard, with 24.0% of patients known to be HIV positive, which is in keeping with data from other centres in South Africa.…”

“…The impact of the HIV epidemic is apparent in this regard, with 24.0% of patients known to be HIV positive, which is in keeping with data from other centres in South Africa. [10 , 13 , 14] …”

Critical care research in the resource-limited setting: Leveraging the power of the database

“…The results of the study by Khan et al [1] are contrary to much of the published literature on the association between pre-ICU length of stay and patient outcomes. There are a number of potential reasons for this.…”

“…pre-ICU hospital length of stay and ICU outcomes in a resource-limited setting. [1] The methodology of the study is noteworthy as it included data on 2 040 intensive care patients that were extracted from an electronic ICU patient database. Notably, this database is from a regional hospital and not from an academic hospital with an established electronic health record.…”