The impact of a delay in intensive care unit admission for community-acquired pneumonia

Abstract

The primary objective of the present study was to evaluate the effect on hospital mortality of a delay in intensive care unit (ICU) admission for severe community-acquired pneumonia (CAP). The secondary objectives were to assess if such delays were associated with treatment variations by the emergency department (ED) and deterioration in the general wards, and to evaluate the prognostic ability of the Infectious Disease Society of America (IDSA)/ American Thoracic Society (ATS) minor criteria.We retrospectively compared patients who were admitted straight from the ED to the ICU (direct group, n554) and those who were first admitted from the ED to the general wards before ICU transfer (delayed group, n549), over 2.5 yrs.Even after excluding patients who required mechanical ventilation and/or vasopressors at the ED, delayed ICU admission was an independent predictor of hospital mortality (OR 9.61). The delayed group received fewer fluid boluses in the ED and rapidly deteriorated in the general wards. The presence of o3 IDSA/ATS minor criteria was associated with increased mortality in the delayed group.In conclusion, prompt recognition of severe CAP using the IDSA/ATS minor criteria, followed by aggressive management at the ED and direct ICU admission, are all crucial toward improving outcomes.

Update in Pulmonary Infections 2010

“…Not surprisingly, patients admitted to the ICU after initial triage to the ward had substantially poorer outcomes, including 30-day mortality, compared with those sent straight to the ICU from the emergency department. Almost identical findings were demonstrated in a study from Singapore (19). Mortality was again substantially higher in patients admitted to the floor (72.7%) than those admitted to the ICU initially (33.3%) with more than three IDSA/ATS minor criteria (12).…”

“…In keeping with this hypothesis, French and colleagues (25) studied the efficacy of the 7-valent conjugate pneumococcal vaccine in a randomized, double-blind, placebo-controlled study of 496 adolescents and adults in Malawi, 89% of whom were infected with HIV. The primary endpoint of the study, infection due to serotype 6A covered by the 7-valent vaccine, showed a substantial reduction in events in the vaccine group (5 vs. 19). The overall value of the vaccine was limited by the finding that 64% of pneumococcal infections were by nonvaccine serotypes; it is hoped that coverage will improve as higher-valent conjugate vaccines become available.…”

Management-based risk prediction in community-acquired pneumonia by scores and biomarkers

“…Accordingly, a multicentre database in the USA previously found that only a small proportion of patients experiencing cardiac arrest while hospitalised with pneumonia showed features of severe CAP, such as shock (33%) or mechanical ventilation (36%), and 38% of arrests occurred in a normal ward with only 52% being under cardiorespiratory monitoring [4]. Clinical deterioration, septic organ dysfunction or death predominantly occur within a well-defined time frame of 24-72 h after hospitalisation [2,[4][5][6]. For this vulnerable early period, interventions like intensive monitoring and management in the intensive care unit (ICU) [6][7][8], optimised sepsis management (''sepsis bundles'') [9] and early adequate antibiotic therapy [10,11] potentially translate into substantial prognosis improvement.…”

Why the surgical patients are so critical in their intensive care unit arrival?

“…The authors found that the patient group awaiting ICU admission for over 6 hours were hospitalized for longer periods in the ICU (10.7 vs 8.4 days) and hospital mortality was higher (17.4% vs 12.9%). The problem is aggravated by the fact that individuals with increased length of stay in the ICU are more exposed to infections, have less favorable prognosis, and incur higher hospital costs, which together have an evident negative impact on the observed outcome 14,15 . It is worth highlighting that a tertiary university hospital serves as reference for performance of highly complex procedures, so there is a real need for adjustment of the number of ICU beds.…”