How Long To Learn Cicu
Crit Care Med. Author manuscript; available in PMC 2017 Apr 1.
Published in final edited form as:
PMCID: PMC4792682
NIHMSID: NIHMS753352
Human relationship Betwixt ICU Length of Stay and Long-term Bloodshed for Elderly ICU Survivors
Vivek Chiliad. Moitra
1Department of Anesthesiology, Higher of Physicians & Surgeons, Columbia University, New York, New York
Carmen Guerra
iSection of Anesthesiology, Higher of Physicians & Surgeons, Columbia University, New York, New York
Walter T. Linde-Zwirble
2ZD Associates, Perkasie, Pennsylvania
Hannah Wunsch
1Department of Anesthesiology, College of Physicians & Surgeons, Columbia University, New York, New York
3Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
ivDepartment of Anesthesiology, University of Toronto, Toronto, ON, Canada
- Supplementary Materials
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Appendix Tabular array ane.
GUID: 5AE6E0E3-6A92-4E62-81D2-7A92C06DBB75
Appendix Table 2.
GUID: 65ECA1FB-5E89-4532-AB16-76BC1539721A
Abstract
Objective
To evaluate the clan between length of ICU stay and 1-year mortality for elderly patients who survived to hospital discharge in the United States.
Design and Setting
Retrospective cohort study of a random sample of Medicare beneficiaries who survived to infirmary discharge, with 1 and 3-year follow-upwardly, stratified by the number of days of intensive intendance and with boosted stratification based on receipt of mechanical ventilation.
Patients
The accomplice included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to hospital discharge in 2005.
Measurements and Chief Results
Among 34,696 patients who survived to hospital discharge, the hateful ICU length of stay was three.4 (±4.5) days. 88.9% of patients were in the ICU for one–6 days, representing 58.six% of ICU bed-days. 1.iii% of patients were in the ICU for 21+ days, but these patients used 11.6% of bed-days. The percent of mechanically ventilated patients increased with increasing length of stay (6.3% for 1–6 days in the ICU and 71.3% for 21+ days). Ane-yr mortality was 26.half dozen%, ranging from 19.4% for patients in the ICU for one twenty-four hours, up to 57.eight% for patients in the ICU for 21+ days. For each twenty-four hour period beyond 7 days in the ICU, there was an increased odds of decease by one-yr of i.04 (95% CI ane.03–1.05) irrespective of the need for mechanical ventilation.
Conclusions
Increasing ICU length of stay is associated with higher 1-year mortality for both mechanically ventilated and non-mechanically ventilated patients. No specific cut-off was associated with a articulate plateau or sharp increment in long-term risk.
Keywords: Respirator artificial, critical affliction, chronic disease, outcomes research, respiratory intendance units, mechanical ventilation
INTRODUCTION
Due to advancements in medical engineering and management of illnesses such as sepsis, an increasing number of intensive care unit (ICU) patients are stabilized during acute illness following prolonged resuscitation and handling. These patients develop metabolic, neuroendocrine, immunological, and neuromuscular disturbances, get dependent on intensive care therapies, and may require prolonged organ back up. These patients are oftentimes described as beingness "chronically critically ill"(ane). The development of this new type of patient in the modern era poses novel challenges for intendance, prognosis, and health intendance utilization in the ICU and after discharge (2). Yet, studies are hampered by a lack of data identifying the advisable at-chance groups, and associated long-term outcomes, and often focus on data from unmarried centers (3–8). In detail, definitions of chronic critical illness vary and outcomes differ based on cohort definitions (9). Near studies use a minimum length of stay in the ICU such as 21 days (x), or 28 days to define this disease (3–v, vii, 8). Several studies have investigated patients who specifically received prolonged mechanical ventilation (ranging from 24 hours to 28 days) (v, 6, 9, eleven–18), while others accept used the demand for tracheostomy (ii, 13, 17, 19). However, patients who are mechanically ventilated represent a modest subgroup of elderly patients who receive intensive care in the United States (20), and the broader population of infirmary survivors who received intensive care remains unexplored.
We therefore sought to decide the human relationship between ICU length of stay and long-term mortality for elderly Medicare beneficiaries admitted to the ICU and survived to hospital discharge in order to provide data relevant for both future enquiry and prognostication.
METHODS
Design and Data Sources
Nosotros conducted a retrospective, cohort report using data from 2004 through 2008 from the v% Medicare Standard Analytic Files from the Centers for Medicare and Medicaid Services. The data fix contains all fee-for-service claims, including hospital inpatient, infirmary outpatient, skilled nursing facility, and "carrier" claims (which includes all office visits), for a random, longitudinal v% sample of beneficiaries.
Cohort
Nosotros created a accomplice of all Medicare beneficiaries who were 66 years of age or older who received intensive care in 2005 using a random 5% sample. We categorized any person with intensive care room charges as having received intensive care. We excluded anyone who received intermediate intensive care or but coronary care or intermediate coronary care room charges considering these patients have lower hospital mortality and constitute a distinct group of patients with cardiac disease. We then excluded anyone who died during the hospitalization, and so that the cohort consisted of patients who survived to infirmary discharge.
Data Analyses
The exposure of interest was days spent in the ICU. The primary effect was one year mortality, and secondary outcome was three year mortality. We beginning calculated summary statistics for demographic and clinical characteristics, including historic period, sex, race, and comorbidities of patients by using percentages, means ± standard deviations (±sd), and medians with interquartile ranges (IQR) when appropriate. For the purposes of summary statistics, nosotros grouped patients based on the number of days spent in the ICU (ane–6 days, seven–13, 14–twenty, 21+). Due to the minor sample size, nosotros grouped all patients who were in the ICU for 21 or more days together. Using information from the index hospitalization, we identified patients who received any mechanical ventilation, defined as ICD-9 process code 31.i (temporary tracheostomy) or 96.7x (mechanical ventilation) or the Diagnosis-Related Group 483 (tracheostomy with mechanical ventilation > 96 hours) (21). We besides stratified patients who received mechanical ventilation as less than 96 hours (96.71) and 96 hours or more (96.72). Non-surgical and surgical patients were divers using DRGs, and nosotros grouped patients by age at hospitalization (66 to 74, 75 to 84, and 85 years and in a higher place) for the whole accomplice and for mechanically ventilated subgroups. We used information from all health care encounters from the 4 quarters prior to the index hospitalization and secondary diagnoses from the index hospitalization to summate Elixhauser comorbidities by using ICD-9-CM codes (22). Nosotros present counts of the total number of Elixhauser comorbidities (see Appendix Table i).
We then examined the human relationship between total ICU length of stay and 1- and 3-year mortality, with one-year mortality the primary upshot. Nosotros beginning assessed this visually, then generated logistic regression models to determine whether at that place was an increased gamble of 1-year bloodshed associated with each boosted day spent in the ICU. Due to the fact that (i) the majority of patients spent 1–half-dozen days in the ICU, and we were interested in determining the relative gamble for patients with longer lengths of stay in the ICU, nosotros created a model that excluded patients who spent i–vi days in the ICU, and used patients who were in the ICU for seven days as the baseline group.
Variables included in the model for chance-aligning included age, sex, race, Elixhauser comorbidities, whether the patients were medical or surgical, and whether or not the patient was mechanically ventilated. Due to an a priori hypothesis of different relationships between ICU length of stay and mortality for patients who did or did not require mechanical ventilation, nosotros assessed for a possible interaction between mechanical ventilation and length of stay in the model using the Breslow-24-hour interval test and determined that there was no statistically significant interaction. Considering of the concern for immortality bias associated with longer stays in ICU, nosotros did not include factors that would accrue during a stay in ICU (such as dialysis). We did include mechanical ventilation considering information technology typical occurs on day one in the ICU.
Database management and statistical assay were performed with Excel (Microsoft, Redmond, WA), and SAS version nine.2 (SAS Institute Inc., Cary, NC) software. All hypothesis tests were 2-sided and considered statistically significant if ≤ 0.05. We besides assessed differences for clinical significance because of the large size of the data ready. This inquiry involved secondary analyses of de-identified data and was granted a waiver of consent by the Columbia University Medical Heart Institutional Review Board.
RESULTS
After exclusions (Figure 1), the accomplice included 34,696 Medicare beneficiaries older than 65 years who received intensive care and survived to infirmary discharge in 2005.
Patient flowchart of accomplice of ICU survivors
ICU Length of Stay
The mean ICU length of stay was three.4 (±4.5) days for intensive intendance patients who survived to hospital discharge, with a median of ii day (IQR 1–4) (Table 1). A third of patients (35.9%) spent only 1 twenty-four hours in the ICU and 88.ix% of patients were in the ICU for 1–6 days, representing 58.vi% of the ICU bed-days in the cohort. Only ane.iii% of patients were in the ICU for 21+ days, merely these patients took upwardly 11.6% of bed-days (Figure 2).
Distribution of Medicare beneficiaries who survived to hospital discharge, and proportion of total bed days, stratified by length of stay in ICU
Table ane
Characteristics of Medicare beneficiaries who received intensive care, stratified past days spent in an ICU
| Days spent in an ICU (days) | |||||
|---|---|---|---|---|---|
| Characteristics | Survived to infirmary discharge | 1–6 | 7–13 | 14–20 | 21+ |
| (N=34,696) | (Due north=30,855) | (Due north=two,769) | (North=636) | (North=436) | |
| Male, n (%) | 16,460 (47.four) | 14586 (47.3) | 1348 (48.7) | 318 (50.0) | 208 (47.seven) |
| Historic period, (yrs), median (IQR) | 77 (72–82) | 77 (72–82) | 77 (72–82) | 77 (72–81) | 75 (70–81) |
| Age, (yrs) mean (±sd) | 77.three ± 7.i | 77.iii ± 7.2 | 77.v ± 7.0 | 76.9 ± 6.v | 75.8 ± 6.7 |
| Age, (yrs), n (%) | |||||
| 66–69 | 5640 (sixteen.3) | 5061 (16.four) | 409 (xiv.8) | 82 (12.9) | 88 (20.2) |
| 70–74 | 7875 (22.7) | 6979 (22.6) | 610 (22.0) | 173 (27.two) | 113 (25.nine) |
| 75–79 | 8270 (23.8) | 7301 (23.7) | 699 (25.ii) | 165 (25.9) | 105 (24.1) |
| fourscore–84 | 7080 (twenty.4) | 6280 (20.4) | 579 (xx.nine) | 135 (21.2) | 86 (19.7) |
| 85+ | 5831 (sixteen.viii) | 5234 (17.0) | 472 (17.1) | 81 (12.seven) | 44 (10.1) |
| Race, n (%) | |||||
| White, non-Hispanic | 30375 (87.6) | 27124 (87.9) | 2362 (85.3) | 521 (81.9) | 368 (84.4) |
| Black, non-Hispanic | 2964 (viii.five) | 2535 (8.2) | 296 (x.seven) | 82 (12.ix) | 51 (11.7) |
| Hispanic/Other Races | 1357 (iii.9) | 1196 (3.nine) | 111 (iv.0) | 33 (five.ii) | 17 (3.9) |
| Non-surgical, n (%) | 18839 (54.3) | 17175 (55.seven) | 1376 (49.seven) | 232 (36.v) | 56 (12.8) |
| Co-morbiditiesa, n (%) | |||||
| 0 | 8098 (23.3) | 7401 (24.0) | 513 (18.five) | 110 (17.three) | 74 (17.0) |
| 1 | 8292 (23.ix) | 7502 (24.3) | 613 (22.one) | 99 (15.6) | 78 (17.9) |
| 2 | 6617 (19.one) | 5876 (19.0) | 509 (18.4) | 143 (22.v) | 89 (20.4) |
| 3+ | 11689 (33.vii) | 10076 (32.7) | 1134 (41.0) | 284 (44.vii) | 195 (44.7) |
| Mechanical Ventilation, n (%) | |||||
| None | 31235 (90.0) | 28899 (93.vii) | 1923 (69.5) | 288 (45.iii) | 125 (28.seven) |
| < 96 hoursb | 2022 (5.8) | 1635 (five.3) | 321 (xi.60) | 55 (8.7) | 11 (2.v) |
| ≥ 96 hours or moreb | 1439 (4.2) | 321 (ane.0) | 525 (nineteen.0) | 293 (46.1) | 300 (68.viii) |
| Tracheostomy | 486 (1.4) | 82 (0.three) | 84 (iii.0) | 109 (17.1) | 211 (48.iv) |
| Organ failurec | |||||
| None | 25675 (74.0) | 23995 (77.viii) | 1370 (49.5) | 200 (31.5) | 110 (25.two) |
| one | 7110 (20.five) | 5699 (xviii.5) | 948 (34.2) | 271 (42.6) | 192 (44.0) |
| ii+ | 1911 (5.5) | 1161 (3.8) | 451 (16.3) | 165 (25.9) | 134 (xxx.7) |
| ICU length of stay, mean (±sd) | 3.4 ± 4.5 | 2.3 ± 1.4 | nine.0 ± viii.0 | 16.4 ± 2.0 | 31.iv ± 12.0 |
| ICU length of stay, median (IQR) | 2 (i–four) | 2 (1–3) | 8 (vii–10) | xvi (fifteen–xviii) | 28 (23–36) |
| Not-ICU Infirmary length of stay, mean (±sd) | 4.6 ± half dozen.1 | 4.three ± 5.four | 6.4 ± 7.6 | 7.8 ± 10.4 | 9.1 ± xvi.iii |
| Full Hospital length of stayd, mean (±sd) | 8.0 ± 8.2 | half-dozen.6 ± 5.8 | 15.four ± 7.nine | 24.2 ± x.5 | 40.five ± 21.three |
| Discharge location | |||||
| Dwelling house | 15776 (45.v) | 15118 (48.ix) | 561 (20.3) | 68 (10.7) | 29 (half dozen.7) |
| Skilled care/rehab | 12866 (37.one) | 10455 (33.9) | 1595 (57.vi) | 454 (71.4) | 362 (83.0) |
| Other astute infirmary | 5101 (14.7) | 4530 (14.7) | 476 (17.ii) | 70 (11.0) | 25 (five.vii) |
| Hospice | 867 (2.5) | 670 (2.2) | 134 (4.viii) | 43 (six.eight) | 20 (4.six) |
| Other | 86 (0.2) | 82 (0.3) | NA | NA | NA |
Cohort Characteristics
Of the cohort, 47.4% were male person and 87.6% were not-Hispanic white (Table ane). The hateful age of the cohort was 77.3 ±7.1. Near patients (76.seven%) had at least one Elixhauser comorbidity (see Appendix Table 1 for full list of comorbidities), and 33.vii% had 3 or more comorbidities. Among survivors to hospital discharge, almost 1 quarter of patients had organ failure. For patients in the ICU betwixt vii and xiii days, over fifty% of patients had at least ane organ that had failed and for patients in the ICU more than 21 days (three weeks), 75% of patients had i or more organs fail. (Tabular array i) (23). Stratified by ICU length of stay, gender and age distributions were like. The per centum of patients who were non-surgical decreased every bit the ICU length of stay increased, such that only 12.8% of patients who stayed 21+ days were non-surgical.
The bulk of patients (90.0%) who were admitted to ICU and survived to infirmary discharge were non mechanically ventilated. Amidst patients who stayed simply i–six days in the ICU, merely 6.3% received mechanical ventilation (Effigy 3). This increased to 71.3% of patients who were in the ICU for 21+ days.
Percentage of Medicare beneficiaries who survived to hospital discharge who received mechanical ventilation, stratified by length of stay in the ICU
Discharge Destination
Amongst all ICU patients who survived to hospital discharge, 45.5% were discharged to home (Table ane). Very few patients who stayed in the ICU for more than than 14 days were discharged dwelling (10.7% for patients 14–20 days; 6.7% for 21+ days). As length of stay in the ICU increased, the percentage discharged to skilled care facilities or rehabilitation increased (83.0% for patients in the ICU 21+ days).
one- and 3-year bloodshed
The 1-twelvemonth mortality ranged from 19.4% for patients who stayed one mean solar day in the ICU, upwards to 57.8% for patients staying 21+ days (Figure four), and 3-year mortality ranged from 35.1% to 70.4% (data not shown). Characteristics of ICU patients stratified by 1-year survival are reported in Appendix Table 2. Overall bloodshed for patients who were not mechanically ventilated was lower than for mechanically ventilated patients (Figure 5), with a 1-year mortality of l.four% for non-mechanically ventilated patients (versus 60.viii% for those mechanically ventilated) who received intensive care for 21+ days.
1-year bloodshed for Medicare beneficiaries who received intensive intendance and survived to hospital belch, by days in the ICU
1-year mortality for Medicare beneficiaries who received intensive intendance and survived to infirmary discharge, stratified past days in the ICU and whether or non patients received invasive mechanical ventilation
After multivariable modeling, for each day beyond seven days in the ICU, at that place was an increased odds of decease by 1-twelvemonth of 1.04 (95% CI 1.03–1.05), irrespective of the demand for mechanical ventilation (Tabular array 2). This estimate was similar for the model using 3-year mortality adjusted OR 1.04 (95% CI 1.02–1.05) (data not shown).
Table 2
Multivariable Logistic Regression Analysis of Association betwixt Days Spent in and ICU and Bloodshed 1 Year afterwards Discharge
| Variable | Adjusted OR | (95% CI) | P Value |
|---|---|---|---|
| Spent 7 days in an ICU | ref | ||
| Each boosted mean solar day spent in an ICU | one.04 | (1.03–1.05) | <0.0001 |
| White, non-Hispanic | ref | ||
| Hispanic/Other Races | 0.89 | (0.63–1.25) | 0.fifty |
| Black, non-Hispanic | 1.26 | (1.01–ane.57) | 0.04 |
| Female | ref | ||
| Male person | ane.12 | (0.98–1.29) | 0.ten |
| Age (centered at mean=77 years) | ref | ||
| Age (each 1 year increment) | one.06 | (1.05–i.07) | <0.0001 |
| Surgical patient | ref | ||
| Medical patient | one.55 | (1.34–i.79) | <0.0001 |
| Not Mechanically ventilated | ref | ||
| Mechanically ventilated | one.67 | (ane.44–1.93) | <0.0001 |
| Prior medical history (ref=no history of status) | ref | ||
| Congestive centre failure | 1.25 | (1.07–1.46) | <0.01 |
| Neurological disorders | 1.34 | (1.10–ane.62) | <0.01 |
| Chronic pulmonary disease | ane.22 | (1.05–1.41) | 0.01 |
| Renal Failure | 1.36 | (1.05–ane.76) | 0.02 |
| Metastatic Cancer | three.14 | (1.93–5.10) | <0.01 |
| Solid tumor w/out metastasis | one.41 | (1.13–1.77) | <0.01 |
| Weight loss | 1.49 | (1.18–one.87) | <0.001 |
| Fluid and electrolyte disorders | 1.37 | (1.15–i.62) | <0.001 |
| Deficiency Anemias | one.26 | (1.08–ane.47) | <0.01 |
DISCUSSION
Approximately 1.4 meg elderly Medicare beneficiaries survive to infirmary discharge after receiving intensive care. Elderly patients who are discharged alive and required prolonged critical intendance services represent a pocket-sized portion of all ICU patients, still this population consumes a disproportionate percentage of health care resources (24). In this accomplice of elderly US ICU survivors who were discharged from the hospital, 40% of ICU days were used past the 11% of patients who were in the ICU for one week or more. After experiencing i week of intensive care and surviving to hospital discharge, more than than a third of patients died within one yr of discharge regardless of whether or non they received mechanical ventilation. We found that overall mortality rates continued to increment with increased length of stay, contained of mechanical ventilation.
Definitions of chronic critical affliction used in studies do vary, including mechanical ventilation for more than than 24 hours (14, 25), 2 days (26), 4 days (12), xiv days (11, 27), 21 days (6, 9, sixteen, 18), and 28 days (5); tracheostomy (2, thirteen, 17, 19); or ICU length of stay of more than than 7 days (28, 29), 10 days (xxx, 31), 14 days (32–35), 21 days (ten), and 28 days (3–5, 7, 8). After studying the impact of a categorical continuum of ICU length of stay on bloodshed, nosotros found that although mortality rates increased with increasing length of stay, there does not announced to exist a clear length of stay cutoff at which a patient'south prognosis significantly changes. Our data suggest that chronic critically sick patients accept a mixed trajectory, likely influenced by specific physiological changes and reserve.
Patients with prolonged mechanical ventilation accept been identified every bit a group with a high mortality who swallow a meaning proportion of health care resources (vi, 9, 36). In our cohort of elderly patients, 60% of patients who were in the ICU for more than a week did not receive mechanical ventilation, and the bulk were surgical patients (based on DRG). Limiting economic investigations of the chronically critically ill to patients whose lungs are mechanically ventilated for a prolonged menses may underestimate the financial impact of this unique grouping of patients (24). Poor outcomes, contained of the need for mechanical ventilation, may be attributable to the observed complications of prolonged critical care: nosocomial infections, immunosuppression, protein-wasting malnutrition, suppression of anterior pituitary hormone secretion, myopathy, posttraumatic stress disorder, and encephalon dysfunction (1).
Inadequate communication betwixt health care providers and patients and their families is problematic (17, 35). The brunt on caregivers and the ability to return domicile may be important when discussing quality of life after hospitalization. Only a small number of patients who were in the ICU for more than two weeks were discharged to abode. Surrogate decision makers consider hospital and 1-yr mortality "important to know." A published survey reported that 94% of respondents did not receive information on 1-year survival (37). As patients stay longer and longer in the ICU, significant changes accumulate in short- and long-term morbidity and bloodshed, which may be important to consider in medical decision-making. While nosotros plant that only 7% of patients in our cohort who were in the ICU for over 21 days were discharged to home, a piffling over twoscore% of those patients survived to 1 year. Although the overall prognosis of chronic disquisitional illness is poor, these data also propose that a significant number of patients really survive chronic critical disease. While extended time in the ICU may often feel to caregivers similar information technology must be associated with futile care, this simple marker does not provide whatever satisfactory cut-betoken.
The use of an administrative data set and the retrospective nature of this study are limitations. In particular, the utilize of Medicare data means that the assay includes only those patients who are older than 65 years. Notwithstanding, the majority of Us citizens older than 65 years participate in Medicare (19). Another limitation is that nosotros do not have data about delayed or premature discharge from the ICU, both of which may have an impact on ultimate outcomes for patients and could influence our findings regarding the association between ICU length of stay and outcomes. It is also notable that the bulk of long-stay ICU patients who survived to infirmary belch were classified as "surgical" based on their DRG. It is impossible to determine whether this is due to the fact that high-hazard surgical patients represent a large proportion of this long-stay grouping, or whether increased length of stay in the ICU is associated with ultimately requiring a surgical procedure that may decide the DRG. This event warrants further investigation. Nosotros practice non have detailed data regarding the length of mechanical ventilation in these patients, which has oft been used as a mark of chronic critical disease in other studies. Nosotros, therefore, cannot correlate the overall ICU length of stay with the exact length of mechanical ventilation for some patients. Finally, our database does non include physiological measurements that may bear on management decisions.
CONCLUSIONS
These data provide important epidemiologic and prognostic data regarding the association between ICU length of stay and outcomes in elderly hospital survivors. Later on systematically, studying the touch of ICU length of stay on bloodshed in elderly hospital survivors, we found that long-term mortality rates increase with ICU length of stay regardless of whether or non patients experienced surgery or mechanical ventilation. Outcome studies of the chronically critically ill that limit inclusion criteria to patients who experience prolonged mechanical ventilation, and are only "medical" will exclude a significant number of at-adventure patients. Nosotros as well found that there is no clear ICU length of stay cut-off that identifies a chronically critically ill population at risk for poor long-term outcome.
Supplementary Textile
Appendix Tabular array 1
Appendix Table 2
Acknowledgments
Funding/Support: This study was supported by a Foundation for Anesthesia Education and Research (FAER) Fellowship Grant to Hannah Wunsch in 2008–2009, and besides Award Number K08AG038477 from the National Found On Crumbling
Footnotes
Copyright form disclosures:
Dr. Moitra served equally a malpractice expert for several cases which are unrelated to this topic and received support for article enquiry from the National Institutes of Health (NIH). His institution received funding from the Foundation for Anesthesia Education and Research (FAER) (Fellowship Grant to Hannah Wunsch in 2008–2009) and from the National Establish On Aging (Award Number K08AG038477). The remaining authors have disclosed that they do not have any potential conflicts of involvement.
Institution where piece of work was performed: Columbia University, College of Physicians & Surgeons
Financial Disclosures: The authors take no conflicts of interest to declare.
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How Long To Learn Cicu,
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4792682/
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