Clinical Review

Survival After Long-Term Residence in an Intensive Care Unit

Fed Pract. 2016 June;33(6):18-27

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Methods

The VA Research and Development Committee and the Stanford Panel on Human Subjects approved the authors’ data collection and reporting.The study was conducted at the 15-bed mixed-medical/surgical VAPAHCS ICU. Analyzed data were drawn from all patients admitted during a 19-month period (July 14, 2008, to January 28, 2010). A serial log was used to prospectively capture basic data regarding each admission. Medical patients received care from the ICU service, and surgical patients were comanaged by the surgical and ICU teams.

A mortality database was constructed with data from the Decedent Affairs Office and from the national VistA database. The data included all deaths recorded either inside or outside the hospital or systemwide nursing facility. Mortality reported in the Computerized Patient Record System (CPRS) was queried further for patients with a length of stay (LOS) of more than 14 days.

Statistical Analysis

Calculations were based on denominators of individual patients or on number of admissions. All mortality calculations were based on a denominator of individual patients. For mortality analysis, only the last admission was included, unless a patient survived a full year between admissions. The Kruskal-Wallis test for nonnormally distributed data and the Dunn posttest for multiple comparisons were used for continuous variables (eg, age, LOS, risk scores); the Fisher exact test was used for categorical data; and the log-rank test was used to compare survival curves. For all analyses, P < .05 was considered statistically significant.

Mortality and Functional Status

Mortality risk scores on ICU admission were calculated with the Mortality Prediction Model–Admission III (MPM-III), using data from the CPRS. Specifics on this calculation are described in the eAppendix.

Current survival status of patients who were in the ICU more than 14 days was determined from the CPRS and telephone discussions with the patient or with relatives. Functional status was evaluated with the 36-Item Short Form Health Survey (SF-36), which has been used in comparable studies.^27,28 Disposition at 6 months and 1 year was established by inspecting the CPRS for dates corresponding to these exact periods. For example, a patient in the hospital about 1 year after ICU discharge would be considered to be at home if discharged 1 day before the 365-day anniversary. In a few cases, progress notes indicated that the patient was receiving around-the-clock nursing care at home; in the analysis, these cases were included with those of patients known to be in traditional nursing facilities. In cases in which the CPRS lacked mortality information, the patient was presumed to be alive even if there were no records of clinic visits or other medical attention. Serial admission data from a mixed-medical/surgical ICU were collected over a 19-month period (July 14, 2008, to January 28, 2010) and analyzed.

Results

The final data set consisted of 1,113 admissions and 976 patients (one-third medical, two-thirds surgical). In this cohort, 12% of all patients studied were readmitted to the ICU at least once, and 12% of all ICU admissions were repeat admissions. The medical/surgical proportion was similar for readmitted patients. Demographics and other data are available in eTable 1.

Length of Stay

The distribution of all patients by LOS in the study period is shown in eFigure 1A. Data are skewed rightward toward longer LOS. The median LOS of 3 days for the entire population differed according to specialty, with a median of 3 days for medical patients (interquartile range, 2-7 days) and a median of 2 days for surgical patients (interquartile range, 1-5 days; P < .01 for medical vs surgical patients).

The LOS differed between ICU patients admitted for the first time and those readmitted within the 19-month study period. For both admission categories, LOS was longer for medical patients than for surgical patients. However, there were no significant differences between percentages of medical and surgical patients who were readmitted (Table 2). Despite comprising about 12% of the population, patients with more than 1 admission accounted for 23% of admissions and 25% of all bed occupancies during the study period.

Figure e1B shows ICU bed occupancy for different LOS intervals (calculated as bed days) and indicates that despite accounting for a small percentage of admissions, patients with long LOS accounted for a significant portion of total occupancy (32% for more than 1 month, 45% for more than 14 days). The medical and surgical contributions of these long-LOS patients were about equal. The figures indicate that more than half of medical ICU patient occupancy involved LOS of more than 14 days, while surgical patients tended to have shorter LOS.