Long stay in ICU Audit of hospitals in North Wales Mohammad Abdul Rahim, Usman Al-Sheik, Yvonne Soon, Louisa Brock 22 nd 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 period between :  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 rate of 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 patients over 23 year period  Concluded that LOS was not independently associated with an increased risk of 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

Age Age RangeMedian All hospitals Wrexham YGC YG

Reason for ICU Admission Secondary Primary Medical:  Infective  Non Infective  Post operative Emergency  Post operative Elective  Trauma  Pancreatitis Surgical

Primary reason for admission to ICU Surgical Admissions Total number of patients: 30 Percentage from total: %37.97

Primary Reasons for Surgical Admissions to ICU Breakdown

Primary Reasons for Admission to ICU Medical Admissions Total number of patients: 51 Percentage from total: 64.55%

Primary Reasons for Medical Admissions to ICU Breakdown

Mean Stay on ICU in days:

Cause for long stay in ICU (6) (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) (6) (25) (15) (16) (61) (24) (15) (29) (6) (2) (6) (25) (15) (16) (61) (24) (15) (29)

Mortality: ICU Outcome, After Six Months, After One Year 41.77% 40.5% 18.98%

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 conclusions regarding 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: Laupland K et al. Long-term Mortality Outcome Associated With Prolonged Admission To the ICU. Chest 2006; 129:954– O Friedrich et al. Long-term outcomes and clinical predictors of hospital mortality in 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 and long-term mortality of critically ill adult patients. British Journal of Anaesthesia 104 (4): 459–64 (2010).

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