Volume 1, Issue 2

 

Clinical Outcome of Nursing Home and Non-Nursing home patients admitted to Intensive Care Unit

August 2, 2010

Introduction:

Catastrophically ill nursing home (NH) residents with high Acute Physiology and Chronic Health Evaluation (APACHE score) are admitted to Medical Intensive Care Unit (MICU) for life prolonging therapy. However the burdens of MICU care may outweigh the benefits for patients with poor functional status, multiple co- morbidities and limited life expectancy. It is suggested that these patients should receive palliative care and spared the tribulation of the MICU.

 Study Design:

Retrospective chart review

Patients and method:

 We reviewed hospital records of patients admitted to The Brooklyn Hospital Center’s MICU during the year 2007. Patients were randomly selected (142) and divided into two groups; NH admissions and those from community who served as the control (not matched by age, propensity score). The primary outcome measure was all-cause in- hospital mortality and functional status post discharge. These outcomes were correlated to admission APACHE-II score, pre-morbid functional status and underlying chronic co-morbidities.

Statistical Analysis:

Chi square was used to compare the outcome between groups.

  Results:

 A total of 95 NH and 77 non- NH patient records were examined (Table below).  The NH group was significantly older with greater hospital mortality (p < 0.0001 each). These patients required prolonged ventilatory support (p = 0.018), and APACHE based mortality was significantly greater (p = 0.024).

  Baseline  Characteristics :

Age

77.7 + 11.7

59.0 + 18.5

Male

37(38.94%)

24(31.16%)

Female

58(61.05%)

53(68.83%)

Feeding

 

 

Oral

46(48.42%)

76(98.70%)

Gastrostomy tube feeding

35(36.84%)

none

Functional Status

 

 

Ambulatory

7(7.36%)

64(83.11%)

Bed bound

61(64%)

2(2.6%)

Co-morbidities

 

 

Hypertension

47(49.47%)

43(55.48%)

COPD

38 (40%)

16 (20.77%)

DM

38 (40%)

30 (38.96%)

CHF

27 (28.42 %)

21 ( 27.27 %)

CAD

25 (26.31%)

15(11.55%)

Decubitus  ulcer

24 (25.26%)

1 (0.77 %)

Anemia

21 ( 22.1 %)

4 ( 3.08%)

Seizure

18 (18.94%)

5 (3.58%)

CVA

17 (17.89%)

2 (1.58%)

Atrial fibrillation

15 (14.25%)

5(3.58%)

Chronic Kidney Disease

11 (10.45%)

12 (15.58%)

Maintenance HD 

8 (7.60%)

2 (2.59%)

Cognition

 

 

Dementia

32 (33.68 %)

3 (3.89%)

Major Rx Intervention

 

 

IV Vasoactive medications

13 (13.68%)

5 (3.89%)

Central line

74 (77.89%)

22 (28.58%)

Invasive ventilation

57 (60%)

17 (22%)

Tracheostomy

14 (15%)

3 (3.89%)

 

Primary Diagnosis:

Respiratory Failure

43(45.26%)

26(33.76%)

Cardiopulmonary Arrest

6(6.31%)

3(3.89%)

Septic Shock

13(13.68%)

5(3.89%)

Gastrointestinal Bleed

5(5.26%)

8(10.38%)

CVA

3(3.15%)

14(18.18%)

DKA

none

15(19.5%)

 

Outcome:

 

Nursing Home

 ( n=95)

Community  (n=77)

APACHE – II based In Hospital mortality

 

 

        < 25

15 (34.88%)

5 (83.33%)

        > 25

28 (65.11%)

1 (16.66 %)

MICU median LOS

34.5

19.5

Outcome

 

 

Dead

43 (45.26%)

6 (7.79%)

Alive

37 (39%)

64 (83.11)

Ventilator dependent

14 (15%)

3 (3.89%)

Withdrawal of Life support

3 (3%)

1 (1.29%)

Conclusion:

Nursing Home residents with immobility, multiple chronic co-morbidities and high APACHE-II score had a high mortality. Encumbrance of intensive therapy outweighs the benefit and is associated with high utilization of health care resources. Advance care planning, well structured palliative and hospice care counseling can help avoid costly burdensome intensive care.

References:

  1. Nursing home patients in the Intensive care unit: risk factors for mortality- Mattison ML, Rudolph JL, Kiely DK, Marcantonio ER

   2.      Nursing home patient admitted to medical intensive    care unit; Goldstein Med Care. 1984 Sep;22(9):854-62.