OUTCOME OF INTENSIVE-CARE PATIENTS IN A GROUP OF BRITISH INTENSIVE-CARE UNITS

Objective: To identify priorities for intensive care unit (ICU) interv ention and research. Design: Analysis of a large intensive care databa se. Setting: twenty-four ICUs in the North Thames region of the United Kingdom. Patients: All patients admitted to an ICU between January 1, 1992, and April 31, 1996, on whom data had been entered into the data base. Patients who were admitted after cardiac surgery, who had burns, or were <16 yrs of age were excluded from the study, as were data fro m patients with a previous ICU admission within 6 mos or where ICU or hospital outcome was unknown. Data were excluded from units that had e ntered <300 patients into the database. Interventions: None. Measureme nts and Main Results: A total of 23,331 admissions with complete recor ds were available. After exclusions, 12,762 admissions from 15 ICUs we re selected for analysis. Hospital mortality was 32.5% with a mortalit y ratio of 1.14 (95% confidence interval 1.10 to 1.17). Nonsurvivors w ere older than survivors and had longer ICU stays. Patients admitted f rom wards had a higher mortality than patients from the operating room /recovery or the emergency department. Observed percentage mortality i ncreased linearly with mortality predicted by Acute Physiology and Chr onic Health Evaluation II, although the number of patients who died re mained broadly constant across the range of predicted mortality. Twent y-seven percent of all deaths occurred after discharge from the ICU. P atients admitted after cardiopulmonary resuscitation constituted 30% o f all deaths. Thirty-four percent of patients were in the ICU for >2 d ays, and they accounted for nearly 81% of bed days. Conclusions: Early identification of patients at risk, both before admission and after d ischarge from the ICU, may allow treat ment to decrease mortality. Res earch and resources may be best directed at patients who die, despite a relatively low predicted mortality. Although these patients are a sm all percentage of the low-risk admissions, they constitute a targe num ber of ICU deaths. Many patients die after discharge from ICU and this mortality may be decreased by minimizing inappropriate early discharg e to the ward, by the provision of high dependency and step down units , and by continuing advice and follow-up by the ICU team after the pat ient has been discharged. Intervention before ICU admission and suppor t of patients after discharge from the ICU should be part of the effor t to decrease mortality for ICU patients. Inadequate provision of reso urces for critically ill patients may result in excess intensive care mortality that is not detected with ICU outcome prediction methods.