Organizational characteristics of intensive care units related to outcomesof abdominal aortic surgery

Context Morbidity and mortality rates in intensive care units (ICUs) vary w idely among institutions, but whether ICU structure and care processes affe ct these outcomes is unknown. Objective To determine whether organizational characteristics of ICUs are r elated to clinical and economic outcomes for abdominal aortic surgery patie nts who typically; receive care in an ICU. Design Observational study, with patient data collected retrospectively and ICU data collected prospectively. Setting All Maryland hospitals that performed abdominal aortic surgery from 1994 to 1996. Patients and Participants We analyzed hospital discharge data for patients in nonfederal acute care hospitals in Maryland who had a principal procedur e code for abdominal aortic surgery from January 1994 through December 1996 (n = 2987) We obtained information about ICU organizational characteristic s by surveying ICU medical directors at the 46 Maryland hospitals that perf ormed abdominal aortic surgery. Thirty-nine (85%) of the ICU directors comp leted this survey. Main Outcome Measures In-hospital mortality and hospital and ICU length of stay. Results For patients undergoing abdominal aortic surgery, in-hospital morta lity varied among hospitals from 0% to 66%. In multivariate analysis adjust ed for patient demographics, comorbid disease, severity of illness, hospita l and surgeon volume, and hospital characteristics, not having daily rounds by an ICU physician was associated with a 3-fold increase in in-hospital m ortality (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.9-4.9). Fur thermore, not having daily rounds by an ICU physician was associated with a n increased risk of cardiac arrest (OR, 2.9; 95% CI, 1.2-7.0), acute renal failure (OR, 2.2; 95% CI, 1.3-3.9), septicemia (OR, 1.8, 95 % CI, 1.2-2.6), platelet transfusion (OR, 6.4; 95% CI, 3.2-12.4), and reintubation (OR, 2. 0; 95% CI, 1.0-4.1). Not having daily rounds by an ICU physician, having an ICU nurse-patient ratio of less than 1:2, not having monthly review of mor bidity and mortality, and extubating patients in the operating room were as sociated with increased resource use. Conclusions Organizational characteristics of ICUs are related to differenc es among hospitals in outcomes of abdominal aortic surgery. Clinicians and hospital leaders should consider the potential impact of ICU organizational characteristics on outcomes of patients having high-risk operations.