Clinical Review

Survival After Long-Term Residence in an Intensive Care Unit

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

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The mortality rate was significantly lower for surgical patients than it was for medical patients at all intervals studied, with the largest separation in the short-term categories of ICU and 30-day mortality. The post-ICU mortality rates for medical and surgical patients are similar to those reported in several other studies, including a study of veterans.^14-16,33,34 Among the present patients with LOS of more than 14 days, surviving surgical patients were significantly younger than nonsurviving surgical patients and both surviving and nonsurviving medical patients.

The few SF-36 responses collected revealed no differences between medical and surgical patients.

A Trial of Therapy

The present data are useful in describing the landscape of post-ICU survival to patients and their families. The data demonstrated a higher mortality trend that correlated with increases in age and increases in ICU duration and readmission. Within this continuum, there was no break point at which survivors and nonsurvivors clearly separated. The data therefore lack a boundary that can be used to define a trial of therapy. However, the added risks of age and recovery longer than 1 week are clear and should be included in care decisions. The generally better survival of surgical patients (nearly all of whom had elective surgery) in comparison with medical patients suggests these populations should be considered separately.

In the absence of a point distinguishing survivors from nonsurvivors, the authors performed a more detailed analysis of patients in the ICU for more than 14 days to provide some perspective on health care dependence in the subsequent year. That ICU survival does not necessarily equate to overall survival and independence long after ICU residence is an important matter for patients and families to consider when making decisions about critical care residence. The 14-day LOS data, though using a fairly arbitrary time point, suggest that patients who cannot recover from critical illness in less than 14 days should be advised of the range of short- and long-term mortality and the likelihood of high dependence on medical care within the subsequent year.

The concepts of hospital-dependent patient and persistent inflammation, immunosuppression, and catabolism syndrome have been introduced to describe the condition of progressive deterioration and inability to regain full independence after illness.^32,35 These illness patterns deserve attention in prognosis discussions. The present study focused not on ICU survival but on 1-year mortality and functional independence, and it is these longer term outcomes that critical care professionals should consider. Intensive care units are successful in improving short-term survival, but a long line of successful ICU discharges may lead an intensivist to think that longer term survival is important as well and convey this impression to patients and their families.

Study Strengths

This study is one of a few to investigate the short- and long-term survival of an unselected cohort of critically ill patients and is unique in its inclusion of both medical and surgical patients receiving care in the same environment. Medical and surgical patients have different survival profiles that may necessitate separate studies of these subpopulations. However, the finding of different survival profiles under the same care highlights the intrinsic differences between these groups. Use of a 1.5-year study period allowed the authors to capture ICU patients with long LOS and to include multiple episodes of care provided by more than 10 different attending physicians. Therefore, these data likely were not influenced by any rare events or idiosyncrasies in practice styles. Further, the same teams of physicians and nurses cared for all the medical and surgical patients, and all unit-based protocols and quality improvement activities were applied to all patients.

Study Limitations

The intensive care patients come from a large catchment area; however, conditions seen in tertiary referral centers, such as bone marrow transplants, cerebrovascular, transplant surgery, and ventricular-assist devices are not represented in this population.

In this study, bed days were used as a crude measure of care burden. From a nursing perspective, however, the workload may be higher with quick-turnover beds than with long-term residents. On the other hand, long-term ICU residents are visited by multiple consultants and receive a much larger set of interventions, including weeks of ventilation and hemodialysis, line changes, and family meetings. A comparison of the costs involved for different ICU subpopulations would add valuable information to this discussion.

The authors took a conservative approach in establishing the mortality and residence of patients 1 year after their ICU stays. At 6 months, 1-year patients without evidence of hospital or nursing facility residence were assumed to be home. In reality, nearly all these patients had multiple admissions or emergency department stays, or there was other evidence of intensive care. Some patients who were assumed to be home may have left the area and become untraceable. All estimates of care dependence and mortality should therefore be considered minimums. The authors cannot envision how any of their estimates could overstate the morbidity and mortality.