INFLUENCE OF THE ADMISSION PATTERN ON THE OUTCOME OF PATIENTS ADMITTED TO A RESPIRATORY INTENSIVE CARE UNIT: DOES A STEP-DOWN ADMISSION DIFFER FROM A STEP-UP ONE?

Objective: The outcomes of patients admitted to a Respiratory Intensive Care Unit (RICU) have been evaluated in the past but no study has so far considered the influence of location prior to RICU admission

Design: Prospectively collected data from a total of 326 consecutive patients were analyzed

Settings: A 7-bed RICU (Respiratory Intensive Care Unit).

Measurements: The primary endpoints were the patients’ survival and severity of morbidity-related complications, evaluated according to the patients’ location prior to the RICU admission. Three different admission pathways were considered: (i) “step-down” for patients transferred from the Intensive Care Units (ICU) of our hospital; (ii) “step-up” for patients coming from our Respiratory Wards (RW) or other Medical Wards (MW); and (iii) “directly” from the Emergency Room (ER). The secondary end-point was the potential influence of several risk factors for morbidity and mortality.

Main results: Of the 326 patients, 92 (28%) died. Overall, patients admitted in a step-up process had a significantly higher mortality (p<0.001) than patients in the other groups. The mortality rate was 64% for patients admitted from RW, 43% for those from MW and 18% for patients from both ICU and ER (RW vs MW p<0.05; RW vs ER p<0.001; RW vs ICU p<0.001; MW vs ER p<0.001 and MW vs ICU p<0.001). Patients admitted from a RW had a lower albumin level and SAPS II score was significantly higher in patients following a step-up admission. About 30% of the patients admitted from a RW received non-invasive mechanical ventilation (NIV) as a “ceiling treatment”. The highest odds ratios related to survival were patients’ location prior to RICU admission and female gender. Lack of use of NIV, younger age, female gender, higher albumin level, lower SAPSII score, higher Barthel score and the absence of chronic heart failure were also statistically associated with a lower risk of death.