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Intensive Care Medicine

, Volume 44, Issue 12, pp 2134–2144 | Cite as

Timing of onset of persistent critical illness: a multi-centre retrospective cohort study

  • Sean M. BagshawEmail author
  • Henry T. Stelfox
  • Theodore J. Iwashyna
  • Rinaldo Bellomo
  • Dan Zuege
  • Xioaming Wang
Original

Abstract

Purpose

Persistent critical illness has been described as a subtype of chronic critical illness, characterized as a transition after ICU admission where primary diagnosis and illness acuity are no better at predicting outcome than pre-hospital characteristics. Herein we describe the occurrence and outcomes associated with persistent critical illness in a large Canadian health region.

Methods

In this multi-center observational cohort study, all patients aged older than 14 years admitted to 12 ICUs in Alberta, Canada, between June 2012 and December 2014 were included. Primary outcome was in-hospital mortality. Predictors at ICU admission were separated into: (1) antecedent characteristics component (e.g., demographics, chronic health component of the APACHE II score, comorbid conditions); and (2) acute illness component (e.g., APACHE II score at admission, SOFA score, primary diagnostic category, surgical status, acute organ support). Using multiple statistical methods and randomly splitting the cohort into development and validation samples for risk scoring using logistic regression, we examined mortality prediction of each of these components to characterize the timing of transition to persistent critical illness.

Results

We included 17,783 patients with a median (IQR) age 61 years (49–71), 62% were male, and mean APACHE II score was 19.0 (7.9). In-hospital mortality was 16.8%. Among patients alive and in ICU, the acute illness component, which accurately predicted outcome at the time of admission [area under the receiver operating characteristics curve (AUC) 0.861; 95% CI 0.860–0.862], progressively lost predictive ability and was no longer more predictive than antecedent characteristics after 9 days. This transition defined the onset of persistent critical illness and comprised 16.1% (n = 2856) of the cohort. Transition ranged between 5 and 21 days across subgroups. In-hospital mortality was greater for those with persistent critical illness [23.9% vs. 15.5%, odds ratio (OR) 1.54; 95% CI 1.43–1.67, p < 0.001]. Persistently critically ill patients accounted for 54.5% of 97844 ICU bed-days and 36.3% of 420119 hospital bed-days, respectively.

Conclusions

Persistent critical illness occurred in one in six patients admitted to Alberta ICUs and portended greater risk of death, prolonged ICU and hospital stay, and disproportionate use of health resources compared to patients without persistent critical illness.

Keywords

Intensive care unit Persistent critical illness Timing of onset Mortality Burden of care 

Notes

Acknowledgements

SMB is supported by a Canada Research Chair in Critical Care Nephrology. HTS is supported by a Population Health Investigator Award from Alberta Innovates and an Embedded Clinician Researcher award from the Canadian Institutes of Health Research.

Funding

This work was funded by a Partnership for Research and Innovation in the Health System (PRIHS) grant, Alberta Innovates—Health Solutions and Alberta Health Services (Grant Record Number: 201300467). The funding agency had no role in the design or conduct of the study, in the collection, management, analysis or interpretation of the data, or in the preparation, review or approval of the manuscript.

Compliance with ethical standards

Conflicts of interest

The authors have no conflicts of interest to declare.

Ethics approval and consent to participate

This study was approved by the research ethics board at the University of Alberta, Edmonton, Canada (File # Pro00046184). The need for written informed consent was waived.

Availability of data and material

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplementary material

134_2018_5440_MOESM1_ESM.docx (464 kb)
Supplementary material 1 (DOCX 463 kb)

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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature and ESICM 2018

Authors and Affiliations

  1. 1.Department of Critical Care Medicine, Faculty of Medicine and DentistryUniversity of AlbertaEdmontonCanada
  2. 2.Alberta Health Services Critical Care Strategic Clinical NetworkAlberta Health ServicesEdmontonCanada
  3. 3.Department of Critical Care Medicine, Cumming School of MedicineUniversity of CalgaryCalgaryCanada
  4. 4.Department of Internal MedicineUniversity of Michigan, and Veteran Affairs (VA) Ann Arbor Healthcare SystemAnn ArborUSA
  5. 5.Department of Intensive CareAustin HospitalMelbourneAustralia
  6. 6.eCritical AlbertaAlberta Health ServicesCalgaryCanada
  7. 7.Research Facilitation, Data Integration, Management and Reporting (DIMR)Alberta Health ServicesCalgaryCanada

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