Chest
Volume 137, Issue 3, March 2010, Pages 552-557
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Original Research
Critical Care Medicine
Late Admission to the ICU in Patients With Community-Acquired Pneumonia Is Associated With Higher Mortality

https://doi.org/10.1378/chest.09-1547Get rights and content

Background

Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.

Methods

A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, ≥ day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures.

Results

Eighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02).

Conclusion

Patients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.

Section snippets

Methods

This is a retrospective cohort study of patients hospitalized with CAP at two academic tertiary care hospitals in San Antonio, Texas. The Institutional Review Board of the University Health Science Center at San Antonio classified this project as an exempt study.

Results

We identified 161 patients who were admitted to the ICU with a diagnosis of severe CAP with confirmatory radiology that met our eligibility criteria. Out of these, 88% (n = 142) of patients had direct ICU admission or admission within 24 h of presentation (EICUA) and 19 patients had late ICU admission (LICUA).

Discussion

The main finding of our study was that patients with severe CAP admitted to the ICU after 24 h of hospital admission have a much higher mortality compared with those with direct admission within 24 h of presentation. In addition, the survival curves suggest that those patients with late admission to the ICU, whether in days 2 to 4 or 5 to 9 had similar rates of higher mortality when compared with patients admitted directly to the ICU or within 24 h, respectively. Despite the numerical longer

Acknowledgments

Author contributions: Dr Restrepo: contributed to design, data analysis, interpretation, and manuscript preparation.

Dr Mortensen: contributed to designing and securing funding for the primary study and participated in design, data analysis, interpretation, and manuscript revision.

Dr Rello: contributed to design, interpretation, and manuscript revision.

Dr Brody: contributed to design, interpretation, and manuscript revision.

Dr Anzueto: contributed to design, interpretation, and manuscript

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Funding/Support: Dr Restrepo is supported by a Department of Veteran Affairs Veterans Integrated Service Network 17 new faculty grant and National Health Institute grant KL2 RR025766. Dr Mortensen was supported by Howard Hughes Medical Institute faculty-start up grant 00378-001 and a Department of Veteran Affairs Veterans Integrated Service Network 17 new faculty grant.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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