Elsevier

Resuscitation

Volume 144, November 2019, Pages 40-45
Resuscitation

Clinical paper
Acute respiratory compromise on hospital wards: Association between recent ICU discharge and outcome

https://doi.org/10.1016/j.resuscitation.2019.09.002Get rights and content

Abstract

Introduction

Acute respiratory compromise (ARC), respiratory distress requiring emergent assisted ventilation, has a mortality of 20–40%. The relationship between recent discharge from an intensive care unit (ICU) and outcomes of patients suffering ARC on hospital wards is not well known. We hypothesized that a significant percentage of ARC events would occur in patients recently discharged from an ICU, that these patients would have worse outcomes than those without prior ICU stays, and that weekend ICU discharge would be associated with higher than expected post-ICU ARC frequency.

Methods

Using the Get-With-The-Guidelines-Resuscitation ARC registry, we included adult, index ARC events occurring on hospital wards. Our primary analysis used multivariable logistic regression accounting for clustering by hospital to examine the association between prior ICU discharge and survival after an ARC event.

Results

Of 11,800 ARCs, 937 (8%) occurred within two calendar days and 1010 (9%) >two calendar days after an ICU discharge. Patients with ICU discharge within two days had higher survival compared to those with no prior ICU stay (odds ratio 1.28 (95% CI: 1.11–1.48, p = 0.001)). Survival was not different in those with an ICU discharge more than two days prior and no prior ICU stay. Patients with ARC within two days of ICU discharge were not more likely to have left the ICU on a weekend.

Conclusions

Contrary to our hypothesis, discharge from an ICU within two calendar days was associated with better odds for survival compared to no prior ICU discharge or ICU discharge more than two days prior.

Introduction

Acute respiratory compromise (ARC), defined as the sudden onset of respiratory distress requiring emergency assisted ventilation, occurs in over 40,000 patients annually on inpatient wards in the United States.1 Approximately 40% of these patients will not survive the hospital stay, making in-hospital ARC as lethal as septic shock.2, 3 In spite of this, ARC is comparatively understudied, and targets for intervention are thus poorly characterized.

Approximately one in ten patients admitted to an ICU die during the hospital stay, with even higher mortality if organ failure is present.4, 5, 6, 7 Multiple efforts have been made to identify subsets with especially high mortality, with the goal of finding modifiable targets for intervention. Prior literature has shown that patients discharged from an ICU subsequently requiring readmission to the ICU (so-called “bounce backs”) have a mortality up to five times higher than those not requiring ICU readmission.8 Leaving the ICU on a night or a weekend, compared to a weekday, may also be associated with higher mortality.9, 10 Whether ward patients with ARC occurring shortly after ICU discharge are at increased risk of death compared to those with no prior ICU admission has not been reported previously. Whether the frequency of ARC events in ward patients recently in the ICU varies by day of ICU discharge is also unknown.

We utilized the American Heart Association’s GWTG-R database to investigate whether ICU discharge withing two calendar days is a risk factor for mortality for patients experiencing ARC on hospital wards. We secondarily assessed whether the frequency of ARC events in patients recently discharged from the ICU varies by day of ICU discharge. Finally, we compared the outcome of ARC events occurring on weekdays and weekend days.

Section snippets

Study design and data source

This was an analysis of prospectively collected data from the GWTG-R registry, a national quality improvement registry of in-hospital cardiac arrests, medical emergency team events, and ARC events sponsored by the American Heart Association. Trained personnel at each site collect data on all acute respiratory compromise events according to standard definitions. Data integrity is enhanced through certification of data entry personnel and the use of standardized software. Additional details on

Study population

Out of 28,843 ARC events occurring at 276 hospitals from 2007 to 2014, 11,800 met our inclusion criteria (see Fig. 1). Of these, 937 (8%) occurred within two calendar days of an ICU discharge and 1010 (9%) occurred greater than two days after an ICU discharge. Overall approximately 4% of ARC events progressed to cardiac arrest for which chest compressions were done. The distribution of cardiac arrest events matched the distribution of ARC events across the 3 groups. Baseline characteristics of

Discussion

In this analysis of over 11,000 ARC events occurring on hospital wards across the United States, we found that patients who had been discharged from an ICU within two calendar days were more likely to survive to hospital discharge than patients either discharged from an ICU more than two calendar days prior or with no prior ICU stay. We also found that preceding discharge from the ICU on a Friday or weekend day did not occur with disproportionate frequency in patients with an ARC event within

Conclusions

In a large database of patients experiencing an acute respiratory compromise event on the hospital wards, patients who had been discharged from an ICU within two calendar days had better odds of survival than patients with no ICU stay within the prior two days or those with an ICU stay more than two days before the ARC event. Mortality from an ARC event was not higher on weekends when compared to weekdays.

Conflict of interest

No authors have any relevant conflict of interest to disclose.

Author contributions

All authors contributed to study design and critically revised the manuscript at all stages of development. In addition, KMB conceived the research question and drafted the manuscript. LWA and AVG performed all analyses and AVG oversaw the final version.

Subject Category: 4.6 (ICU Management and outcome).

At-a-glance commentary

Scientific knowledge on the subject: Acute respiratory compromise occurring on hospital wards has a high mortality. Patients who return to the ICU shortly after ICU discharge are known to have worse outcomes than those who do not require readmission, but whether patients with acute respiratory compromise who have recently left the ICU have worse outcomes than those without a recent ICU stay is unknown.

What this study adds to the field: In this study we found that patients having an acute

Acknowledgements

Dr. Berg is supported by the NHLBI (K23 HL128814-03). Dr. Moskowitz is supported by the NIH (K23GM128005-01). Dr. Donnino is supported by the NIH (K24HL127101). Dr. Grossestreuer is supported by a KL2/Catalyst Medical Research Investigator Training award (an appointed KL2 award) from Harvard Catalyst | The Harvard Clinical and Translational Science Center (National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health Award KL2

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