Treatment limitations at admission to intensive care units in Australia and New Zealand

Department of Intensive CareThe Alfred Hospital, Melbourne, Victoria, Australia.
Critical care medicine (Impact Factor: 6.31). 05/2012; 40(7):2082-9. DOI: 10.1097/CCM.0b013e31824ea045
Source: PubMed


Previous studies have addressed patients in whom treatment is withheld or withdrawn after a period of intensive care unit management. However, no studies have investigated the epidemiology of patients with treatment limitations in place at the time of intensive care unit admission.
To report the epidemiology and outcome of patients with treatment limitations at intensive care unit admission and to identify characteristics associated with survival and discharge to home.
Retrospective database study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database.
Australian and New Zealand intensive care units.
One hundred eighty-seven thousand four hundred and one intensive care patients collected over a 3-yr period, 5,989 (3.2%) of whom had treatment limitations at admission to the intensive care unit.
Retrospective database study with no interventions. Data collected included patient characteristics, length of stay, mortality, and discharge destination. Mean intensive care unit bed days were used as a surrogate for resource consumption.
Between January 1, 2007, and December 31, 2009, 5,989 (3.2%) patients were reported to the Australia and New Zealand Intensive Care Society Adult Patient Database who had treatment limitation orders at admission to intensive care unit. Mortality was 53% (95% confidence interval 51.7%-54.3%) compared with 9% (95% confidence interval 8.9%-9.1%) in patients admitted for full active management (p ≤ .001). Overall, 30% of patients with treatment limitations were discharged directly to their homes. Intensive care unit bed day usage was similar between the two groups. Within the treatment limitation group, younger patients, those with less comorbid diseases, less acute physiological disturbance, and those admitted following elective surgery, were more likely to survive and be discharged home. Admission diagnosis was an important determinant of outcome with intracranial or subarachnoid hemorrhage predicting a extremely high mortality.
Patients with treatment limitations on intensive care unit admission comprise approximately 2,000 patients per year in Australia and New Zealand. Despite such limitations, almost half of these patients survive their hospital admission and a third return directly to their home.

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Available from: David V Pilcher, Dec 19, 2013
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    • "Each of these components and the composite APACHE III score were extracted from the APD. We also extracted additional variables such as treatment limitation [22], hospital source of admission, lead time, elective admission, APACHE II chronic illnesses, and others, as presented in Table E1 [22]. "
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    ABSTRACT: Purpose: The aim of this study was to assess the association of phosphate concentration with key clinical outcomes in a heterogeneous cohort of critically ill patients. Materials and methods: This was a retrospective observational study at a general intensive care unit (ICU) of an Australian university teaching hospital enrolling 2730 adult critically ill patients. Results: We studied 10504 phosphate measurements with a mean value of 1.17 mmol/L (measurements every 28.8 hours on average). Hyperphosphatemia (inorganic phosphate [iP] concentration > 1.4 mmol/L) occurred in 45% and hypophosphatemia (iP ≤ 0.6 mmol/L) in 20%. Among patients without any episodes of hyperphosphatemia, patients with at least 1 episode of hypophosphatemia had a higher ICU mortality than those without hypophosphatemia (P = .004). In addition, ICU nonsurvivors had lower minimum phosphate concentrations than did survivors (P = .009). Similar results were seen for hospital mortality. However, on multivariable logistic regression analysis, hypophosphatemia was not independently associated with ICU mortality (adjusted odds ratio, 0.86 [95% confidence interval, 0.66-1.10]; P = .24) and hospital mortality (odds ratio, 0.89 [0.73-1.07]; P = .21). Even when different cutoff points were used for hypophosphatemia (iP ≤ 0.5, 0.4, 0.3, or 0.2 mmol/L), hypophosphatemia was not an independent risk factor for ICU and hospital morality. In addition, timing of onset and duration of hypophosphatemia were not independent risk factor for ICU and hospital mortality. Conclusions: Hypophosphatemia behaves like a general marker of illness severity and not as an independent predictor of ICU or in-hospital mortality in critically ill patients.
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