Admission to critical care

Published Date: 16th August 2016

Publication Authors: Bolton N, , England L, Feeney J, Tridente A, Wilkinson K

Introduction

Critical Care (CC) services are in increasing demand but published guidance for triaging admissions may no longer reflect current practice [1-2]. Exercise tolerance and clinical frailty assessment may have a role in assessing patients (pts) referred to CC [3]. We aimed to establish the impact of frailty and other factors on this decision making process.

Methods

Referrals to CC were prospectively enrolled in a review cohort. Data included patient demographics, a measure of acute physiological derangement (early warning score, EWS), prior hospital length of stay (LOS), exercise tolerance (ET), functional and dependence status, Canadian Clinical Frailty Scale (CCFS) and comorbidities. Logistic regression analysis was used to assess factors influencing admission, using STATA 14.1. Results are expressed as median (interquartile range) and odds ratios (OR) for admission with 95% confidence intervals (CI).

Results

Data was collected on 617 pts referred to CC between November 2013 and October 2014, of whom 344 (55.8%) were made out of hours, 279 (45.2%) were admitted. Median age was 65 (50-74) years, 311 (50.4%) were male and the median LOS prior to referral was 2 (0-2) days. The median CCFS, MET grading and EWS were 4 (3-6), 4 (0-6) and 4 (2-6) respectively. The majority of referrals came from the medical specialties (246 pts, 39.9%), directly from the emergency department (190 pts, 30.8%) and the surgical specialties (129, 20.9%). The most common comorbidities were cardiovascular (238 pts, 38.6%) diseases, respiratory (141 pts, 22.9%) and diabetes (108 pts, 17.5%). The most common referral reason was sepsis (140 pts, 22.7%), with post-operative monitoring accounting for 61 referrals (10%). At age and gender adjusted logistic regression analysis the EWS (OR per point 1.12, CI 1-1.25, p = 0.04), the CCFS (OR per point 0.79, CI 0.69-0.91, p = 0.001), ET > 30 yards (OR 2.5, CI 1.6-3.98, p <0.001), self-caring status (OR 2.5, CI 1.6-3.97, p < 0.001) and housebound status (OR 0.38, CI 0.24-0.58, p < 0.001) influenced admission. The number of CC beds available, the LOS prior to referral and the MET grading did not.

Conclusions

Frailty, level of dependence and exercise tolerance appear to be major factors in decision making regarding admission to CC, even after adjusting for age. These factors may support decision making by allowing objective quantification of functional reserve.

Dudziak, J; Feeney, J; Wilkinson, K, England, L; Bolton, N; Tridente, A et al. (2016). Admission to critical care: the quantification of functional reserve​ . Critical Care. 20 (Suppl 2), 171-172

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