Outcomes of trauma patients who survive prolonged lengths of stay in the intensive care unit

Abstract

Objective: To examine a subgroup of severely injured patients spending > or = 3 weeks in the intensive care unit (ICU) and to determine their disposition and eventual functional outcome.

Methods: A retrospective review of our trauma registry and medical records over a 7-year period (January of 1991 to December of 1997) identified 115 patients with ICU length of stay (LOS) > or = 3 weeks. Variables selected included age, length of stay, injury severity score, injuries, disposition, and charges. Functional independence measures (FIM) were obtained in patients requiring inpatient rehabilitation and a written questionnaire (Rand 36-item Health Survey) was mailed to all patients alive at discharge.

Results: Mean ICU length of stay of the 115 patients was 36 days (range, 21-106 days); mean age, 49 years (range, 4-89 years); 73 patients (63%) were males, 42 patients (37%) were females. Overall mortality was 22% (n = 25). The remaining 90 patients survived to discharge with the following disposition: rehabilitation facility 60% (n = 54), home with temporary disability 22% (n = 20), nursing home 8% (n = 7), home with permanent disability 4% (n = 4), transferred 6% (n = 5). Mean hospital charge was $193,000 (range, $77,000-$528,000). No variable or combination could predict outcome except age. Elderly patients (age > or = 75, n = 24) had an overall mortality of 42% (n = 10). Eight of 14 survivors fulfilled admission criteria and entered our rehabilitation facility. The remaining six elderly patients either went to nursing homes or were permanently disabled. Complete FIM scores were available on 47 of 54 patients who went to rehabilitation facility. The mean rehabilitation facility admission FIM score was 52, indicating either complete dependence or the need for moderate assistance. After they had remained at the rehabilitation facility for a mean of 48 days (range, 7-278 days), patients' FIM scores improved to a mean of 86, signifying minimal contact assistance or supervision only. Three-month follow-up FIM scores continued to improve to a mean of 101, a score denoting complete independence. Elderly patients within the rehabilitation facility fared as well as the younger group. For the Rand-36 survey, 47 of 90 patients or family members were contacted. Twelve patients died since discharge, leaving 35 patients to complete the survey. Despite excellent FIM scores, overall mean health was only fair to good, with limitations to activity and lack of energy cited as the main problems.

Conclusion: Despite tremendous resource utilization, the majority of trauma patients with prolonged ICU stays can eventually return to varying degrees of functional daily living and independence, but not to preinjury levels. A subgroup of severely injured elderly patients had a significantly higher mortality rate. However, elderly survivors that entered our rehabilitation facility fared as well as the younger patients.