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. 2020 Aug;158(2):579-587.
doi: 10.1016/j.chest.2020.02.061. Epub 2020 Mar 27.

The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care

Kelly C Vranas  1 , Jennifer Y Scott  2 , Omar Badawi  3 , Michael O Harhay  4 , Christopher G Slatore  5 , Donald R Sullivan  5 , Meeta Prasad Kerlin  6
Affiliations

The Association of ICU Acuity With Adherence to ICU Evidence-Based Processes of Care

Kelly C Vranas et al. Chest. 2020 Aug.

Abstract

Background: Admission to high-acuity ICUs has been associated with improved outcomes compared with outcomes in low-acuity ICUs, although the mechanism for these findings is unclear.

Research question: The goal of this study was to determine if high-acuity ICUs more effectively implement evidence-based processes of care that have been associated with improved clinical outcomes.

Study design and methods: This retrospective cohort study was performed in adult ICU patients admitted to 322 ICUs in 199 hospitals in the Philips ICU telemedicine database between 2010 and 2015. The primary exposure was ICU acuity, defined as the mean Acute Physiology and Chronic Health Evaluation IVa score of all admitted patients in a calendar year, stratified into quartiles. Multivariable logistic regression was used to examine relations of ICU acuity with adherence to evidence-based VTE and stress ulcer prophylaxis, and with the avoidance of potentially harmful events. These events included hypoglycemia, sustained hyperglycemia, and liberal transfusion practices (defined as RBC transfusions prescribed for nonbleeding patients with preceding hemoglobin levels ≥ 7 g/dL).

Results: Among 1,058,510 ICU admissions, adherence to VTE and stress ulcer prophylaxis was high across acuity levels. In adjusted analyses, those admitted to low-acuity ICUs compared with the highest acuity ICUs were more likely to experience hypoglycemic events (adjusted OR [aOR], 1.12; 95% CI, 1.04-1.19), sustained hyperglycemia (aOR, 1.07; 95% CI, 1.04-1.10), and liberal transfusion practices (aOR, 1.55; 95% CI, 1.33-1.82).

Interpretation: High-acuity ICUs were associated with better adherence to several evidence-based practices, which may be a marker of high-quality care. Future research should investigate how high-acuity ICUs approach ICU organization to identify targets for improving the quality of critical care across all ICU acuity levels.

Keywords: ICU; critical care; evidence-based medicine; guidelines; patient safety.

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Figures

Figure 1
Figure 1
Combined ICU and patient-level exclusion criteria. ACUTE = Acute Physiology and Chronic Health Evaluation.
Figure 2
Figure 2
Expected rate of (A) hypoglycemic events, (B) sustained hyperglycemia, and (C) liberal transfusion practices based on ICU acuity as defined by the average APACHE IVa score per ICU year. Each line represents results for teaching hospitals compared with nonteaching hospitals. APACHE IVa scores < 10 or > 70 were collapsed into two groups given the small number of patients in the study cohort with scores beyond these thresholds. See Figure 1 legend for expansion of abbreviation.
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Comment in

  • Do the Right Thing.
    Lanspa MJ, Peltan ID. Lanspa MJ, et al. Chest. 2020 Aug;158(2):442-443. doi: 10.1016/j.chest.2020.05.550. Chest. 2020. PMID: 32768058 Free PMC article. No abstract available.

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