PurposeTo estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients.MethodsWe performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt… Click to show full abstract
PurposeTo estimate the effect of prompt admission to critical care on mortality for deteriorating ward patients.MethodsWe performed a prospective cohort study of consecutive ward patients assessed for critical care. Prompt admissions (within 4 h of assessment) were compared to a ‘watchful waiting’ cohort. We used critical care strain (bed occupancy) as a natural randomisation event that would predict prompt transfer to critical care. Strain was classified as low, medium or high (2+, 1 or 0 empty beds). This instrumental variable (IV) analysis was repeated for the subgroup of referrals with a recommendation for critical care once assessed. Risk-adjusted 90-day survival models were also constructed.ResultsA total of 12,380 patients from 48 hospitals were available for analysis. There were 2411 (19%) prompt admissions (median delay 1 h, IQR 1–2) and 9969 (81%) controls; 1990 (20%) controls were admitted later (median delay 11 h, IQR 6–26). Prompt admissions were less frequent (p < 0.0001) as strain increased from low (22%), to medium (15%) to high (9%); the median delay to admission was 3, 4 and 5 h respectively. In the IV analysis, prompt admission reduced 90-day mortality by 7.4% (95% CI 1.7–18.5%, p = 0.117) overall, and 16.2% (95% CI 1.1–31.3%, p = 0.036) for those recommended for critical care. In the risk-adjust survival model, 90-day mortality was similar.ConclusionAfter allowing for unobserved prognostic differences between the groups, we find that prompt admission to critical care leads to lower 90-day mortality for patients assessed and recommended to critical care.
               
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