Simple organisation can save lives in ICU

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Oncologic patients are among the most fragile ICU patients and prone to complications, but a large Brazil-US study found that the risk of these problems can be reduced through relatively simple organisational processes.

Oncologic patients are now among the main users of ICUs in the world, and they’re also among the most fragile and prone to complications that can lead to death, such as hospital infections and adverse drug reactions. But the risk of these problems can be reduced through relatively simple processes of organisation, such as holding meetings to discuss clinical cases between oncologists and intensivists, using care protocols and the presence of pharmacists in ICUs.

These are the findings of a large study coordinated by researchers from the D’Or Institute for Research and Education, IDOR (Brazil), in partnership with the University of Pittsburgh (US) and several Brazilian institutions.

The research was the result of a major collaborative effort between hospitals and institutions and is the world’s first research to examine the impact of organizational factors of ICUs in cancer patients.

The researchers analysed data from nearly 10,000 cancer patients hospitalised in 70 ICUs of 49 Brazilian hospitals (of which, 13 are specialised cancer treatment centres), seeking to identify which organisational factors are associated with reduction of mortality in this group.

It is estimated that one in six people that is hospitalised in an ICU has cancer and that between 10 and 70% of patients with cancer, depending on the type of disease, need intensive care for at least once in life. In the study, cancer patients represented 17% of admissions in the participating ICUs. “The cancer patient quantitatively represents a very large part of the admissions in the ICUs, in a way that intensive units have become an important support treatment for these patients,” says research leader, Dr Marcio Soares, from IDOR.

The study indicates that survival is higher in ICUs that follow processes such as having daily meetings between oncologists and intensivists to set goals and develop plans of care for patients; having the presence of a pharmacist and following protocols already used in general ICUs to reduce infections and the risk of treatment-related complications. “They are simple and low cost processes of local culture change and regulation that can reduce mortality in this group,” says Soares.

“Cancer patients undergo very complex procedures and surgeries, they usually have their immune system weakened by the treatment, leaving them more susceptible to infections and other complications; so it is important that physicians talk about treatment options and follow protocols to avoid problems.”

The pharmacist presence is also essential due to the ever-larger number of treatment types against cancer, to avoid complications from toxicities and drug interactions, as well as to guide dose adjustments.

These measures also reduce costs in the ICU, by promoting a more efficient use of resources. It is estimated that an average of 0.5 to 1% of the GDP of a country is spent on intensive care. That represents, depending on the country, up to 10% of total spending on health. “For developing countries, like Brazil, attention to organisational factors in ICUs is even more urgent,” adds the lead researcher.

The study also shows that there is no difference in the mortality rate of cancer patients admitted to general hospitals ICUs or to specialised cancer treatment centres. If the flow optimisation measures are taken, the survival rate is higher regardless of the type of ICU.

“Our population is ageing and we expect an increase in demand from cancer patients seeking admission. We don’t have specialised hospitals for everyone, but studies like ours can help to reduce the gap between hospitals”, says Soares.

Abstract
Purpose: To investigate the impact of organizational characteristics and processes of care on hospital mortality and resource use in patients with cancer admitted to intensive care units (ICUs).
Patients and Methods: We performed a retrospective cohort study of 9,946 patients with cancer (solid, n = 8,956; hematologic, n = 990) admitted to 70 ICUs (51 located in general hospitals and 19 in cancer centers) during 2013. We retrieved patients’ clinical and outcome data from an electronic ICU quality registry. We surveyed ICUs regarding structure, organization, staffing patterns, and processes of care. We used mixed multivariable logistic regression analysis to identify characteristics associated with hospital mortality and efficient resource use in the ICU.
Results: Median number of patients with cancer per center was 110 (interquartile range, 58 to 154), corresponding to 17.9% of all ICU admissions. ICU and hospital mortality rates were 15.9% and 25.4%, respectively. After adjusting for relevant patient characteristics, presence of clinical pharmacists in the ICU (odds ratio [OR], 0.67; 95% CI, 0.49 to 0.90), number of protocols (OR, 0.92; 95% CI, 0.87 to 0.98), and daily meetings between oncologists and intensivists for care planning (OR, 0.69; 95% CI, 0.52 to 0.91) were associated with lower mortality. Implementation of protocols (OR, 1.52; 95% CI, 1.11 to 2.07) and meetings between oncologists and intensivists (OR, 4.70; 95% CI, 1.15 to 19.22) were also independently associated with more efficient resource use. Neither admission to ICUs in cancer centers compared with general hospitals nor annual case volume had an impact on mortality or resource use.
Conclusion: Organizational aspects, namely the implementation of protocols and presence of clinical pharmacists in the ICU, and close collaboration between oncologists and ICU teams are targets to improve mortality and resource use in critically ill patients with cancer.

Authors
Marcio Soares, Fernando A Bozza, Luciano CP Azevedo, Ulysses VA Silva, Thiago D Corrêa, Fernando Colombari, André P Torelly, Pedro Varaschin, William N Viana, Marcos F Knibel, Moyzés Damasceno, Rodolfo Espinoza, Marcus Ferez, Juliana G Silveira, Suzana A Lobo, Ana Paula P Moraes, Ricardo A Lima, Alexandre GR de Carvalho, Pedro EAA do Brasil, Jeremy M Kahn, Derek C Angus, Jorge IF Salluh

d’Or Institute for Research and Education material
Journal of Clinical Oncology abstract


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