Mass. General study provides insight into use of critical care resources

April 08, 2019

A study by Massachusetts General Hospital (MGH) investigators has found wide variation in the use of different hospital units - intensive care or general medical units - to deliver a type of advanced respiratory support called non-invasive ventilation. The team's report published in Critical Care Medicine found no differences in length of stay or in-hospital deaths among patients with chronic obstructive pulmonary disease (COPD) receiving this treatment that were associated with whether they were treated on a general medical unit or an intensive care unit (ICU).

"Even hospitals in the same city deliver respiratory care differently," says lead and corresponding author Laura C. Myers MD, MPH, of the MGH Division of Pulmonary and Critical Care Medicine. "Some hospitals try to bring critical care resources to the general medical unit to avoid transferring patients - which can be disruptive to their care - while others centralize critically ill patients in the ICU. Our goal was to document the variation in practice and determine whether hospitals more likely to deliver non-invasive ventilation on the general medical unit have equivalent outcomes after adjusting for patients' severity of illness."

Non-invasive ventilation delivers respiratory support through a mask rather than through an endotracheal or tracheostomy tube. For their study, the investigators used data from 424 hospitals from the State Inpatient Database maintained by the U.S. Agency for Healthcare Research and Quality. They selected 12 states - Arkansas, Kentucky, Massachusetts, Maryland, North Carolina, New Jersey, Nevada, New York, Oregon, Utah, Vermont and Washington - that provided information on whether a patient was treated in an ICU and analyzed data from 2014, before the imposition of penalties for COPD readmissions.

Of more than 5,000 patients receiving non-invasive ventilation whose data were analyzed, 48 percent were treated on a general medical unit, while 52 percent were treated in an ICU. While some hospitals delivered almost all non-invasive ventilation in the ICU, others delivered almost all of it on the general medical unit. As might be expected, when patients were treated on the general medical unit, costs per hospitalization were around $1,500 less. Patients in higher-ICU-utilizing hospitals also had a greater likelihood of receiving invasive monitoring, such as the placement of central/arterial lines, which could reflect the need to monitor key respiratory parameters and deliver life-saving medications. But there was little difference in the incidence of organ failure, which is a marker of severity of illness, between lower- and higher-ICU-utilizing hospitals. The difference in the average number of organ failures per patient between the lowest- and highest-ICU-utilizing hospitals was only 0.15, which is strikingly small, Myers notes.

She says, "We may be able to deliver safe and less costly respiratory care on the general medical unit, but we have to acknowledge the limitations of our data. It's not clear from this retrospective study whether patients who received the invasive monitoring - central/arterial lines - in the ICU actually needed it to achieve outcomes equivalent to those of patients on the general medical unit or whether that represented a lower threshold for intensive care specialists at some hospitals to do such procedures when patients are admitted to the ICU."

Further studies may reveal the reasons why hospitals have such variations in policies regarding the delivery of non-invasive ventilation. "Based on the data we analyzed, we cannot advocate for standardizing a single policy across all hospitals," says Myers. "Going forward, we'd like to use a qualitative approach to understand the range of hospitals' policies. Some hospitals have team 'huddles' prior to initiating non-invasive ventilation on a general medical unit, a practice we follow at MGH. Others require pulmonary consultation if patients do not improve within a certain time frame. Still others may have dedicated respiratory floors with specially trained respiratory nurses/therapists available. A network-based study may help us determine whether a specific method of care delivery is associated with better outcomes, which we could then test in a prospective trial."
-end-
Co-authors of the Critical Care Medicine report are Paul Currier, MD, MGH Pulmonary and Critical Care Medicine; and Mohammad Kamal Faridi, MPH, and Carlos Camargo Jr. MD, DrPH, MGH Department of Emergency Medicine. the study was supported by an MGH Innovation Grant and funds from the Agency for Healthcare Research and Quality.

Massachusetts General Hospital, founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH Research Institute conducts the largest hospital-based research program in the nation, with an annual research budget of more than $925 million and major research centers in HIV/AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, genomic medicine, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, photomedicine and transplantation biology. The MGH topped the 2015 Nature Index list of health care organizations publishing in leading scientific journals and earned the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service. In August 2018 the MGH was once again named to the Honor Roll in the U.S. News & World Report list of "America's Best Hospitals."

Massachusetts General Hospital

Related Intensive Care Articles from Brightsurf:

Hospital COVID-19 risk lowest among intensive care staff
Contrary to expectations, the risk of COVID-19 infection among hospital staff at the height of the coronavirus pandemic was lowest among intensive care clinicians, reveals a study of one major UK medical centre, published in the journal Thorax.

Muscle weakness in patients in intensive care: Potential approach to treatment
Critical Illness Myopathy (CIM) has taken on a new relevance as a result of the Corona virus.

Pregnant women with COVID-19 may more likely need intensive care and give birth early
Pregnant women seen in hospitals with covid-19 are less likely to show symptoms, and seem to be at increased risk of needing admission to an intensive care unit than non-pregnant women of similar age, finds a study published by The BMJ today.

Many children in intensive care may not be getting rehabilitation therapy, study shows
Adult patients in hospital intensive care units (ICUs) are often given rehabilitation therapy and urged to keep mobile from an early point in their hospital stays.

Cognitive impairment after intensive care linked to long-lasting inflammation
People who have been treated in intensive care commonly suffer from residual cognitive impairment, but the reason for this is unknown.

New guidelines for hepatic failure in the intensive care unit
For critical care specialists, hepatic failure poses complex challenges unlike those of other critical illnesses.

Trial suggests babies in intensive care can be better protected from parental bacteria
Now, a Johns Hopkins Medicine research team reports it has developed and tested a relatively simple strategy for reducing the chance of parents exposing their babies in the NICU to one of the most commonly diagnosed and potentially deadly microbial scourges in a hospital: Staphylococcus aureus.

Artificial intelligence-based algorithm for intensive care of traumatic brain injury
A recent Finnish study, published in Scientific Reports, presents the first artificial intelligence (AI) based algorithm that may be utilized in the intensive care unit for treating patients with severe traumatic brain injury.

Once scarce, neonatal intensive care proliferates
Is NICU care being driven by medical need or competition?

Flu vaccine reduces risk of dying for elderly intensive care patients
An influenza vaccine does not just work when it comes to influenza.

Read More: Intensive Care News and Intensive Care Current Events
Brightsurf.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com.