Identifying causes of unplanned ICU trauma admissions at a level 2 trauma center

Author(s):
Mahad A. Minhas; Mark L. Volker; Omar Cespedes-Gomez; Jacob Helmer; Patrick J. Miles; Kersten L. Schwanz; Kaysie Banton

Background:

Unplanned ICU admissions are associated with comorbid conditions, acute renal failure, and respiratory failure. Moreover, mortality amongst unplanned ICU admissions (47%) is twice as high as planned admissions (25%). The University of Minnesota Medical Center’s (UMMC) trauma service saw a dramatic increase in unplanned ICU admissions from 2015 through 2017.

Hypothesis:

We hypothesized that unplanned admissions increased due to respiratory failure.

Methods:

We conducted a retrospective chart review of patients with unplanned ICU admissions identified from the UMMC’s trauma registry from May 2015 to June 2017. The registry was queried for patients admitted to the ICU after initial transfer to the floor and/or patients with an unplanned return to the ICU after initial ICU discharge. Patients requiring planned postoperative surgical care or those that were housed in the ICU due to bed availability issues were excluded. Information regarding demographics, mechanism of injury, interventions, and etiology of decline in status requiring ICU care was also collected.

Results:

UMMC maintained a mature level two trauma center status during the study period. Unplanned admission increased from 3 in 2015 to 15 in 2016 and 7 through June 2017. A total of 25 patients met inclusion criteria (28% mortality, all due to care withdrawal); 21 patients had one unplanned admission (19% mortality) and 4 patients had 2 unplanned admissions (75% mortality) for a total of 29 unplanned admissions. Approximately 56% of the cohort was female, 72% of patients were over the age of 65, with a mean age of 72.8 years old. Roughly 84% were admitted to the hospital due to a fall injury. Fractures made up 82% of known injuries, with spinal and rib fractures being most prevalent. Most unplanned admissions (63%) originated from the step-down unit. Of 29 unplanned admissions, 19 (65%) had respiratory etiology. Among those 19, 7 (37%) had sputum cultures (2 positive for infection) and 13 (68%) received antibiotics; of those 13, only 5 (38%) had sputum cultures. Mortality was higher in both the sputum culture group (43% vs 30%) and the antibiotic group (45% vs 17%).