Direct admission to the intensive care unit from the emergency department and mortality in critically ill hematology patients

Olivier Peyrony; Sylvie Chevret; Anne-Pascale Meert; Pierre Perez; Achille Kouatchet; Frédéric Pène; Djamel Mokart; Virginie Lemiale; Alexandre Demoule; Martine Nyunga; Fabrice Bruneel; Christine Lebert; Dominique Benoit; Adrien Mirouse; Elie Azoulay

doi:10.1186/s13613-019-0587-7

Direct admission to the intensive care unit from the emergency department and mortality in critically ill hematology patients

Ann Intensive Care. 2019 Oct 2;9(1):110. doi: 10.1186/s13613-019-0587-7.

Authors

Olivier Peyrony¹, Sylvie Chevret^{2

3

4}, Anne-Pascale Meert⁵, Pierre Perez⁶, Achille Kouatchet⁷, Frédéric Pène^{4

8

9}, Djamel Mokart¹⁰, Virginie Lemiale¹¹, Alexandre Demoule^{12

13

14}, Martine Nyunga¹⁵, Fabrice Bruneel¹⁶, Christine Lebert¹⁷, Dominique Benoit¹⁸, Adrien Mirouse¹¹, Elie Azoulay^{3

4

11}

Affiliations

¹ Emergency Department, Hôpital Saint-Louis, 1 avenue Claude Vellefaux, 75010, Paris, France. o.peyrony@hotmail.fr.
² Biostatistics and Medical Information Department, Hôpital Saint-Louis, Paris, France.
³ Centre de Recherche en Épidémiologie et Statistiques - Université de Paris (CRESS-INSERM-UMR1153), Epidemiology and Clinical Statistics for Tumor, Respiratory, and Resuscitation Assessments (ECSTRRA) Team, Paris, France.
⁴ Université de Paris, Paris, France.
⁵ Intensive Care Unit, Institut Jules Bordet, Université libre de Bruxelles (ULB), Brussels, Belgium.
⁶ Intensive Care Unit, Hôpital Brabois, Vandoeuvre Les Nancy, France.
⁷ Intensive Care Unit, Centre hospitalier régional universitaire, Angers, France.
⁸ Intensive Care Unit, Hôpital Cochin, Paris, France.
⁹ Institut Cochin, INSERM U1016, CNRS UMR 8104, Paris, France.
¹⁰ Intensive Care Unit, Institut Paoli Calmettes, Marseille, France.
¹¹ Intensive Care Unit, Hôpital Saint-Louis, Paris, France.
¹² Intensive Care Unit, Hôpital Pitié-Salpêtrière, Paris, France.
¹³ INSERM, UMRS 1158 Neurophysiologie respiratoire expérimentale et clinique, Paris, France.
¹⁴ Université Paris Sorbonne, Paris, France.
¹⁵ Intensive Care Unit, Hôpital Victor Provo, Roubaix, France.
¹⁶ Intensive Care Unit, Hôpital André Mignot, Versailles, France.
¹⁷ Intensive Care Unit, Centre hospitalier départemental Vendee, La Roche Sur Yon, France.
¹⁸ Intensive Care Unit, Hôpital universitaire de Ghent, Ghent, Belgium.

Abstract

Background: The aim of this study was to assess the benefit of direct ICU admission from the emergency department (ED) compared to admission from wards, in patients with hematological malignancies requiring critical care.

Methods: Post hoc analysis derived from a prospective, multicenter cohort study of 1011 critically ill adult patients with hematologic malignancies admitted to 17 ICU in Belgium and France from January 2010 to May 2011. The variable of interest was a direct ICU admission from the ED and the outcome was in-hospital mortality. The association between the variable of interest and the outcome was assessed by multivariable logistic regression after multiple imputation of missing data. Several sensitivity analyses were performed: complete case analysis, propensity score matching and multivariable Cox proportional-hazards analysis of 90-day survival.

Results: Direct ICU admission from the ED occurred in 266 (26.4%) cases, 84 of whom (31.6%) died in the hospital versus 311/742 (41.9%) in those who did not. After adjustment, direct ICU admission from the ED was associated with a decreased in-hospital mortality (adjusted OR: 0.63; 95% CI 0.45-0.88). This was confirmed in the complete cases analysis (adjusted OR: 0.64; 95% CI 0.45-0.92) as well as in terms of hazard of death within the 90 days after admission (adjusted HR: 0.77; 95% CI 0.60-0.99). By contrast, in the propensity score-matched sample of 402 patients, direct admission was not associated with in-hospital mortality (adjusted OR: 0.92; 95% CI 0.84-1.01).

Conclusions: In this study, patients with hematological malignancies admitted to the ICU were more likely to be alive at hospital discharge if they were directly admitted from the ED rather than from the wards. Assessment of early predictors of poor outcome in cancer patients admitted to the ED is crucial so as to allow early referral to the ICU and avoid delays in treatment initiation and mis-orientation.

Keywords: Direct admission; Emergency department; Hematological malignancy; Intensive care unit.