Death in hospital following ICU discharge: insights from the LUNG SAFE study

Abstract

Background: To determine the frequency of, and factors associated with, death in hospital following ICU discharge to the ward.

Methods: The Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE study was an international, multicenter, prospective cohort study of patients with severe respiratory failure, conducted across 459 ICUs from 50 countries globally. This study aimed to understand the frequency and factors associated with death in hospital in patients who survived their ICU stay. We examined outcomes in the subpopulation discharged with no limitations of life sustaining treatments ('treatment limitations'), and the subpopulations with treatment limitations.

Results: 2186 (94%) patients with no treatment limitations discharged from ICU survived, while 142 (6%) died in hospital. 118 (61%) of patients with treatment limitations survived while 77 (39%) patients died in hospital. Patients without treatment limitations that died in hospital after ICU discharge were older, more likely to have COPD, immunocompromise or chronic renal failure, less likely to have trauma as a risk factor for ARDS. Patients that died post ICU discharge were less likely to receive neuromuscular blockade, or to receive any adjunctive measure, and had a higher pre- ICU discharge non-pulmonary SOFA score. A similar pattern was seen in patients with treatment limitations that died in hospital following ICU discharge.

Conclusions: A significant proportion of patients die in hospital following discharge from ICU, with higher mortality in patients with limitations of life-sustaining treatments in place. Non-survivors had higher systemic illness severity scores at ICU discharge than survivors.

Trial registration: ClinicalTrials.gov NCT02010073 .

Keywords: Acute hypoxemic respiratory failure; Acute respiratory distress syndrome; Hospital survival; ICU discharge; LUNG SAFE.

Conflict of interest statement

Prof Laffey reports personal fees from consultancy for Baxter and Cala Medical, and funds to his institution from grants from Science Foundation Ireland, the Health Research Board and others. All other authors attest that they have no conflicts of interest in regard to the subject of this manuscript.

Figures

Fig. 1

Flowchart of study population subdivided into the patient groups with and without treatment limitations

Fig. 2

Patients with no treatment limitations who die in hospital following ICU discharge have higher overall SOFA scores (a), which appeared to be due to higher systemic organ injury severity scores (b) as pulmonary organ injury severity scores (c, d) were similar, compared to survivors, at both ICU admission and at ICU discharge

Fig. 3

Patients with no treatment limitations who die in hospital require comparable or lower degrees of ventilatory support on the last day of assisted ventilation in the ICU compared to survivors at ICU discharge. Specifically, last day FiO2 (a) and peak initiatory pressures (b) were lower, while tidal volume, respiratory rates, dynamic compliance and minute volumes (c–f) were similar, in comparison to hospital survivors

Fig. 4

Outcomes of patients that survive to hospital discharge. In a length of ICU stay was similar in patients who survived to hospital discharge and those that died, both with and without treatment limitations. In b, hospital survival rates post ICU discharge were significantly lower in patients that had treatment limitations, compared to those with no limitations. In c in patients with no limitations, survival was significantly higher in those that received adjunctive therapies