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Identifying Potentially Ineffective Care in the Sickest Critically Ill Patients on the Third ICU Day^*

^* From the Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine (Drs. Afessa, Mohammad, Finkielman, and Peters), and Division of Critical Care, Department of Anesthesia (Dr. Keegan), Mayo Clinic College of Medicine, Rochester, MN.

Correspondence to: Bekele Afessa, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905; e-mail: Afessa.Bekele{at}mayo.edu

Objective: To determine if an increase in the third-ICU-day acute physiology score (APS) of the APACHE (acute physiology and chronic health evaluation) III prognostic system can identify potentially ineffective care.

Design: Retrospective cohort study.

Setting: Academic medical center.

Patients: Adult patients with first-ICU-day predicted mortality rate 80%.

Measurements: Demographics, ICU admission source, admission type, ICU admission diagnosis, first- and third-ICU-day APSs, APACHE III score, APACHE III-predicted hospital mortality, hospital discharge status, 100-day survival, and ICU and hospital length of stay.

Results: A total of 302 patients (age [mean ± SD], 64.7 ± 15.8 years; 54.3% male gender) were included in the study. Respiratory failure was the most common reason for ICU admission. Nonoperative admissions accounted for 94.7%. The first- and third-ICU-day APSs were 106.8 ± 19.8 and 70.5 ± 29.9, respectively. The first- and third-ICU-day predicted hospital mortality rates were 87.8 ± 5.3% and 86.5 ± 14.8%, respectively. The hospital mortality rate was 61.3%, and the 100-day survival rate 28.5%. The third-ICU-day APS was higher than the first-ICU-day APS in 34 patients (11.3%). Only 2 of these 34 patients (6%) survived to hospital discharge, compared to 115 of 268 patients (43%) without an increase in APS (p < 0.0001). Of the two hospital survivors with increased APS, only one patient survived 100 days after hospital discharge. In predicting 100-day mortality, the sensitivity of an increase in the third-ICU-day APS was 15.3% (95% confidence interval, 11.1 to 20.7%), specificity was 98.8% (95% confidence interval, 93.7 to 99.8%), positive predictive value was 97.1% (95% confidence interval, 85.1 to 99.5%), and negative predictive value was 31.7% (95% confidence interval, 26.4 to 37.5%).

Conclusions: A higher APS on the third ICU day, compared to the first ICU day, identifies potentially ineffective care in patients with the first-day predicted hospital mortality rate 80%.

Key Words: acute physiology and chronic health evaluation • hospital mortality • ICU • length of stay • medical futility • prognosis

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