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Unplanned intensive care unit admission in hospitalized older patients: Association with a geriatric vulnerability score

2022; Wiley; Volume: 70; Issue: 11 Linguagem: Inglês

10.1111/jgs.17944

1532-5415

Vinicius B. O. Silva, Márlon Juliano Romero Aliberti, Christian Valle Morinaga, Thiago Junqueira Avelino‐Silva, Pedro Kallas Curiati,

Intensive Care Unit Cognitive Disorders

Older adults admitted to intensive care units (ICUs) have a high risk of adverse outcomes, including functional decline and death. When intensive care follows unforeseen complications, the risk is even higher.1, 2 A previous study showed that clinical deterioration, rather than triage error, accounted for most unplanned ICU admissions and that age-related disabilities and multimorbidity, which are measures of geriatric vulnerability, were better predictors than illness severity.3 Despite a growing body of evidence, existing screening instruments have limited accuracy in predicting adverse outcomes and ICU admission following Emergency Department (ED) visits.4 We completed a longitudinal study comprising stable patients aged +70 years who visited a Geriatric ED (ProAGE) and were initially admitted to non-ICU beds between 2017 and 2020. ProAGE geriatricians systematically documented patients' and visits' characteristics using REDCap resources.5 Our standardized assessment includes delirium according to the Confusion Assessment Method (CAM), frailty according to the FRAIL scale, prognosis according to Identification of Seniors at Risk (ISAR) scores; risk of prolonged length of hospital stay according to PRO-AGE scores; and ED visit outcome. The PRO-AGE scoring system (Table S1) is a validated mnemonic method used to assess vulnerability and predict hospital admission, prolonged length of stay (LoS), and death in older adults at the ED.6 It is used to evaluate P = physical impairment, R = recent hospitalization, O = older age, A = acute mental status change, G = getting thinner, and E = exhaustion (Table S1).6 In its original derivation and validation study sample, those with long hospitalization scores ≥5 had a ≥25% risk of prolonged stays.6 Our main outcome was unplanned ICU admission, defined as a transfer to ICU following clinical deterioration. Our main predictor of interest was geriatric vulnerability, measured by PRO-AGE prolonged LoS (0–8; higher = worse). As the PRO-AGE scoring system does not have validated cut-off values, we opted to define its categories using tertiles, a similar strategy to previous work.6 We used logistic regression models adjusted for sex and comorbidity (defined according to Charlson Comorbidity Index, CCI) to examine the association between geriatric vulnerability and unplanned ICU admission. The study protocol was reviewed and approved by our Institutional Ethics Review Board. Access to de-identified retrospective data from the Geriatric ED clinical database was approved with an exemption of informed consent. Between 2017 and 2020, 1831 patients were assessed and included in the study. They had a mean age of 82 years, and 959 (52%) were female. On admission, we found that 825 (45%) had been hospitalized in the previous 6 months, 882 (48%) were frail, 345 (19%) had prevalent delirium, and 112 (6%) visited the ED because they had fallen (Table 1). A total of 120 (7%) experienced unplanned ICU admission due to unforeseen clinical deterioration, of which 33 (28%) had sepsis, 24 (20%) had a complicated postoperative course, 19 (16%) had hemodynamic instability, and 15 (13%) had respiratory failure (Figure S1). Patients in the ICU group had a higher prevalence of male sex, diabetes mellitus, heart failure, and liver disease, as well as higher median PRO-AGE score (Table 1). Likewise, patients in the upper tertiles of PRO-AGE scores were older, had more comorbidities, were more frequently male, delirious, and frail, and had higher rates of hospitalizations in the previous 6 months, ED visits and unplanned ICU admission than those in the lowest tertile (Table S2). After adjusting for possible confounders, we found that the highest tertile of PRO-AGE scores was independently associated with a greater risk of unplanned ICU admission (OR = 1.64, 95% CI = 1.04–2.57) (Table 2). In this longitudinal study, we found that geriatric vulnerability was associated with unplanned ICU admissions in hospitalized older adults. Our results indicate that a geriatric assessment in the ED could help identify patients at a higher risk of adverse clinical outcomes. Furthermore, a straightforward geriatric score developed to predict prolonged LoS was useful to predict unplanned ICU admission, even before clinical deterioration signs emerge. Interestingly, the PRO-AGE prolonged LoS score includes functional status measures, which have been described as important predictors of ICU admission in a previous study.3 To the best of our knowledge, this is the first geriatric vulnerability instrument shown to be associated with unplanned ICU admission in a sample of hospitalized older adults. We must acknowledge that only the highest tertile of PRO-AGE scores had a relative increase in risk of unplanned ICU admission, as the middle tertile did not reach statistical significance despite an adjusted odds ratio of 1.33. It is possible that with a larger sample significant risk would have been confirmed. Prognostication in the ED is a challenge, especially for older adults,7 as aging appears to decrease the accuracy of illness acuity screening tools and multiple factors increase the older adults' risk of experiencing deterioration.7-9 Because conventional screening tools often fail to capture key elements of risk in older persons, they can misclassify illness severity in patients aged ≥65 years.7 All investigators who contributed significantly to this work have been included in the authors' list. Concept and design: Vinicius B. O. Silva, Thiago J. Avelino-Silva, Pedro K. Curiati. Acquisition of data: Vinicius B. O. Silva, Christian V. Morinaga, Thiago J. Avelino-Silva, Pedro K. Curiati. Analysis and interpretation of data: Marlon J. R. Aliberti, Thiago J. Avelino-Silva. Preparation of the manuscript: Vinicius B. O. Silva, Christian V. Morinaga, Marlon J. R. Aliberti, Thiago J. Avelino-Silva, Pedro K. Curiati. Critical revision of the manuscript for important intellectual content: Vinicius B. O. Silva, Christian V. Morinaga, Marlon J. R. Aliberti, Thiago J. Avelino-Silva, Pedro K. Curiati. Study supervision: Christian Valle Morinaga, Pedro K. Curiati, Thiago J. Avelino-Silva. The authors thank those who supported this study, particularly the Geriatric ED team, who cared for our participants and helped implement our Geriatric ED program. No specific funding was received for this work. There are no financial or personal conflicts to declare. No sponsorship was received for this study. Supplementary Table S1: PRO-AGE scoring system. Supplementary Table S2: Characteristics of the study population according to tertiles of the PRO-AGE score (prolonged length of stay model). Figure S1: Causes of unplanned ICU admission (n = 120). Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.