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The Impact of Hospital and ICU Organizational Factors on Outcome in Critically Ill Patients: Results From the Extended Prevalence of Infection in Intensive Care Study*

Sakr, Yasser MD, PhD1; Moreira, Cora L. MD1; Rhodes, Andrew MBBS2; Ferguson, Niall D. MD3; Kleinpell, Ruth PhD, RN, FCCM4; Pickkers, Peter MD5; Kuiper, Michael A. MD, PhD, FCCM6,7; Lipman, Jeffrey MD8; Vincent, Jean-Louis MD, PhD, FCCM9; on behalf of the Extended Prevalence of Infection in Intensive Care Study Investigators

doi: 10.1097/CCM.0000000000000754
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Objective: To investigate the impact of various facets of ICU organization on outcome in a large cohort of ICU patients from different geographic regions.

Design: International, multicenter, observational study.

Setting: All 1,265 ICUs in 75 countries that contributed to the 1-day point prevalence Extended Prevalence of Infection in Intensive Care study.

Patients: All adult patients present on a participating ICU on the study day.

Interventions: None.

Measurements and Main Results: The Extended Prevalence of Infection in Intensive Care study included data on 13,796 adult patients. Organizational characteristics of the participating hospitals and units varied across geographic areas. Participating North American hospitals had greater availability of microbiologic examination and more 24-hour emergency departments than did the participating European and Latin American units. Of the participating ICUs, 82.9% were closed format, with the lowest prevalence among North American units (62.7%) and the highest in ICUs in Oceania (92.6%). The proportion of participating ICUs with 24-hour intensivist coverage was lower in North America than in Latin America (86.8% vs 98.1%, p = 0.002). ICU volume was significantly lower in participating ICUs from Western Europe, Latin America, and Asia compared with North America. In multivariable logistic regression analysis, medical and mixed ICUs were independently associated with a greater risk of in-hospital death. A nurse:patient ratio of more than 1:1.5 on the study day was independently associated with a lower risk of in-hospital death.

Conclusions: In this international large cohort of ICU patients, hospital and ICU characteristics varied worldwide. A high nurse:patient ratio was independently associated with a lower risk of in-hospital death. These exploratory data need to be confirmed in large prospective studies that consider additional country-specific ICU practice variations.

1Department of Anesthesiology and Intensive Care, Friedrich-Schiller University, Jena, Germany.

2Department of Critical Care, St George’s Healthcare NHS Trust, London, United Kingdom.

3Interdepartmental Division of Critical Care Medicine, University of Toronto, University Health Network, Toronto, Canada.

4Center for Clinical Research and Scholarship, Rush University Medical Center, Chicago, IL.

5Department of Intensive Care, Nijmegen Institute for Infection, Inflammation and Immunity, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.

6Department of Intensive Care Medicine, Academic Medical Center, Amsterdam, The Netherlands.

7Department of Intensive Care Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands.

8Burns, Trauma, and Critical Care Research Centre, The University of Queensland, Queensland, Australia.

9Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium.

* See also p. 695.

Dr. Sakr conceived and designed the study. Drs. Sakr, Rhodes, Ferguson, Kleinpell, Pickkers, Kuiper, Lipman, and Vincent acquired the data. Drs. Sakr, Moreira, and Vincent analyzed and interpreted the data. Drs. Sakr and Moreira drafted the article. Drs. Sakr, Moreira, Rhodes, Ferguson, Kleinpell, Pickkers, Kuiper, Lipman, and Vincent critically revised the article for important intellectual content. Drs. Sakr and Vincent did statistical analysis. Dr. Vincent provided administrative, technical, or material support. Drs. Sakr and Vincent did study supervision.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal).

Dr. Rhodes consulted for Masimo and lectured for LiDCO and Edwards. Dr. Kleinpell is employed at Rush University Medical Center–Center for Clinical Research and Rush University College of Nursing, has reviewed medical legal cases and provided expert testimony, lectured (Agency for Healthcare Research & Policy grant), and received royalties from Springer Publishing (editor of book). Her institution received grant support from the Agency for Healthcare Research & Policy grant. Dr. Lipman served as a board member for Bayer European Society of Intensive Care Medicine Advisory Board; consulted for Merck Sharp Dohme (Aust) Pty, Pfizer Australia, and AstraZeneca; received grant support from AstraZeneca; and lectured for AstraZeneca and Pfizer Australia Pty. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: jlvincen@ulb.ac.be

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