Nina Raoof

Premortem clinical diagnoses and postmortem autopsy findings: discrepancies in critically ill cancer patients

IntroductionLimited data are available regarding the relationship of premortem clinical diagnoses and postmortem autopsy findings in cancer patients who die in an oncologic intensive care unit (ICU). The purposes of this study were to compare the premortem clinical and postmortem diagnoses of cancer patients who died in the ICU and to analyze any discrepancies between them.MethodsThis is a retrospective review of medical records and autopsy reports of all cancer patients who died in a medical-surgical ICU and had an autopsy performed between 1 January 1999 and 30 September 2005 at a tertiary care cancer center. Premortem clinical diagnoses were compared with the postmortem findings. Major missed diagnoses were identified and classified, according to the Goldman criteria, into class I and class II discrepancies.ResultsOf 658 deaths in the ICU during the study period, 86 (13%) autopsies were performed. Of the 86 patients, 22 (26%) had 25 major missed diagnoses, 12 (54%) patients had class I discrepancies, 7 (32%) had class II discrepancies, and 3 (14%) had both class I and class II discrepancies. Class I discrepancies were due to opportunistic infections (67%) and cardiac complications (33%), whereas class II discrepancies were due to cardiopulmonary complications (70%) and opportunistic infections (30%).ConclusionThere was a discrepancy rate of 26% between premortem clinical diagnoses and postmortem findings in cancer patients who died in a medical-surgical ICU at a tertiary care cancer center. Our findings underscore the need for enhanced surveillance, monitoring, and treatment of infections and cardiopulmonary disorders in critically ill cancer patients.

Review of A Large Clinical Series: Intrahospital Transport of Critically Ill Patients: Outcomes, Timing, and Patterns

The purpose of this study was to analyze the relationship of intrahospital transport patterns with patient throughput and outcomes in an oncological intensive care unit. We retrospectively reviewed all patients admitted to a closed medical-surgical intensive care unit at a cancer center between January 1, 2004 and December 31, 2005. We compared the clinical characteristics and outcomes of patients with and without transport and analyzed all intrahospital transports in relation to intensive care unit occupancy, length of stay, and intensive care unit and hospital outcomes. Transport patterns were also assessed by day of week, time of day, timing of the first transport to intensive care unit admission, and destination. Transported patients (n = 413, 43.5%) had significantly higher severity of illness scores on intensive care unit admission, greater use of vasopressors and mechanical ventilation, and longer intensive care unit and hospital length of stay and higher hospital mortality than nontransported patients (n = 535, 56.5%). Multiple transports (!2) occurred in 45% of the transported patients. The number of transports was directly proportional to intensive care unit length of stay. The highest transport rates and nearly half of all first transports occurred during the first 24 hours of intensive care unit admission. Transports were most common during weekdays and on afternoon and evening hours and most frequently to the computed tomography suite. Our study shows that intrahospital transport of the critically ill is a multifaceted process with important implications for intensive care unit resource analysis, workload and throughput.

ICU Admissions After Actual or Planned Hospital Discharge : Incidence, Clinical Characteristics, and Outcomes in Patients With Cancer

BACKGROUND Unexpected ICU admissions may result from early or premature discharge from the hospital. We sought to determine the incidence, clinical characteristics, and outcomes of patients admitted to the ICU after actual or planned hospital discharge and to analyze whether the need for ICU admission was related or unrelated to the associated hospitalization. METHODS We retrospectively reviewed all adult ICU admissions between January 2004 and December 2006 at a tertiary care cancer center and identified the following two groups of patients: those patients admitted directly to the ICU within 48 h of actual hospital discharge (group A); and those patients admitted to the ICU within 48 h of planned hospital discharge (group B). RESULTS Of 60,462 patients discharged from the hospital during the study period, 826 patients (1.4%) required readmission to the hospital within 48 h of discharge; of these, 13 patients (1.5%) were admitted directly to the ICU (group A). An additional 12 patients were admitted to the ICU within 48 h of a planned hospital discharge (group B). The majority of these 25 patients (68%) [groups A and B] required ICU admission for a condition that was related to the previous or current hospitalization. The overall hospital mortality rate for both groups was 16%. CONCLUSIONS A small, but unique group of patients is admitted to the ICU within 48 h of actual or planned hospital discharge. Worsening of the underlying condition that necessitated the previous or current hospitalization often is the reason for ICU admission. Whether ICU admission could have been prevented by continued hospital care or improved diagnostic evaluation during the prior or current hospitalization requires further study.