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Critical Care Admissions and Discharge Criteria in Cancer Patients

  • Ignacio Pujol VarelaEmail author
  • Isidro Prieto del Portillo
Living reference work entry
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Abstract

More and more patients with solid or hematological tumors are admitted to the Intensive Care Units. The improvement in the physiopathological understanding of this group of patients, as well as the increasingly better and more targeted treatment options for their underlying disease, have led to a significant increase in their survival over the past two decades. We are living in an era in which we are defining the standards that offer the best way to care for them: From the organization and running of ICUs, the definition of clear admission criteria from the available evidence, and the development of new admission policies that expand the classic dichotomous view of whether or not they are candidates for admission to ICUs to analyzing the best treatment for them, avoiding excessive treatment, and, above all, respecting their principle of autonomy.

Keywords

Oncologic patients Admission policies Multidisciplinary care Early response team Critical care transition programs Full code admission ICU trial Palliative care 

Introduction

Cancer patients are increasingly common in intensive care units around the world. One out of every six to eight patients admitted to intensive care units (ICUs) worldwide presents a neo-proliferative process [1, 3]. Those of us who treated this type of patient two decades ago in hospitals dedicated to cancer treatment were accused of using very expensive resources in patients with a short life expectancy. At the time, some scientific societies, such as the American College of Chest Physicians or the Society of Critical Care Medicine in its 1992 Consensus Conference, pointed out the futility of admitting oncology patients to Intensive Care Units, arguing that if they needed mechanical ventilation, catecholamine, or renal replacement therapies, their mortality rate of over 90% was not worth the therapeutic effort. At the time, the fact of being a cancer patient was an independent risk factor for refusing to admit the patient to the ICUs [2].

The incidence of cancer does not stop growing; diagnosis is made at an earlier stage, which increases the treatment and life expectancy of these patients; the social and healthcare level in developed countries increases, and we find ourselves with an increasingly aging population and therefore more prone to suffering mutations in genetic structure that make it develop a neo-formative process. The age-adjusted incidence of cancer is 533.8 cases (532.6–535.1) per 100,000 population with a 95% CI [3]. To give you an idea of its magnitude, in 2009 there were 1.4 million and 3.2 million newly diagnosed cases of cancer in the USA and Europe, respectively (100,000 and 230,000 cases of oncological blood disorders in the same period). And this increase in the number of cases leads to more and more people being admitted to Intensive Care Units. During the first 100 days after the diagnosis of cancer, the risk of entering the ICU is considerably high and this exponential growth is subsequently reduced. Nearly 5.2% of all cancer patients develop a complication requiring ICU admission within 2 years of diagnosis [4]. If we are talking about patients with allogeneic hematopoietic stem cell transplantation (HSCT), up to 20% of them will require ICU admission after their procedure.

This whole process is underpinned by scientific research. While the first studies on cancer patients in the 1990s were rare and merely observational about their occurrence and survival (mainly developed in France, Brazil, and the USA), today, on the other hand, there is a proliferation of articles written all across the world by single-unit ICUs, general ICUs, including multicentric ICUs that bring together large numbers of patients. Contributions include retrospective or prospective articles aimed both at describing the experience of specialized centers with regard to their patients, for example with lung cancer [5] or after cytoreductive surgery Mogal et al. [51], and above all, studies aimed at reviewing signs of admission, studies that assess factors that influence their short- and long-term prognosis or those aimed at finding the best organization of units to treat them [6]. The societies of Intensive Care and Oncology seek meeting points and create work units to improve the outcome for their patients, as is the case with the SEOM and SEMICYUC in Spain [7]. A section within the new working guidelines [8] on admission, discharge criteria, and patient triage from the Society of Critical Care Medicine (SCCCM) has included a section on the admission criteria for cancer patients.

What Has Changed to Improve the Prognosis of Cancer Patients in ICUs?

Comparative mortality studies have shown a significant improvement in the life expectancy of cancer patients in ICUs in recent years. Of these, the systematic reviews of Puxty et al. [4] and Soubani [9] are noteworthy. The first one deals with the review of 48 articles between 1997 and 2011 with a total of 74,061 patients with solid tumors in which the overall mortality in ICU was 31.2% and in hospitalized patients 38.2%, but with such a wide range of intra-Intensive Care Unit mortality between 4.5% and 85% due to the great heterogeneity of the sample. Soubani [9] compares studies from the 1980s and 1990s where mortality of patients with cancer and mechanical ventilation was around 80–90%, while more recent studies describe mortalities between 27% and 30% in solid tumors, 40% in autologous transplants, and around 60% in allogeneic transplants.

The reasons for this improvement in outcome results are multifactorial and due to improvements and innovations in all fields of cancer research, diagnosis, and treatment, as well as intensive care.

In the field of Critical Care, the main change has been the return to the physiological understanding of the different pathologies and its application in their treatment. Understanding and using optimal peep, limiting plateau pressure or tidal volume, meaning of the response or non-response to volume administration during resuscitation, assessing weaning-related cardiac dysfunction, limiting airway pressure to optimize cardiovascular function, understanding why prone positioning minimizes lung damage and improves gas exchange, understanding that small changes in creatinine can lead to significant kidney damage, all of these are some examples of practices that we all develop today and whose basis is our physiology [10]. The use of noninvasive ventilation or high-flow systems capable of generating positive pressure has been shown to be effective in reducing intubation and mortality due to respiratory distress [11]. Improvements in sedation and analgesia techniques, with less depth in them and with periodic interruptions to improve weaning; being attentive to the psychological needs of the patient and the family, preventing and diagnosing delirium of our critical patients early; the daily use for bedside diagnosis or for safer techniques through ultrasound; the improvement of nutrition for critical patients; better understanding of common processes such as polyneuropathy or myopathy of the critically ill, etc., and thus small advances in all areas of intensive care have contributed to a more physiological and less aggressive management of our patients. From an organizational point of view, the systematic work carried out using operating protocols, the progressive distribution of our Intensive Care Units and medium level units according to the need for monitoring, the complexity of each patient, and the nursing care ratios allow us to attend to each of our patients with a specific level of priority, thereby being more cost-effective.

In the field of Oncology, surgery is becoming more and more sophisticated, more advanced supplemented before, after, and even at the same time with chemotherapy or radiotherapy. Other developments include advances in conventional RT or brachytherapy, improving optimal doses and minimizing damage to healthy tissues, development, and augmentation of proton RT indications. Furthermore, we have the increasingly physiological hormone therapy in those dependent tumors and the great advancement in immunotherapy. Regarding chemotherapy, on the one hand, the use of intensive schemes that allow a greater response or cure and, on the other, the development of therapies directed at certain genetic and biological targets.

Just as important as these advances are, there is also the development of a better and earlier supportive treatment: nutritional, psychological, and pharmacological; the importance of a correct nutritional and psychological assessment to prepare the patient for treatment. Other factors include pharmacological development with potent antiemetics, granulocyte stimulators that decrease the duration of neutropenia, and new bisphosphonates or recombinant rasburicase that decrease the toxicity of chemotherapy.

Nowadays, early diagnosis of infections is fundamental through the systematic use of b-D glucan, galactomannan, PCR, or procalcitonin tests [12] as well as the use of noninvasive ventilation (NIV) or high-flow devices to perform fibrobronchoscopies and thus obtain samples for culture. Also the early use of better targeted antibiotics and the development of new antifungals and antibiotics after a long period without new patents have caused mortality around the treatment to decrease. Because of all this, from the 1990s to the present day, mortality from cancer has fallen by 23% [13].

But multidisciplinary collaboration and patient care decisions between oncologists, hematologists, and Intensive Care specialists have undoubtedly been fundamental, as demonstrated in numerous articles such as Soares et al. [6]. Primary care physicians are able to inform us of the prognosis, treatment options, and adverse effects of the traditional and new chemotherapy regimens. Intensivists can make the overall situation about the patient be understood from the real expectation of the medical situation that is being developed. And together, a plan can be agreed on in terms of time, in terms of limiting efforts, and together informing the patient and the family. The inclusion of other specialists such as pharmacists in cancer patient care has been shown to be beneficial because of the combination of polymedication and potential toxicity and interactions [6].

Better Results, but at What Cost?

The cost of this improvement in survival rates entails not only economic costs, even though this is very high (the cost of intensive care beds amounts to between 16.9% and 38.4% of hospital costs; approximately 200 billion dollars per year) but also more and more sick people those are dying in our units. A US review of Medicare of over 85,000,000 patients shows that the percentage of patients who were in ICU in their last month of life increased [14], rising from 24.3% in 2000 to 29.2% in 2009. Because of this, it has come to be considered as a quality measurement factor in many health care systems. Although the majority of cancer patients would prefer to die at home, the truth is that in the USA 40% of citizens die in hospital and nearly 60% do so after being admitted to the ICUs. One in five Americans dies in our units.

Organizational Aspects of the ICUs

In the following points, we will describe what organizational characteristics of our Intensive Care Units have proven to be beneficial in the treatment of cancer patients.

Oncologic vs General ICUs: volume of cases

With the first studies there seemed to be a difference in mortality in favour of ICUs specialising in cancer, mainly due to the large volume of admissions to intensive care. Patients with cancer and ARDS or septic shock had a mortality rate of between 34% and 50% when they were managed in oncology specialized ICUs while it raise to 66–68% in general ICUs [15]. Little by little, due to the transmission of knowledge and the monitoring of standardized protocols, this gap is gradually narrowing to practically the same level. Soares et al. [6] in a study of 9,946 patients with solid tumors could not demonstrate that the higher number of cases or the specialization of the ICU were determining factors for improving outcomes in these patients.

Multidisciplinary Care

Each day the ICUs are becoming less closed off and there is greater collaboration with a large number of specialists: oncologists, hematologists, specialists in infectious diseases, nephrologists, cardiologists, pneumologists, pharmacologists, etc. Although the daily burden of decision-making lies with the intensivist, there is more and more joint work with these specialists, both in terms of carrying out complementary tests and for consulting on specific problems or the progression of the illness. The development of working protocols in ICUs has also been shown to decrease the mortality of our patients, including general protocols for infection prevention, initiating early enteral nutrition, developing protective mechanical ventilation, using intermittent sedation, beginning physiotherapy and early mobilization, etc.

When deciding on admission to the ICU, several studies ([16]; Nasir et al. [17]) have shown that although a joint assessment by several specialists may be useful, it is the intensivist, due to his global assessment of the patient and experience in making such decisions, who is best placed to approach the reality of the process and who can best prevent inappropriate admissions (up to 37% according to Nasir et al. [17]), avoiding both aggressive procedures, family and patient stress, as well as delaying access to quality palliative care.

Joint daily sessions between intensivists and oncologists/hematologists for decision-making and the presence of a clinical pharmacologist on the rounds are associated with a reduction in mortality in critical oncology patients [6]. In addition, the presence of palliative care specialists on the rounds helps to improve patient comfort, improve symptom control, communication, and family participation in decisions.

Early Warning and Admissions

The importance of early detection of multi-organic dysfunction outside intensive care units has been noted for some time now; for this reason, “out of wall” ICU strategies have been developed over years to recognize this early dysfunction by means of early intervention teams or the active assessment of frail patients by intensivists. Song et al. [52] demonstrated in a general hospital that those patients who are transferred to the ICU early (four-hour cut-off point) have significantly lower mortality rates, lower costs, and significantly shorter hospital stays. Onco-hematological patients are fragile patients, their immunological and nutritional status and the toxicity of their treatments make them particularly sensitive to a rapid deterioration in their physical functioning if something happens that makes them unstable. Therefore, early intervention in these patients is perhaps more important and evident than in the case of other sufferers. Recent studies carried out in Seoul [18] show that prompt care (<1.5 h after detecting the anomaly and assessing it) with respect to late care (>1.5 h) was accompanied by lower mortality in ICU (18.1% vs. 42.4%) and for hospital care (29% vs. 55.3%). Late care was also accompanied by increased need for vasoactive drugs, more severe neutropenia, and documented infection data.

Two multicentric studies in hematological [19] or oncological patients undergoing shock [20] show that delaying their admission to ICUs is an independent mortality factor.

The benefit is clearly associated with aggressive and early treatment of multi-organ dysfunction and prevention of organ failure. And within this group, tests or risk procedures would be performed on our patients in a safer and more controlled environment such as our ICUs.

Admission Policies

The decision to admit a patient to the ICU has always had a certain interpersonal and variable component; this is even more evident with cancer patients because of an ICU doctor’s memory of not admitting them.

A study by Thiery et al. [21] showed that in a tertiary hospital, when cancer patients were referred to the ICU, 50% of them were rejected, with the label “cancer” being the main reason for their rejection. The 20% who were not admitted because they were “too well to be admitted” died before leaving the hospital and the 25% of patients who were initially rejected and subsequently admitted to the ICU left the hospital alive. This shows how difficult it is to get the admission decision right.

For all these reasons, admission policies in Intensive Care are changing and recommendations are being sought based on best practices and available evidence. All of them have a low level of evidence except the high-intensity ICU model characterized by the intensivist being responsible for day-to-day management of the patient in a closed ICU setting (level of evidence 1B) [8]. In the specific case of cancer patients, the SCCM recommends (no evidence available):
  • Access to ICU on the basis established for all critical care patients, with careful consideration of their long-term prognosis

  • These patients be reassessed and discussed with the patient, next of kin, legal representative, or power of attorney at regular intervals.

Given the difficulty of giving weight to these recommendations, new admission policies have been developed for cancer patients, and full code, ICU trial, or palliative care in ICU will be discussed in more detail at a later point.

As a summary of what is external to the patients themselves, Table 1 shows the factors that have been seen to have a positive influence on the care of the oncology patient in our Units.
Table 1

Hospital organizational factors that improve care

Hospital organizational factors that improve care

A high-intensity ICU model characterized by the intensivist being responsible for day-to-day management of the patient in a closed ICU setting

ICU’s relationship and collaboration with other services

Joint daily decision-making between critical care physicians, hematologists, and oncologists

Participation in medical rounds made by other specialists such as palliative care physicians or clinical pharmacologists

Drawing up protocols for routine care and procedures in intensive care as well as the provision of clinical guidelines

Strategies for the early detection of multiorganic dysfunction, either by means of early intervention teams, through alarms in clinical information systems, or with the help of rounds by intensive care physicians assessing the frail patients at the request of their treating physicians

Dissemination of the knowledge and facts about the cancer patients in triage for admission to hospital

Introducing early palliative care for critical ill cancer patients

Structure and equipment so as to offer the necessary care in the different admission policies: Full code, ICU trial, exceptional admissions, or palliative care in ICU

Admission Criteria

The criteria that the intensivist must assess to admit a patient into the unit should include:
  • The true indication or need for management in the ICU

  • Presence of a trained specialist in the field

  • Prioritizing depending on the patient’s condition

  • Reason for admission

  • Bed availability

  • Objective vital data

  • Patient prognosis

  • Potential benefit of interventions performed on the patient

This is really what is done every day when patients are assessed. According to the beds available in the unit, the patient is assessed, taking into account his/her background, prognosis, acute condition, and whether or not his/her needs can be met in the ICU.

There are four pillars of assessment (Fig. 1) when it comes to determining whether to admit a cancer patient to the ICU from the patient’s perspective.
Fig. 1

Pillars of assessment

In the following paragraphs, what factors within each of these pillars will be explained and how they can and should affect our decision when deciding to admit a cancer patient.

The Patient and Their Characteristics

The cancer patient presents some differentiating characteristics in comparison with other patients. This does not mean that different measures are taken to restrict their access to the ICU; moreover, because they are cancer patients, they should not have fewer opportunities for admission than others.

Among the characteristics that should not influence us when deciding on their admission are age, the presence of neutropenia, as well as hematological disease with autologous transplants.

It has already been demonstrated in numerous articles that access to intensive care units is not restricted for the elderly. Recommendation 2c of the SCCM guidelines is to assess the comorbidities of patients, their physical functional status, and the severity of the process coupled with their opinion rather than the chronological age in patients over the age of 80. Specifically in our patients, a review of Auclin et al. [22] found no difference in the subgroup of older cancer patients (75 +/− 6.7 years) with those who did not have tumor disease (33.6% vs. 32.6%).

Neutropenia in cancer patients is not a risk factor for them. Bouteloup et al. [23] in a systematic review of 6,054 cancer patients of whom 2,097 had neutropenia in studies between 2005 and 2015 found that neutropenia when adjusted for patient severity did not affect patient mortality.

Patients with blood disorders, who have undergone autologous bone marrow transplantation, due to the intensity of chemotherapy and the increased frequency of neutropenia and organ failure have typically presented slightly higher mortality rates; but advances in supportive care and ICU treatments have made it similar to that of any patient in general intensive care units today [24].

Among the factors that marginally affect their prognosis are admission severity scores (which actually tell us about the patient’s multi-organ dysfunction) as well as excessive comorbidity.

All the clinical scoring commonly used in ICUs at admission (MPM, APACHE, or SAPS) overestimate the severity of the cancer patients’ condition by considerably increasing the probability of having tumor disease [25]. For all these reasons, other more specific indices (HCT-CI or Cancer Mortality Model CMM) ([26, 53]) have been developed and are pending validation through multicenter trials. SOFA does appear to have a good discriminatory capacity to predict mortality rates in ICUs and hospitals of oncology patients admitted for medical reasons, rather than for surgical procedures, according to a review by Cárdenas-Turanzas et al. [27] of a population of 6,645 patients admitted to an oncology ICU. Aygencel et al. [28] found a SOFA value of 9 or higher in patients with solid tumors or 10 or higher in patients with hematological tumors as the highest mortality indicator in critical oncological patients. More important than the number of organ failures on admission of our patients is their response to treatment during the first few days of their stay in our units. The persistence or worsening of this multi-organ dysfunction is clearly associated with mortality in ICU. This is the basis of the ICU trial that will be discussed below.

Other factors, which should be taken into account, are their previous quality of life, their performance status, personal and family decisions regarding their decision to be admitted to the ICU, and the appearance of complications in an allogeneic transplant.

The patient’s previous quality of life as measured by the performance status (PS) is a simple scale that assesses the patient’s physical functionality and quality of life (Table 2). It is useful for predicting mortality in all critical patients and has been corroborated by numerous studies in critical cancer patients. A PS 3–4 is associated with an increase in ICU mortality of four to seven times in patients with a PS 0–2 [4]. Only those situations in which the deterioration of the patient’s condition is due to a recent diagnosis of the tumor or a potentially reversible cause would be significantly improved with aggressive treatment.
Table 2

ECOG perfomance status

Grade

ECOG performance status

Description

0

Fully active, able to carry out all pre-disease performance without restriction

1

Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature

2

Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours

3

Capable of only limited self-care, confined to bed or chair more than 50% of waking hours

4

Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair

5

Dead

According to the 5th International Consensus Conference on Intensive Care, the decision to limit treatment in the ICU should be based on the principle of patient autonomy.

Because that only 5% of the patients admitted to our units have the capacity to make decisions about their illness intact [29], prior consensus between the patient, family members, and treating physicians is essential. When this does not occur, the patient receives more aggressive measures and usually loses the possibility of receiving quality palliative care. For all these reasons, it is essential to advance along the path of dynamic decision-making during the course of the disease [30]. The oncologist’s continuous, immediate, and clear communication, the patient’s functional status, as well as the therapeutic options at all times must be weighed against each other in order to clearly understand the transition from curative to palliative care. But we still find that even in cancer centers, many patients are not sure of the essential measures they need to take with their oncologists, such as non-resuscitation [31].

The need for intensive care admission for allogeneic transplant patients has decreased by 8% over the past two decades; mortality has also decreased from 80% in the 1990s to 60% today [32]. Although infections are common in these patients, the main cause of death is severe respiratory failure requiring mechanical ventilation of a noninfectious origin. In spite of the high mortality rate, admission is still recommended for its management, especially if complications appear in the immediate post-transplant period. But the appearance of multi-organ failure in these patients, especially in the midst of anti-graft disease, should prompt us to reconsider the decision to go ahead.

Tumor Type and Stage

Cancer patients are an extremely heterogeneous group of patients. There are many and very different types of tumors, each one of them with a different evolution according to its genetics and biology; with different answers for the same treatment depending on the evolutionary stage of the disease and even in each individual.

Intensivist cannot base the decision of admission to the ICU on the stage of the tumor. This has been inconsistently associated with increased mortality. Thus, while some studies showed that patients with stage IV or metastatic tumors were more likely to die in hospital [33, 34], other more recent studies with a greater number of patients ([22, 35]) did not find a link between disseminated disease and short-term outcomes (ICU and hospital mortality).

Provided there are therapeutic options, the failure of any treatment line should not be a reason to refuse admission [11]. Yes, tumor progression without treatment options is associated with poor prognosis.

The origin and histological classification of the tumor is not related to prognosis in the ICU, although it does influence long-term outcomes. Typically, hemato-oncological diseases have had worse outcomes than solid tumors, but these differences have been disappearing over the years in ICU and hospital mortality outcomes [36, 37]. However there are groups of patients in whom mortality has remained virtually unchanged and remains extremely high and whose admission must be considered; these bone marrow transplant patients with severe graft-versus-host disease (GVHD) do not respond to immunosuppressive therapy. Also, these are the patients who exhibit solid tumors with severe complications such as acute respiratory failure due to lymphangitis, meningeal carcinomatosis, and coma or when they infiltrate and produce spinal cord failure.

With regard to tumor disease, it is believed that the following indications (Table 3) are shown in and are usually accepted in any cancer center.
Table 3

Admission criteria from the perspective of the disease

Admission criteria from the perspective of the disease

Patients in complete remission

Newly diagnosed patients of less than 3 months and with a life expectancy of more than 6 months

Patient with failure of one or more treatment lines but with future options (transplant, clinical trial) without malignant involvement of vital organs

Patients with treatment toxicity, complications of this treatment or of procedures related to its process

Patients in clinical trials whose aggravation may be related to the treatment

Patients in whom it is essential to reduce tumor pressure, which is responsible for complications and organ failure. QT is safe in the ICU and its administration does not worsen the prognosis [11]

Reason for Admission

Each hospital has its own particular caseload regarding the reasons for admission of oncohematological patients to its ICUs; this will depend on whether we are in an oncology hospital, in a privately or publicly managed hospital, and the ratio of ICU beds to the patient reference population.

We will now look at the main reasons for admission to our units Soubani [9] and the advances and changes that have led to improved survival of clinical profiles (Table 4).
Table 4

Improvement areas depending cause of admission

Causes of admission (%)

Improvement areas

Postoperative elective or emergency 50–60%

Increased specialization in surgery, as well as in case management, and fast track recovery management

Severe sepsis and septic shock 16–18%

Early recognition of sepsis and rapid implementation of sepsis bundles

Better understanding and management of multiorgan failure

Use of biomarkers to diagnostic

Respiratory failure 10%

 Infectious

 Noninfectious: ARDS secondary to polytransfusion, underlying disease, treatment and/or toxicity of same

Early NIV may be harmful

High-flow oxygen has demonstrated survival benefits compared to NIV [38, 39]

Compared to BAL, noninvasive tests have the same diagnostic and therapeutic fields

Do not delay mechanical ventilation if indicated

Protective lung ventilation

Change in level of consciousness 5%

 Metabolic

 Sepsis

 Cerebral LOE versus bleeding

 Posterior reversible encephalopathy

Daily interruption of sedation

New sedative agents

Sedation based on analgesia

Oncological emergencies: 3%

 Tumor lysis syndrome (TLS)

 Superior vena cava syndrome (SVCS)

 Cardiac tamponade

 Airway obstruction

 Hypercalcemia

Early admission of cancer patients at risk of tumor lysis syndrome or renal failure has been shown to improve survival

Use of ultrasound at the bedside

Bleeding from leakage, coagulopathy, thrombopenia 2%

The values of Hb without active bleeding are considered safe around 7 g/dl except in postoperative major surgery which should be greater than 9 g/dl [40]

The dysfunction of platelet aggregation and the alteration of vascular integrity means that we should not look only at the number of platelets to indicate their transfusion

Concomitant medical processes: ischemic heart disease, COPD, PTE, liver failure, renal failure, etc. 2%

The increasing knowledge of the adverse effects of cancer treatments helps us to focus on the dysfunction of the affected organ

Administration of QT in fragile patients or patients with an allergy to QT 1%

Providing it in the safe environment of the ICU reduces complications and has better results. Associated sepsis or need for life support at the same time is not a contraindication to administer it [41]

PostRCP

Survival is <2% and ICU care after resuscitation may be considered futile

Multiple readmissions for organic dysfunction after ICU admission

Hospital mortality is multiplied by 11 and cancer treatment is not usually continued, so continued readmissions can be considered futile

New Strategies of ICU Admission

There are four scenarios in which cancer patients have a place depending on all the variables previously analyzed (Fig. 2):
  • Full code management: This would be treatment with curative intent and without restrictions, similar to any other critical care patient.

  • ICU trial: An increasingly accepted admission policy that began with a study of hematological patients with respiratory failure by Lecuyer et al. [42]. All oncohematological patients (except bedridden patients, those who refused admission and palliative care patients) were admitted to the ICU for 3 days without restrictions in terms of techniques, treatments (including QT), and resources. It was observed that all patients who worsened in terms of their organ dysfunction (by measuring the SOFA) by day three of admission showed a clearly unfavorable development with those who improved in terms of their organ dysfunction by the third day of admission. All those patients who required mechanical ventilation, vasopressors, or dialysis after the third day died. This unrestricted ICU test is currently the path being followed in most intensive care units when faced with the admission of an oncology patient [43, 44]. Recent studies attempt to establish the optimal trial period such as Shrime et al. [45] concluding that trials of ICU care lasting 1–4 days may be sufficient in patients with poor-prognosis solid tumors, whereas patients with hematologic malignant neoplasms or less severe illness seem to benefit from longer trials of intensive care.

  • No ICU admission and no intensive care treatment: No indication of admission or use of intensive care therapy such as renal clearance techniques or noninvasive ventilation.

  • ICU admission outside of routine indications: Here there would be prophylactic admissions, exceptional admissions, as well as palliative care administration.

Fig. 2

Admission policies

ICU Discharge

Related literature in the last few years is full of admission criteria, patient and disease characteristics, causes for admission, and its policies, but few articles evaluate the reasons, timing, and follow-up of ICU discharges, especially in relation to cancer patients.

A meta analysis of Hosein et al. [46] on the discharge from ICU of almost two million patients found that, of every 100 patients discharged alive from ICU, between 4 and 6 are re-admitted and 3–7 die before being discharged again from hospital. This has led to the search for safety predictors in patients discharged from the ICUs, as well as to the enabling of discharge or follow-up policies that reduce these complications.

The discharge APACHE II score and hospital length of stay before ICU admission are significant independent factors in predicting post-ICU mortality and is superior to the admission APACHEII score in predicting early ICU readmission in surgical ICU patients.

On the other hand, seeing how the rapid response teams have demonstrated their usefulness in reducing the mortality of cancer patients in ICUs by detecting their organic dysfunction early, an attempt has been made to transfer this model to close monitoring by intensive care doctors, nurses, and respiratory specialists of those patients who are discharged from ICUs during the first 48–72 h. These Critical care transition programs have been widely assessed by Stelfox et al. [47]. After analyzing 32,234 patients over 10 years in eight hospitals, he has observed that, although there is a certain trend towards a decrease in readmissions in the patients followed by these teams compared to the control group (also described in the meta-analysis by Niven et al. for the NHS), a significant difference in mortality cannot be determined for both groups.

The SCCM in its guidelines on admission and discharge policy for ICUs recommends a series of actions, most of them lacking any compelling evidence, but which are widely accepted and usually carried out by the majority of intensive care physicians.
  • Discharge patients when they are physiologically stable and do not require monitoring or their own intensive care treatment.

  • Discharge patients at a lower level of acute care depending on patient disposition, prognosis, stability, or the need for patient interventions.

  • Taking into account, as we discussed previously APACHE II at discharge, the rates as an aid in identifying those patients at high risk of deterioration following discharge from the ICU.

  • Whenever possible, especially with frail patients, talk to the doctor receiving the patient to tell him/her about their progress, treatment, and management. This could reduce the frequency of readmissions.

  • With level 2C, patients would not be discharged at night, hospital mortality has increased (OR1.31), but there is no difference between discharging them on weekdays and weekends.

  • Also, with level 2C there would be the use of intermediate care units or long-stay hospitals for those patients who are still fragile, either because of the severity of the disease, their multiple comorbidities, physiological instability, or because they still have the support of a vital organ at discharge.

Regarding the survival and quality of life outcomes of cancer patients, studies tend to focus on intra-ICU mortality, hospital mortality or mortality at 30–90 days. Such short results do not give us valid conclusions as to the actual benefits and overall cost-effectiveness of ICU care in cancer patients. Fifteen years ago, the one-year survival rate for cancer and haematological patients was 25% [48], whereas more recent studies place it between 18 and 64% [49].

In general, it seems to be shown that the long-term survival of cancer patients does not depend on the severity of the process or the time spent in the ICUs, but rather on the prognosis of the tumour disease [50].

Summary

The progressive increase in the incidence of cancer cases (mainly solids), the technological advance, the accumulated experience, and, above all, the better knowledge of the etiopathogenesis of the neoformative processes have sparked interest in this type of patients from all areas. The ICUs are not alien to this interest, seeing in these patients the possibilities that they did not see before, considering this group of patients in a similar way to another subgroup of severe diseases. But not everything goes, sensibly they have been developing guidelines of action or strategies against them according to the moment of the diagnosis and treatment options, with special attention to the moment in which they develop failure of some organ and evaluating each day this dysfunction. This careful monitoring within a multidisciplinary team, far from the usual loneliness of the intensivist, has brought the possibilities of survival in our units closer to that of any other type of seriously ill patient. Today we can say that no cancer patient should have fewer opportunities for treatment than another critical patient, always respecting personal autonomy.

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Ignacio Pujol Varela
    • 1
    Email author
  • Isidro Prieto del Portillo
    • 1
  1. 1.Department of Critical CareHospital MD Anderson Cancer CenterMadridSpain

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