Identifying potentially ineffective care in the sickest critically III patients on the third ICU day

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%.