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      Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

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          Abstract

          Objective

          To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).

          Design

          Retrospective cohort study.

          Setting

          1727 acute care hospitals in the United States.

          Participants

          Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015.

          Main outcome measure

          30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI.

          Results

          The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval −11.9 to −0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (−0.9 to 3.4) percentage points).

          Conclusions

          ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.

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          Most cited references39

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          Nurse staffing and inpatient hospital mortality.

          Cross-sectional studies of hospital-level administrative data have shown an association between lower levels of staffing of registered nurses (RNs) and increased patient mortality. However, such studies have been criticized because they have not shown a direct link between the level of staffing and individual patient experiences and have not included sufficient statistical controls. We used data from a large tertiary academic medical center involving 197,961 admissions and 176,696 nursing shifts of 8 hours each in 43 hospital units to examine the association between mortality and patient exposure to nursing shifts during which staffing by RNs was 8 hours or more below the staffing target. We also examined the association between mortality and high patient turnover owing to admissions, transfers, and discharges. We used Cox proportional-hazards models in the analyses with adjustment for characteristics of patients and hospital units. Staffing by RNs was within 8 hours of the target level for 84% of shifts, and patient turnover was within 1 SD of the day-shift mean for 93% of shifts. Overall mortality was 61% of the expected rate for similar patients on the basis of modified diagnosis-related groups. There was a significant association between increased mortality and increased exposure to unit shifts during which staffing by RNs was 8 hours or more below the target level (hazard ratio per shift 8 hours or more below target, 1.02; 95% confidence interval [CI], 1.01 to 1.03; P<0.001). The association between increased mortality and high patient turnover was also significant (hazard ratio per high-turnover shift, 1.04; 95% CI, 1.02 to 1.06; P<0.001). In this retrospective observational study, staffing of RNs below target levels was associated with increased mortality, which reinforces the need to match staffing with patients' needs for nursing care. (Funded by the Agency for Healthcare Research and Quality.).
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            Treatment of myocardial infarction in a coronary care unit. A two year experience with 250 patients.

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              • Article: not found

              ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction).

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                Author and article information

                Contributors
                Role: professor
                Role: associate professor
                Role: director
                Role: associate professor
                Role: associate professor
                Role: professor
                Role: assistant professor
                Journal
                BMJ
                BMJ
                BMJ-US
                bmj
                The BMJ
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2019
                04 June 2019
                : 365
                : l1927
                Affiliations
                [1 ]Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
                [2 ]Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
                [3 ]Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor, MI, USA
                [4 ]VA Center for Clinical Management Research, Ann Arbor, MI, USA
                [5 ]Center for Health Outcomes and Policy, University of Michigan, Ann Arbor, MI, USA
                [6 ]Cardiac Intensive Care Unit, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
                [7 ]Cardiovascular Critical Care Research, Inova Heart and Vascular Institute, Inova Fairfax Medical Center, Falls Church, VA, USA
                [8 ]Richard and Susan Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
                [9 ]Department of Medicine, Harvard Medical School, Boston, MA, USA
                [10 ]Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
                Author notes
                Correspondence to: T Valley valleyt@ 123456umich.edu or @tsvalley on Twitter
                Author information
                https://orcid.org/0000-0002-5766-4970
                Article
                valt048284
                10.1136/bmj.l1927
                6547840
                31164326
                caebc83e-2616-423b-b652-a75d065e0ed8
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 16 April 2019
                Categories
                Research
                1779

                Medicine
                Medicine

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