PMC:29010 / 23002-28022 JSONTXT

{"project":"2_test","denotations":[{"id":"11056720-2231994-23622497","span":{"begin":713,"end":715},"obj":"2231994"}],"text":"Discussion\nDevelopment of specialized areas of care for the critically ill has \t\t occurred in most hospitals in the USA [1,12,13], leading to the growth in number \t\t and utilization of ICUs. Despite this growth, there is little information \t\t available related to the demographics and quality of rural ICUs [2]. Without specific data on outcomes of rural ICU patient \t\t care, it is difficult to evaluate quality of care issues. This lack of data is \t\t of particular interest when committees have tried to rationalize and justify \t\t regionalization of critical care in rural areas [2,3].\nIn the rural centers, the emergency room (ER) was the source of \t\t admission for 56% of the ICU patients. Escarce and Kelley [14] have suggested that patients admitted to the ICU from the \t\t ER often have improved survival rates when compared with patients being \t\t admitted to the ICU from other areas. We might anticipate, therefore, that the \t\t high percentage of admissions from ERs into rural ICUs could have a favorable \t\t impact on survival rates in those ICUs. Undoubtedly, the rural ER has a \t\t critical role in providing triage and stabilization of acutely ill \t\t patients.\nThe mean ICU bed occupancy rate of 53% found in all rural hospitals \t\t indicates that there was generally an ICU bed available to admit a critically \t\t ill patient. ICU bed availability might be an advantage to the rural hospitals \t\t by allowing prompt implementation and management of life-sustaining \t\t interventions.\nHigher mortality rates were found for rural patients with conditions \t\t which required complicated ventilation. Mortality rates in rural patients with \t\t conditions such as ARDS, MODS, and sepsis with DIC were 53%, 58% and 63%, \t\t respectively. These rates are higher than the overall rural mortality rate of \t\t 36%. This suggests there are certain high-risk patients who may benefit from \t\t transfer to a tertiary care center with greater resources and technology. The \t\t significantly higher mortality rates for persons with high-risk conditions \t\t suggests that these conditions might serve as primary indicators for evaluating \t\t the appropriateness of transferring patients to tertiary care centers.\nThere are many similarities in demographics and patient \t\t characteristics between the small RHs and the RRHs, including mean age, sex, \t\t APACHE II score, mortality and the rate of transfer. The most striking \t\t differences occur in the variation for lengths of stay in total hospital days, \t\t ICU days and ventilator days. This longer length of stay for RRHs cannot be \t\t explained by patient record selection alone. In looking for patients ventilated \t\t for significant time periods, few were found in the small rural centers. This \t\t may indicate that patients with complex medical illnesses, living in counties \t\t supported by a small RH may seek acute care and admission from physicians \t\t providing services in association with referral centers. This selection process \t\t may contribute to the favorable mortality rates for these smaller units. The \t\t longer length of stay in the RRHs is likely to have contributed to the higher \t\t nosocomial event rate.\nCertain limitations of this study need to be acknowledged. First, \t\t since the study enrollment was limited to just 20 hospitals, it is not possible \t\t to know how representative these were when compared with RHs in other \t\t geographic areas. Second, our exclusion criteria eliminated patients requiring \t\t only brief periods of ventilation. Had rapidly extubated patients with a good \t\t prognosis been included, survival rates might have been higher. Also, exclusion \t\t of patients who were ventilated briefly before transfer to another facility may \t\t have affected survival rates. Despite these limitations, this study, for the \t\t first time to our knowledge, provides information on rural hospital \t\t demographics and patient characteristics. These baseline data constitute the \t\t starting point for evaluating the quality issues associated with low patient \t\t volume. Similar data collection from other rural hospitals in geographically \t\t distinct areas may provide the data set required to re-evaluate the \t\t opportunities for regionalization of critical care in rural areas. The concept \t\t of regionalization for specific diagnoses has been supported by other studies \t\t [2,15]. On the basis of the higher \t\t mortality rates seen in rural patients with medical conditions resulting in \t\t difficult or complicated ventilation, our data seem to support the suggestion \t\t by Moscovice and Rosenblatt [3] that success in rural \t\t hospitals is best actualized through 'compartmentalization' or the \t\t ability to provide only that care which can be performed safely, efficiently \t\t and effectively. Early triage and appropriate identification of those high-risk \t\t patients who might benefit from transfer to a facility with specialized \t\t technology and greater resources may further reduce the mortality currently \t\t seen in patients admitted to rural ICUs."}

{"project":"Colil","denotations":[{"id":"T2","span":{"begin":713,"end":715},"obj":"2231994"}],"namespaces":[{"prefix":"_base","uri":"http://pubannotation.org/docs/sourcedb/PubMed/sourceid/"}],"text":"Discussion\nDevelopment of specialized areas of care for the critically ill has \t\t occurred in most hospitals in the USA [1,12,13], leading to the growth in number \t\t and utilization of ICUs. Despite this growth, there is little information \t\t available related to the demographics and quality of rural ICUs [2]. Without specific data on outcomes of rural ICU patient \t\t care, it is difficult to evaluate quality of care issues. This lack of data is \t\t of particular interest when committees have tried to rationalize and justify \t\t regionalization of critical care in rural areas [2,3].\nIn the rural centers, the emergency room (ER) was the source of \t\t admission for 56% of the ICU patients. Escarce and Kelley [14] have suggested that patients admitted to the ICU from the \t\t ER often have improved survival rates when compared with patients being \t\t admitted to the ICU from other areas. We might anticipate, therefore, that the \t\t high percentage of admissions from ERs into rural ICUs could have a favorable \t\t impact on survival rates in those ICUs. Undoubtedly, the rural ER has a \t\t critical role in providing triage and stabilization of acutely ill \t\t patients.\nThe mean ICU bed occupancy rate of 53% found in all rural hospitals \t\t indicates that there was generally an ICU bed available to admit a critically \t\t ill patient. ICU bed availability might be an advantage to the rural hospitals \t\t by allowing prompt implementation and management of life-sustaining \t\t interventions.\nHigher mortality rates were found for rural patients with conditions \t\t which required complicated ventilation. Mortality rates in rural patients with \t\t conditions such as ARDS, MODS, and sepsis with DIC were 53%, 58% and 63%, \t\t respectively. These rates are higher than the overall rural mortality rate of \t\t 36%. This suggests there are certain high-risk patients who may benefit from \t\t transfer to a tertiary care center with greater resources and technology. The \t\t significantly higher mortality rates for persons with high-risk conditions \t\t suggests that these conditions might serve as primary indicators for evaluating \t\t the appropriateness of transferring patients to tertiary care centers.\nThere are many similarities in demographics and patient \t\t characteristics between the small RHs and the RRHs, including mean age, sex, \t\t APACHE II score, mortality and the rate of transfer. The most striking \t\t differences occur in the variation for lengths of stay in total hospital days, \t\t ICU days and ventilator days. This longer length of stay for RRHs cannot be \t\t explained by patient record selection alone. In looking for patients ventilated \t\t for significant time periods, few were found in the small rural centers. This \t\t may indicate that patients with complex medical illnesses, living in counties \t\t supported by a small RH may seek acute care and admission from physicians \t\t providing services in association with referral centers. This selection process \t\t may contribute to the favorable mortality rates for these smaller units. The \t\t longer length of stay in the RRHs is likely to have contributed to the higher \t\t nosocomial event rate.\nCertain limitations of this study need to be acknowledged. First, \t\t since the study enrollment was limited to just 20 hospitals, it is not possible \t\t to know how representative these were when compared with RHs in other \t\t geographic areas. Second, our exclusion criteria eliminated patients requiring \t\t only brief periods of ventilation. Had rapidly extubated patients with a good \t\t prognosis been included, survival rates might have been higher. Also, exclusion \t\t of patients who were ventilated briefly before transfer to another facility may \t\t have affected survival rates. Despite these limitations, this study, for the \t\t first time to our knowledge, provides information on rural hospital \t\t demographics and patient characteristics. These baseline data constitute the \t\t starting point for evaluating the quality issues associated with low patient \t\t volume. Similar data collection from other rural hospitals in geographically \t\t distinct areas may provide the data set required to re-evaluate the \t\t opportunities for regionalization of critical care in rural areas. The concept \t\t of regionalization for specific diagnoses has been supported by other studies \t\t [2,15]. On the basis of the higher \t\t mortality rates seen in rural patients with medical conditions resulting in \t\t difficult or complicated ventilation, our data seem to support the suggestion \t\t by Moscovice and Rosenblatt [3] that success in rural \t\t hospitals is best actualized through 'compartmentalization' or the \t\t ability to provide only that care which can be performed safely, efficiently \t\t and effectively. Early triage and appropriate identification of those high-risk \t\t patients who might benefit from transfer to a facility with specialized \t\t technology and greater resources may further reduce the mortality currently \t\t seen in patients admitted to rural ICUs."}