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Background: The COVID-19 pandemic led authorities to evacuate via various travel modalities critically ill ventilated patients into less crowded units. However, it is not known if interhospital transport impacts COVID-19 patient's mortality in intensive care units (ICUs). A cohort from three French University Hospitals was analysed in ICUs between 15th of March and the 15th of April 2020. Patients admitted to ICU with positive COVID-19 test and mechanically ventilated were recruited. Results: Among the 133 patients included in the study, 95 (71%) were male patients and median age was 63 years old (interquartile range: 54–71). Overall ICU mortality was 11%. Mode of transport included train (48 patients), ambulance (6 patients), and plane plus helicopter (14 patients). During their ICU stay, 7 (10%) transferred patients and 8 (12%) non-transferred patients died (p = 0.71). Median SAPS II score at admission was 33 (interquartile range: 25–46) for the transferred group and 35 (27–42) for non-transferred patients (p = 0.53). SOFA score at admission was 4 (3–6) for the transferred group versus 3 (2–5) for the non-transferred group (p = 0.25). In the transferred group, median PaO2/FiO2 ratio (P/F) value in the 24 h before departure was 197 mmHg (160–250) and remained 166 mmHg (125–222) in the first 24 h post arrival (p = 0.13). During the evacuation 46 (68%) and 21 (31%) of the patients, respectively, benefited from neuromuscular blocking agents and from vasopressors. Transferred and non-transferred patients had similar rate of nosocomial infections, 37/68 (54%) versus 34/65 (52%), respectively (p = 0.80). Median length of mechanical ventilation was significantly increased in the transferred group compared to the non-transferred group, 18 days (11–24) and 14 days (8–20), respectively (p = 0.007). Finally, ICU and hospital length of stay did not differ between groups. Conclusions: In France, inter-hospital evacuation of COVID-19 ventilated ICU patients did not appear to increase mortality and therefore could be proposed to manage ICU surges in the future. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether ICUs caring for higher volumes of acute respiratory distress syndrome patients would be associated with lower ICU mortality.Design: A 9-year multicenter retrospective cohort study of prospectively collected data.Setting: French medical ICUs.Patients: From 2004 to 2012, acute respiratory distress syndrome cases were identified from a coding system through a regional database (Collège des Utilisateurs de Données en Réanimation).Interventions: None.Measurements and Main Results: Volume was calculated as the cumulative annual mean number of acute respiratory distress syndrome cases. Severity (Simplified Acute Physiology Score 2) and ICU mortality between categories (low, medium, and high) of acute respiratory distress syndrome cases volume were analyzed. Multivariable analysis using mixed effects models was performed to adjust for severity of illness and confounding factors. Over the study period, 8,383 acute respiratory distress syndrome patients among 31 ICUs met the study inclusion criteria. Overall, Simplified Acute Physiology Score 2 (median [interquartile]) was 58 (43-74), whereas ICU mortality was 53.7%. Severity as assessed by Simplified Acute Physiology Score 2 (median [interquartile]) was significantly higher in high-volume ICUs (> 65 acute respiratory distress syndrome per year) as compared to low (≤ 29 acute respiratory distress syndrome per year) and medium-volume ICUs (> 29-65 acute respiratory distress syndrome per year): 61 (46-77) versus 55 (41-72) and 55.0 (40-72), respectively (p < 0.01). ICU mortality was similar across the acute respiratory distress syndrome volume categories (53.6%, 54.1%, and 53.3% in low-, medium-, and high-volume categories ICUs, respectively). After adjustment for confounders, acute respiratory distress syndrome case volume was independently associated with ICU mortality (odds ratio for log-transformed volume: 0.77 [95% CI, 0.62-0.96]; p = 0.02).Conclusions: ICUs caring for higher volumes of acute respiratory distress syndrome cases were associated with lower ICU mortality. [ABSTRACT FROM AUTHOR]

Importance: The high mortality rate in critically ill elderly patients has led to questioning of the beneficial effect of intensive care unit (ICU) admission and to a variable ICU use among this population.Objective: To determine whether a recommendation for systematic ICU admission in critically ill elderly patients reduces 6-month mortality compared with usual practice.Design, Setting, and Participants: Multicenter, cluster-randomized clinical trial of 3037 critically ill patients aged 75 years or older, free of cancer, with preserved functional status (Index of Independence in Activities of Daily Living ≥4) and nutritional status (absence of cachexia) who arrived at the emergency department of one of 24 hospitals in France between January 2012 and April 2015 and were followed up until November 2015.Interventions: Centers were randomly assigned either to use a program to promote systematic ICU admission of patients (n=1519 participants) or to follow standard practice (n=1518 participants).Main Outcomes and Measures: The primary outcome was death at 6 months. Secondary outcomes included ICU admission rate, in-hospital death, functional status, and quality of life (12-Item Short Form Health Survey, ranging from 0 to 100, with higher score representing better self-reported health) at 6 months.Results: One patient withdrew consent, leaving 3036 patients included in the trial (median age, 85 [interquartile range, 81-89] years; 1361 [45%] men). Patients in the systematic strategy group had an increased risk of death at 6 months (45% vs 39%; relative risk [RR], 1.16; 95% CI, 1.07-1.26) despite an increased ICU admission rate (61% vs 34%; RR, 1.80; 95% CI, 1.66-1.95). After adjustments for baseline characteristics, patients in the systematic strategy group were more likely to be admitted to an ICU (RR, 1.68; 95% CI, 1.54-1.82) and had a higher risk of in-hospital death (RR, 1.18; 95% CI, 1.03-1.33) but had no significant increase in risk of death at 6 months (RR, 1.05; 95% CI, 0.96-1.14). Functional status and physical quality of life at 6 months were not significantly different between groups.Conclusions and Relevance: Among critically ill elderly patients in France, a program to promote systematic ICU admission increased ICU use but did not reduce 6-month mortality. Additional research is needed to understand the decision to admit elderly patients to the ICU.Trial Registration: clinicaltrials.gov Identifier: NCT01508819. [ABSTRACT FROM AUTHOR]

Purpose: To assess the prevalence of decisions to forgo life-sustaining treatment (DFLST), the patients characteristics, and to estimate the impact of DFLST stages on mortality.Methods: Observational study of a prospective database between 2005 and 2012 from 13 ICUs. DFLST were defined as follows: no escalation of treatment (stage 1), not to start or escalate treatment even if such treatment is considered in the future; withholding (stage 2), not to start or escalate necessary treatment; withdrawal (stage 3), to stop necessary treatment. The impact of daily DFLST stage on day-30 hospital mortality was tested with a discrete-time Cox's model and adjusted for admission severity and daily SOFA score.Results: Of 10,080 patients, 1290 (13%) made DFLST. The highest DFLST stage during the ICU stay was no escalation of treatment in 339 (26%) patients, withholding in 502 (39%) patients, and withdrawal in 449 (35%) patients. Older patients, patients with at least one chronic disease, and patients with greater ICU severity were significantly more numerous in the DFLST group. Day-30 mortality was 13% for non-DFLST patients, 35% for no escalation of treatment, 75% for withholding, 93% for withdrawal. After adjustment, an increase in day-30 mortality was associated with withholding and withdrawal (hazard ratio 95% CI 5.93 [4.95-7.12] and 20.05 [15.58-25.79], P < 0.0001), but not with no escalation of treatment (HR 1.14 [0.91-1.44], P = 0.25).Conclusions: DFLST were made in 13% of ICU patients. Withholding, withdrawal, older age, more comorbidities, and higher severity of illness were associated with higher mortality. No escalation of treatment was not associated with increased mortality. [ABSTRACT FROM AUTHOR]

Objectives: To investigate mortality of ICU patients over a 3-month period after an initial episode of septic shock and to identify factors associated with mortality. Design: Prospective multicenter observational cohort study. Setting: Fourteen ICUs from 10 French nonacademic and university teaching hospitals. Patients: All consecutive adult patients with septic shock admitted between October 2009 and September 2011 were eligible. Intervention: None. Measurements and Main Results: Multivariable analyses were performed using a Cox proportional hazard model and a flexible extension of the Cox model. In total, 1,495 of 10,941 patients (13.7%) had septic shock and 1,488 patients (99.5%) were included. Median age was 68 years (range, 58-78 yr). The majority of admissions (84%) were medical. Median (interquartile range) Simplified Acute Physiological Score II and Sequential Organ Failure Assessment were, respectively, 56 (45-70) and 11 (9-14). ICU and hospital mortality were, respectively, 39.4% and 48.6%. At 3 months, 776 patients (52.2%) had died. Factors significantly associated with increased risk of death in the multivariable Cox model were older age, male sex, comorbidities (immune deficiency, cirrhosis), Knaus C/D score, and high Sequential Organ Failure Assessment score. Flexible analyses indicated that the impact of Sequential Organ Failure Assessment score was greatest early after septic shock, while the onset of the effect of age, nosocomial infection, and cirrhosis was later. Conclusions: This is the most recent large-scale epidemiological study to investigate medium-term mortality in nonselected patients hospitalized in the ICU for septic shock. Advances in early management have improved survival at the initial phase, but risk of death persists in the medium term. Flexible modeling techniques yield insights into the profile of the risk of death in the first 3 months. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses the viability of decisions to admit elderly patients to intensive care units (ICUs), and it mentions the costs associated with ICU care, as well as the article "Effect of Systematic Intensive Care Unit Triage on Long-Term Mortality Among Critically Ill Elderly Patients in France: A Randomized Clinical Trial" by G. Guidet and others which appears in the same issue of the journal. ICU admission criteria and bed supply are examined.