Impact of critical care outreach in blood and marrow transplantation

Introduction

Hematopoietic stem cell transplantation (HSCT) is the standard treatment for various hematological disorders. While offering the potential for cure, it continues to be associated with significant morbidity and mortality, with 10 to 40% of recipients requiring admission to the ICU. Critical Care Outreach (CCO) is a service designed to provide timely access to ICU-level care and earlier stabilization of critically ill patients. The objective of our study was to compare outcomes of adult HSCT recipients before and after the initiation of a CCO team.

Methods

Adults undergoing HSCT at The Ottawa Hospital were divided into the pre-CCO cohort (January 2000 to December 2004, n = 520) and the post-CCO cohort (January 2005 to December 2007, n = 309). The primary outcome was nonrelapse mortality at day 100 post-transplant (NRM-100). Secondary outcomes were incidence of ICU admission, duration of ICU admission, incidence of mechanical ventilation (MV), duration of MV, APACHE II score and number of failing organs at time of ICU admission, and NRM-100 for patients admitted to the ICU.

Results

Following the introduction of CCO, there was a trend towards reduced NRM-100 (10.2% vs. 8.4%, P = 0.46) and reduced incidence of ICU admission (13.6% vs. 12.3%, P = 0.65) for all HSCT patients. For those admitted to the ICU, there were no significant differences pre-CCO and post-CCO in the proportion of patients requiring MV (70.3% vs. 78.6%, P = 0.47), duration of MV (8.9 vs. 8.5 days, P = 0.87), length of ICU admission (12.6 vs. 17.4 days, P = 0.25), APACHE II score (23.8 vs. 23.5, P = 0.78), and NRM-100 (48% vs. 50%, P = NS). The number of failed organs upon admission to the ICU, however, was significantly reduced (2.31 vs. 1.85, P = 0.039). Patients undergoing allogeneic transplants post-CCO had a nonsignificant reduction in NRM-100 (22.5% vs. 18.0%, P = 0.25), and for those admitted to the ICU we detected a trend towards reduced duration of MV (10.4 vs. 6.0 days, P = 0.11) and improved NRM-100 (71.4% vs. 53.8%, P = 0.19).

Conclusion

CCO in a tertiary care HSCT program is associated with a trend towards reduced nonrelapse mortality and ICU admission. Patients transferred to the ICU in the post-CCO era had fewer failed organ systems at the time of ICU admission. Those patients at highest risk of treatment-related complications appeared to experience greater overall benefit from the CCO intervention. Our experience suggests that CCO be considered an important service for HSCT transplant centres.