Role of critical care outreach to provide the intention to treat of hematological disorders: a pilot study

Introduction

Hematological malignancy patients admitted to the ICU due to complications are at high risk of death. In the second half of 2008 we started Critical Care Outreach (CCO) activity. The purpose of this team was to start intensive care early as possible for avoiding mechanical ventilation and multiorgan failure for improving intensive treatment outcome.

Methods

One hundred and twenty-six hematological patients from 2003 to November 2009 were included in the study. We divided patients into three groups: (1) pre-CCO group: 56 patients from 2003 to 31 December 2007; (2) transition group (2008): 22 patients admitted to the ICU and three treated in the hematology ward; (3) post-CCO group (January to November 2009): 18 patients admitted to the ICU and 27 patients treated in the haematology ward. In the post-CCO group 10 of the 27 patients were admitted to the ICU and 17 of these were treated in hematology ward, and nine of these received NIV (Figure 1). We defined six criteria for activation of the CCO team: radiological signs of pneumonia, organ failure, positive microbiological test, need for increase in oxygen therapy, SIRS progression, and Modified Early Warning Score (MEWS) >3 [1]. Primary outcome is the ability of the CCO to provide the intention to treat hematological malignancies.

Figure 1

Results

After CCO introduction, intention to treat was guaranteed at 90% in 2008 and at 41% in 2009. Comparing the number of criteria of activation, during 2008 and 2009 intensivists were activated earlier, with a lower number of criteria. The ICU mortality rate passed from 60% in 2003 to 54.5% in 2008 and 33.3% in 2009. Also the need for mechanical ventilation decreased after CCO introduction.

Conclusions

The introduction of CCO and activation criteria improves the intention to treat and reduces ICU admissions and mortality.