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Evaluating the Characteristics and Outcome Differences Between Patients Admitted to the Surgical ICU versus the Step-Down Unit
Gabriel Ryb, Sarah Bunker
*Department of Surgery, Baystate Medical Center, Ludlow, MA
Background: Given the limited availability of surgical intensive care unit (SICU) beds, patients admitted to SICU are those requiring mechanical ventilation, vasopressors, and continuous /frequent monitoring. Hence, a considerable proportion of our trauma patients with high burden of injury or significant comorbidities are admitted to a step-down unit (SDU). The aim of this review is to describe SDU patients and compare their characteristics and outcomes to those admitted to the SICU or acute care ward (AW).
Study Design: Retrospective analysis of registry data of injured patients (age ?21) admitted to level one trauma center between 1/1/2020-12/31/2023. Patients’ characteristics, injury type/severity, complications, and outcome measures were analyzed by disposition. We used univariate (averages, medians and proportions) and multivariate [multiple logistic regression (MLR)] analyses. A p value of <0.05 used for statistical significance.
Results: 5,525 cases identified: 9.74% (n=538) SICU, 16.7% (n=925) SDU, 73.5% (n=4062) AW. SDU were older (mean 65.1y) than those admitted to AW or SICU (62.6y and 57.9y). No difference between SDU and AW or SICU patients on prevalence of CHF, Cirrhosis, COPD, MI, Renal failure, and PAD, but higher prevalence of CVA (3.6%), dementia (9.41%), DM (18.27%), HTN (43.57%), and anticoagulation (19.35%). SDU experienced higher prevalence of Alcoholism (11.14%) than AW and higher prevalence of smoking (14.7%) but lower prevalence of drug use (7.24%) than SICU. Mean ISS and maximum abbreviated injury severity 3+ (MAIS3+) of the head/neck was higher for the SICU (ISS 20.9, MAIS3+ 58.2%) than SDU (ISS 13.7, MAIS3+ 29.6%) and AW (ISS 9.0, MAIS3+ 14.2%), but Chest MAIS3+ prevalence was higher for SDU (37.62%) than SICU (26.95%) and AW (19.01%). Abdominal MAIS3+ injuries were similar in SDU (7.03%) and SICU (8.92%) but higher than in the AW (2.09%). SDU had shorter length of stay, ICU and ventilator days (7.8d, 0.54d, 0.35d) than SICU (12.5d, 5.7d, 4.4d) but longer than AW (5.4d, 0.1d, 0d). Mortality was 1.63%, 3.57%, and 29.74% for AW, SDU, and SICU groups respectively. MLR for prediction of death, adjusting for age, comorbidities and injury variables, SDU had a significantly decreased adjusted risk of death (OR 0.091) compared to SICU. SDU adjusted risk of death (OR 1.73) was not statistically significance when compared with AW. SDU had higher unplanned ICU admissions than SICU and AW (7.46%, 3.90%, 1.87%, respectively), but mortality of SDU cases with unplanned ICU admissions (24.64%) was similar than those admitted directly to SICU (29.74%).
Conclusion: The SDU is an appropriate setting for the management of patients with high burden of injury and comorbidity not requiring SICU care. A greater proportion of SDU patients have advanced age, severe chest injuries, brain injuries, and certain comorbidities. Given the elevated burden of injury and comorbidities, the mortality of patients in this setting is acceptable.
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