Should STEMI patients recover in ICU?

A visit to an intensive care unit can be twice as expensive as a stay in a non-ICU hospital room, but a new study reveals that intensive care is still the right option for some vulnerable patients after a serious heart attack.

The challenge is to determine which people are best served in the ICU during their convalescence.

The new Michigan Medicine research (University of Michigan), published in The bmj, found that ICU admission was badociated with an improvement in the 30-day mortality rate in patients with STEMI heart attacks who were not clearly indicated for an intensive care unit or a unit that did not have ICU. use of an intensive care unit.

"For those patients who could reasonably be treated in one or the other place, admission to ICU was beneficial," said lead author, Thomas Valley, MD, M. Sc., An badistant professor of internal medicine at Michigan Medicine, who cares for intensive resuscitation patients. care unit.

But Valley warns against simply continuing to send almost everyone to the USI.

"Intensive care is a treatment like any drug," explains Valley. "Providers need to know if it suits a person, as we try to do with a prescription drug."

The researchers badyzed Medicare data from more than 100,000 hospitalized patients with STEMI, or ST-elevation myocardial infarction, a dangerous heart attack that requires rapid opening of the blocked blood vessel to restore blood flow. These patients were hospitalized in 1,727 acute care hospitals in the United States for almost two years, from January 2014 to October 2015, and most were sent to the ICU after treatment.

"A big part of the goal is to get these people to the cardiac catheterization lab as soon as possible to open the blood vessel, but less is known about what you do after that," said Valley.

Current US guidelines do not indicate whether patients should be referred to the USI, while European guidelines recommend the USI.

According to Valley, providers could use clearer guidelines on how to make these decisions.

In this study, the death rate was 6.1% lower after 30 days for those admitted to the USI of their hospital. According to Valley, the surprising results – contrary to other studies showing excessive use of intensive care units – show that intensive care unit care is poorly managed.

"An important debate in cardiology"

This study addresses an important problem in the field of critical care, says Michael Thomas, MD, an badistant professor of internal medicine, who heads the cardiac intensive care unit of the Michigan Medicine Center of Cardiovascular Medicine.

"At Michigan Medicine, all of our STEMI patients are admitted to the cardiac intensive care unit," says Thomas, who was not involved in the BMJ paper. "However, knowing where to send these patients after STEMI is an important debate in cardiology right now."

"Some recent studies suggest that many patients do not need the level of care of the ICU and that it wastes resources, but before we withdraw from this model, we need to better understand this problem," he says. did he declare.

Across the country, 75% of STEMI heart attack patients are sent to the intensive care unit, most of the time after reperfusion treatment in the catheterization lab to open the stuck vessel.

ICU care and non-ICU care

Among the very sick patients, the ICUs were originally designed for recovering patients who are recovering from STEMI, so providers may not even think about upsetting the status quo at long term, explains Valley.

"The historical thought was:" Why not send everyone to the UTI? "We now see that risks are badociated," said Valley. "For example, at the USI, you are more likely to have a procedure, whether you need it more or more.

"We must also take into account the risk of infection, sending a person to a unit filled with really sick patients who may be infected with C. diff or other serious infections. . "

The quality of sleep while people recover from their heart attack may also be worse in the intensive care unit because patients receive nursing care so closely, said Valley.

This is necessary for the sickest patients, but it could disturb people on the bubble who could be getting better and better off on a regular floor, he says.

Medicare has requirements for what constitutes ICU care, such as high levels of nurses and access to life-saving care.

"Because of Medicare's requirements, ICUs tend to be more similar in hospitals than non-ICUs," said Valley.

"Some hospitals may be able to take care of patients anywhere, while others really need to use the ICU at a high rate in order to provide secure care. "

An obvious advantage for some, an increased cost for others

According to Valley, these data show a clear benefit of ICU care for vulnerable patients, as opposed to non-STEMI patients studied who did not show a significant difference in mortality rates with or without ICU admission.

"Doctors could look at patients with STEMI and ask themselves," Do they really need the intensive care unit? Could it hurt them? Does it mean a good use of resources? "Explains Valley.

Mr. Valley, a member of UM's Institute for Health Policy and Innovation, has already found that less critical patients hospitalized for a chronic obstructive pulmonary disease (COPD) outbreak or heart failure had been overexploited in the intensive care unit. In this study, ICU admission resulted in a significant increase in the cost of care, without increasing survival benefits.

The next step, according to Valley, is to determine what is good for the ICU for the patients who benefit. He says this could lead hospitals to adopt some critical care practices on non-ICU floors.

Valley hopes that making non-USI soils more similar to the USI could, in some ways, improve outcomes while reducing the cost of care and the risk of infection.

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