INTRODUCTION: The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU. METHODS: An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days). RESULTS: One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002). CONCLUSIONS: The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment. TRIAL REGISTRATION: Clinicaltrials.gov NCT01422070. Registered 19 August 2011.

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Latour J, Lopez-Camps V, Rodriguez-Serra M, Giner JS, Nalasco A, Alvarez-Dardet C. Predictors of death following ICU discharge. Intensive Care Med. 1990;16:125–127. doi: 10.1007/BF02575307. PubMed DOI

Rowan KM, Kerr JH, Major E, McPherson K, Short A, Vessey MP. Intensive Care Society’s APACHE II study in Britain and Ireland–II: Outcome comparisons of intensive care units after adjustment for case mix by the American APACHE II method. BMJ. 1993;307:977–981. doi: 10.1136/bmj.307.6910.977. PubMed DOI PMC

Munn J, Willatts SM, Tooley MA. Health and activity after intensive care. Anaesthesia. 1995;50:1017–1021. doi: 10.1111/j.1365-2044.1995.tb05942.x. PubMed DOI

Goldhill DR, Sumner A. Outcome of intensive care patients in a group of British intensive care units. Crit Care Med. 1998;26:1337–1345. doi: 10.1097/00003246-199808000-00017. PubMed DOI

Azoulay E, Alberti C, Legendre I, Brun Buisson C, Le Gall J-R, for the European Sepsis Group Post-ICU mortality in critically ill infected patients: an international study. Intensive Care Med. 2005;31:56–63. doi: 10.1007/s00134-004-2532-x. PubMed DOI

Metnitz PG, Moreno RP, Almeida E, Jordan B, Bauer P, Abizanda Campos R, Iapichino G, Edbrooke D, Capuzzo M, Le Gall J-R, on behalf of the SAPS 3 Investigators SAPS 3-From evaluation of the patient to evaluation of the intensive care unit. Part 1: objectives, methods and cohort description. Intensive Care Med. 2005;31:1336–1344. doi: 10.1007/s00134-005-2762-6. PubMed DOI PMC

Poole D, Rossi C, Latronico N, Rossi G, Finazzi S, Bertolini G, GiViTI Comparison between SAPS II and SAPS 3 in predicting hospital mortality in a cohort of 103 Italian ICUs. Is new always better? Intensive Care Med. 2012;38:1280–1288. doi: 10.1007/s00134-012-2578-0. PubMed DOI

Moreno R, Miranda DR, Matos R, Fevereiro T. Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge. Intensive Care Med. 2001;27:999–1004. doi: 10.1007/s001340100966. PubMed DOI

Goldfrad C, Rowan K. Consequences of discharges from intensive care at night. Lancet. 2000;355:1138–1142. doi: 10.1016/S0140-6736(00)02062-6. PubMed DOI

Bone RC, McElwee NE, Eubanks DH, Gluck EH. Analysis of indications for early discharge from the intensive care unit. Clinical efficacy assessment project: American College of Physicians. Chest. 1993;104:1812–1817. doi: 10.1378/chest.104.6.1812. PubMed DOI

Zimmerman JE, Wagner DP, Knaus WA, Williams JF, Kolakowski D, Draper EA. The use of risk predictions to identify candidates for intermediate care units. Implications for intensive care utilization and cost. Chest. 1995;108:490–499. doi: 10.1378/chest.108.2.490. PubMed DOI

Ryan DW, Bayly PJ, Weldon OG, Jingree M. A prospective two-month audit of the lack of provision of a high-dependency unit and its impact on intensive care. Anaesthesia. 1997;52:265–270. doi: 10.1111/j.1365-2044.1997.068-az0055.x. PubMed DOI

Weissman C. Analyzing the impact of long-term patients on ICU bed utilization. Intensive Care Med. 2000;26:1319–1325. doi: 10.1007/s001340000612. PubMed DOI

Durbin CG, Kopel RF. A case–control study of patients readmitted to the intensive care unit. Crit Care Med. 1993;21:1547–1553. doi: 10.1097/00003246-199310000-00025. PubMed DOI

Chen LM, Martin CM, Keenan SP, Sibbald WJ. Patients readmitted to the intensive care unit during the same hospitalization: clinical features and outcomes. Crit Care Med. 1998;26:1834–1841. doi: 10.1097/00003246-199811000-00025. PubMed DOI

Rosenberg AL, Watts C. Patients readmitted to ICUs*: a systematic review of risk factors and outcomes. Chest. 2000;118:492–502. doi: 10.1378/chest.118.2.492. PubMed DOI

Coggins R, de Cossart L. Improving postoperative care: the role of the surgeon in the high dependency unit. Ann R Coll Surg Engl. 1996;78:163–167. PubMed PMC

Vincent JL, Burchardi H. Do we need intermediate care units? Intensive Care Med. 1999;25:1345–1349. doi: 10.1007/s001340051077. PubMed DOI

Iapichino G, Morabito A, Mistraletti G, Ferla L, Radrizzani D, Miranda DR. Determinants of post-intensive care mortality in high-level treated critically ill patients. Intensive Care Med. 2003;29:1751–1756. doi: 10.1007/s00134-003-1915-8. PubMed DOI

Beck DH, McQuillan P, Smith GB. Waiting for the break of dawn? The effects of discharge time, discharge TISS scores and discharge facility on hospital mortality after intensive care. Intensive Care Med. 2002;28:1287–1293. doi: 10.1007/s00134-002-1412-5. PubMed DOI

Hutchings A, Durand MA, Grieve R, Harrison D, Rowan K, Green J, Cairns J, Black N: Evaluation of modernisation of adult critical care services in England: time series and cost effectiveness analysis.BMJ 2009, 339:b4353. PubMed PMC

Junker C, Zimmerman JE, Alzola C, Draper EA, Wagner DP. A multicenter description of intermediate-care patients: comparison with ICU low-risk monitor patients. Chest. 2002;121:1253–1261. doi: 10.1378/chest.121.4.1253. PubMed DOI

Peelen L, de Keizer NF, Peek N, Scheffer GJ, van der Voort PHJ, de Jonge E: The influence of volume and intensive care unit organization on hospital mortality in patients admitted with severe sepsis: a retrospective multicentre cohort study.Crit Care 2007, 11:R40. PubMed PMC

Solberg BCJ, Dirksen CD, Nieman FHM, van Merode G, Poeze M, Ramsay G: Changes in hospital costs after introducing an intermediate care unit: a comparative observational study.Crit Care 2008, 12:R68. PubMed PMC

Keegan MT, Brown DR, Thieke MP, Afessa B. Changes in intensive care unit performance measures associated with opening a dedicated thoracic surgical progressive care unit. J Cardiothorac Vasc Anesth. 2008;22:347–353. doi: 10.1053/j.jvca.2007.12.015. PubMed DOI

Smith L, Orts CM, O’Neil I, Batchelor AM, Gascoigne AD, Baudouin SV. TISS and mortality after discharge from intensive care. Intensive Care Med. 1999;25:1061–1065. doi: 10.1007/s001340051012. PubMed DOI

European Mortality and Length Of ICU Stay (ELOISE) [http://eloise.esicm.org]

Valentin A, Ferdinande P, and the ESICM Working Group on Quality Improvement Recommendations on basic requirements for intensive care units: structural and organizational aspects. Intensive Care Med. 2011;37:1575–1587. doi: 10.1007/s00134-011-2300-7. PubMed DOI

Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–2963. doi: 10.1001/jama.1993.03510240069035. PubMed DOI

Moreno RP, Metnitz PG, Almeida E, Jordan B, Bauer P, Abizanda Campos R, Iapichino G, Edbrooke D, Capuzzo M, Le Gall J-R, on behalf of the SAPS 3 Investigators SAPS 3-from evaluation of the patient to evaluation of the intensive care unit. Part 2: development of a prognostic model for hospital mortality at ICU admission. Intensive Care Med. 2005;31:1345–1355. doi: 10.1007/s00134-005-2763-5. PubMed DOI PMC

Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707–710. doi: 10.1007/BF01709751. PubMed DOI

Reis Miranda D, Moreno RP, Iapichino G. Nine equivalents of nursing manpower use score (NEMS) Intensive Care Med. 1997;23:760–765. doi: 10.1007/s001340050406. PubMed DOI

Ruttimann UE, Pollack MM. Variability in duration of stay in pediatric intensive care units: a multiinstitutional study. J Pediatr. 1996;128:35–44. doi: 10.1016/S0022-3476(96)70425-0. PubMed DOI

Localio AR, Berlin JA, Ten Have TR, Kimmel SE. Adjustments for center in multicenter studies: an overview. Ann Intern Med. 2001;135:112–123. doi: 10.7326/0003-4819-135-2-200107170-00012. PubMed DOI

Iapichino G, Radrizzani D, Rossi C, Pezzi A, Anghileri A, Boffelli S, Giardino M, Mistraletti G, Bertolini G, GiViTI Group Proposal of a flexible structural-organizing model for the Intensive Care Units. Minerva Anestesiol. 2007;73:501–506. PubMed

Deeks JJ, Dinnes J, D’Amico R, Sowden AJ, Sakarovitch C, Song F, Petticrew M, Altman DG, International Stroke Trial Collaborative Group; European Carotid Surgery Trial Collaborative Group: Evaluating non-randomised intervention studies.Health Technol Assess 2003, 7:iii-x. 1–173. PubMed

Iapichino G, Gattinoni L, Radrizzani D, Simini B, Bertolini G, Ferla L, Mistraletti G, Porta F, Miranda DR. Volume of activity and occupancy rate in intensive care units. Association with mortality. Intensive Care Med. 2004;30:290–297. doi: 10.1007/s00134-003-2113-4. PubMed DOI

Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364:2128–2137. doi: 10.1056/NEJMsa1010705. PubMed DOI PMC

Zuber B, Tran TC, Aegerter P, Grimaldi D, Charpentier J, Guidet B, Mira JP, Pène F, CUB-Réa Network Impact of case volume on survival of septic shock in patients with malignancies. Crit Care Med. 2012;40:55–62. doi: 10.1097/CCM.0b013e31822d74ba. PubMed DOI

Kanhere MH, Kanhere HA, Cameron A, Maddern GJ. Does patient volume affect clinical outcomes in adult intensive care units? Intensive Care Med. 2012;38:741–751. doi: 10.1007/s00134-012-2519-y. PubMed DOI

Kahn JM. What’s new in ICU volume-outcome relationships? Intensive Care Med. 2013;39:1635–1637. doi: 10.1007/s00134-013-2992-y. PubMed DOI

Fernández R, Altaba S, Cabre L, Lacueva V, Santos A, Solsona JF, Añon JM, Catalan RM, Gutierrez MJ, Fernandez-Cid R, Gomez-Tello V, Curiel E, Fernandez-Mondejar E, Oliva JC, on behalf of the Sabadell Score Group Relationship between volume and survival in closed intensive care units is weak and apparent only in mechanically ventilated patients. Anesthesiology. 2013;119:871–879. doi: 10.1097/ALN.0b013e31829c3029. PubMed DOI

Rhodes A, Ferdinande P, Flaatten H, Guidet B, Metnitz PG, Moreno RP. The variability of critical care bed numbers in Europe. Intensive Care Med. 2012;38:1647–1653. doi: 10.1007/s00134-012-2627-8. PubMed DOI

Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes A, European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380:1059–1065. doi: 10.1016/S0140-6736(12)61148-9. PubMed DOI PMC

Pupelis G, Vanags I: Mortality after surgery in Europe.Lancet 2013, 381:369. PubMed

Mikstacki A: Mortality after surgery in Europe.Lancet 2013, 381:369. PubMed

Franek E, Osisnska B, CzeCh M, Figat J. Mortality after surgery in Europe. Lancet. 2013;381:369–370. doi: 10.1016/S0140-6736(13)60161-0. PubMed DOI

Doherty S, Conroy RM, Dunne H, on behalf of the ISOS group: Mortality after surgery in Europe.Lancet 2013, 382:2063. PubMed

Van Schalkwyk JM, Campbell D: Mortality after surgery in Europe.Lancet 2013, 381:370. PubMed

Brodner G, Van Achen H: Mortality after surgery in Europe.Lancet 2013, 381:370. PubMed

Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, Vallet B, Vincent JL, Hoeft A, Rhodes A. Mortality after surgery in Europe. Authors’ reply. Lancet. 2013;381:370–371. doi: 10.1016/S0140-6736(13)60164-6. PubMed DOI

Ranzani OT, Zampieri FG, Taniguchi LU, Forte DN, Azevedo LC, Park M. The effects of discharge to an intermediate care unit after a critical illness: a 5-year cohort study. J Crit Care. 2014;29:230–235. doi: 10.1016/j.jcrc.2013.10.013. PubMed DOI

Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet. 2000;356:185–189. doi: 10.1016/S0140-6736(00)02478-8. PubMed DOI

West E, Barron DN, Harrison D, Rafferty AM, Rowan C, Sanderson C. Nurse staffing, medical staffing and mortality in intensive care: an observational study. Int J Nurs Stud. 2014;51:781–794. doi: 10.1016/j.ijnurstu.2014.02.007. PubMed DOI

Wheelan SA, Burchill CN, Tilin F. The link between teamwork and patients’ outcomes in intensive care units. Am J Crit Care. 2003;12:527–534. PubMed

Guery B, Guidet B, Beloucif S, Floret D, Le Gall C, Montravers P, Chouaid C, Jarreau PH, Régnier B. The organisation of intensive care in a situation of pandemic avian influenza. Rev Mal Respir. 2008;25:223–235. doi: 10.1016/S0761-8425(08)71519-5. PubMed DOI

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