Results: Of all ICU patients studied, 5.7% developed acute renal failure after admission and 4.7% of patients received renal replacement therapy (most often continuous replacement). The most common contributing factor to the development of acute renal failure was septic shock (48%), followed by major surgery (34%) and cardiogenic shock (26%). Up to 19% of the cases of acute renal failure were estimated to be drug-related. The in-hospital mortality for critically ill patients with acute renal failure was 60%, which was substantially higher than the mortality estimated by other physiologic scoring systems (45% mortality according to SAPS II). Of those who survived to hospital discharge, only 14% required ongoing hemodialysis.
Discussion: This large, multinational, multicenter prospective observational study helps better define the prevalence and characteristic of acute renal failure that develops in critically ill patients. Overall, acute renal failure in the ICU setting is relatively uncommon, is most often caused by septic shock, and typically does require renal replacement therapy. There was a surprisingly high rate of acute renal failure thought to be secondary to medication or drug effect (19%).
The mortality in patients who develop renal failure in the ICU is high but, surprisingly, if patients survive, they are unlikely to need long-term hemodialysis. The study is limited in that it was not randomized and outcomes associated with particular interventions could not be determined. Yet, the data adds to our understanding of acute renal failure in the ICU and knowledge of the prevalence and expected outcomes could potentially help with prognosis and end-of-life discussions in the intensive care unit.
Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143:121.
Background: Adequate communication between hospitalists and outpatient providers is essential to patient safety as well as patient and physician satisfaction. It is estimated that more than half of all preventable adverse events occurring soon after hospital discharge have been related to poor communication among providers. With increasing pressure to limit inpatient length of stay, patients are often discharged with numerous laboratory or radiologic test results pending.
Methods: Roy and colleagues at a tertiary care academic medical center prospectively determined the prevalence and characteristics of tests pending at discharge and assessed physician awareness as well as satisfaction. All patients discharged from two hospitalist services over four months in 2004 were followed. Researchers identified all pending test results for these patients and all abnormal tests were reviewed by study physicians and judged to be “potentially actionable” or not (if it could change the management of the patient by requiring a new treatment or diagnostic test, change in a treatment, scheduling of an earlier follow-up, etc).
Results: Of the 2,644 patients discharged, 1,095 (41%) had laboratory or radiographic tests pending. Approximately 43% of all pending tests were abnormal and ~10% of the pending tests were judged by physician-reviewers to be potentially actionable. Examples include a TSH that returned as <0.01 mU/mL after discharge in a patient with new atrial fibrillation, or a urine culture that grew an organism resistant to the antibiotics given at discharge. Of note, outpatient physicians were unaware of two-thirds of the “potentially actionable” results. Finally, when surveyed, the majority of inpatient physicians were concerned about appropriate follow-up of tests and dissatisfied with the system used.