Elderly patients undergoing mechanical ventilation in and out of intensive care units: a comparative, prospective study of 579 ventilations

INTRODUCTION: Many mechanically ventilated elderly patients in Israel are treated outside of intensive care units (ICUs). The decision as to whether these patients should be treated in ICUs is reached without clear guidelines. We therefore conducted a study with the aim of identifying triage criteria and factors associated with in-hospital mortality in this population. METHODS: All mechanically invasive ventilated elderly (65+) medical patients in the hospital were included in a prospective, non-interventional, observational study. RESULTS: Of the 579 ventilations, 283 (48.9%) were done in ICUs compared with 296 (51.1%) in non-ICU wards. The percentage of ICU ventilations in the 65 to 74, 75 to 84, and 85+ age groups was 62%, 45%, and 23%, respectively. The decision to ventilate in ICUs was significantly and independently influenced by age (Odds Ratio (OR) = 0.945, P < 0.001), and pre-hospitalization functional status by functional independence measure (FIM) scale (OR = 1.054, P < 0.001). In-hospital mortality was 53.0% in ICUs compared with 68.2% in non-ICU wards (P < 0.001), but the rate was not independently and significantly affected by hospitalization in ICUs. CONCLUSIONS: In Israel, most elderly patients are ventilated outside ICUs and the percentage of ICU ventilations decreases as age increases. In our study groups, the lower mortality among elderly patients ventilated in ICUs is related to patient characteristics and not to their treatment in ICUs per se. Although the milieu in which this study was conducted is uncommon today in the western world, its findings point to possible means of managing future situations in which the demand for mechanical ventilation of elderly patients exceeds the supply of intensive care beds. Moreover, the findings of this study can contribute to the search for ways to reduce costs without having a negative effect on outcome in ventilated elderly patients.