title: Late admission to the ICU in patients with community-acquired pneumonia is associated with higher mortality.
abstract: BACKGROUND
  Limited data are available on the impact of time to ICU admission and outcomes for patients with severe community acquired pneumonia (CAP). Our objective was to examine the association of time to ICU admission and 30-day mortality in patients with severe CAP.
  
  
  METHODS
  A retrospective cohort study of 161 ICU subjects with CAP (by International Classification of Diseases, 9th edition, codes) was conducted over a 3-year period at two tertiary teaching hospitals. Timing of the ICU admission was dichotomized into early ICU admission (EICUA, direct admission or within 24 h) and late ICU admission (LICUA, >or= day 2). A multivariable analysis using Cox proportional hazard model was created with the primary outcome of 30-day mortality (dependent measure) and the American Thoracic Society (ATS) severity adjustment criteria and time to ICU admission as the independent measures.
  
  
  RESULTS
  Eighty-eight percent (n = 142) were EICUA patients compared with 12% (n = 19) LICUA patients. Groups were similar with respect to age, gender, comorbidities, clinical parameters, CAP-related process of care measures, and need for mechanical ventilation. LICUA patients had lower rates of ATS severity criteria at presentation (26.3% vs 53.5%; P = .03). LICUA patients (47.4%) had a higher 30-day mortality compared with EICUA (23.2%) patients (P = .02), which remained after adjusting in the multivariable analysis (hazard ratio 2.6; 95% CI, 1.2-5.5; P = .02).
  
  
  CONCLUSIONS
  Patients with severe CAP with a late ICU admission have increased 30-day mortality after adjustment for illness severity. Further research should evaluate the risk factors associated and their impact on clinical outcomes in patients admitted late to the ICU.
authors.affiliation: Veterans Evidence Based Research Dissemination and Implementation Center, South Texas Veterans Health Care System, San Antonio, TX 78229, USA. restrepom@uthscsa.edu
authors.forename: Marcos I
authors.initials: MI
authors.lastname: Restrepo
authors.forename: Eric M
authors.initials: EM
authors.lastname: Mortensen
authors.forename: Jordi
authors.initials: J
authors.lastname: Rello
authors.forename: Jennifer
authors.initials: J
authors.lastname: Brody
authors.forename: Antonio
authors.initials: A
authors.lastname: Anzueto
mesh_terms: D017714:Community-Acquired Infections / Q000401:mortality* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000639:trends*; D018410:Pneumonia, Bacterial / Q000401:mortality* / Q000628:therapy; D011023:Pneumonia, Staphylococcal / Q000401:mortality* / Q000628:therapy; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013290:Streptococcal Infections / Q000401:mortality* / Q000628:therapy; D015996:Survival Rate / Q000639:trends; D013781:Texas / Q000453:epidemiology; D013997:Time Factors