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Objective: Mortality after many procedures is lower in centers where more procedures are done. It is controversial whether this is true for intensive care units, too. We examined the relationship between the volume of activity of intensive care units (ICUs) and mortality by a measure of risk-adjusted volume of activity specific for ICUs., Design: Prospective, multicenter, observational study., Setting: Eighty-nine ICUs in 12 European countries., Patients: During a 4-month study period, 12,615 patients were enrolled., Interventions: Demographic and clinical statistics, severity at admission and a score of nursing complexity and workload were collected., Results: Total volume of activity was defined as the number of patients admitted per bed per year, high-risk volume as the number of high-risk patients admitted per bed per year (selected combining of length of stay and severity of illness). A multi-step risk-adjustment process was planned. ICU volume corresponding both to overall [odds ratio (OR) 0.966] and 3,838 high-risk (OR 0.830) patients was negatively correlated with mortality. Relative mortality decreased by 3.4 and 17.0% for every five extra patients treated per bed per year in overall volume and high-risk volume, respectively. A direct relationship was found between mortality and the ICU occupancy rate (OR 1.324 and 1.351, respectively)., Conclusions: Intensive care patients, whatever their level of risk, are best treated where more high-risk patients are treated. Moreover, the higher the ICU occupancy rate, the higher is the mortality.

Objective: To identify objective trends of the course of illness that might be used as benchmarks in the auditing of the organization/performance of Intensive Care Units (ICU)., Design: Retrospective analysis., Patients and Setting: A group of 12,615 patients and 55,464 patient-days prospectively collected in 89 ICUs of 12 European countries., Methods: The complexity of daily care in the ICU was classified as high (HT) or low (LT), according to six activities registered in NEMS,a daily therapeutic index for ICUs., Results: Six trends of clinical course were identified: LT during the whole ICU stay (5,424 patients, mortality 1.8%); HT (3,480 patients, mortality 30.4%); HT followed by LT (2,781 patients, mortality 2.8%); LT followed by HT (197 patients, mortality 39.1%); finally, LT/HT/LT in 298 patients (mortality 10.5%); and HT/LT/HT (mortality 20.1%) in 438 patients. A group of 930 patients had the complexity of treatment increased (mortality 21.1%) and 3,711 patients received both treatments. Low-care before high-care periods had a mean duration of 2.2 +/- 3.5 days, low-care after high-care 2.7 +/- 3.1 days, and between two high-care periods 2.1 +/- 2.2 days. A group of 1,538 'surgical scheduled' patients only received LT, whereas 2,231 received HT (whether or not exclusively). Overall ICU mortality rate was low (3%) and the length of stay short, regardless of diagnosis and complexity of care received., Conclusions: The use of therapeutic indexes help to classify the daily complexity of ICU care. The classification can be used as an indicator of clinical performance and resource utilization.