November 27, 2019

A cohort study

NSA an independent risk factor for ICU and hospital mortality


ICUs face frequent resource strains, in which admissions of two or more patients are expected in a very short period of time, the so-called Near-Simultaneous Admissions (NSA). Under these circumstances, caregivers have to perform a great number of tasks, almost simultaneously, leading to increased clinical, technical and communication demands. Although other studies have already examined the impact of high-strain leading to an increase in errors/complications and other negative patient outcomes, literature about the effects of NSA remains sparse.

Dr Kashiouris and his team (2019) conducted a retrospective, single-centre, cohort study on a tertiary academic medical ICU of 24 beds. They analysed the time of admission and outcomes for five years of 13,234 consecutive admitted patients. They also determined an Elapsed Time since the Last ICU Admission (ETLA) fracture point to evaluate the mismatch between the demand of ICU admission and the ability to “accommodate patients in greater numbers and rising acuity”.

A quarter of the cohort had an ETLA of less than 55 minutes. The research team considered that beyond this time, clinically relevant delays might negatively impact patient outcomes. The results showed that NSA was an independent risk factor for mortality and adverse patient outcomes: the shorter the interval between two admissions, the higher the risk of ICU death [1.16 – 95% CI, 1.04-1.44, p=0.01), independent of the overnight admission status and the admission source (p=0.37). Moreover, they found a dose-effect, as for surviving NSA patients, the longer the time between the last admission within the 55-min NSA timeframe, the higher the chances of a home discharge.



This study highlights that NSA are an independent risk factor for ICU and hospital mortality. The authors stress the importance of analysing structural elements – for example, night-time shift admissions on each unit – in order for ICUs to adapt to an increasing number of patients with rising acuity.

The main limitations concern the retrospective, observational methodology, and the single-centre nature of the study, which impact the level of evidence and limit its external validity.



Near-Simultaneous Admissions often occur in the ICU and are directly associated with adverse patient outcomes.  These situations increase the strain and time-pressure on teams, and new, specific paths of team management should be explored to improve patient outcomes.


This article review was prepared and submitted by Silvia Calvino Günther, on behalf of the N&AHP section.




1) Markos G. Kashiouris, Curtis N. Sessler, Rehan Qayyum, Venu Velagapudi, Christos Stefanou, Rahul Kashyap, Niall Crowley, Craig Daniels and Kianoush Kashani. Near-simultaneous intensive care unit (ICU) admissions and all-cause mortality: a cohort study. Intensive Care Med (2019) 45: 1559-1569.

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