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Ahlberg CD, Wallam S, Tirba LA, Itumba SN, Gorman L, Galiatsatos P. Linking Sepsis with chronic arterial hypertension, diabetes mellitus, and socioeconomic factors in the United States: A scoping review. J Crit Care 2023; 77:154324. [PMID: 37159971 DOI: 10.1016/j.jcrc.2023.154324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/11/2023]
Abstract
RATIONALE Sepsis is a syndrome of life-threatening organ dysfunction caused by a dysregulated host immune response to infection. Social risk factors including location and poverty are associated with sepsis-related disparities. Understanding the social and biological phenotypes linked with the incidence of sepsis is warranted to identify the most at-risk populations. We aim to examine how factors in disadvantage influence health disparities related to sepsis. METHODS A scoping review was performed for English-language articles published in the United States from 1990 to 2022 on PubMed, Web of Science, and Scopus. Of the 2064 articles found, 139 met eligibility criteria and were included for review. RESULTS There is consistency across the literature of disproportionately higher rates of sepsis incidence, mortality, readmissions, and associated complications, in neighborhoods with socioeconomic disadvantage and significant poverty. Chronic arterial hypertension and diabetes mellitus also occur more frequently in the same geographic distribution as sepsis, suggesting a potential shared pathophysiology. CONCLUSIONS The distribution of chronic arterial hypertension, diabetes mellitus, social risk factors associated with socioeconomic disadvantage, and sepsis incidence, are clustered in specific geographical areas and linked by endothelial dysfunction. Such population factors can be utilized to create equitable interventions aimed at mitigating sepsis incidence and sepsis-related disparities.
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Affiliation(s)
- Caitlyn D Ahlberg
- Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Sara Wallam
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Lemya A Tirba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Stephanie N Itumba
- The Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
| | - Linda Gorman
- Harrison Medical Library, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, the Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Nielsen FE, Chafranska L, Sørensen R, Abdullah OB. Predictors of outcomes in emergency department patients with suspected infections and without fulfillment of the sepsis criteria. Am J Emerg Med 2023; 68:144-154. [PMID: 37018890 DOI: 10.1016/j.ajem.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Data on patient characteristics and determinants of serious outcomes for acutely admitted patients with infections who do not fulfill the sepsis criteria are sparse. The study aimed to characterize acutely admitted emergency department (ED) patients with infections and a composite outcome of in-hospital mortality or transfer to the intensive care unit without fulfilling the criteria for sepsis and to examine predictors of the composite outcome. METHODS This was a secondary analysis of data from a prospective observational study of patients with suspected bacterial infection admitted to the ED between October 1, 2017 and March 31, 2018. A National Early Warning Score 2 (NEWS2) ≥ 5 within the first 4 h in the ED was assumed to represent a sepsis-like condition with a high risk for the composite endpoint. Patients who achieved the composite outcome were grouped according to fulfillment of the NEWS2 ≥ 5 criteria. We used logistic regression analysis to estimate the unadjusted and adjusted odds ratio (OR) for the composite endpoint among patients with either NEWS2 < 5 (NEWS2-) or NEWS2 ≥ 5 (NEWS2+). RESULTS A total of 2055 patients with a median age of 73 years were included. Of these, 198 (9.6%) achieved the composite endpoint, including 59 (29.8%) NEWS2- and 139 (70.2%) NEWS2+ patients, respectively. Diabetes (OR 2.23;1.23-4.0), a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (OR 2.57;1.37-4.79), and a Do-not-attempt-cardiopulmonary-resuscitation order (DNACPR) on admission (OR 3.70;1.75-7.79) were independent predictive variables for the composite endpoint in NEWS2- patients (goodness-of-fit test P = 0.291; area under the receiver operating characteristic curve for the model (AUROC) = 0.72). The regression model for NEWS2+ patients revealed that a SOFA score ≥ 2 (OR 2.79; 1.59-4.91), hypothermia (OR 2.48;1.30-4.75), and DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test P = 0.62; AUROC for the model = 0.70). CONCLUSION Approximately one-third of the patients with infections and serious outcomes during hospitalization did not meet the NEWS2 threshold for likely sepsis. Our study identified factors with independent predictive values for the development of serious outcomes that should be tested in future prediction models.
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Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions in patients admitted through the emergency department in a Swedish University Hospital – An observational study of outcome, patient characteristics and changes in DNACPR decisions. Resusc Plus 2022; 9:100209. [PMID: 35169759 PMCID: PMC8829126 DOI: 10.1016/j.resplu.2022.100209] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 11/23/2022] Open
Abstract
Aims The aims were to examine patient and hospital characteristics associated with Do-Not-Attempt-Cardiopulmonary-Resuscitation (DNACPR) decisions for adult admissions through the emergency department (ED), for patients with DNACPR decisions to examine patient and hospital characteristics associated with hospital mortality, and to explore changes in CPR status. Methods This was a retrospective observational study of adult patients admitted through the ED at Karolinska University Hospital 1 January to 31 October 2015. Results The cohort included 25,646 ED admissions, frequency of DNACPR decisions was 11% during hospitalisation. Patients with DNACPR decisions were older, with an overall higher burden of chronic comorbidities, unstable triage scoring, hospital mortality and one-year mortality compared to those without. For patients with DNACPR decisions, 63% survived to discharge and one-year mortality was 77%. Age and comorbidities for patients with DNACPR decisions were similar regardless of hospital mortality, those who died showed signs of more severe acute illness on ED arrival. Change in CPR status during hospitalisation was 5% and upon subsequent admission 14%. For patients discharged with DNACPR decisions, reversal of DNACPR status upon subsequent admission was 32%, with uncertainty as to whether this reversal was active or a consequence of a lack of consideration. Conclusion For a mixed population of adults admitted through the ED, frequency of DNACPR decisions was 11%. Two-thirds of patients with DNACPR decisions were discharged, but one-year mortality was high. For patients discharged with DNACPR decisions, reversal of DNACPR status was substantial and this should merit further attention.
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Fan R, Yang S, Bu X, Chen Y, Wang Y, Shen B, Qiu C, Li X. Symptomatic Features and Factors Associated With Do-Not-Resuscitate Consent in Advanced Cancer Patients Admitted to Palliative Care Ward. Am J Hosp Palliat Care 2022; 39:1312-1324. [PMID: 35041534 DOI: 10.1177/10499091211068824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aimed to conduct a retrospective cross-sectional study to investigate the prevalence of symptoms and symptom clusters on sociodemographic and disease characteristics, as well as factors associated with Do-Not-Resuscitate (DNR) consent. Advanced cancer patients were enrolled between 2018 and 2020 with available data. Demographic and clinical data were obtained for analysis from Hospital Information System (HIS) in China. Symptom clusters were extracted by hierarchical cluster analysis. Chi-square test and multiple logistic regression were conducted to investigate the prevalence characteristics of symptoms and influencing factors of DNR consent, respectively. 798 advanced cancer patients were enrolled. The most prevalent symptoms were pain (93%), anorexia (36.5%), and sleep disorders (34.2%). High heart rate was associated with poor performance status and more symptoms. Three clusters were extracted: fatigue-related, respiratory-circulatory system, and digestive system symptom clusters. The incidence of symptoms was statistically significant in age, gender, education level, residence, BMI, performance status, distress score, ADL, and primary pain level. The DNR signature rate was 15.5%. Female, distant metastasis, in-ward rescue, and appearance of dyspnea were independent influencing factors of DNR signature.Chinese hospitalized cancer patients had more symptoms burden that were influenced by various demographic characteristics, especially pain and fatigue-related symptoms. Concerning the trajectory of vital signs is important among advanced cancer patients. The DNR signature rate was lower and our finding indicating an urgency to accurately assess the prognosis and give more palliative care education to enhance DNR rates and early signing in Chinese context.
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Affiliation(s)
- Rongrong Fan
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Siyu Yang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xiaofan Bu
- 12570Xiangya Nursing School of Central South University, Changsha, China
| | - Yongyi Chen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Ying Wang
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Boyong Shen
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Cuiling Qiu
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
| | - Xuying Li
- 117924Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya Nursing School of Central South University, Changsha, China
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Jiang T, Ma Y, Zheng J, Wang C, Cheng K, Li C, Xu F, Chen Y. Prevalence and related factors of do-not-resuscitate orders among in-hospital cardiac arrest patients. Heart Lung 2021; 51:9-13. [PMID: 34731700 DOI: 10.1016/j.hrtlng.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Studies concerning do-not-resuscitate (DNR) orders in mainland China are rather scarce. We explored the prevalence and related factors of DNR orders among in-hospital cardiac arrest (IHCA) patients at a general tertiary hospital in mainland China. MATERIALS AND METHODS We identified all IHCA patients hospital-wide between July 2019 and September 2020. Data regarding DNR status were collected from medical records. We investigated the frequency of DNR orders and explored the determinant factors of DNR establishment using logistic regression. RESULTS A total of 1154 IHCA patients were included, 535 (46.4%) of whom established DNR orders. The following variables were independently associated with a higher DNR rate: female (OR 1.491; 95% CI 1.130-1.965), older age (OR 1.016; 95% CI 1.008-1.024), being a local resident (OR 1.790; 95% CI 1.344-2.383), pulmonary infection (OR 1.398; 95% CI 1052-1.859), respiratory insufficiency (OR 1.356; 95% CI 1.009-1.823), shock (OR 1.735; 95% CI 1.301-2.313), acute stroke (OR 1.821; 95% CI 1.235-2.686),neurological dysfunction (OR 1.527; 95% CI 1.149-2.028) and cancer (OR 3.316; 95% CI 2.461-4.468). Counterintuitively, patients with new-onset coronary artery disease (OR 0.592; 95% CI 0.419-0.837) were less likely to create DNR orders. CONCLUSION In mainland China, the DNR order signing rate is low, and the establishment of a DNR order is associated with demographics and comorbidity characteristics.
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Affiliation(s)
- Tangxing Jiang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Yanyan Ma
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Jiaqi Zheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chunyi Wang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Kai Cheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Chuanbao Li
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China; Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Qilu Hospital of Shandong University, Jinan, China; Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences; The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine; Qilu Hospital of Shandong University, Jinan, China.
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Wu CY, Jen CH, Chuang YS, Fang TJ, Wu YH, Wu MT. Factors associated with do-not-resuscitate document completion among patients hospitalized in geriatric ward. BMC Geriatr 2021; 21:472. [PMID: 34433419 PMCID: PMC8386141 DOI: 10.1186/s12877-021-02407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With a rapidly aging population, there is an increasing need for do-not-resuscitate (DNR) and advance care planning (ACP) discussions. This study investigated the factors associated with signing DNR documents of older patients in the geriatric ward. METHODS We conducted a retrospective cohort study at a geriatric ward in a tertiary hospital in Southern Taiwan. Three hundred and thirty-seven hospitalized older patients aged ≥65 years in the geriatric ward from 2018 to 2019. The Hospital Information System and electronic medical records were accessed to obtain details regarding patients' demographics, daily living activities, serum albumin level, nutrition screening score, intensive care unit transferal, resuscitation procedure, days of hospital stay, and survival status on discharge, and DNR status was recorded retrospectively. Patients were classified into DNR and non-DNR groups, with t-tests and Chi-square tests applied to compare the differences between groups. Logistic regression was performed to predict factors related to the DNR documents. RESULTS A total of 337 patients were included, 66 of whom had signed a DNR during hospitalization. After multivariate logistic regression, age 85 or more compared to age 65-74 (adjusted odds ratio, aOR 5.94), poor nutrition with screening score two or more (aOR 2.71), albumin level less than 3 (aOR 3.24), Charlson Comorbidity Index higher than 2 (aOR 2.46) and once transferred to ICU (aOR 5.11) were independently associated with DNR documentation during hospitalization. CONCLUSIONS Several factors related to DNR documents for geriatric patients were identified which could provide clinical information for physicians, patients, and their families to discuss DNR and ACP.
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Affiliation(s)
- Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chun-Hao Jen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
| | - Tzu-Jung Fang
- Division of Geriatrics and Gerontology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Yu-Hsuan Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
| | - Ming-Tsang Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan. .,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan. .,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan. .,Program of Environmental and Occupational Medicine and Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
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Mody P, Pandey A, Slutsky AS, Segar MW, Kiss A, Dorian P, Parsons J, Scales DC, Rac VE, Cheskes S, Bierman AS, Abramson BL, Gray S, Fowler RA, Dainty KN, Idris AH, Morrison L. Gender-Based Differences in Outcomes Among Resuscitated Patients With Out-of-Hospital Cardiac Arrest. Circulation 2020; 143:641-649. [PMID: 33317326 DOI: 10.1161/circulationaha.120.050427] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Studies examining gender-based differences in outcomes of patients experiencing out-of-hospital cardiac arrest have demonstrated that, despite a higher likelihood of return of spontaneous circulation, women do not have higher survival. METHODS Patients successfully resuscitated from out-of-hospital cardiac arrest enrolled in the CCC trial (Trial of Continuous or Interrupted Chest Compressions during CPR) were included. Hierarchical multivariable logistic regression models were constructed to evaluate the association between gender and survival after adjustment for age, gender, cardiac arrest rhythm, witnessed status, bystander cardiopulmonary resuscitation, episode location, epinephrine dose, emergency medical services response time, and duration of resuscitation. Do not resuscitate (DNR) and withdrawal of life-sustaining therapy (WLST) order status were used to assess whether differences in postresuscitation outcomes were modified by baseline prognosis. The analysis was replicated among ALPS trial (Amiodarone, Lidocaine, or Placebo in Out-of-Hospital Cardiac Arrest) participants. RESULTS Among 4875 successfully resuscitated patients, 1825 (37.4%) were women and 3050 (62.6%) were men. Women were older (67.5 versus 65.3 years), received less bystander cardiopulmonary resuscitation (49.1% versus 54.9%), and had a lower proportion of cardiac arrests that were witnessed (55.1% versus 64.5%) or had shockable rhythm (24.3% versus 44.6%, P<0.001 for all). A significantly higher proportion of women received DNR orders (35.7% versus 32.1%, P=0.009) and had WLST (32.8% versus 29.8%, P=0.03). Discharge survival was significantly lower in women (22.5% versus 36.3%, P<0.001; adjusted odds ratio, 0.78 [95% CI, 0.66-0.93]; P=0.005). The association between gender and survival to discharge was modified by DNR and WLST order status such that women had significantly reduced survival to discharge among patients who were not designated DNR (31.3% versus 49.9%, P=0.005; adjusted odds ratio, 0.74 [95% CI, 0.60-0.91]) or did not have WLST (32.3% versus 50.7%, P=0.002; adjusted odds ratio, 0.73 [95% CI, 0.60-0.89]). In contrast, no gender difference in survival was noted among patients receiving a DNR order (6.7% versus 7.4%, P=0.90) or had WLST (2.8% versus 2.4%, P=0.93). Consistent patterns of association between gender and postresuscitation outcomes were observed in the secondary cohort. CONCLUSIONS Among patients resuscitated after experiencing out-of-hospital cardiac arrest, discharge survival was significantly lower in women than in men, especially among patients considered to have a favorable prognosis.
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Affiliation(s)
- Purav Mody
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas.,VA North Texas Health System, Dallas (P.M.)
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Arthur S Slutsky
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Departments of Medicine, Surgery, and Biomedical Engineering, Interdepartmental Division of Critical Care (A.S.S.), University of Toronto, Ontario, Canada
| | - Matthew W Segar
- Division of Cardiology, Department of Internal Medicine (P.M., A.P., M.W.S.), University of Texas Southwestern Medical Center, Dallas
| | - Alex Kiss
- Evaluative Clinical Sciences, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Institute for Health Policy and Management (A.K.), University of Toronto, Ontario, Canada
| | - Paul Dorian
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine, Institute of Medical Sciences (P.D.), University of Toronto, Ontario, Canada
| | - Janet Parsons
- Applied Health Research Centre at the Li Ka Shing Knowledge Institute, St Michael's Hospital, Department of Physical Therapy and the Rehabilitation Sciences Institute (J.P.), University of Toronto, Ontario, Canada
| | - Damon C Scales
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (D.C.S.), University of Toronto, Ontario, Canada
| | - Valeria E Rac
- Ted Rogers Centre for Heart Research and Peter Munk Cardiac Centre and Toronto General Hospital Research Institute, Toronto Health Economics and Technology Assessment (THETA) Collaborative, Institute of Health Policy, Management and Evaluation (V.E.R.), University of Toronto, Ontario, Canada
| | - Sheldon Cheskes
- Sunnybrook Centre for Prehospital Medicine, Division of Emergency Medicine, Department of Family and Community Medicine (S.C.), University of Toronto, Ontario, Canada
| | - Arlene S Bierman
- Centre for Practice Improvement, Agency for Healthcare Research and Quality, Rockville, MD (A.S.B.)
| | - Beth L Abramson
- Division of Cardiology, St Michael's Hospital, Division of Cardiology, Department of Medicine, Faculty of Medicine (B.L.A.), University of Toronto, Ontario, Canada
| | - Sara Gray
- Emergency Medicine and Critical Care, St Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Interdepartmental Division of Critical Care, Faculty of Medicine (S.G.), University of Toronto, Ontario, Canada
| | - Rob A Fowler
- Sunnybrook Health Sciences Center, Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, Institute for Health Policy and Management (R.A.F.), University of Toronto, Ontario, Canada
| | - Katie N Dainty
- North York General Hospital, Institute for Health Policy and Management (K.N.D.), University of Toronto, Ontario, Canada
| | - Ahamed H Idris
- Department of Emergency Medicine (A.H.I.), University of Texas Southwestern Medical Center, Dallas
| | - Laurie Morrison
- Rescu at the Li Ka Shing Knowledge Institute, Emergency Medicine, St. Michael's Hospital, Division of Emergency Medicine, Department of Medicine, Faculty of Medicine, Institute for Health Policy and Management (L.M.), University of Toronto, Ontario, Canada
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Ouyang DJ, Lief L, Russell D, Xu J, Berlin DA, Gentzler E, Su A, Cooper ZR, Senglaub SS, Maciejewski PK, Prigerson HG. Timing is everything: Early do-not-resuscitate orders in the intensive care unit and patient outcomes. PLoS One 2020; 15:e0227971. [PMID: 32069306 PMCID: PMC7028295 DOI: 10.1371/journal.pone.0227971] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 01/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background The use of Do-Not-Resuscitate (DNR) orders has increased but many are placed late in the dying process. This study is to determine the association between the timing of DNR order placement in the intensive care unit (ICU) and nurses’ perceptions of patients’ distress and quality of death. Methods 200 ICU patients and the nurses (n = 83) who took care of them during their last week of life were enrolled from the medical ICU and cardiac care unit of New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan and the surgical ICU at the Brigham and Women’s Hospital in Boston. Nurses were interviewed about their perceptions of the patients’ quality of death using validated measures. Patients were divided into 3 groups—no DNR, early DNR, late DNR placement during the patient’s final ICU stay. Logistic regression analyses modeled perceived patient quality of life as a function of timing of DNR order placement. Patient’s comorbidities, length of ICU stay, and procedures were also included in the model. Results 59 patients (29.5%) had a DNR placed within 48 hours of ICU admission (early DNR), 110 (55%) placed after 48 hours of ICU admission (late DNR), and 31 (15.5%) had no DNR order placed. Compared to patients without DNR orders, those with an early but not late DNR order placement had significantly fewer non-beneficial procedures and lower odds of being rated by nurses as not being at peace (Adjusted Odds Ratio namely AOR = 0.30; [CI = 0.09–0.94]), and experiencing worst possible death (AOR = 0.31; [CI = 0.1–0.94]) before controlling for procedures; and consistent significance in severe suffering (AOR = 0.34; [CI = 0.12–0.96]), and experiencing a severe loss of dignity (AOR = 0.33; [CI = 0.12–0.94]), controlling for non-beneficial procedures. Conclusions Placement of DNR orders within the first 48 hours of the terminal ICU admission was associated with fewer non-beneficial procedures and less perceived suffering and loss of dignity, lower odds of being not at peace and of having the worst possible death.
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Affiliation(s)
- Daniel J. Ouyang
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Lindsay Lief
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - David Russell
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Sociology, Appalachian State University, Boone, North Carolina, United State of America
| | - Jiehui Xu
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - David A. Berlin
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
| | - Eliza Gentzler
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Amanda Su
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
| | - Zara R. Cooper
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Steven S. Senglaub
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, United State of America
| | - Paul K. Maciejewski
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- Department of Radiology, Weill Cornell Medicine, New York, New York, United State of America
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care, Weill Cornell Medicine, New York, New York, United State of America
- Department of Medicine, Weill Cornell Medicine, New York, New York, United State of America
- * E-mail:
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9
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Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS. Do Sex Differences Exist in the Establishment of "Do Not Attempt Resuscitation" Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest? J Am Heart Assoc 2020; 9:e014200. [PMID: 32063126 PMCID: PMC7070220 DOI: 10.1161/jaha.119.014200] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Women have higher utilization of “do not attempt resuscitation” (DNAR) orders during treatment for critical illness. Occurrence of sex differences in the establishment of DNAR orders after resuscitation from in‐hospital cardiac arrest is unknown. Whether differences in DNAR use by sex lead to disparities in survival remains unclear. Methods and Results We identified 71 820 patients with return of spontaneous circulation (ROSC) after in‐hospital cardiac arrest from the Get With The Guidelines–Resuscitation registry. Multivariable models evaluated the association between de novo DNAR (anytime after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) by sex and the association between sex and survival to discharge accounting for DNAR. All models accounted for clustering of patients within hospital and adjusted for demographic and cardiac arrest characteristics. The cohort included 30 454 (42.4%) women, who were slightly more likely than male participants to establish DNAR orders anytime after ROSC (45.0% versus 43.5%; adjusted relative risk: 1.15 [95% CI, 1.10–1.20]; P<0.0001). Of those with DNAR orders, women were more likely to be DNAR status within the first 12 hours (51.8% versus 46.5%; adjusted relative risk: 1.40 [95% CI, 1.30–1.52]; P<0.0001) and within 72 hours after ROSC (75.9% versus 70.9%; adjusted relative risk: 1.35 [95% CI, 1.26–1.45]; P<0.0001). However, no difference in survival to hospital discharge between women and men (34.5% versus 36.7%; adjusted relative risk: 1.00 [95% CI, 0.99–1.02]; P=0.74) was appreciated. Conclusions In patients successfully resuscitated from in‐hospital cardiac arrest, there was no survival difference between men and women while accounting for DNAR. However, women had a higher rate of DNAR status early after resuscitation (<12 and <72 hours) in comparison to men.
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Affiliation(s)
- Sarah M Perman
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO
| | - Brenda L Beaty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Stacie L Daugherty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO.,Division of Cardiology University of Colorado School of Medicine Aurora CO
| | | | - Jason S Haukoos
- Department of Emergency Medicine University of Colorado, School of Medicine Aurora CO.,Department of Emergency Medicine Denver Health Medical Center Denver CO.,Department of Epidemiology Colorado School of Public Health Aurora CO
| | - Elizabeth Juarez-Colunga
- Adult and Child Consortium for Health Outcomes Research and Delivery Science University of Colorado, School of Medicine Aurora CO
| | - Steven M Bradley
- Minneapolis Heart Institute and Minneapolis Heart Institute Foundation Minneapolis MN
| | | | - Paul S Chan
- Department of Cardiology Mid America Heart Institute Kansas City MO
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10
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Chen CH, Cheng YH, Chen FJ, Huang EY, Liu PM, Kung CT, Su CH, Chen SH, Chien PC, Hsieh CH. Association Between the Communication Skills of Physicians and the Signing of Do-Not-Resuscitate Consent for Terminally Ill Patients in Emergency Rooms (Cross-Sectional Study). Risk Manag Healthc Policy 2019; 12:307-315. [PMID: 31849547 PMCID: PMC6911809 DOI: 10.2147/rmhp.s232983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 11/21/2019] [Indexed: 12/01/2022] Open
Abstract
Background The signing of do-not-resuscitate (DNR) consent is mandatory in providing a palliative approach in the end-of-life care for the terminally ill patients and requires an effective communication between the physician and the patients or their family members. This study aimed to investigate the association between the communication skills of physicians who participated in the SHARE (supportive environment, how to deliver the bad news, additional information, reassurance, and emotional support) model course on the patient notification and the signing of do-not-resuscitate (DNR) consent by the terminally ill patients at emergency rooms. Methods Between May 1, 2017 and April 30, 2018, a total of 109 terminally ill patients were enrolled in this study, of which 70 had signed a DNR and 39 had not. Data regarding the patients’ medical records, a questionnaire survey completed by family members, and patient observation forms were used for the assessment of physicians’ communication skills during patient notification. The observation form was designed based on the SHARE model. A multivariate logistic regression model was applied to identify the independent significant factors of the patient and family member variables as well as the four main components of the observation form. Results The results revealed that knowing how to convey bad news and providing reassurance and emotional support were significantly correlated with a higher rate of signing DNR consent. Additionally, physician-initiated discussion with family members and a predicted limited life expectancy were negative independent significant factors for signing DNR consent. Conclusion This study revealed that good communication skills help to increase the signing of DNR consent. The learning of such skills from attendance of the SHARE model course is encouraged for the physicians in the palliative care of terminally ill patients in an emergency room.
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Affiliation(s)
- Chih-Hung Chen
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Graduate Institute of Adult Education, National Kaohsiung Normal University, Kaohsiung 802, Taiwan
| | - Ya-Hui Cheng
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, 736, Taiwan
| | - Fen-Ju Chen
- Department of Healthcare Administration, I-Shou University Medical Campus, Kaohsiung 824, Taiwan
| | - Eng-Yen Huang
- Department of Radiation Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Po-Ming Liu
- Department of Emergency Medicine, Kaohsiung 802, Taiwan
| | - Chia-Te Kung
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Chao-Hui Su
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Shu-Hwa Chen
- Department of Nursing, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.,School of Nursing, Fooyin University, Kaohsiung 831, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
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Epidemiologic Trends of Adoption of Do-Not-Resuscitate Status After Pediatric In-Hospital Cardiac Arrest. Pediatr Crit Care Med 2019; 20:e432-e440. [PMID: 31246741 DOI: 10.1097/pcc.0000000000002048] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate the prevalence of do-not-resuscitate status, assess the epidemiologic trends of do-not-resuscitate status, and assess the factors associated with do-not-resuscitate status in children after in-hospital cardiac arrest using large, multi-institutional data. DESIGN Generalized estimating equations logistic regression model was used to evaluate the trends of do-not-resuscitate status and evaluate the factors associated with do-not-resuscitate status after cardiac arrest. SETTING American Heart Association's Get With the Guidelines-Resuscitation Registry. PATIENTS Children (< 18 yr old) with an index in-hospital cardiac arrest and greater than or equal to 1 minute of documented chest compressions were included (2006-2015). Patients with no return of spontaneous circulation after cardiac arrest were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In total, 8,062 patients qualified for inclusion. Of these, 1,160 patients (14.4%) adopted do-not-resuscitate status after cardiac arrest. We found low rates of survival to hospital discharge among children with do-not-resuscitate status (do-not-resuscitate vs no do-not-resuscitate: 6.0% vs 69.7%). Our study found that rates of do-not-resuscitate status after cardiac arrest are highest in children with Hispanic ethnicity (16.4%), white race (15.0%), and treatment at institutions with larger PICUs (> 50 PICU beds: 17.8%) and at institutions located in North Central (17.6%) and South Atlantic/Puerto Rico (17.1%) regions of the United States. Do-not-resuscitate status was more common among patients with more preexisting conditions, longer duration of cardiac arrest, greater than 1 cardiac arrest, and among patients requiring extracorporeal cardiopulmonary resuscitation. We also found that trends of do-not-resuscitate status after cardiac arrest in children are decreasing in recent years (2013-2015: 13.8%), compared with previous years (2006-2009: 16.0%). CONCLUSIONS Patient-, hospital-, and regional-level factors are associated with do-not-resuscitate status after pediatric cardiac arrest. As cardiac arrest might be a signal of terminal chronic illness, a timely discussion of do-not-resuscitate status after cardiac arrest might help families prioritize quality of end-of-life care.
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12
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Bruckel J, Nallamothu BK, Ling F, Howell EH, Lowenstein CJ, Thomas S, Bradley SM, Mehta A, Walkey AJ. Do-Not-Resuscitate Status and Risk-Standardized Mortality and Readmission Rates Following Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes 2019; 12:e005196. [PMID: 30879325 PMCID: PMC6424127 DOI: 10.1161/circoutcomes.118.005196] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Important administrative-based measures of hospital quality, including those used by Centers for Medicare and Medicaid Services, may not adequately account for patient illness and social factors that vary between hospitals and can strongly affect outcomes. Do-not-resuscitate (DNR) order on admission (within the first 24 hours) is one such factor that may reflect higher preadmission illness burden as well as patients' desire for less-intense therapeutic interventions and has been shown to vary widely between hospitals. We sought to evaluate how accounting for early DNR affected hospital quality measures for acute myocardial infarction. Methods AND RESULTS We identified all patients admitted with acute myocardial infarction using the California State Inpatient Database, which captures early DNR use within 24 hours of admission. We generated hospital risk-standardized mortality and readmissions using random-effects logistic regression, before and after including early DNR status, to examine changes in overall model fit and hospital outlier designations. We included 109 521 patients from 289 hospitals and found that 8.5% (9356) patients had early DNR. Early DNR use varied widely, with median (interquartile range) hospital rates of 7.9% (4.1%-14.0%). Including early DNR in models used to assess hospital quality resulted in improvement in the mortality model (C statistics from 0.754 [0.748-0.759] to 0.784 [0.779-0.789]) but not the readmissions model. Of the hospitals designated high outliers for mortality and readmissions by the Centers for Medicare/Medicaid Services model, and therefore destined for a financial penalty, 6/25 (24%) were reclassified as nonoutliers for mortality and 2/14 (14.3%) for readmissions after including DNR status. Agreement in outlier status between the models before and after inclusion of early DNR status was moderate for mortality (κ, 0.603 [0.482-0.724]; P<0.001) and high for readmissions (κ, 0.888 [0.800-0.977]; P<0.001). Conclusions Including early DNR status in risk-adjustment models significantly improved model fit and resulted in substantial reclassification of hospital performance rankings for mortality and moderate reclassification for readmissions. DNR status at hospital admission should be considered when reporting risk-standardized hospital mortality.
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Affiliation(s)
- Jeffrey Bruckel
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Brahmajee K. Nallamothu
- University of Michigan Health System, Division of Cardiovascular Medicine and Michigan Integrated Center for Health Analytics and Medical Prediction (M-CHAMP), Ann Arbor, MI; Ann Arbor VA Center for Clinical Management and Research, Ann Arbor, MI
| | - Frederick Ling
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Erik H. Howell
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Charles J. Lowenstein
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | - Sabu Thomas
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, NY
| | | | - Anuj Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health, Denver, CO; Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado, Denver, CO National Jewish Health, Denver, CO
| | - Allan J. Walkey
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University Medical Center, Boston,MA
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13
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Factors Underlying Racial Disparities in Sepsis Management. Healthcare (Basel) 2018; 6:healthcare6040133. [PMID: 30463180 PMCID: PMC6315577 DOI: 10.3390/healthcare6040133] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 12/13/2022] Open
Abstract
Sepsis, a syndrome characterized by systemic inflammation during infection, continues to be one of the most common causes of patient mortality in hospitals across the United States. While standardized treatment protocols have been implemented, a wide variability in clinical outcomes persists across racial groups. Specifically, black and Hispanic populations are frequently associated with higher rates of morbidity and mortality in sepsis compared to the white population. While this is often attributed to systemic bias against minority groups, a growing body of literature has found patient, community, and hospital-based factors to be driving racial differences. In this article, we provide a focused review on some of the factors driving racial disparities in sepsis. We also suggest potential interventions aimed at reducing health disparities in the prevention, early identification, and clinical management of sepsis.
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Characteristics, treatment and outcomes for all emergency department patients fulfilling criteria for septic shock: a prospective observational study. Eur J Emerg Med 2018; 25:97-104. [PMID: 27547885 DOI: 10.1097/mej.0000000000000419] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Most published data on emergency department (ED) patients with septic shock have been generated from studies examining the effect of early protocolised resuscitation in selected cohorts. Consequently, these data do not generally represent patients falling outside trial inclusion criteria or judged unsuitable for aggressive treatment. Our aim was to determine the characteristics, treatment and outcomes for all ED patients fulfilling the criteria for septic shock. METHODS Septic shock patients were identified from a prospective database of consecutive ED patients admitted with infection. Descriptive data were compared with those from previous studies and associations between ED processes of care and mortality were determined. RESULTS A total of 399 septic shock patients were identified, with a 30-day mortality of 19.5%. The median ED length of stay was 9.2 h. Rates of vasopressor use (22.6%) and ICU admission (37.3%) were low. Subgroups fulfilling the lactate criteria alone, hypotension criteria alone and both criteria represented distinct shock phenotypes with increasing severity of illness and mortality. Mortality for patients with limitations to treatment determined in the ED was 65.6% and 6.1% for those without limitations. Greater volumes of intravenous fluid and early vasopressor therapy for appropriate patients were associated with survival. CONCLUSION Median length of stay over 9 hours may have enhanced identification of patients with limitations to treatment and fluid responders, reducing invasive therapies and ICU admissions. Distinct shock phenotypes were apparent, with implications for revision of septic shock definitions and future trial design. Liberal fluids and early vasopressor use in appropriate patients were associated with survival.
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15
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Stream S, Nolan A, Kwon S, Constable C. Factors associated with combined do-not-resuscitate and do-not-intubate orders: A retrospective chart review at an urban tertiary care center. Resuscitation 2018; 130:1-5. [PMID: 29935341 DOI: 10.1016/j.resuscitation.2018.06.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 06/09/2018] [Accepted: 06/18/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND In clinical practice, do-not-intubate (DNI) orders are generally accompanied by do-not-resuscitate (DNR) orders. Use of do-not-resuscitate (DNR) orders is associated with older patient age, more comorbid conditions, and the withholding of treatments outside of the cardiac arrest setting. Previous studies have not unpacked the factors independently associated with DNI orders. OBJECTIVE To compare factors associated with combined DNR/DNI orders versus isolated DNR orders, as a means of elucidating factors associated with the addition of DNI orders. DESIGN Retrospective chart review. SETTING/SUBJECTS Patients who died on a General Medicine or MICU service (n = 197) at an urban public hospital over a 2-year period. MEASUREMENTS Logistic regression was used to identify demographic and medical data associated with code status. RESULTS Compared with DNR orders alone, DNR/DNI orders were associated with a higher median Charlson Comorbidity Index (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13-1.43); older age (OR 1.02, 95% CI 1.01-1.04); malignancy (OR 2.27, 95% CI 1.18-4.37); and female sex (OR 1.98, 95% CI 1.02-3.87). In the last 3 days of life, they were associated with morphine administration (OR 2.76, 95% CI 1.43-5.33); and negatively associated with use of vasopressors/inotropes (OR 10.99, 95% CI 4.83-25.00). CONCLUSIONS Compared with DNR orders alone, combined DNR/DNI orders are more strongly associated with many of the same factors that have been linked to DNR orders. Awareness of the extent to which the two directives may be conflated during code status discussions is needed to promote patient-centered application of these interventions.
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Affiliation(s)
- Sara Stream
- New York University Internal Medicine Residency Program, NY, United States
| | - Anna Nolan
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States; Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States
| | - Sophia Kwon
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, New York University School of Medicine, NY, United States
| | - Catherine Constable
- Division of Ethics, Department of Population Health, New York University School of Medicine, NY, United States; Department of Medicine, New York University Langone Medical Center, NY, United States.
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16
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Bruckel J, Mehta A, Bradley SM, Thomas S, Lowenstein CJ, Nallamothu BK, Walkey AJ. Variation in Do-Not-Resuscitate Orders and Implications for Heart Failure Risk-Adjusted Hospital Mortality Metrics. JACC. HEART FAILURE 2017; 5:743-752. [PMID: 28958349 PMCID: PMC7552359 DOI: 10.1016/j.jchf.2017.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/17/2017] [Accepted: 07/27/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study evaluated the effect of patient do-not-resuscitate (DNR) status on hospital risk-adjusted heart failure mortality metrics. BACKGROUND Do-not-resuscitate orders limit the use of life-sustaining therapies. Patients with DNR orders have increased in-hospital mortality, and DNR rates vary among hospitals. Variations in DNR rates could strongly confound risk-adjusted hospital mortality rates for heart failure. METHODS We identified a cohort of adults with primary diagnosis of heart failure by using the 2011 California State Inpatient Database, a claims database that captures "early DNR," within 24 h of admission. Hospital-level risk-standardized in-hospital mortality was determined using random effects logistic regression. We explored changes in outlier status in models with and without early DNR status. RESULTS Among 55,865 patients from 290 hospitals hospitalized with heart failure, 12.1% (11.8% to 12.4%) had an early DNR order. Hospitals with higher risk-standardized DNR rates had higher risk-standardized mortality (ρ = 0.241; 95% confidence interval [CI]: 0.129 to 0.346; p < 0.001). Including DNR in models used to benchmark hospital mortality improved model performance (c-statistic from 0.821 [95% CI: 0.812 to 0.830] to 0.845 [95% CI: 0.837 to 0.853]; increased model explanatory power by 17%). Including DNR resulted in reclassification of 9.3% of hospitals' outlier status. Agreement in hospital outlier designation between models with and without DNR was low to moderate (kappa coefficient: 0.492; 95% CI: 0.331 to 0.654). CONCLUSIONS Accounting for DNR status resulted in a change in estimated risk-standardized mortality rates and classification of hospitals as performance "outliers." Given public reporting of heart failure mortality measurements and their influence on reimbursement, accounting for the presence of early DNR orders in quality measures should be considered.
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Affiliation(s)
- Jeffrey Bruckel
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York.
| | - Anuj Mehta
- Division of Pulmonary, Critical Care, and Sleep Medicine, National Jewish Health System, Denver, Colorado
| | | | - Sabu Thomas
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York
| | - Charles J Lowenstein
- Division of Cardiovascular Medicine, University of Rochester Medical Center, Rochester, New York
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan; Michigan Integrated Center for Health Analytics and Medical Prediction, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Center for Clinical Management and Research, Ann Arbor, Michigan
| | - Allan J Walkey
- Division of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Boston University Medical Center, Boston, Massachusetts
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Huang CT, Chuang YC, Tsai YJ, Ko WJ, Yu CJ. High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia. PLoS One 2016; 11:e0159501. [PMID: 27416064 PMCID: PMC4944975 DOI: 10.1371/journal.pone.0159501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/05/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan. METHODS A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care. RESULTS Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66-14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients. CONCLUSIONS From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.
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Affiliation(s)
- Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ju Tsai
- Graduate Institute of Biomedical and Pharmaceutical Science, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Wen-Je Ko
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Walkey AJ, Weinberg J, Wiener RS, Cooke CR, Lindenauer PK. Association of Do-Not-Resuscitate Orders and Hospital Mortality Rate Among Patients With Pneumonia. JAMA Intern Med 2016; 176:97-104. [PMID: 26658673 PMCID: PMC6684128 DOI: 10.1001/jamainternmed.2015.6324] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
IMPORTANCE Hospital quality measures that do not account for patient do-not-resuscitate (DNR) status may penalize hospitals admitting a greater proportion of patients with limits on life-sustaining treatments. OBJECTIVE To evaluate the effect of analytic approaches accounting for DNR status on risk-adjusted hospital mortality rates and performance rankings. DESIGN, SETTING, AND PARTICIPANTS A retrospective, population-based cohort study was conducted among adults hospitalized with pneumonia in 303 California hospitals between January 1 and December 31, 2011. We used hierarchical logistic regression to determine associations between patient DNR status, hospital-level DNR rates, and mortality measures. Changes in hospital risk-adjusted mortality rates after accounting for patient DNR status and interhospital variation in the association between DNR status and mortality were examined. Data analysis was conducted from January 16 to September 16, 2015. EXPOSURES Early DNR status (within 24 hours of admission). MAIN OUTCOMES AND MEASURES In-hospital mortality, determined using hierarchical logistic regression. RESULTS A total of 90,644 pneumonia cases (5.4% of admissions) were identified among the 303 California hospitals evaluated during 2011; mean (SD) age of the patients was 72.5 (13.7) years, 51.5% were women, and 59.3% were white. Hospital DNR rates varied (median, 15.8%; 25th-75th percentile, 8.9%-22.3%). Without accounting for patient DNR status, higher hospital-level DNR rates were associated with increased patient mortality (adjusted odds ratio [OR] for highest-quartile DNR rate vs lowest quartile, 1.17; 95% CI, 1.04-1.32), corresponding to worse hospital mortality rankings. In contrast, after accounting for patient DNR status and between-hospital variation in the association between DNR status and mortality, hospitals with higher DNR rates had lower mortality (adjusted OR for highest-quartile DNR rate vs lowest quartile, 0.79; 95% CI, 0.70-0.89), with reversal of associations between hospital mortality rankings and DNR rates. Only 14 of 27 hospitals (51.9%) characterized as low-performing outliers without accounting for DNR status remained outliers after DNR adjustment. Hospital DNR rates were not significantly associated with composite quality measures of processes of care for pneumonia (r = 0.11; P = .052); however, DNR rates were positively correlated with patient satisfaction scores (r = 0.35; P < .001). CONCLUSIONS AND RELEVANCE Failure to account for DNR status may confound the evaluation of hospital quality using mortality outcomes, penalizing hospitals that admit a greater proportion of patients with limits on life-sustaining treatments. Stakeholders should seek to improve methods to standardize and report DNR status in hospital discharge records to allow further assessment of implications of adjusting for DNR in quality measures.
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Affiliation(s)
- Allan J Walkey
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Janice Weinberg
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Renda Soylemez Wiener
- The Pulmonary Center, Division of Pulmonary and Critical Care Medicine, Boston University School of Medicine, Boston, Massachusetts3Center for Healthcare Organization & Implementation Research, Edith Nourse Rogers Memorial Veterans Affairs Hospital, Bedfo
| | - Colin R Cooke
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan, Ann Arbor 5Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Peter K Lindenauer
- Center for Quality of Care Research, Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts7Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts
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