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Krieger JA, Sheehan J, Hernandez MA, Thau MR, Johnson NJ, Robinson BRH. Characteristics of victims of trauma requiring invasive mechanical ventilation with a short stay in critical care. Am J Emerg Med 2024; 77:1-6. [PMID: 38096634 DOI: 10.1016/j.ajem.2023.11.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/20/2023] [Accepted: 11/25/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Many patients who are admitted to the intensive care unit (ICU) have needs which rapidly resolve and are discharged alive within 24 h. We sought to characterize the outcomes of critically ill trauma victims at our institution with a short stay in the ICU. METHODS We conducted a retrospective cohort study of all critically ill adult trauma victims presenting to our ED between January 1st, 2011 and December 31st, 2019. We included patients who were endotracheally intubated in either the prehospital setting or the ED and were admitted either to the operating room (OR), angiography suite, or ICU. Our primary outcome was the proportion of patients who were discharged alive from the ICU within 24 h. RESULTS We included 3869 patients meeting the criteria above who were alive at 24 h. This population was 78% male with a median age of 40 and 76% of patients suffered from blunt trauma. The median injury severity score (ISS) of the group was 21 [inter-quartile range (IQR) 11-30]. In-hospital mortality amongst the group was 12%. 17% of the group were discharged alive from the ICU within 24 h. Thirty-four percent of the group had an ISS ≤ 15. Of the group which left the ICU alive within 24 h, six patients (0.9%) died in the hospital, 2 % of patients were re-admitted to an ICU, and 0.6% of patients required re-intubation. CONCLUSIONS We found that 17% of patients who were intubated in the prehospital setting or emergency department and subsequently hospitalized were discharged alive from the ICU within 24 h.
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Affiliation(s)
- Joshua A Krieger
- Department of Hospital Care, Section of Critical Care, UCHealth Memorial Hospital Central, Colorado Springs, CO, United States of America.
| | - Jordan Sheehan
- Department of Emergency Medicine, University of Washington Medical Center, Seattle, WA, United States of America.
| | - Michael A Hernandez
- Department of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, United States of America.
| | - Matthew R Thau
- Department of Medicine, Division of Critical Care, Pulmonary and Sleep, University of Texas McGovern Medical School, Houston, TX, United States of America.
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington Medical Center, Seattle, WA, United States of America; Department of Pulmonary, Critical Care and Sleep Medicine, University of Washington Medical Center, Seattle, WA, United States of America
| | - Bryce R H Robinson
- Department of Surgery, University of Washington Medical Center, Harborview Medical Center, Seattle, WA, United States of America.
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Ishii E, Nawa N, Hashimoto S, Shigemitsu H, Fujiwara T. Development, validation, and feature extraction of a deep learning model predicting in-hospital mortality using Japan's largest national ICU database: a validation framework for transparent clinical Artificial Intelligence (cAI) development. Anaesth Crit Care Pain Med 2023; 42:101167. [PMID: 36302489 DOI: 10.1016/j.accpm.2022.101167] [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: 06/20/2022] [Revised: 09/01/2022] [Accepted: 09/28/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVE While clinical Artificial Intelligence (cAI) mortality prediction models and relevant studies have increased, limitations including the lack of external validation studies and inadequate model calibration leading to decreased overall accuracy have been observed. To combat this, we developed and evaluated a novel deep neural network (DNN) and a validation framework to promote transparent cAI development. METHODS Data from Japan's largest ICU database was used to develop the DNN model, predicting in-hospital mortality including ICU and post-ICU mortality by days since ICU discharge. The most important variables to the model were extracted with SHapley Additive exPlanations (SHAP) to examine the DNN's efficacy as well as develop models that were also externally validated. MAIN RESULTS The area under the receiver operating characteristic curve (AUC) for predicting ICU mortality was 0.94 [0.93-0.95], and 0.91 [0.90-0.92] for in-hospital mortality, ranging between 0.91-0.95 throughout one year since ICU discharge. An external validation using only the top 20 variables resulted with higher AUCs than traditional severity scores. CONCLUSIONS Our DNN model consistently generated AUCs between 0.91-0.95 regardless of days since ICU discharge. The 20 most important variables to our DNN, also generated higher AUCs than traditional severity scores regardless of days since ICU discharge. To our knowledge, this is the first study that predicts ICU and in-hospital mortality using cAI by post-ICU discharge days up to over a year. This finding could contribute to increased transparency on cAI applications.
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Affiliation(s)
- Euma Ishii
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nobutoshi Nawa
- Department of Medical Education Research and Development, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoru Hashimoto
- Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hidenobu Shigemitsu
- Institute of Global Affairs, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeo Fujiwara
- Department of Global Health Promotion, Tokyo Medical and Dental University, Tokyo, Japan.
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ICU-Managed Patients' Epidemiology, Characteristics, and Outcomes: A Retrospective Single-Center Study. Anesthesiol Res Pract 2023; 2023:9388449. [PMID: 36704543 PMCID: PMC9873425 DOI: 10.1155/2023/9388449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/17/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023] Open
Abstract
Background Resources are limited, and it is exceedingly difficult to provide intensive care in developing nations. In Somalia, intensive care unit (ICU) care was introduced only a few years ago. Purpose In this study, we aimed to determine the epidemiology, characteristics, and outcome of ICU-managed patients in a tertiary hospital in Mogadishu. Methods We retrospectively evaluated the files of 1082 patients admitted to our ICU during the year 2021. Results The majority (39.7%) of the patients were adults (aged between 20 and 39 years), and 67.8% were male patients. The median ICU length of stay was three days (IQR = 5 days), and nonsurvivors had shorter stays, one day. The mortality rate was 45.1%. The demand for critical care services in low-income countries is high. Conclusion The country has a very low ICU bed capacity. Critical care remains a neglected area of health service delivery in this setting, with large numbers of patients with potentially treatable conditions not having access to such services.
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Oh AR, Park J, Lee JH, Choi DC, Yang K, Choi JH, Ahn J, Sung JD, Lee S. Association between Mortality and Sequential Organ Failure Assessment Score during a Short Stay in the Intensive Care Unit after Non-Cardiac Surgery. J Clin Med 2022; 11:jcm11195865. [PMID: 36233732 PMCID: PMC9573186 DOI: 10.3390/jcm11195865] [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: 08/29/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The sequential organ failure assessment (SOFA) score has been validated in various clinical situations. However, it has not been investigated during a short stay in the intensive care unit (ICU). This study aimed to evaluate the association between the SOFA score and outcomes in patients who were monitored for less than one day after non-cardiac surgery. Methods: From a total of 203,787 consecutive adult patients who underwent non-cardiac surgery between January 2011 and June 2019, we selected 17,714 who were transferred to the ICU immediately after surgery and stayed for less than 24 h. Patients were divided according to quartile value and change between the initial and follow-up levels of SOFA score. Results: Three-year mortality tended to increase with a higher initial SOFA score (11.7%, 11.8%, 15.1%, and 17.8%, respectively). The patients were divided according to changes in the SOFA score at the midnight postoperative follow-up check: 16,176 (91.3%) in the stable group and 1538 (8.7%) in the worsened group. The worsened group showed significantly higher three-year mortality and complications (13.2% vs. 18.6%; HR [hazard ratio]: 1.236; 95% CI [confidence interval]: 1.108−1.402; p ≤ 0.0021 for three-year mortality and 3.8% vs. 9.1%; HR: 2.13; 95% CI: 1.73−2.60; p < 0.001 for acute kidney injury). Conclusions: The SOFA score during a short stay in the ICU after non-cardiac surgery showed an association with mortality. The change in SOFA score may need to be considered at discharge from the ICU.
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Affiliation(s)
- Ah Ran Oh
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Dan-Cheong Choi
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwangmo Yang
- Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon 16499, Korea
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jin-ho Choi
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Joonghyun Ahn
- Statistics and Data Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul 06351, Korea
| | - Ji Dong Sung
- Rehabilitation and Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Seunghwa Lee
- Rehabilitation and Prevention Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
- Department of Biomedical Engineering, Seoul National University College of Medicine, Seoul 07061, Korea
- Correspondence:
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Miller AC. What's new in critical illness and injury science? Resource allocation and very short intensive care unit stays. Int J Crit Illn Inj Sci 2022; 12:119-120. [PMID: 36506921 PMCID: PMC9728069 DOI: 10.4103/ijciis.ijciis_61_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/09/2022] [Indexed: 12/15/2022] Open
Affiliation(s)
- Andrew C. Miller
- Department of Emergency Medicine, Alton Memorial Hospital, Alton, IL, USA,Address for correspondence: Dr. Andrew C. Miller, Department of Emergency Medicine, Alton Memorial Hospital, 1 Memorial Dr, Alton, IL 62002, USA. E-mail:
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Pandit PN, Mallozzi M, Mohammed R, McDonough G, Treacy T, Zahustecher N, Yoo EJ. A retrospective cohort study of short-stay admissions to the medical intensive care unit: Defining patient characteristics and critical care resource utilization. Int J Crit Illn Inj Sci 2022; 12:127-132. [PMID: 36506929 PMCID: PMC9728074 DOI: 10.4103/ijciis.ijciis_6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/28/2022] [Accepted: 02/21/2022] [Indexed: 12/15/2022] Open
Abstract
Background Little is known about the mortality and utilization outcomes of short-stay intensive care unit (ICU) patients who require <24 h of critical care. We aimed to define characteristics and outcomes of short-stay ICU patients whose need for ICU level-of-care is ≤24 h compared to nonshort-stay patients. Methods Single-center retrospective cohort study of patients admitted to the medical ICU at an academic tertiary care center in 2019. Fisher's exact test or Chi-square for descriptive categorical variables, t-test for continuous variables, and Mann-Whitney two-sample test for length of stay (LOS) outcomes. Results Of 819 patients, 206 (25.2%) were short-stay compared to 613 (74.8%) nonshort-stay. The severity of illness as measured by the Mortality Probability Model-III was significantly lower among short-stay compared to nonshort-stay patients (P = 0.0001). Most short-stay patients were admitted for hemodynamic monitoring not requiring vasoactive medications (77, 37.4%). Thirty-six (17.5%) of the short-stay cohort met Society of Critical Care Medicine's guidelines for ICU admission. Nonfull-ICU LOS, or time spent waiting for transfer out to a non-ICU bed, was similar between the two groups. Hospital mortality was lower among short-stay patients compared to nonshort-stay patients (P = 0.01). Conclusions Despite their lower illness severity and fewer ICU-level care needs, short-stay patients spend an equally substantial amount of time occupying an ICU bed while waiting for a floor bed as nonshort-stay patients. Further investigation into the factors influencing ICU triage of these subacute patients and contributors to system inefficiencies prohibiting their timely transfer may improve ICU resource allocation, hospital throughput, and patient outcomes.
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Affiliation(s)
- Pooja N. Pandit
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark Mallozzi
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rahed Mohammed
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gregory McDonough
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Taylor Treacy
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Erika J. Yoo
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA,Address for correspondence: Dr. Erika J. Yoo, Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, TJU and NJH, Sidney Kimmel Medical College, Thomas Jefferson University, 834 Walnut Street, Suite 650, Philadelphia, PA 19107, USA. E-mail:
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Othman F, Ismaiel Y, Alkhathran S, Alshamrani A, Alghamdi M, Ismaeil T. The duration of mechanical ventilation in patients with chronic obstructive pulmonary disease and acute respiratory distress syndrome admitted to the intensive care unit: Epidemiological findings from a tertiary hospital. J Nat Sci Biol Med 2020. [DOI: 10.4103/jnsbm.jnsbm_188_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Plate JDJ, Peelen LM, Leenen LPH, Houwert RM, Hietbrink F. Assessment of the intermediate care unit triage system. Trauma Surg Acute Care Open 2018; 3:e000178. [PMID: 30234163 PMCID: PMC6135419 DOI: 10.1136/tsaco-2018-000178] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/23/2018] [Accepted: 05/13/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND An important critique with respect to the utilization of intermediate care units (IMCU) is that they potentially admit patients who would otherwise be cared for on the regular ward. This would lead to an undesired waste of critical care resources. This article aims to (1) describe the caseload at the IMCU and (2) to assess the triage system at the IMCU to determine potentially unnecessary admissions. METHODS This cohort study included all admissions at the mixed-surgical IMCU from 2001 to 2015. The Therapeutic Intervention Scoring System-28 (TISS-28) was prospectively collected for all admissions to describe the caseload at the IMCU and to identify medical criteria for admission. These were combined with logistical criteria to assess the IMCU triage system. RESULTS A total of 8816 admissions were included in the study. The average TISS-28 was 20.19 (95% CI 18.05 to 22.33), corresponding with 3.57 (95% CI 3.19 to 3.94) hours of direct patient-related work per patient per nursing shift. Over time, this increased by an average of 0.27 points/year (p<0.001). Of all admissions, 6539 (74.2%) were medically considered to be justly admitted, and 7093 (80.4%) were logistically considered to be justly admitted. With these criteria combined, a total of 8324 (94.4%) were correctly admitted. DISCUSSION Most admissions to the IMCU are medically and/or logistically necessary, as the majority of admitted patients demand a higher level of nursing care than available on the general ward. Continuous triage is thereby essential. These findings support further utilization of the IMCU in our current healthcare system and has important implications for IMCU-related management decisions. LEVEL OF EVIDENCE Level VI.
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Affiliation(s)
- Joost D J Plate
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Linda M Peelen
- Julius Centre for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands
- Departments of Anesthesiology and Intensive Care Medicine, Utrecht University, Utrecht, The Netherlands
| | - Luke P H Leenen
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - R Marijn Houwert
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Falco Hietbrink
- Division of Surgery, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Chidi OO, Perman SM, Ginde AA. Characteristics of Short-stay Critical Care Admissions From Emergency Departments in Maryland. Acad Emerg Med 2017; 24:1204-1211. [PMID: 28323374 DOI: 10.1111/acem.13188] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/28/2017] [Accepted: 03/10/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Critical care is an expensive and limited resource, and short-stay critical care admissions may be treated in alternate, less costly settings. This study objective was to determine the proportion of critical care admissions with a short critical care length of stay (LOS) and identify the clinical characteristics and diagnoses associated with high and low rates of short-stay critical care admissions. METHODS This study was a secondary analysis of the 2011 Maryland State Inpatient Database. The study included adult emergency department (ED) visits admitted to a critical care unit. We compared clinical data and discharge diagnoses for short- (≤1 day) versus longer- (≥2 days) stay critical care admissions. RESULTS A total of 30,212 critical care admissions were eligible, of which 11,494 (38.0%) were short stay. There were significant differences in age, insurance, and comorbidities between the short-stay and the longer-stay critical care admissions. Of short-stay critical care admissions, 3,404 (29.6%) also had a 1-day overall hospital LOS. The diagnoses with the highest proportion of short-stay critical care admissions were nonspecific chest pain (87.9%), syncope (70.6%), and transient cerebral ischemia (67.6%) and the lowest proportion were respiratory failure (17.9%), sepsis (19.4%), and aspiration pneumonitis (19.8%). CONCLUSIONS Over one-third of critical care admissions were short stay. Alternate strategies to manage these patients, including ED-based critical care units or other venues of inpatient care, may be more cost-efficient for selected patients.
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Affiliation(s)
- Obiora O. Chidi
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora CO
- Department of Emergency Medicine; University of California San Diego School of Medicine; San Diego CA
| | - Sarah M. Perman
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora CO
| | - Adit A. Ginde
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora CO
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Vincent JL, Rubenfeld GD. Does intermediate care improve patient outcomes or reduce costs? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:89. [PMID: 25774925 PMCID: PMC4346102 DOI: 10.1186/s13054-015-0813-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ICUs are an essential but expensive part of all modern hospitals. With increasingly limited healthcare funding, methods to reduce expenditure without negatively influencing patient outcomes are, therefore, of interest. One possible solution has been the development of ‘intermediate care units’, which provide more intensive monitoring and patient management with higher nurse:patient ratios than the general ward but less than is offered in the ICU. However, although such units have been introduced in many hospitals, there is relatively little published, especially prospective, evidence to support the benefits of this approach on costs or patient outcomes. We review the available data and suggest that, where possible, a larger unit with combined intermediate care and intensive care beds in one location may be preferable in terms of greater flexibility and efficiency.
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Sakr Y, Marques J, Mortsch S, Gonsalves MD, Hekmat K, Kabisch B, Kohl M, Reinhart K. Is the SAPS II score valid in surgical intensive care unit patients? J Eval Clin Pract 2012; 18:231-7. [PMID: 20860597 DOI: 10.1111/j.1365-2753.2010.01559.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES We investigated the performance of the simplified acute physiology score II (SAPS II) in a large cohort of surgical intensive care unit (ICU) patients and tested the hypothesis that customization of the score would improve the uniformity of fit in subgroups of surgical ICU patients. METHODS Retrospective analysis of prospectively collected data from all 12,938 patients admitted to a postoperative ICU between January 2004 and January 2009. Probabilities of hospital death were calculated for original and customized (C1-SAPS II and C2-SAPS II) scores. A priori subgroups were defined according to age, probability of death according to the SAPS II score, ICU length of stay (LOS), surgical procedures and type of admission. RESULTS The median ICU LOS was 1 (1-3) day. ICU and hospital mortality rates were 5.8% and 10.3%, respectively. Discrimination of the SAPS II was moderate [area under receiver operating characteristic curve (aROC) = 0.76 (0.75-0.78)], but calibration was poor. This model markedly overestimated hospital mortality rates [standardized mortality rate: 0.35 (0.33-0.37)]. First-level customization (C1-SAPS II) did not improve discrimination in the whole cohort or the subgroups, but calibration improved in some subgroups. Second-level customization (C2-SAPS II) improved discrimination in the whole cohort [aROC = 0.82 (0.79-0.85)] and most of the subgroups (aROC range 0.65-86). Calibration in this model (C2-SAPS II) improved in the whole cohort and in subgroups except in patients with ICU LOS 4-14 days and those undergoing neuro- or gastrointestinal surgery. CONCLUSIONS In this large cohort of surgical ICU patients, performance of the original SAPS II model was generally poor. Although second-level customization improved discrimination and calibration in the whole cohort and most of the subgroups, it failed to simultaneously improve calibration in the subgroups stratified according to the type of surgery, age or ICU LOS.
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Affiliation(s)
- Yasser Sakr
- Department of Anaesthesiology and Intensive Care, Friedrich-Schiller-University Hospital, Jena, Germany.
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Vasilevskis EE, Kuzniewicz MW, Cason BA, Lane RK, Dean ML, Clay T, Rennie DJ, Vittinghoff E, Dudley RA. Mortality probability model III and simplified acute physiology score II: assessing their value in predicting length of stay and comparison to APACHE IV. Chest 2009; 136:89-101. [PMID: 19363210 DOI: 10.1378/chest.08-2591] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND To develop and compare ICU length-of-stay (LOS) risk-adjustment models using three commonly used mortality or LOS prediction models. METHODS Between 2001 and 2004, we performed a retrospective, observational study of 11,295 ICU patients from 35 hospitals in the California Intensive Care Outcomes Project. We compared the accuracy of the following three LOS models: a recalibrated acute physiology and chronic health evaluation (APACHE) IV-LOS model; and models developed using risk factors in the mortality probability model III at zero hours (MPM(0)) and the simplified acute physiology score (SAPS) II mortality prediction model. We evaluated models by calculating the following: (1) grouped coefficients of determination; (2) differences between observed and predicted LOS across subgroups; and (3) intraclass correlations of observed/expected LOS ratios between models. RESULTS The grouped coefficients of determination were APACHE IV with coefficients recalibrated to the LOS values of the study cohort (APACHE IVrecal) [R(2) = 0.422], mortality probability model III at zero hours (MPM(0) III) [R(2) = 0.279], and simplified acute physiology score (SAPS II) [R(2) = 0.008]. For each decile of predicted ICU LOS, the mean predicted LOS vs the observed LOS was significantly different (p <or= 0.05) for three, two, and six deciles using APACHE IVrecal, MPM(0) III, and SAPS II, respectively. Plots of the predicted vs the observed LOS ratios of the hospitals revealed a threefold variation in LOS among hospitals with high model correlations. CONCLUSIONS APACHE IV and MPM(0) III were more accurate than SAPS II for the prediction of ICU LOS. APACHE IV is the most accurate and best calibrated model. Although it is less accurate, MPM(0) III may be a reasonable option if the data collection burden or the treatment effect bias is a consideration.
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Affiliation(s)
- Eduard E Vasilevskis
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of General Internal Medicine, University of California at San Francisco, San Francisco, CA; Division of Hospital Medicine, University of California at San Francisco, San Francisco, CA; Department of Medicine (General Internal Medicine and Public Health) [Dr. Vasilevskis], Vanderbilt University, Nashville, TN; Geriatric Research Education and Clinical Care, Tennessee Valley Healthcare System, Nashville, TN; Clinical Research Training Center of Excellence, Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN.
| | - Michael W Kuzniewicz
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of Neonatology, University of California at San Francisco, San Francisco, CA
| | - Brian A Cason
- Department of Anesthesiology and Perioperative Medicine, University of California at San Francisco, San Francisco, CA; Veterans Affairs Medical Center, San Francisco, CA
| | - Rondall K Lane
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Department of Anesthesiology and Perioperative Medicine, University of California at San Francisco, San Francisco, CA
| | - Mitzi L Dean
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
| | - Ted Clay
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
| | - Deborah J Rennie
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, University of California at San Francisco, San Francisco, CA
| | - R Adams Dudley
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, San Francisco, CA; Division of Pulmonary and Critical Care Medicine, University of California at San Francisco, San Francisco, CA
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Varelas PN, Conti MM, Spanaki MV, Potts E, Bradford D, Sunstrom C, Fedder W, Hacein Bey L, Jaradeh S, Gennarelli TA. The impact of a neurointensivist-led team on a semiclosed neurosciences intensive care unit*. Crit Care Med 2004; 32:2191-8. [PMID: 15640630 DOI: 10.1097/01.ccm.0000146131.03578.21] [Citation(s) in RCA: 97] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of a newly appointed neurointensivist on neurosciences intensive care unit (NICU) patient outcomes and quality of care variables. DESIGN Observational cohort with historical controls. SETTING Ten-bed neurointensive care unit in tertiary university hospital. PATIENTS Mortality, length of stay (LOS), and discharge disposition of all patients admitted to the NICU were compared between two 19-month periods, before and after the appointment of a neurointensivist. Data regarding these patients were collected using the hospital database and the University Hospitals Consortium database. Individual patient medical records were reviewed for major complications and important prognostic variable documentation. INTERVENTIONS Appointment of a neurointensivist. MEASUREMENTS AND MAIN RESULTS We analyzed 1,087 patients before and 1,279 after the neurointensivist's appointment. The unadjusted in-hospital mortality decreased from 10.1% in the before to 9.1% in the after period (95% confidence interval, -1.3 to 3%, relative mortality reduction of 9.9%), but this decrease was significantly different than the expected increase of 1.4% in University Hospitals Consortium mortality during the same period (p = .048). The unadjusted mortality in the NICU decreased from 8% to 6.3% (95% confidence interval, -0.5 to 4, relative mortality reduction 21%) and mean NICU LOS from 3.5 to 2.9 days (95% confidence interval, 0.2 to 0.9, relative NICU LOS reduction 17%). A significant 42% reduction of the risk of death during the first 3 days of NICU admission (p = .003) and a 12% greater risk for NICU discharge (p = .02) were found in the after period in multivariate proportional hazard models. Discharge home increased from 51.7% in the before to 59.7% in the after period (95% confidence interval, 4 to 12, relative increase of 15%) and discharge to a nursing home decreased from 8.1% to 6.8% (95% confidence interval, -1 to 4, relative decrease of 16%). Although a higher total number of complications occurred in the after period, fewer of them occurred in the NICU (odds ratio, 0.2; 95% confidence interval, 0.08 to 0.54, p = .001); this may possibly be due to the better documentation by the NICU team in the after period. CONCLUSIONS The institution of a neurointensivist-led team model was associated with an independent positive impact on patient outcomes, including a lower intensive care unit mortality, LOS, and discharge to a skilled nursing facility and a higher discharge home.
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