Simple triage scoring system predicting death and the need for critical care resources for use during epidemics

Prehospital early warning scores for adults with suspected sepsis: the PHEWS observational cohort and decision-analytic modelling study

Background

Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department.

Objectives

To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment.

Design

Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness.

Setting

Two ambulance services and four acute hospitals in England.

Participants

Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded.

Interventions

Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation.

Main outcome measures

Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained.

Results

Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed.

Limitations

We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling.

Conclusions

No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis.

Study registration

This study is registered as Research Registry (reference: researchregistry5268).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Assessment of the ABC2-SPH risk score to predict invasive mechanical ventilation in COVID-19 patients and comparison to other scores

Background

Predicting the need for invasive mechanical ventilation (IMV) is important for the allocation of human and technological resources, improvement of surveillance, and use of effective therapeutic measures. This study aimed (i) to assess whether the ABC2-SPH score is able to predict the receipt of IMV in COVID-19 patients; (ii) to compare its performance with other existing scores; (iii) to perform score recalibration, and to assess whether recalibration improved prediction.

Methods

Retrospective observational cohort, which included adult laboratory-confirmed COVID-19 patients admitted in 32 hospitals, from 14 Brazilian cities. This study was conducted in two stages: (i) for the assessment of the ABC2-SPH score and comparison with other available scores, patients hospitalized from July 31, 2020, to March 31, 2022, were included; (ii) for ABC2-SPH score recalibration and also comparison with other existing scores, patients admitted from January 1, 2021, to March 31, 2022, were enrolled. For both steps, the area under the receiving operator characteristic score (AUROC) was calculated for all scores, while a calibration plot was assessed only for the ABC2-SPH score. Comparisons between ABC2-SPH and the other scores followed the Delong Test recommendations. Logistic recalibration methods were used to improve results and adapt to the studied sample.

Results

Overall, 9,350 patients were included in the study, the median age was 58.5 (IQR 47.0-69.0) years old, and 45.4% were women. Of those, 33.5% were admitted to the ICU, 25.2% received IMV, and 17.8% died. The ABC2-SPH score showed a significantly greater discriminatory capacity, than the CURB-65, STSS, and SUM scores, with potentialized results when we consider only patients younger than 80 years old (AUROC 0.714 [95% CI 0.698-0.731]). Thus, after the ABC2-SPH score recalibration, we observed improvements in calibration (slope = 1.135, intercept = 0.242) and overall performance (Brier score = 0.127).

Conclusion

The ABC2-SPHr risk score demonstrated a good performance to predict the need for mechanical ventilation in COVID-19 hospitalized patients under 80 years of age.

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

BACKGROUND

Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment.

METHODS

We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression.

RESULTS

We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386).

CONCLUSION

No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2.

TRIAL REGISTRATION NUMBER

researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.

Improved performance of an intensive care unit after changing the admission triage model

The aim of this study is to analyze the effect of implementing a prioritization triage model for admission to an intensive care unit on the outcome of critically ill patients. Retrospective longitudinal study of adult patients admitted to the Intensive Care Unit (ICU) carried out from January 2013 to December 2017. The primary outcome considered was vital status at hospital discharge. Patients were divided into period 1 (chronological triage) during the years 2013 and 2014 and period 2 (prioritization triage) during the years 2015-2017. A total of 1227 patients in period 1 and 2056 in period 2 were analyzed. Patients admitted in period 2 were older (59.8 years) compared to period 1 (57.3 years; p < 0.001) with less chronic diseases (13.6% vs. 19.2%; p = 0.001), and higher median APACHE II score (21.0 vs. 18.0; p < 0.001)) and TISS 28 score (28.0 vs. 27.0; p < 0.001). In period 2, patients tended to stay in the ICU for a shorter time (8.5 ± 11.8 days) compared to period 1 (9.6 ± 16.0 days; p = 0.060) and had lower mortality at ICU (32.8% vs. 36.9%; p = 0.016) and hospital discharge (44.2% vs. 47.8%; p = 0.041). The change in the triage model from a chronological model to a prioritization model resulted in improvement in the performance of the ICU and reduction in the hospital mortality rate.

Comparison of 4 Different Threshold Values of Shock Index in Predicting Mortality of COVID-19 Patients

OBJECTIVE

The object of this study was to examine the accuracy in prehospital shock index (SI) for predicting intensive care unit (ICU) requirement and 30-d mortality among from coronavirus disease 2019 (COVID-19) patients transported to the hospital by ambulance.

METHODS

All consecutive patients who were the age ≥18 y, transported to the emergency department (ED) by ambulance with a suspected or confirmed COVID-19 in the prehospital frame were included in the study. Four different cutoff points were compared (0.7, 0.8, 0.9, and 1.0) to examine the predictive performance of both the mortality and ICU requirement of the SI. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) was used to evaluate each cut-off value discriminatory for predicting 30-d mortality and ICU admission.

RESULTS

The total of 364 patients was included in this study. The median age in the study population was 69 y (range, 55-80 y), of which 196 were men and 168 were women. AUC values for 30-d mortality outcome were calculated as 0.672, 0.674, 0.755, and 0.626, respectively, for threshold values of 0.7, 0.8, 0.9 and 1.0. ICU admission was more likely for the patients with prehospital SI > 0.9. Similarly, the mortality rate was higher in patients with prehospital SI > 0.9.

CONCLUSIONS

Early triage of COVID-19 patients will ensure efficient use of health-care resources. The SI could be a helpful, fast, and powerful tool for predicting mortality status and ICU requirements of adult COVID-19 patients. It was concluded that the most useful threshold value for the shock index in predicting the prognosis of COVID-19 patients is 0.9.

Stay Home, Work Safe: Attitudes and Beliefs of Members of a Department of Palliative Care, Rehabilitation, and Integrative Medicine Regarding Remote Work during the COVID-19 Pandemic

Background: The coronavirus disease 2019 (COVID-19) pandemic compelled rapid transition to work from home for the University of Texas MD Anderson Cancer Center Palliative, Rehabilitation, and Integrative Medicine (PRIM) department to ensure social distancing and prevention of transmission. Objectives: To survey the attitudes and beliefs of personnel toward remote work during the COVID-19 pandemic. Methods: One hundred forty-eight clinical, research, and administrative PRIM department employees were invited to participate in an anonymous voluntary survey in May 2020, two months after the beginning of the COVID-19 pandemic and transition to work from home in the geographic location of Houston, Texas. The survey comprised 25 questions, including employee demographics and attitudes and beliefs toward working from home and the COVID-19 pandemic. Results: Ninety-four percent (139) of employees responded, with high response rates among all three employee arms. The majority of respondents were female (74%), between the ages of 30 and 59 years (87%), had broadband Internet (93%), and shared office space before working from home (59%). There were overall positive reports of experience (87%) and emotional response (79%) toward working from home, especially for those more concerned about COVID-19 illness and spread, shared office space, and those reporting adequate resources and equipment for remote work. Clinical role, however, was associated with a less positive response (80%), less productivity (29%), and higher levels of stress (62%). Most of the department also reported increased emotional exhaustion (68%). When surveyed about permanently working from home, most of the department responded favorably (69%). Conclusions: The PRIM rapid transition to remote work was associated with positive perceptions by most members of the clinical, research, and administrative teams. Insight from this survey can serve as a model for future rapid transitions in remote work and merits follow-up studies to prepare us for a postpandemic work environment. Clinical Trial Registration number NCI-2021-01265.

A literature review of severity scores for adults with influenza or community-acquired pneumonia - implications for influenza vaccines and therapeutics

Influenza vaccination and antiviral therapeutics may attenuate disease, decreasing severity of illness in vaccinated and treated persons. Standardized assessment tools, definitions of disease severity, and clinical endpoints would support characterizing the attenuating effects of influenza vaccines and antivirals. We review potential clinical parameters and endpoints that may be useful for ordinal scales evaluating attenuating effects of influenza vaccines and antivirals in hospital-based studies. In studies of influenza and community-acquired pneumonia, common physiologic parameters that predicted outcomes such as mortality, ICU admission, complications, and duration of stay included vital signs (hypotension, tachypnea, fever, hypoxia), laboratory results (blood urea nitrogen, platelets, serum sodium), and radiographic findings of infiltrates or effusions. Ordinal scales based on these parameters may be useful endpoints for evaluating attenuating effects of influenza vaccines and therapeutics. Factors such as clinical and policy relevance, reproducibility, and specificity of measurements should be considered when creating a standardized ordinal scale for assessment.

Measurement of respiratory rate using wearable devices and applications to COVID-19 detection

We show that heart rate enabled wearable devices can be used to measure respiratory rate. Respiration modulates the heart rate creating excess power in the heart rate variability at a frequency equal to the respiratory rate, a phenomenon known as respiratory sinus arrhythmia. We isolate this component from the power spectral density of the heart beat interval time series, and show that the respiratory rate thus estimated is in good agreement with a validation dataset acquired from sleep studies (root mean squared error = 0.648 min^-1, mean absolute error = 0.46 min^-1, mean absolute percentage error = 3%). We use this respiratory rate algorithm to illuminate two potential applications (a) understanding the distribution of nocturnal respiratory rate as a function of age and sex, and (b) examining changes in longitudinal nocturnal respiratory rate due to a respiratory infection such as COVID-19. 90% of respiratory rate values for healthy adults fall within the range 11.8-19.2 min^-1 with a mean value of 15.4 min^-1. Respiratory rate is shown to increase with nocturnal heart rate. It also varies with BMI, reaching a minimum at 25 kg/m², and increasing for lower and higher BMI. The respiratory rate decreases slightly with age and is higher in females compared to males for age <50 years, with no difference between females and males thereafter. The 90% range for the coefficient of variation in a 14 day period for females (males) varies from 2.3-9.2% (2.3-9.5%) for ages 20-24 yr, to 2.5-16.8% (2.7-21.7%) for ages 65-69 yr. We show that respiratory rate is often elevated in subjects diagnosed with COVID-19. In a 7 day window from D_-1 to D₊₅ (where D₀ is the date when symptoms first present, for symptomatic individuals, and the test date for asymptomatic cases), we find that 36.4% (23.7%) of symptomatic (asymptomatic) individuals had at least one measurement of respiratory rate 3 min^-1 higher than the regular rate.

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review

PURPOSE

This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable.

MATERIALS AND METHODS

Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation.

RESULTS

Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care.

CONCLUSIONS

This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study

Objective

To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon sequential organ failure assessment (SOFA) for decision support for a Crisis Standards of Care team.

Materials and Methods

We developed, verified, and deployed a stacked generalization model to predict mortality using data available in the electronic health record (EHR) by combining 5 previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We verified the model with prospectively collected data from 12 hospitals in Colorado between March 2020 and July 2020. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index.

Results

The prospective cohort included 27 296 encounters, of which 1358 (5.0%) were positive for SARS-CoV-2, 4494 (16.5%) required intensive care unit care, 1480 (5.4%) required mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94. In the subset of patients with COVID-19, the stacked model predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85.

Discussion

Stacked regression allows a flexible, updatable, live-implementable, ethically defensible predictive analytics tool for decision support that begins with validated models and includes only novel information that improves prediction.

Conclusion

We developed and validated an accurate in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model that improved upon SOFA.

Performance of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 (CURB-65) score among patients with COVID-19 pneumonia in an emergency department triage setting: a retrospective study

BACKGROUND

Healthcare institutions are confronted with large numbers of patient admissions during large-scale or long-term public health emergencies like pandemics. Appropriate and effective triage is needed for effective resource use.

OBJECTIVES

To evaluate the effectiveness of the Pandemic Medical Early Warning Score (PMEWS), Simple Triage Scoring System (STSS) and Confusion, Uremia, Respiratory rate, Blood pressure and age ≥ 65 years (CURB-65) score in an emergency department (ED) triage setting.

DESIGN AND SETTING

Retrospective study in the ED of a tertiary-care university hospital in Düzce, Turkey.

METHODS

PMEWS, STSS and CURB-65 scores of patients diagnosed with COVID-19 pneumonia were calculated. Thirty-day mortality, intensive care unit (ICU) admission, mechanical ventilation (MV) need and outcomes were recorded. The predictive accuracy of the scores was assessed using receiver operating characteristic curve analysis.

RESULTS

One hundred patients with COVID-19 pneumonia were included. The 30-day mortality was 6%. PMEWS, STSS and CURB-65 showed high performance for predicting 30-day mortality (area under the curve: 0.968, 0.962 and 0.942, respectively). Age > 65 years, respiratory rate > 20/minute, oxygen saturation (SpO2) < 90% and ED length of stay > 4 hours showed associations with 30-day mortality (P < 0.05).

CONCLUSIONS

CURB-65, STSS and PMEWS scores are useful for predicting mortality, ICU admission and MV need among patients diagnosed with COVID-19 pneumonia. Advanced age, increased respiratory rate, low SpO2 and prolonged ED length of stay may increase mortality. Further studies are needed for developing the triage scoring systems, to ensure effective long-term use of healthcare service capacity during pandemics.

Real-Time Electronic Health Record Mortality Prediction During the COVID-19 Pandemic: A Prospective Cohort Study

Background

The SARS-CoV-2 virus has infected millions of people, overwhelming critical care resources in some regions. Many plans for rationing critical care resources during crises are based on the Sequential Organ Failure Assessment (SOFA) score. The COVID-19 pandemic created an emergent need to develop and validate a novel electronic health record (EHR)-computable tool to predict mortality.

Research Questions

To rapidly develop, validate, and implement a novel real-time mortality score for the COVID-19 pandemic that improves upon SOFA.

Study Design and Methods

We conducted a prospective cohort study of a regional health system with 12 hospitals in Colorado between March 2020 and July 2020. All patients >14 years old hospitalized during the study period without a do not resuscitate order were included. Patients were stratified by the diagnosis of COVID-19. From this cohort, we developed and validated a model using stacked generalization to predict mortality using data widely available in the EHR by combining five previously validated scores and additional novel variables reported to be associated with COVID-19-specific mortality. We compared the area under the receiver operator curve (AUROC) for the new model to the SOFA score and the Charlson Comorbidity Index.

Results

We prospectively analyzed 27,296 encounters, of which 1,358 (5.0%) were positive for SARS-CoV-2, 4,494 (16.5%) included intensive care unit (ICU)-level care, 1,480 (5.4%) included invasive mechanical ventilation, and 717 (2.6%) ended in death. The Charlson Comorbidity Index and SOFA scores predicted overall mortality with an AUROC of 0.72 and 0.90, respectively. Our novel score predicted overall mortality with AUROC 0.94. In the subset of patients with COVID-19, we predicted mortality with AUROC 0.90, whereas SOFA had AUROC of 0.85.

Interpretation

We developed and validated an accurate, in-hospital mortality prediction score in a live EHR for automatic and continuous calculation using a novel model, that improved upon SOFA.

Take Home Points

Study Question: Can we improve upon the SOFA score for real-time mortality prediction during the COVID-19 pandemic by leveraging electronic health record (EHR) data?Results: We rapidly developed and implemented a novel yet SOFA-anchored mortality model across 12 hospitals and conducted a prospective cohort study of 27,296 adult hospitalizations, 1,358 (5.0%) of which were positive for SARS-CoV-2. The Charlson Comorbidity Index and SOFA scores predicted all-cause mortality with AUROCs of 0.72 and 0.90, respectively. Our novel score predicted mortality with AUROC 0.94.Interpretation: A novel EHR-based mortality score can be rapidly implemented to better predict patient outcomes during an evolving pandemic.

Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice

BACKGROUND

The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks.

METHODS

We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design.

RESULTS

From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason.

CONCLUSIONS

This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.

Spanish Influenza Score (SIS): Usefulness of machine learning in the development of an early mortality prediction score in severe influenza

OBJECTIVE

To develop a mortality prediction score (Spanish Influenza Score [SIS]) for patients with severe influenza considering only variables at ICU admission, and compare its performance respect of Random Forest (RF).

DESIGN

Sub-analysis from the GETGAG/SEMICYUC database.

SCOPE

Intensive Care Medicine.

PATIENTS

Patients admitted to 184 Spanish ICUs (2009-2018) with influenza infection Intervention: None.

VARIABLES

Demographic data, severity of illness, times from symptoms onset until hospital admission (Gap-H), hospital to ICU (Gap-ICU) or hospital to diagnosis (Gap-Dg), antiviral vaccination, number of quadrants infiltrated, acute renal failure, invasive or noninvasive ventilation, shock and comorbidities. The study variable cut-off points and importance were obtained automatically. Logistic regression analysis with cross-validation was performed to develop the SIS score using the output coefficients. Accuracy and discrimination (AUC-ROC) were applied to evaluate SIS and RF. All analyses were performed using R (CRAN-R Project).

RESULTS

A total of 3959 patients were included. The mean age was 55 years (range 43-67), 60% were men, APACHE II 16 (12-21) and SOFA 5 (4-8), with ICU mortality 21.3%. Mechanical ventilation, shock, APACHE II, SOFA, acute renal failure and Gap-ICU were included in the SIS. The latter was generated according to the ORs obtained by logistic regression, and showed an accuracy of 83% with an AUC-ROC of 82%, similar to RF (AUC-ROC 82%).

CONCLUSIONS

The SIS score is easy to apply and shows adequate capacity to stratify the risk of ICU mortality. However, further studies are needed to validate the tool prospectively.

Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival

OBJECTIVES

Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions.

DATA SOURCES

PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies.

STUDY SELECTION

Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email.

DATA EXTRACTION

References and data were based on relevance and author consensus.

DATA SYNTHESIS

We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients.

CONCLUSIONS

Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

Shock Index: A Simple and Effective Clinical Adjunct in Predicting 60-Day Mortality in Advanced Cancer Patients at the Emergency Department

Deciding between palliative and overly aggressive therapies for advanced cancer patients who present to the emergency department (ED) with acute issues requires a prediction of their short-term survival. Various scoring systems have previously been studied in hospices or intensive care units, though they are unsuitable for use in the ED. We aim to examine the use of a shock index (SI) in predicting the 60-day survival of advanced cancer patients presenting to the ED. Identified high-risk patients and their families can then be counseled accordingly. Three hundred and five advanced cancer patients who presented to the EDs of three tertiary hospitals were recruited, and their data retrospectively analyzed. Relevant data regarding medical history and clinical presentation were extracted, and respective shock indices calculated. Multivariate logistic regression analyses were performed. Receiver operating characteristic (ROC) curves were plotted to evaluate the predictive performance of the SI. Nonsurvivors within 60 days had significantly lower body temperatures and blood pressure, as well as higher pulse rates, respiratory rates, and SI. Each 0.1 SI increment had an odds ratio of 1.39 with respect to 60-day mortality. The area under the ROC curve was 0.7511. At the optimal cut-off point of 0.94, the SI had 81.38% sensitivity and 73.11% accuracy. This makes the SI an ideal evaluation tool for rapidly predicting the 60-day mortality risk of advanced cancer patients presenting to the ED. Identified patients can be counseled accordingly, and they can be assisted in making informed decisions on the appropriate treatment goals reflective of their prognoses.

The Critical Care Society of Southern Africa Consensus Statement on ICU Triage and Rationing (ConICTri)

Background

In South Africa (SA), intensive care is faced with the challenge of resource scarcity as well as an increasing demand for intensive care unit (ICU) services. ICU services are expensive, and practitioners in low- to middle-income countries experience daily the consequences of limited resources. Critically limited resources necessitate that rationing and triage (prioritisation) decisions are frequently necessary in SA, particularly in the publicly funded health sector.

Purpose

The purpose of this consensus statement is to examine key questions that arise when considering the status of ICU resources in SA, and more specifically ICU admission, rationing and triage decisions. The accompanying guideline in this issue is intended to guide frontline triage policy and ensure the best utilisation of intensive care in SA, while maintaining a fair distribution of available resources. Fair and efficient triage is important to ensure the ongoing provision of high-quality care to adult patients referred for intensive care.

Recommendations

In response to 14 key questions developed using a modified Delphi technique, 29 recommendations were formulated and graded using an adapted GRADE score. The 14 key questions addressed the status of the provision of ICU services in SA, the degree of resource restriction, the efficiency of resource management, the need for triage, and how triage could be most justly implemented. Important recommendations included the need to formally recognise and accurately quantify the provision of ICU services in SA by national audit; actively seek additional resources from governmental bodies; consider methods to maximise the efficiency of ICU care; evaluate lower level of care alternatives; develop a triage guideline to assist policy-makers and frontline practitioners to implement triage decisions in an efficient and fair way; measure and audit the consequence of triage; and promote research to improve the accuracy and consistency of triage decisions. The consensus document and guideline should be reviewed and revised appropriately within 5 years.

Conclusion

In recognition of the absolute need to limit patient access to ICU because of the lack of sufficient intensive care resources in public hospitals, recommendations and a guideline have been developed to guide policy-making and assist frontline triage decision-making in SA. These documents are not a complete plan for quality practice but rather the beginning of a long-term initiative to engage clinicians, the public and administrators in appropriate triage decision-making, and promote systems that will ultimately maximise the efficient and fair use of available ICU resources.

Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review

Background: To improve outcomes for patients who present to hospital with suspected sepsis, it is necessary to accurately identify those at high risk of adverse outcomes as early and swiftly as possible. To assess the prognostic accuracy of shock index (heart rate divided by systolic blood pressure) and its modifications in patients with sepsis or community-acquired pneumonia. Methods: An electronic search of MEDLINE, EMBASE, Allie and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Open Grey, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (WHO ITRP) was conducted from conception to 26th March 2019. Eligible studies were required to assess the prognostic accuracy of shock index or its modifications for outcomes of death or requirement for organ support either in sepsis or pneumonia. The methodological appraisal was carried out using the Downs and Black checklist. Evidence was synthesised using a narrative approach due to heterogeneity. Results: Of 759 records screened, 15 studies (8697 patients) were included in this review. Shock index ≥ 1 at time of hospital presentation was a moderately accurate predictor of mortality in patients with sepsis or community-acquired pneumonia, with high specificity and low sensitivity. Only one study reported outcomes related to organ support. Conclusions: Elevated shock index at time of hospital presentation predicts mortality in sepsis with high specificity. Shock index may offer benefits over existing sepsis scoring systems due to its simplicity.

Shock Index in Patients Presenting With Acute Heart Failure: A Multicenter Multinational Observational Study

Shock index (SI) has a prognostic role in coronary heart disease; however, data on acute heart failure (AHF) are lacking. We evaluated the predictive values of SI in patients with AHF. Data were retrospectively analyzed from the Gulf Acute Heart Failure Registry. Patients were categorized into low SI versus high SI based on the receiver operating characteristic curves. Primary outcomes included cardiogenic shock (CS) and mortality. Among 4818 patients with AHF, 1143 had an SI ≥0.9. Compared with SI <0.9, patients with high SI were more likely males, younger, and having advanced New York Heart Association class, fewer cardiovascular risk factors and less prehospital β-blockers and angiotensin-converting enzyme inhibitor use. Shock index had significant negative correlations with age, pulse pressure, mean arterial pressure, and left ventricle ejection fraction and had positive correlation with hospital length of stay. Shock index ≥0.9 was significantly associated with higher composite end points, in-hospital, and 3-month mortality. Shock index ≥0.9 had 96% negative predictive value (NPV) and 3.5 relative risk for mortality. Multivariate regression analysis showed that SI was independent predictor of mortality and CS. With a high NPV, SI is a simple reliable bedside tool for risk stratification of patients with AHF. However, this conclusion needs further support.

Comparison of SIRS, qSOFA, and NEWS for the early identification of sepsis in the Emergency Department

OBJECTIVES

The increasing use of sepsis screening in the Emergency Department (ED) and the Sepsis-3 recommendation to use the quick Sepsis-related Organ Failure Assessment (qSOFA) necessitates validation. We compared Systemic Inflammatory Response Syndrome (SIRS), qSOFA, and the National Early Warning Score (NEWS) for the identification of severe sepsis and septic shock (SS/SS) during ED triage.

METHODS

This was a retrospective analysis from an urban, tertiary-care academic center that included 130,595 adult visits to the ED, excluding dispositions lacking adequate clinical evaluation (n = 14,861, 11.4%). The SS/SS group (n = 930) was selected using discharge diagnoses and chart review. We measured sensitivity, specificity, and area under the receiver-operating characteristic (AUROC) for the detection of sepsis endpoints.

RESULTS

NEWS was most accurate for triage detection of SS/SS (AUROC = 0.91, 0.88, 0.81), septic shock (AUROC = 0.93, 0.88, 0.84), and sepsis-related mortality (AUROC = 0.95, 0.89, 0.87) for NEWS, SIRS, and qSOFA, respectively (p < 0.01 for NEWS versus SIRS and qSOFA). For the detection of SS/SS (95% CI), sensitivities were 84.2% (81.5-86.5%), 86.1% (83.6-88.2%), and 28.5% (25.6-31.7%) and specificities were 85.0% (84.8-85.3%), 79.1% (78.9-79.3%), and 98.9% (98.8-99.0%) for NEWS ≥ 4, SIRS ≥ 2, and qSOFA ≥ 2, respectively.

CONCLUSIONS

NEWS was the most accurate scoring system for the detection of all sepsis endpoints. Furthermore, NEWS was more specific with similar sensitivity relative to SIRS, improves with disease severity, and is immediately available as it does not require laboratories. However, scoring NEWS is more involved and may be better suited for automated computation. QSOFA had the lowest sensitivity and is a poor tool for ED sepsis screening.

Prehospital shock index, modified shock index, and pulse pressure heart rate ratio as predictors of massive blood transfusions in modern warfare injuries: A retrospective analysis

Background

Massive hemorrhage is the leading preventable cause of death in modern warfare injuries. Early and accurate detection of source of hemorrhage and massive blood transfusions remain the mainstay of management in such cases. Hemodynamic indices like shock index (SI), modified shock index (MSI), and pulse pressure heart rate (PP/HR) ratio have shown promising results in predicting massive transfusion in trauma patients. The present study aimed at assessing the accuracy of SI, MSI, and PP/HR ratio to predict the requirement of massive blood transfusions.

Methods

A retrospective analysis was done from 1st January 2016 to 31st December 2016 of the data taken from the trauma register of our hospital. Data were analyzed, and scores of SI, MSI, and PP/HR ratio were evaluated using area under receiver operating curves (AUROCs). Massive transfusion was defined as requirement of ≥10 packed red blood cells (PRBCs) in the first 24 hours or ≥4 PRBCs in first hour of hospital admission.

Results

Of the 326 warfare casualties received, a total of 254 patients were enrolled, and 51(23%) patients required massive transfusion on arrival. SI had an AUROC value of 0.798 (95% confidence interval [CI] = 0.739-0.848) which is comparable to MSI at 0.787 (95% CI = 0.728-0.839) and PP/HR ratio with a value of 0.744 (95% CI = 0.681-0.800), (p<0.001).

Conclusion

SI, MSI, and PP/HR ratio are equally efficient in predicting massive transfusion in warfare injuries and can be used as rapidly available marker for prediction of massive transfusion in warfare injuries which can be lifesaving and time-saving.

Oxygen exchange and C-reactive protein predict safe discharge in patients with H1N1 influenza

BACKGROUND

: Pandemic influenza has potential to overwhelm healthcare resources. There is uncertainty over performance of existing triage tools for hospital admission and discharge decisions.

AIM

: Our aim was to identify clinical criteria that predict safe discharge from hospital and develop a pragmatic triage tool to guide physician decision-making.

DESIGN

: We retrospectively examined an existing database of patients who presented to the Royal Liverpool University Hospital during the 2010-11 influenza pandemic.

METHODS

Inclusion criteria: patients ≥18 years, with PCR confirmed H1N1 influenza. Exclusion criteria: died in the emergency department or case notes unavailable. Successful discharge was defined as discharge within 24 h of presentation and no readmission within 7 days.

RESULTS

Eighty-six patients were included and 16 were successfully discharged. Estimated P/F ratio and C-reactive protein predicted safe discharge in a multivariable logistic regression model (AUC 0.883). A composite univariate predictor (estimated P/F minus C-reactive protein, AUC 0.877) was created to calculate specific cut off points for sensitivity and specificity. A pragmatic decision tool was created to incorporate these thresholds and relevant guidelines. Discharge: SpO 2 (in air)   ≥ 94% and CRP <50. Observe: SpO 2  ≥   94% and CRP >50 or SpO 2  ≤   93% and CRP <50. Admit: SpO 2  ≤   93% and CRP >50.

CONCLUSIONS

We identified that oxygen exchange and CRP, a marker of acute inflammation, were the most important predictors of safe discharge. Our proposed simple triage model requires validation but has the potential to aid clinical decisions in the event of a future pandemic, and potentially for seasonal influenza.

The use of the reverse shock index to identify high-risk trauma patients in addition to the criteria for trauma team activation: a cross-sectional study based on a trauma registry system

OBJECTIVES

The presentation of decrease blood pressure with tachycardia is usually an indicator of significant blood loss. In this study, we used the reverse shock index (RSI), a ratio of systolic blood pressure (SBP) to heart rate (HR), to evaluate the haemodynamic status of trauma patients. As an SBP lower than the HR (RSI<1) may indicate haemodynamic instability, the objective of this study was to assess whether RSI<1 can help to identify high-risk patients with potential shock and poor outcome, even though these patients do not yet meet the criteria for multidisciplinary trauma team activation (TTA).

DESIGN

Cross-sectional study.

SETTING

Taiwan.

PARTICIPANTS

We retrospectively reviewed the data of 20 106 patients obtained from the trauma registry system of a level I trauma centre for trauma admissions from January 2009 through December 2014. Patients for whom a trauma team was not activated (regular patients) and who had RSI<1 were compared with regular patients with RSI≥1. The ORs of the associated conditions and injuries were calculated with 95% CIs.

MAIN OUTCOME MEASURES

In-hospital mortality.

RESULTS

Among regular patients with RSI<1, significantly more patients had an Injury Severity Score (ISS) ≥25 (OR 2.4, 95% CI 1.58 to 3.62; p<0.001) and the mortality rate was also higher (2.1% vs 0.5%; OR 3.9, 95% CI 2.10 to 7.08; p<0.001) than in regular patients with RSI≥1. The intensive care unit length of stay was longer in regular patients with RSI<1 than in regular patients with RSI≥1.

CONCLUSIONS

Among patients who did not reach the criteria for TTA, RSI<1 indicates a potentially worse outcome and a requirement for more attention and aggressive care in the emergency department.

Surveillance of Patients in the Waiting Area of the Department of Emergency Medicine

Many patients visiting an emergency department are in reduced general condition of health and at risk of suffering further deterioration during their stay. We wanted to test the feasibility of a new monitoring system in a waiting area of an emergency department.In an observational cross-sectional single-center study, patients with acute cardiac or pulmonary symptoms or in potentially life-threatening conditions were enrolled. Monitoring devices providing vital signs via short range radio (SRR) at certain time points and compliance evaluation forms were used.Out of 230 patients, 4 wanted to terminate their participation prematurely. No data was lost due to technical difficulties. Over a median monitoring period of 178 (118-258) min per patient, 684 h of vital sign data were collected and used to assist managing those patients. Linear regression analysis between clinical symptom category groups of patients showed significant differences in the respiratory rate and noninvasive blood pressure courses. Feedback from patients and users via questionnaires showed overall very good acceptance and patients felt that they were given better care.To assist medical staff of an emergency department waiting area to rapidly response to potentially life-threatening situations of its patients, a new monitoring system proved to be feasible and safe.

Performance of influenza-specific triage tools in an H1N1-positive cohort: P/F ratio better predicts the need for mechanical ventilation and critical care admission

BACKGROUND

Pandemic influenza presents a major threat to global health and socioeconomic well-being. Future demand for critical care may outstrip supply and force clinicians to triage patients for admission. We evaluated the Simple Triage Scoring System (STSS), Ontario Health Plan for an Influenza Epidemic (OHPIP) and PaO2 /FiO2  (P/F) ratio to determine utility in predicting need for mechanical ventilation.

METHODS

We conducted a retrospective case note review of patients admitted to two centres, Royal Liverpool University Hospital and Countess of Chester Hospital, during the UK influenza pandemic of 2010-11. Demand for critical care during this period forced hospitals in Cheshire and Merseyside to implement escalation policies and increase capacity. Inclusion criteria were polymerase chain reaction-confirmed H1N1 influenza and age >18 years. Exclusion criteria were no evidence of treatment for influenza, patient not admitted to hospital or the inability to locate case notes.

RESULTS

One hundred and one patients were included, 29 were admitted to critical care and 23 required mechanical ventilation. The P/F ratio predicted the need for mechanical ventilation with a receiver operating characteristic area under the curve (ROC AUC) of 0.885 (CI 0.817-0.952). Predictive ability was not reduced when the P/F ratio had to be estimated using the Pandharipande tool. The STSS score predicted the need for mechanical ventilation [ROC AUC 0.798 (CI 0.704-0.891)]. The reverse triage component of the OHPIP tool was a poor predictor of patient outcome.

CONCLUSIONS

The P/F ratio was a better predictor of need for mechanical ventilation than STSS. The P/F ratio is a simple and accepted determinant of hypoxaemia and should be used if secondary triaging becomes necessary during future influenza pandemics.

Correlation of shock index and modified shock index with the outcome of adult trauma patients: a prospective study of 9860 patients

BACKGROUND

Triage at emergency department is performed to identify those patients who are relatively more serious and require immediate attention and treatment. Despite current methods of triage, trauma continues to be a leading cause of morbidity and mortality.

AIMS

This study was to evaluate the predictive value of shock index (SI) and modified shock index (MSI) for hospital mortality among adult trauma patients.

MATERIALS AND METHODS

In this prospective longitudinal study, all adult patients who sustained trauma enrolled as per as inclusion/exclusion criteria. After the collection of data, SI and MSI were calculated accordingly. All parameters were again recorded hourly and calculations were done at six-hour intervals. Further, to achieve a value that can be analyzed, we determined threshold value for vital signs, which set the threshold values as heart rate at 120 beats per minute, systolic blood pressure at less than 90, and SI at cut-off 0.5-0.9 and MSI at less than 0.7 to more than 1.3.

RESULTS

We analyzed 9860 adult trauma patients. Multivariate regression analysis demonstrated that heart rate more than 120 beats per minute, systolic blood pressure less than 90 mmHg, and diastolic blood pressure (DBP) less than 60 mmHg correlate with hospital stay and mortality rate. MSI <0.7 and >1.3 had higher odds of mortality as compared to other predictors.

CONCLUSIONS

MSI is an important marker for predicting the mortality rate and is significantly better than heart rate, systolic blood pressure, DBP and SI alone. Therefore, modified SI should be used in the triage of serious patients, including trauma patients in the emergency room.

Modified shock index and mortality rate of emergency patients

BACKGROUND

This study aimed to determine whether modified shock index (MSI) is associated with mortality that is superior to heart rate, blood pressure, or the shock index (SI) in emergency patients.

METHODS

A retrospective database review was performed on 22 161 patients who presented to Peking Union Medical College Hospital Emergency Department and received intravenous fluids from January 1 to December 31, 2009. We gathered data of the patients on age, gender, vital signs, levels of consciousness, presenting complaints, and SI and MSI were calculated for all patients.

RESULTS

Multivariate regression analysis was performed to determine the correlation between risk factors and outcome. There is a significant correlation between emergency patient mortality rate and patient's vital signs obtained at the triage desk (HR>120 beats/min, systolic BP<90 mmHg, diastolic BP<60 mmHg). MSI is a stronger predictor of emergency patient mortality compared to heart rate and blood pressure alone, whereas SI does not have a significant correlation with emergency patient mortality rate.

CONCLUSION

MSI is a clinically significant predictor of mortality in emergency patients. It may be better than using heart rate and blood pressure alone. SI is not significantly correlated with the mortality rate of the emergency patient.

Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older

PURPOSE

Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups.

BASIC PROCEDURES

Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older.

MAIN FINDINGS

The primary analysis included 33906 subjects (101837 weighted) 10 years and older. The secondary analysis included 13393 subjects (37983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years.

CONCLUSIONS

This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.

Predictive factors of severe multilobar pneumonia and shock in patients with influenza

Purpose

To identify risk factors present at admission in adult patients hospitalised due to influenza virus infection during the 2009/10 and 2010/11 seasons—including whether infection was from pandemic or seasonal influenza A infections—that were associated with the likelihood of developing severe pneumonia with multilobar involvement and shock.

Methods

Prospective cohort study. Patients hospitalised due to influenza virus infection were recruited. We collected information on sociodemographic characteristics, pre-existing medical conditions, vaccinations, toxic habits, previous medications, exposure to social environments, and EuroQoL-5D (EQ-5D). Severe pneumonia with multilobar involvement and/or shock (SPAS) was the primary outcome of interest. We constructed two multivariate logistic regression models to explain the likelihood of developing SPAS and to create a clinical prediction rule for developing SPAS that includes clinically relevant variables.

Results

Laboratory-confirmed A(H1N1)pdm09, EQ-5D utility score 7 days before admission, more than one comorbidity, altered mental status, dyspnoea on arrival, days from onset of symptoms, and influenza season were associated with SPAS. In addition, not being vaccinated against seasonal influenza in the previous year, anaemia, altered mental status, fever and dyspnoea on arrival at hospital, difficulties in performing activities of daily living in the previous 7 days, and days from onset of symptoms to arrival at hospital were related to the likelihood of SPAS (area under the curve value of 0.75; Hosmer–Lemeshow p value of 0.84).

Conclusions

These variables should be taken into account by physicians evaluating a patient affected by influenza as additional information to that provided by the usual risk scores.

Triage of mechanical ventilation for pediatric patients during a pandemic

OBJECTIVE

The novel H1N1 influenza pandemic renewed the concern that during a severe pandemic illness, critical care and mechanical ventilation resources will be inadequate to meet the needs of patients. Several published protocols address the need to triage patients for access to ventilator resources. However, to our knowledge, none of these has addressed the pediatric populations.

METHODS

We used a systematic review of the pediatric critical care literature to evaluate pediatric critical care prognosis and multisystem organ failure scoring systems. We used multiple search engines, including MEDLINE and EMBASE, using a search for terms and key words including including multiple organ failure, multiple organ dysfunction, PELOD, PRISM III, pediatric risk of mortality score, pediatric logistic organ dysfunction, pediatric index of mortality pediatric multiple organ dysfunction score, "child+multiple organ failure + scoring system." Searches were conducted in the period January 2010-February 2010.

RESULTS

Of the 69 papers reviewed, 22 were used. Five independently derived scoring systems were evaluated for use in a respiratory pandemic ventilator triage protocol. The Pediatric Logistic Organ Dysfunction (PELOD) scoring system was the most appropriate for use in such a triage protocol.

CONCLUSIONS

We present a pediatric-specific ventilator triage protocol using the PELOD scoring system to complement the NY State adult triage protocol. Further evaluation of pediatric scoring systems is imperative to ensure appropriate triage of pediatric patients.

A modified sequential organ failure assessment score for critical care triage

OBJECTIVE

The Sequential Organ Failure Assessment (SOFA) score has been recommended for triage during a mass influx of critically ill patients, but it requires laboratory measurement of 4 parameters, which may be impractical with constrained resources. We hypothesized that a modified SOFA (MSOFA) score that requires only 1 laboratory measurement would predict patient outcome as effectively as the SOFA score.

METHODS

After a retrospective derivation in a prospective observational study in a 24-bed medical, surgical, and trauma intensive care unit, we determined serial SOFA and MSOFA scores on all patients admitted during the 2008 calendar year and compared the ability to predict mortality and the need for mechanical ventilation.

RESULTS

A total of 1770 patients (56% male patients) with a 30-day mortality of 10.5% were included in the study. Day 1 SOFA and MSOFA scores performed equally well at predicting mortality with an area under the receiver operating curve (AUC) of 0.83 (95% confidence interval 0.81-.85) and 0.84 (95% confidence interval 0.82-.85), respectively (P = .33 for comparison). Day 3 SOFA and MSOFA predicted mortality for the 828 patients remaining in the intensive care unit with an AUC of 0.78 and 0.79, respectively. Day 5 scores performed less well at predicting mortality. Day 1 SOFA and MSOFA predicted the need for mechanical ventilation on day 3, with an AUC of 0.83 and 0.82, respectively. Mortality for the highest category of SOFA and MSOFA score (>11 points) was 53% and 58%, respectively.

CONCLUSIONS

The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource-constrained settings, but using either score as a triage tool would exclude many patients who would otherwise survive.

Health system resource gaps and associated mortality from pandemic influenza across six Asian territories

Background

Southeast Asia has been the focus of considerable investment in pandemic influenza preparedness. Given the wide variation in socio-economic conditions, health system capacity across the region is likely to impact to varying degrees on pandemic mitigation operations. We aimed to estimate and compare the resource gaps, and potential mortalities associated with those gaps, for responding to pandemic influenza within and between six territories in Asia.

Methods and Findings

We collected health system resource data from Cambodia, Indonesia (Jakarta and Bali), Lao PDR, Taiwan, Thailand and Vietnam. We applied a mathematical transmission model to simulate a “mild-to-moderate” pandemic influenza scenario to estimate resource needs, gaps, and attributable mortalities at province level within each territory. The results show that wide variations exist in resource capacities between and within the six territories, with substantial mortalities predicted as a result of resource gaps (referred to here as “avoidable” mortalities), particularly in poorer areas. Severe nationwide shortages of mechanical ventilators were estimated to be a major cause of avoidable mortalities in all territories except Taiwan. Other resources (oseltamivir, hospital beds and human resources) are inequitably distributed within countries. Estimates of resource gaps and avoidable mortalities were highly sensitive to model parameters defining the transmissibility and clinical severity of the pandemic scenario. However, geographic patterns observed within and across territories remained similar for the range of parameter values explored.

Conclusions

The findings have important implications for where (both geographically and in terms of which resource types) investment is most needed, and the potential impact of resource mobilization for mitigating the disease burden of an influenza pandemic. Effective mobilization of resources across administrative boundaries could go some way towards minimizing avoidable deaths.

Importance of vital signs to the early diagnosis and severity of sepsis: association between vital signs and sequential organ failure assessment score in patients with sepsis

OBJECTIVE

While much attention is given to the fifth vital sign, the utility of the 4 classic vital signs (blood pressure, respiratory rate, body temperature, and heart rate) has been neglected. The aim of this study was to assess a possible association between vital signs and the Sequential Organ Failure Assessment (SOFA) score in patients with sepsis.

METHODS

We performed a prospective, observational study of 206 patients with sepsis. Blood pressure, respiratory rate, body temperature, and heart rate were measured on arrival at the hospital. The SOFA score was also determined on the day of admission.

RESULTS

Bivariate correlation analysis showed that all of the vital signs were correlated with the SOFA score. Multiple regression analysis indicated that decreased values of systolic blood pressure (multivariate regression coefficient [Coef] = -0.030, 95% confidence interval [CI] = -0.046 to -0.013) and diastolic blood pressure (Coef = -0.045, 95% CI = -0.070 to -0.019), increased respiratory rate (Coef = 0.176, 95% CI = 0.112 to 0.240), and increased shock index (Coef = 4.232, 95% CI = 2.401 to 6.062) significantly influenced the SOFA score.

CONCLUSION

Increased respiratory rate and shock index were significantly correlated with disease severity in patients with sepsis. Evaluation of these signs may therefore improve early identification of severely ill patients at triage, allowing more aggressive and timely interventions to improve the prognosis of these patients.

Intensive Care Admission Triage during a Pandemic: A Survey of the Acceptability of Triage Tools

We conducted a survey of the UK Intensive Care Society regarding physician opinion of national guidance on ICU triage during a viral pandemic. Respondents graded agreement for seventeen triage criteria, ten from the Department of Health. We determined whether respondents accepted the whole tool on the basis of proportion of criteria agreed with. A modified tool was devised and acceptability compared. Five hundred and fifty questionnaires were returned (33.1% from senior physicians). Approximately half of senior physicians (49.5%) and 44.4% of other respondents found the tool acceptable. This improved to 68.7% and 59.2% for the modified tool. Chi-square analysis revealed no statistically significant difference between the opinions of senior physicians and other respondents (p=0.850 for the original tool, p=0.593 for the modified tool). A small change to the government guidelines produced a tool with improved acceptability among ICU physicians.

Does triage to critical care during a pandemic necessarily result in more survivors?

OBJECTIVE

The 2009 H1N1 pandemic reinforced the need for a planned response to increased demand for critical care. Triage protocols have been proposed incorporating the exclusion of specified subgroups of patients from critical care. There have been no studies that explore the theoretical underpinning of triage at referral, and it is not clear under what circumstances triage would confer the intended benefits. We sought to explore the mechanisms whereby triage could lead to fewer deaths across a critical care population in the context of a pandemic.

DESIGN

We constructed a mathematical model based on queuing theory to compare the estimated short-term survival achieved by using a critical care service with and without triage at referral. Illustrative scenarios concerning a hypothetical critical care population were constructed to explore the roles of length of stay and critical care survival in determining the impact of triage and to identify "tipping points" of demand at which triage would result in more survivors.

SETTING

Not applicable as this was a data-free mathematical modeling exercise.

MAIN RESULTS

We identified circumstances in which triage would be expected to result in more survivors and circumstances in which it would not. In some scenarios, excluding patient groups solely on the basis of anticipated length of stay could be effective due to a more efficient use of critical care bed days.

CONCLUSIONS

The impact of triage is dependent on the level of demand and on the scale of achievable differences between included and excluded groups in terms of anticipated length of stay and critical care survival. It cannot be assumed that triage can or will result in fewer deaths. It should be remembered that there are considerations other than population-level short-term survival when determining the objectives of triage and its ethical implementation.

The Simple Triage Scoring System (STSS) successfully predicts mortality and critical care resource utilization in H1N1 pandemic flu: a retrospective analysis

INTRODUCTION

Triage protocols are only initiated when it is apparent that resource deficits will occur across a broad geographical area despite efforts to expand or acquire additional capacity. Prior to the pandemic the UK Department of Health (DOH) recommended the use of a staged triage plan incorporating Sepsis-related Organ Failure Assessment (SOFA) developed by the Ontario Ministry of Health to assist in the triage of critical care admissions and discharges during an influenza outbreak in the UK. There are data to suggest that had it been used in the recent H1N1 pandemic it may have led to inappropriate limitation of therapy if surge capacity had been overwhelmed.

METHODS

We retrospectively reviewed the performance of the Simple Triage Scoring System (STSS) as an indicator of the utilization of hospital resources in adult patients with confirmed H1N1 admitted to a university teaching hospital. Our aim was to compare it against the staged initial SOFA score process with regards to mortality, need for intensive care admission and requirement for mechanical ventilation and assess its validity.

RESULTS

Over an 8 month period, 62 patients with confirmed H1N1 were admitted. Forty (65%) had documented comorbidities and 27 (44%) had pneumonic changes on their admission CXR. Nineteen (31%) were admitted to the intensive care unit where 5 (26%) required mechanical ventilation (MV). There were 3 deaths. The STSS group categorization demonstrated a better discriminating accuracy in predicting critical care resource usage with a receiver operating characteristic area under the curve (95% confidence interval) for ICU admission of 0.88 (0.78-0.98) and need for MV of 0.91 (0.83-0.99). This compared to the staged SOFA score of 0.77 (0.65-0.89) and 0.87 (0.72-1.00) respectively. Low mortality rates limited analysis on survival predictions.

CONCLUSIONS

The STSS accurately risk stratified patients in this cohort according to their risk of death and predicted the likelihood of admission to critical care and the requirement for MV. Its single point in time, accuracy and easily collected component variables commend it as an alternative reproducible system to facilitate the triage and treatment of patients in any future influenza pandemic.

A systematic review of clinical decision rules for the diagnosis of influenza

PURPOSE

In this study, we assessed whether multivariate models and clinical decision rules can be used to reliably diagnose influenza.

METHODS

We conducted a systematic review of MEDLINE, bibliographies of relevant studies, and previous meta-analyses. We searched the literature (1962-2010) for articles evaluating the accuracy of multivariate models, clinical decision rules, or simple heuristics for the diagnosis of influenza. Each author independently reviewed and abstracted data from each article; discrepancies were resolved by consensus discussion. Where possible, we calculated sensitivity, specificity, predictive value, likelihood ratios, and areas under the receiver operating characteristic curve.

RESULTS

A total of 12 studies met our inclusion criteria. No study prospectively validated a multivariate model or clinical decision rule, and no study performed a split-sample or bootstrap validation of such a model. Simple heuristics such as the so-called fever and cough rule and the fever, cough, and acute onset rule were each evaluated by several studies in populations of adults and children. The areas under the receiver operating characteristic curves were 0.70 and 0.79, respectively. We could not calculate a single summary estimate, however, as the diagnostic threshold varied among studies.

CONCLUSIONS

The fever and cough, and the fever, cough, and acute onset heuristics have modest accuracy, but summary estimates could not be calculated. Further research is needed to develop and prospectively validate clinical decision rules to identify patients requiring testing, empiric treatment, or neither.

Defining and measuring successful emergency care networks: a research agenda

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.

Clinical review: Considerations for the triage of maternity care during an influenza pandemic--one institution's approach

The ongoing pandemic of 2009 H1N1 swine-origin influenza A has heightened the world's attention to the reality of influenza pandemics and their unpredictable nature. Currently, the 2009 H1N1 influenza strain appears to cause mild clinical disease for the majority of those infected. However, the risk of severe disease from this strain or other future strains remains an ongoing concern and is noted in specific patient populations. Pregnant women represent a unique patient population that historically has been disproportionately affected by both seasonal and pandemic influenza outbreaks. Data thus far suggest that the current 2009 H1N1 outbreak is following this same epidemiologic tendency among pregnant women. The increased predilection to worse clinical outcomes among pregnant women has potential to produce an acute demand for critical care resources that may overwhelm supply in facilities providing maternity care. The ability of healthcare systems to optimize maternal-child health outcomes during an influenza pandemic or other biologic disaster may therefore depend on the equitable allocation of these limited resources. Triage algorithms for resource allocation have been delineated in the general medical population. However, no current guidance considers the unique aspects of pregnant women and their unborn fetuses. An approach is suggested that may help guide facilities faced with these challenges.

The lack of consistent diaspirin cross-linked hemoglobin infusion blood pressure effects in the US and EU traumatic hemorrhagic shock clinical trials

Hemoglobin solutions have demonstrated a pressor effect that could adversely affect hemorrhagic shock patient resuscitation through accelerated hemorrhage, diminished perfusion, or inadequate resuscitation. Data from two parallel, multicenter traumatic hemorrhagic shock clinical trials in 17 US emergency departments and in 27 EU prehospital systems using diaspirin cross-linked hemoglobin (DCLHb), a hemoglobin-based resuscitation fluid. In the 219 patients, patients were 37 years old, 64% sustained blunt injury, 48% received DCLHb, and 36% expired. Although mean systolic blood pressure (SBP) and diastolic blood pressure values differed at 2 of the 10 measured time points, blood pressure (BP) curve analysis showed no SBP, diastolic blood pressure, or MAP differences based on treatment. Although SBP values 160 and 120 mmHg or greater were 2.2x and 2.6x more frequently noted in survivors, they were not more common with DCLHb use or in DCLHb patients who expired in US study nonsurvivors or in any EU study patients. Systolic blood pressure values 160 and 120 mmHg or greater were 2.8x and 1.3x more frequently noted in DCLHb survivors as compared with normal saline survivors. Only 3% of the BP variation noted could be attributed to DCLHb use, and as expected, injury severity and baseline physiologic status were stronger predictors. In the United States alone, treatment group was not correlated by regression with BP at any time point. Neither mean BP readings nor elevated BP readings were correlated with DCLHb treatment of traumatic hemorrhagic shock patients. As such, no clinically demonstrable DCLHb pressor effect could be directly related to the adverse mortality outcome observed in the US study.

Evaluation of pneumonia severity and acute physiology scores to predict ICU admission and mortality in patients hospitalized for influenza

BACKGROUND

The demand for inpatient medical services increases during influenza season. A scoring system capable of identifying influenza patients at low risk death or ICU admission could help clinicians make hospital admission decisions.

METHODS

Hospitalized patients with laboratory confirmed influenza were identified over 3 influenza seasons at 25 Ontario hospitals. Each patient was assigned a score for 6 pneumonia severity and 2 sepsis scores using the first data available following their registration in the emergency room. In-hospital mortality and ICU admission were the outcomes. Score performance was assessed using the area under the receiver operating characteristic curve (AUC) and the sensitivity and specificity for identifying low risk patients (risk of outcome <5%).

RESULTS

The cohort consisted of 607 adult patients. Mean age was 76 years, 12% of patients died (71/607) and 9% required ICU care (55/607). None of the scores examined demonstrated good discriminatory ability (AUC>or=0.80). The Pneumonia Severity Index (AUC 0.78, 95% CI 0.72-0.83) and the Mortality in Emergency Department Sepsis score (AUC 0.77, 95% 0.71-0.83) demonstrated fair predictive ability (AUC>or=0.70) for in-hospital mortality. The best predictor of ICU admission was SMART-COP (AUC 0.73, 95% CI 0.67-0.79). All other scores were poor predictors (AUC <0.70) of either outcome. If patients classified as low risk for in-hospital mortality using the PSI were discharged, 35% of admissions would have been avoided.

CONCLUSIONS

None of the scores studied were good predictors of in-hospital mortality or ICU admission. The PSI and MEDS score were fair predictors of death and if these results are validated, their use could reduce influenza admission rates significantly.

Automated anesthesia

PURPOSE OF REVIEW

Anesthesiologists are overloaded with information and multitasking necessities in an extremely complex work environment. The purpose of this review is to present recent developments toward automated anesthesia and present future technologies for everyday clinical practice.

RECENT FINDINGS

Decision support systems integrate different parameters, clinical scenarios and assessments by (non)-trained personnel into algorithms, which lead to diagnostic suggestions, triage evaluations or treatment options. Target-controlled anesthesia infusion systems reduce the anesthesiologist's workload; target-controlled analgesia systems have the potential to provide more stable hemodynamic control. Closed-loop delivery of anesthesia is feasible and provides anesthetic control as good as or better than human delivery. Teleanesthesia offers the possibility of distant preoperative assessment of the patient's fitness for anesthesia, aid of trained personnel to perform anesthetic tasks and the control of anesthesia delivery in a distant location.

SUMMARY

Decision support systems help to make reliable and standardized decisions in complex environments. Target-controlled infusion systems reduce the anesthetic workload. Closed-loop systems will automate anesthesia care in the near future. Teleanesthesia offers the opportunity to provide safe anesthetic care whenever trained personnel are not available or need support.