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Tirupakuzhi Vijayaraghavan BK, Rashan A, Ranganathan L, Venkataraman R, Tripathy S, Jayakumar D, Ramachandran P, Mohamed ZU, Balakrishnan S, Ramakrishnan N, Haniffa R, Beane A, Adhikari NKJ, de Keizer N, Lone N. Prevalence of frailty and association with patient centered outcomes: A prospective registry-embedded cohort study from India. J Crit Care 2024; 80:154509. [PMID: 38134715 PMCID: PMC10830405 DOI: 10.1016/j.jcrc.2023.154509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/15/2023] [Accepted: 11/30/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE We aimed to study the prevalence of frailty, evaluate risk factors, and understand impact on outcomes in India. METHODS This was a prospective registry-embedded cohort study across 7 intensive care units (ICUs) and included adult patients anticipated to stay for at least 48 h. Primary exposure was frailty, as defined by a score ≥ 5 on the Clinical Frailty Scale and primary outcome was ICU mortality. Secondary outcomes included in-hospital mortality and resource utilization. We used generalized linear models to evaluate risk factors and model association between frailty and outcomes. RESULTS 838 patients were included, with median (IQR) age 57 (42,68) yrs.; 64.8% were male. Prevalence of frailty was 19.8%. Charlson comorbidity index (OR:1.73 (95%CI:1.39,2.15)), Subjective Global Assessment categories mild/moderate malnourishment (OR:1.90 (95%CI:1.29, 2.80)) and severe malnourishment (OR:4.76 (95% CI:2.10,10.77)) were associated with frailty. Frailty was associated with higher odds of ICU mortality (adjusted OR:2.04 (95% CI:1.25,3.33)), hospital mortality (adjusted OR:2.36 (95%CI:1.45,3.84)), development of stage2/3 AKI (unadjusted OR:2.35 (95%CI:1.60, 3.43)), receipt of non-invasive ventilation (unadjusted OR:2.68 (95%CI:1.77, 4.03)), receipt of vasopressors (unadjusted OR:1.47 (95%CI:1.04, 2.07)), and receipt of kidney replacement therapy (unadjusted OR:3.15 (95%CI:1.90, 5.17)). CONCLUSIONS Frailty is common among critically ill patients in India and is associated with worse outcomes. STUDY REGISTRATION CTRI/2021/02/031503.
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Affiliation(s)
| | - Aasiyah Rashan
- Network for Improving Critical care Systems and Training, Colombo, Sri Lanka; University College, London
| | | | | | - Swagata Tripathy
- Department of Anaesthesia and Critical Care Medicine, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Devachandran Jayakumar
- Department of Critical Care Medicine, Apollo Specialty Hospital, Chennai, India; Department of Critical Care Medicine, Dr. Kamakshi Memorial Hospital, Chennai, India
| | | | - Zubair Umer Mohamed
- Department of Anaesthesia and Critical Care Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | - Sindhu Balakrishnan
- Department of Anaesthesia and Critical Care Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, India
| | | | - Rashan Haniffa
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Abi Beane
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand; Centre for Inflammation Research, University of Edinburgh, United Kingdom
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Nicolette de Keizer
- Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, the Netherlands
| | - Nazir Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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Shahi S, Paneru H, Ojha R, Karn R, Rajbhandari R, Gajurel BP. SOFA and APACHE II scoring systems for predicting outcome of neurological patients admitted in a tertiary hospital intensive care unit. Ann Med Surg (Lond) 2024; 86:1895-1900. [PMID: 38576938 PMCID: PMC10990338 DOI: 10.1097/ms9.0000000000001734] [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: 11/03/2023] [Accepted: 01/08/2024] [Indexed: 04/06/2024] Open
Abstract
Background The field of neurology encompasses the study and treatment of disorders that affect the nervous system, and patients with neurological conditions often require specialized care, particularly in the ICU. Predictive scoring systems are measures of disease severity used to predict patient outcomes. The aim of this study was to compare the discriminative power of commonly used scoring systems, namely the sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation II (APACHE II) in the ICU of a tertiary care hospital. Methods This retrospective study included patients with neurological disorders in the ICUs of Tribhuvan University Teaching Hospital from 1 January 2022 to 31 December 2022. Results A total of 153 patients were included. The mean age of the patients was 54.76 ± 17.32 years with higher male predominance (60.78%). Ischaemic stroke was the most common neurological disorder. There were 58 patients (37.9%) who required mechanical ventilation and all-cause mortality was 20.9%. The mean SOFA score was significantly higher (P=0.002) in survivors, whereas the mean APACHE II did not show a significant difference (P=0.238). Receiver operating characteristic (ROC) analysis showed the area of curve (AUC) of SOFA score was 0.765 and of APACHE II was 0.722. Conclusions SOFA score had comparatively higher discriminative power than APACHE II. Assessment of the performance of scoring systems in a specific ICU setting improves the sensitivity and applicability of the model to these settings.
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Affiliation(s)
| | - Hem Paneru
- Critical Care Medicine, Maharajgunj Medical Campus, Institute of Medicine, Maharajgunj, Kathmandu, Nepal
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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023; 8:29. [PMID: 37954925 PMCID: PMC10638482 DOI: 10.12688/wellcomeopenres.18710.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/14/2023] Open
Abstract
Background Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be led by local stakeholders, performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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Affiliation(s)
- The Collaboration for Research, Implementation and Training in Critical Care in Asia and Africa (CCAA)
- Institute of Health Informatics, University College London, London, UK
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Anaesthesia and Intensive Care Medicine, Makerere University, Kampala, Uganda
- Department of Critical Care Medicine, Apollo Hospitals Educational and Research Foundation, Chennai, India
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
- Uganda Heart Institute, University of Makerere, Makerere, Uganda
- D'Or Institute for Research and Education, Sao Paulo, Brazil
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
- Centre for Preoperative Medicine, University College London, London, UK
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
- Department of Planning and Operational Research, Doctors with Africa CUAMM, Padova, Italy
- Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
- Intensive Care Medicine, University of Amsterdam, Amsterdam, The Netherlands
- General Surgery, Wazir Akbar Khan Hospital, Kabul, Afghanistan
- Department of Anaesthesiology and Intensive care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
- Department of Community and Family Medicine, University of Jaffna, Jaffna, Sri Lanka
- Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya
- Department of Targeted Intervention, University College London, London, UK
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
- Teaching Hospital Jaffna, Jaffna, Sri Lanka
- AII India Institute of Medical Sciences, New Delhi, India
- Chennai Critical Care Consultants Private Limited, Chennai, India
| | - Aasiyah Rashan
- Institute of Health Informatics, University College London, London, UK
| | - Abi Beane
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Aniruddha Ghose
- Department of Medicine, Chittagong Medical College Hospital, Chattogram, Bangladesh
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Arthur Kwizera
- Department of Anaesthesia and Intensive Care Medicine, Makerere University, Kampala, Uganda
| | | | - Bruce Biccard
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Cassia Righy
- National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - C. Louise Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
| | - Christopher Pell
- Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Cornelius Sendagire
- Uganda Heart Institute, University of Makerere, Makerere, Uganda
- D'Or Institute for Research and Education, Sao Paulo, Brazil
| | - David Thomson
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
| | - Dilanthi Gamage Done
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Diptesh Aryal
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- D'Or Institute for Research and Education, Sao Paulo, Brazil
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Duncan Wagstaff
- Department of Anaesthesia and Perioperative Medicine, University of Cape Town, Cape Town, South Africa
- Centre for Preoperative Medicine, University College London, London, UK
| | - Farah Nadia
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
| | - Giovanni Putoto
- Department of Planning and Operational Research, Doctors with Africa CUAMM, Padova, Italy
| | - Hem Panaru
- Department of Critical Care, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Ishara Udayanga
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - John Amuasi
- Department of Global Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Jorge Salluh
- D'Or Institute for Research and Education, Sao Paulo, Brazil
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Luigi Pisani
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Madiha Hashmi
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | - Marcus Schultz
- Intensive Care Medicine, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Mavuto Mukaka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mohammed Basri Mat-Nor
- Department of Intensive Care Anaesthesiology, International Islamic University Malaysia, Kuala Lumpur, Malaysia
| | - Moses Siaw-frimpong
- Department of Anaesthesiology and Intensive care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Rashan Haniffa
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - Ronnie P Kaddu
- Department of Anaesthesia, The Aga Khan University, Nairobi, Kenya
| | | | - Srinivas Murthy
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Steve Harris
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Swagata Tripathy
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- AII India Institute of Medical Sciences, New Delhi, India
| | - Tiffany E Gooden
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Timo Tolppa
- Nat-Intensive Care Surveillance, Mahidol Oxford Tropical Medicine Research Unit, Colombo, Sri Lanka
| | - Vrindha Pari
- Chennai Critical Care Consultants Private Limited, Chennai, India
| | | | - Yen Lam Minh
- Oxford University Clinical Research Unit, University of Oxford, Ho Chi Minh City, Vietnam
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Aryal D, Paneru HR, Koirala S, Khanal S, Acharya SP, Karki A, Dona DG, Haniffa R, Beane A, Salluh JIF. Incidence, risk and impact of ICU readmission on patient outcomes and resource utilisation in tertiary level ICUs in Nepal: A cohort study. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18381.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Background: Readmissions to Intensive Care Units (ICUs) result in increased morbidity, mortality, and ICU resource utilisation (e.g. prolonged mechanical ventilation), and as such, is a widely utilised metric of quality of critical care. Most of the evidence on incidence, characteristics, associated risk factors and attributable outcomes of unplanned readmission to ICU are from studies performed in high-income countries This study explores the determinants of risk attributable to unplanned ICU readmission in four ICUs in Kathmandu, Nepal. Methods: The registry-embedded eCRF reported data on case mix, severity of illness, in-ICU interventions (including organ support), ICU outcome, and readmission characteristics. Data were captured in all adult patients admitted between September 2019 and February 2021. Population and ICU encounter characteristics were compared between those with and without readmission. Independent risk factors for readmission were assessed using univariate analysis. Results: In total 2955 patients were included in the study. Absolute unplanned ICU readmission rate was 5.69 % (n=168) for all four ICUs. Median time from ICU discharge to readmission was 3 days (IQR=8,1). Of those readmitted, 29.17% (n=49) were discharged at night following their index admission. ICU mortality was higher following readmission to ICU(p=0.016) and mortality was increased further in patients whose primary index discharge was at night(p= 0.019). Primary diagnosis, age, and use of organ support in the first 24hrs of index admission were all independently attributable risk factors for readmission. Conclusions: Unplanned ICU readmission rates were adversely associated with significantly poorer outcomes, increased ICU resource utilisation. Clinical and organisational characteristics influenced risk of readmission and outcome.
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18710.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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7
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Rashan A, Beane A, Ghose A, Dondorp AM, Kwizera A, Vijayaraghavan BKT, Biccard B, Righy C, Thwaites CL, Pell C, Sendagire C, Thomson D, Done DG, Aryal D, Wagstaff D, Nadia F, Putoto G, Panaru H, Udayanga I, Amuasi J, Salluh J, Gokhale K, Nirantharakumar K, Pisani L, Hashmi M, Schultz M, Ghalib MS, Mukaka M, Mat-Nor MB, Siaw-frimpong M, Surenthirakumaran R, Haniffa R, Kaddu RP, Pereira SP, Murthy S, Harris S, Moonesinghe SR, Vengadasalam S, Tripathy S, Gooden TE, Tolppa T, Pari V, Waweru-Siika W, Minh YL. Mixed methods study protocol for combining stakeholder-led rapid evaluation with near real-time continuous registry data to facilitate evaluations of quality of care in intensive care units. Wellcome Open Res 2023. [DOI: 10.12688/wellcomeopenres.18710.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Improved access to healthcare in low- and middle-income countries (LMICs) has not equated to improved health outcomes. Absence or unsustained quality of care is partly to blame. Improving outcomes in intensive care units (ICUs) requires delivery of complex interventions by multiple specialties working in concert, and the simultaneous prevention of avoidable harms associated with the illness and the treatment interventions. Therefore, successful design and implementation of improvement interventions requires understanding of the behavioural, organisational, and external factors that determine care delivery and the likelihood of achieving sustained improvement. We aim to identify care processes that contribute to suboptimal clinical outcomes in ICUs located in LMICs and to establish barriers and enablers for improving the care processes. Methods: Using rapid evaluation methods, we will use four data collection methods: 1) registry embedded indicators to assess quality of care processes and their associated outcomes; 2) process mapping to provide a preliminary framework to understand gaps between current and desired care practices; 3) structured observations of processes of interest identified from the process mapping and; 4) focus group discussions with stakeholders to identify barriers and enablers influencing the gap between current and desired care practices. We will also collect self-assessments of readiness for quality improvement. Data collection and analysis will be performed in parallel and through an iterative process across eight countries: Kenya, India, Malaysia, Nepal, Pakistan, South Africa, Uganda and Vietnam. Conclusions: The results of our study will provide essential information on where and how care processes can be improved to facilitate better quality of care to critically ill patients in LMICs; thus, reduce preventable mortality and morbidity in ICUs. Furthermore, understanding the rapid evaluation methods that will be used for this study will allow other researchers and healthcare professionals to carry out similar research in ICUs and other health services.
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Aryal D, Paneru HR, Koirala S, Khanal S, Acharya SP, Karki A, Dona DG, Haniffa R, Beane A, Salluh JIF. Incidence, risk and impact of unplanned ICU readmission on patient outcomes and resource utilisation in tertiary level ICUs in Nepal: A cohort study. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.18381.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Unplanned readmissions to Intensive Care Units (ICUs) result in increased morbidity, mortality, and ICU resource utilisation (e.g. prolonged mechanical ventilation), and as such, is a widely utilised metric of quality of critical care. Most of the evidence on incidence, characteristics, associated risk factors and attributable outcomes of unplanned readmission to ICU are from studies performed in high-income countries This study explores the determinants of risk attributable to unplanned ICU readmission in four ICUs in Kathmandu, Nepal. Methods: The registry-embedded eCRF reported data on case mix, severity of illness, in-ICU interventions (including organ support), ICU outcome, and readmission characteristics. Data were captured in all adult patients admitted between September 2019 and February 2021. Population and ICU encounter characteristics were compared between those with and without readmission. Independent risk factors for readmission were assessed using univariate analysis. Results: In total 2948 patients were included in the study. Absolute unplanned ICU readmission rate was 5.60 % (n=165) for all four ICUs. Median time from ICU discharge to readmission was 3 days (IQR=8,1). Of those readmitted, 29.7% (n=49) were discharged at night following their index admission. ICU mortality was higher following readmission to ICU(p=0.016) and mortality was increased further in patients whose primary index discharge was at night(p= 0.019). Primary diagnosis, age, and use of organ support in the first 24hrs of index admission were all independently attributable risk factors for readmission. Conclusions: Unplanned ICU readmission rates were adversely associated with significantly poorer outcomes, increased ICU resource utilisation. Clinical and organisational characteristics influenced risk of readmission and outcome.
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