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Liu Y, Yo CH, Hu JR, Hsu WT, Hsiung JC, Chang YH, Chen SC, Lee CC. Sepsis increases the risk of in-hospital cardiac arrest: a population-based analysis. Intern Emerg Med 2024; 19:353-363. [PMID: 38141118 DOI: 10.1007/s11739-023-03475-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 10/19/2023] [Indexed: 12/24/2023]
Abstract
Sepsis patients have a high risk of developing in-hospital cardiac arrest (IHCA), which portends poor survival. However, little is known about whether the increased incidence of IHCA is due to sepsis itself or to comorbidities harbored by sepsis patients. We conducted a retrospective population-based cohort study comprising 20,022 patients admitted with sepsis to hospitals in Taiwan using the National Health Insurance Research Database (NHIRD). We constructed three non-sepsis comparison cohorts using risk set sampling and propensity score (PS) matching. We used univariate conditional logistic regression to evaluate the risk of IHCA and associated mortality. We identified 12,790 inpatients without infection (matched cohort 1), 12,789 inpatients with infection but without sepsis (matched cohort 2), and 10,536 inpatients with end-organ dysfunction but without sepsis (matched cohort 3). In the three PS-matched cohorts, the odds ratios (OR) for developing ICHA were 21.17 (95% CI 17.19, 26.06), 18.96 (95% CI: 15.56, 23.10), and 1.23 (95% CI: 1.13, 1.33), respectively (p < 0.001 for all ORs). In conclusion, in our study of inpatients across Taiwan, sepsis was independently associated with an increased risk of IHCA. Further studies should focus on identifying the proxy causes of IHCA using real-time monitoring data to further reduce the incidence of cardiopulmonary insufficiency in patients with sepsis.
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Affiliation(s)
- Ye Liu
- Department of Health Policy and Organization, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Chia-Hung Yo
- Department of Emergency Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan
| | - Jiun-Ruey Hu
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Wan-Ting Hsu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jo-Ching Hsiung
- Department of Pediatrics, Jefferson Einstein Hospital, Philadelphia, PA, USA
| | - Yung-Han Chang
- Department of Biostatistics, University of California, Los Angeles, Los Angeles, USA
| | - Shyr-Chyr Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
- The Centre for Intelligent Healthcare, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Chung Shan S. Rd., Zhongzheng Dist., Taipei City, 100, Taiwan.
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Wang YJ, Hsu CY, Yen AMF, Chen HH, Lai CC. Advancing screening tool for hospice needs and end-of-life decision-making process in the emergency department. BMC Palliat Care 2024; 23:51. [PMID: 38389106 PMCID: PMC10885365 DOI: 10.1186/s12904-024-01391-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Predicting mortality in the emergency department (ED) is imperative to guide palliative care and end-of-life decisions. However, the clinical usefulness of utilizing the existing screening tools still leaves something to be desired. METHODS We advanced the screening tool with the A-qCPR (Age, qSOFA (quick sepsis-related organ failure assessment), cancer, Performance Status Scale, and DNR (Do-Not-Resuscitate) risk score model for predicting one-year mortality in the emergency department of Taipei City Hospital of Taiwan with the potential of hospice need and evaluated its performance compared with the existing screening model. We adopted a large retrospective cohort in conjunction with in-time (the trained and the holdout validation cohort) for the development of the A-qCPR model and out-of-time validation sample for external validation and model robustness to variation with the calendar year. RESULTS A total of 10,474 patients were enrolled in the training cohort and 33,182 patients for external validation. Significant risk scores included age (0.05 per year), qSOFA ≥ 2 (4), Cancer (5), Eastern Cooperative Oncology Group (ECOG) Performance Status score ≥ 2 (2), and DNR status (2). One-year mortality rates were 13.6% for low (score ≦ 3 points), 29.9% for medium (3 < Score ≦ 9 points), and 47.1% for high categories (Score > 9 points). The AUROC curve for the in-time validation sample was 0.76 (0.74-0.78). However, the corresponding figure was slightly shrunk to 0.69 (0.69-0.70) based on out-of-time validation. The accuracy with our newly developed A-qCPR model was better than those existing tools including 0.57 (0.56-0.57) by using SQ (surprise question), 0.54 (0.54-0.54) by using qSOFA, and 0.59 (0.59-0.59) by using ECOG performance status score. Applying the A-qCPR model to emergency departments since 2017 has led to a year-on-year increase in the proportion of patients or their families signing DNR documents, which had not been affected by the COVID-19 pandemic. CONCLUSIONS The A-qCPR model is not only effective in predicting one-year mortality but also in identifying hospice needs. Advancing the screening tool that has been widely used for hospice in various scenarios is particularly helpful for facilitating the end-of-life decision-making process in the ED.
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Affiliation(s)
- Yu-Jing Wang
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
| | - Chen-Yang Hsu
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan
- Medical Department, Daichung Hospital, Miaoli, Taiwan
- Taiwan Association of Medical Screening, Taipei, Taiwan
| | - Amy Ming-Fang Yen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Chao-Chih Lai
- Department of Emergency Medicine, Taipei City Hospital, Taiwan. No. 10, Sec. 4, Ren-Ai Road, Ren-Ai Branch, Taipei, Taiwan.
- Master of Public Health Program, National Taiwan University, Taipei, Taiwan.
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Lee SI, Ju YR, Kang DH, Lee JE. Characteristics and outcomes of patients with do-not-resuscitate and physician orders for life-sustaining treatment in a medical intensive care unit: a retrospective cohort study. BMC Palliat Care 2024; 23:42. [PMID: 38355511 PMCID: PMC10868112 DOI: 10.1186/s12904-024-01375-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/02/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND In the intensive care unit (ICU), we may encounter patients who have completed a Do-Not-Resuscitate (DNR) or a Physician Orders to Stop Life-Sustaining Treatment (POLST) document. However, the characteristics of ICU patients who choose DNR/POLST are not well understood. METHODS We retrospectively analyzed the electronic medical records of 577 patients admitted to a medical ICU from October 2019 to November 2020, focusing on the characteristics of patients according to whether they completed DNR/POLST documents. Patients were categorized into DNR/POLST group and no DNR/POLST group according to whether they completed DNR/POLST documents, and logistic regression analysis was used to evaluate factors influencing DNR/POLST document completion. RESULTS A total of 577 patients were admitted to the ICU. Of these, 211 patients (36.6%) had DNR or POLST records. DNR and/or POLST were completed prior to ICU admission in 48 (22.7%) patients. The DNR/POLST group was older (72.9 ± 13.5 vs. 67.6 ± 13.8 years, p < 0.001) and had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (26.1 ± 9.2 vs. 20.3 ± 7.7, p < 0.001) and clinical frailty scale (5.1 ± 1.4 vs. 4.4 ± 1.4, p < 0.001) than the other groups. Solid tumors, hematologic malignancies, and chronic lung disease were the most common comorbidities in the DNR/POLST groups. The DNR/POLST group had higher ICU and in-hospital mortality and more invasive treatments (arterial line, central line, renal replacement therapy, invasive mechanical ventilation) than the other groups. Body mass index, APAHCE II score, hematologic malignancy, DNR/POLST were factors associated with in-hospital mortality. CONCLUSIONS Among ICU patients, 36.6% had DNR or POLST orders and received more invasive treatments. This is contrary to the common belief that DNR/POLST patients would receive less invasive treatment and underscores the need to better understand and include end-of-life care as an important ongoing aspect of patient care, along with communication with patients and families.
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Affiliation(s)
- Song-I Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Ye-Rin Ju
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Da Hyun Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea
| | - Jeong Eun Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University School of Medicine, Chungnam National University Hospital, 282 Munhwa-ro, Jung-gu, Daejeon, 35015, Republic of Korea.
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Nielsen FE, Chafranska L, Sørensen R, Abdullah OB. Predictors of outcomes in emergency department patients with suspected infections and without fulfillment of the sepsis criteria. Am J Emerg Med 2023; 68:144-154. [PMID: 37018890 DOI: 10.1016/j.ajem.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Data on patient characteristics and determinants of serious outcomes for acutely admitted patients with infections who do not fulfill the sepsis criteria are sparse. The study aimed to characterize acutely admitted emergency department (ED) patients with infections and a composite outcome of in-hospital mortality or transfer to the intensive care unit without fulfilling the criteria for sepsis and to examine predictors of the composite outcome. METHODS This was a secondary analysis of data from a prospective observational study of patients with suspected bacterial infection admitted to the ED between October 1, 2017 and March 31, 2018. A National Early Warning Score 2 (NEWS2) ≥ 5 within the first 4 h in the ED was assumed to represent a sepsis-like condition with a high risk for the composite endpoint. Patients who achieved the composite outcome were grouped according to fulfillment of the NEWS2 ≥ 5 criteria. We used logistic regression analysis to estimate the unadjusted and adjusted odds ratio (OR) for the composite endpoint among patients with either NEWS2 < 5 (NEWS2-) or NEWS2 ≥ 5 (NEWS2+). RESULTS A total of 2055 patients with a median age of 73 years were included. Of these, 198 (9.6%) achieved the composite endpoint, including 59 (29.8%) NEWS2- and 139 (70.2%) NEWS2+ patients, respectively. Diabetes (OR 2.23;1.23-4.0), a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (OR 2.57;1.37-4.79), and a Do-not-attempt-cardiopulmonary-resuscitation order (DNACPR) on admission (OR 3.70;1.75-7.79) were independent predictive variables for the composite endpoint in NEWS2- patients (goodness-of-fit test P = 0.291; area under the receiver operating characteristic curve for the model (AUROC) = 0.72). The regression model for NEWS2+ patients revealed that a SOFA score ≥ 2 (OR 2.79; 1.59-4.91), hypothermia (OR 2.48;1.30-4.75), and DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test P = 0.62; AUROC for the model = 0.70). CONCLUSION Approximately one-third of the patients with infections and serious outcomes during hospitalization did not meet the NEWS2 threshold for likely sepsis. Our study identified factors with independent predictive values for the development of serious outcomes that should be tested in future prediction models.
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The Impact of Do-Not-Resuscitate Order in the Emergency Department on Respiratory Failure after ICU Admission. Healthcare (Basel) 2022; 10:healthcare10030434. [PMID: 35326912 PMCID: PMC8956014 DOI: 10.3390/healthcare10030434] [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: 01/12/2022] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/04/2022] Open
Abstract
(1) Background: It has been hypothesized that a discrepancy exists in the understanding of a do-not-resuscitate (DNR) order among physicians. We hypothesized that a DNR order signed in the emergency department (ED) could influence the patients’ prognosis after intensive care unit (ICU) admission. (2) Methods: We included patients older than 17 years, who visited the emergency department for non-traumatic disease, who had respiratory failure, required ventilator support, and were admitted to the ICU between January 2010 and December 2016. The associations between DNR and mortality, hospital length of stay (LOS), and medical fees were analyzed. Prolonged hospital LOS was defined as hospital stay ≥75th percentile (≥26 days for the study). Patients were classified as those who did and did not sign a DNR order. A 1:4 propensity score matching was conducted for demographics, comorbidities, and etiology. (3) Results: The study enrolled a total of 1510 patients who signed a DNR and 6040 patients who did not sign a DNR. The 30-day mortality rates were 47.4% and 28.0% among patients who did and did not sign a DNR, respectively. A DNR order was associated with mortality after adjusting for confounding factors (hazard ratio, 1.9; confidence interval, 1.70−2.03). It was also a risk factor for prolonged hospital LOS in survivors (odds ratio, 1.2; confidence interval, 1.02−1.44). Survivors who signed a DNR order were charged higher medical fees than those who did not sign a DNR (217,159 vs. 245,795 New Taiwan Dollars, p < 0.001). (4) Conclusions: Signing a DNR order in the ED increased the ICU mortality rate among patients who had respiratory failure and needed ventilator support. It increased the risk of prolonged hospital LOS among survivors. Finally, signing a DNR order was associated with high medical fees among survivors.
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Lee SI, Koh JS, Kim YJ, Kang DH, Lee JE. Characteristics and outcomes of patients screened by rapid response team who transferred to the intensive care unit. BMC Emerg Med 2022; 22:18. [PMID: 35114944 PMCID: PMC8811968 DOI: 10.1186/s12873-022-00575-y] [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: 06/17/2021] [Accepted: 01/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The utilization of a rapid response team (RRT) has influenced the clinical outcomes of patients in the general ward. However, the characteristics of RRT-screened patients who are transferred to the intensive care unit (ICU) are unknown. Therefore, the present study aimed to evaluate these factors. METHODS We conducted a retrospective study using patient data from a tertiary medical center in Republic of Korea between January 2016 and December 2017. Multivariate logistic regression analyses were performed to assess the factors associated with the risk of in-hospital mortality. RESULTS A total of 1,096 patients were included: 389 patients were transferred to the ICU, and 707 patients stayed in the ward. Patients in the ICU group were more likely to be admitted for medical reasons, hepatobiliary disease, and high heart rate. More interventions were performed, hospital stays were longer, and the 28-day and in-hospital mortality rates were higher in the ICU group than in the ward group. Multivariate logistic regression analyses showed that risk factors affecting ICU admission were higher Sequential Organ Failure Assessment (SOFA) score, National Early Warning Score (NEWS), platelet count, and lactate level. ICU transfer was not associated with in-hospital mortality. CONCLUSIONS Among RRT-screened patients, those with higher SOFA score, NEWS, and lactate level were more likely to be transferred to the ICU. Therefore, these patients should be closely monitored and considered for ICU transfer.
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Affiliation(s)
- Song-I Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Jeong Suk Koh
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Yoon Joo Kim
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Da Hyun Kang
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea
| | - Jeong Eun Lee
- Department of Pulmonary and Critical Care Medicine, Chungnam National University School of Medicine, 33 Munhwa-ro, Jung-gu, 301-721, Daejeon, Republic of Korea.
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Wu CY, Jen CH, Chuang YS, Fang TJ, Wu YH, Wu MT. Factors associated with do-not-resuscitate document completion among patients hospitalized in geriatric ward. BMC Geriatr 2021; 21:472. [PMID: 34433419 PMCID: PMC8386141 DOI: 10.1186/s12877-021-02407-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 07/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With a rapidly aging population, there is an increasing need for do-not-resuscitate (DNR) and advance care planning (ACP) discussions. This study investigated the factors associated with signing DNR documents of older patients in the geriatric ward. METHODS We conducted a retrospective cohort study at a geriatric ward in a tertiary hospital in Southern Taiwan. Three hundred and thirty-seven hospitalized older patients aged ≥65 years in the geriatric ward from 2018 to 2019. The Hospital Information System and electronic medical records were accessed to obtain details regarding patients' demographics, daily living activities, serum albumin level, nutrition screening score, intensive care unit transferal, resuscitation procedure, days of hospital stay, and survival status on discharge, and DNR status was recorded retrospectively. Patients were classified into DNR and non-DNR groups, with t-tests and Chi-square tests applied to compare the differences between groups. Logistic regression was performed to predict factors related to the DNR documents. RESULTS A total of 337 patients were included, 66 of whom had signed a DNR during hospitalization. After multivariate logistic regression, age 85 or more compared to age 65-74 (adjusted odds ratio, aOR 5.94), poor nutrition with screening score two or more (aOR 2.71), albumin level less than 3 (aOR 3.24), Charlson Comorbidity Index higher than 2 (aOR 2.46) and once transferred to ICU (aOR 5.11) were independently associated with DNR documentation during hospitalization. CONCLUSIONS Several factors related to DNR documents for geriatric patients were identified which could provide clinical information for physicians, patients, and their families to discuss DNR and ACP.
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Affiliation(s)
- Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan.,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Chun-Hao Jen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan.,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Yun-Shiuan Chuang
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
| | - Tzu-Jung Fang
- Division of Geriatrics and Gerontology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Yu-Hsuan Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan
| | - Ming-Tsang Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No.100, Tzyou 1st Road, Kaohsiung, 807, Taiwan. .,Department of Public Health, College of Health Sciences, Kaohsiung Medical University, Kaohsiung City, Taiwan. .,Research Center for Environmental Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan. .,Program of Environmental and Occupational Medicine and Graduate Institute of Clinical Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
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Cillóniz C, Dominedò C, Ielpo A, Ferrer M, Gabarrús A, Battaglini D, Bermejo-Martin J, Meli A, García-Vidal C, Liapikou A, Singer M, Torres A. Risk and Prognostic Factors in Very Old Patients with Sepsis Secondary to Community-Acquired Pneumonia. J Clin Med 2019; 8:jcm8070961. [PMID: 31269766 PMCID: PMC6678833 DOI: 10.3390/jcm8070961] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 06/20/2019] [Accepted: 07/01/2019] [Indexed: 12/12/2022] Open
Abstract
Background: Little is known about risk and prognostic factors in very old patients developing sepsis secondary to community-acquired pneumonia (CAP). Methods: We conducted a retrospective observational study of data prospectively collected at the Hospital Clinic of Barcelona over a 13-year period. Consecutive patients hospitalized with CAP were included if they were very old (≥80 years) and divided into those with and without sepsis for comparison. Sepsis was diagnosed based on the Sepsis-3 criteria. The main clinical outcome was 30-day mortality. Results: Among the 4219 patients hospitalized with CAP during the study period, 1238 (29%) were very old. The prevalence of sepsis in this age group was 71%. Male sex, chronic renal disease, and diabetes mellitus were independent risk factors for sepsis, while antibiotic therapy before admission was independently associated with a lower risk of sepsis. Thirty-day and intensive care unit (ICU) mortality did not differ between patients with and without sepsis. In CAP-sepsis group, chronic renal disease and neurological disease were independent risk factors for 30-day mortality. Conclusion: In very old patients hospitalized with CAP, in-hospital and 1-year mortality rates were increased if they developed sepsis. Antibiotic therapy before hospital admission was associated with a lower risk of sepsis.
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Affiliation(s)
- Catia Cillóniz
- Department of Pneumology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), 28029 Madrid, Spain.
| | - Cristina Dominedò
- Department of Anesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Antonella Ielpo
- Departments of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, 43121 Parma, Italy
| | - Miquel Ferrer
- Department of Pneumology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), 28029 Madrid, Spain
| | - Albert Gabarrús
- Department of Pneumology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), 28029 Madrid, Spain
| | - Denise Battaglini
- Department of Surgical Sciences and Integrated Diagnostic, Policlinico San Martino, University of Genova, 16126 Genova, Italy
| | - Jesús Bermejo-Martin
- Group for Biomedical Research in Sepsis (Bio Sepsis), Hospital Clínico Universitario de Valladolid/IECSCYL, Av. Ramón y Cajal, 3, 47003 Valladolid, Spain
| | - Andrea Meli
- Department of Anesthesia and Intensive Care, University of Milan, 20122 Milan, Italy
| | - Carolina García-Vidal
- Infectious Diseases Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Adamanthia Liapikou
- Respiratory Department, Sotiria Chest Diseases Hospital, Mesogion 152, 11527Athens, Greece
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower St, London WC1E 6BT, UK
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
- Biomedical Research Networking Centres in Respiratory Diseases (Ciberes), 28029 Madrid, Spain.
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Lin KH, Huang SC, Wang CH, Chau-Chung, Chu TS, Chen YY. Physician workload associated with do-not-resuscitate decision-making in intensive care units: an observational study using Cox proportional hazards analysis. BMC Med Ethics 2019; 20:15. [PMID: 30823898 PMCID: PMC6397482 DOI: 10.1186/s12910-019-0355-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 02/22/2019] [Indexed: 12/21/2022] Open
Abstract
Background Physicians play a substantial role in facilitating communication regarding life-supporting treatment decision-making including do-not-resuscitate (DNR) in the intensive care units (ICU). Physician-related factors including gender, personal preferences to life-supporting treatment, and specialty have been found to affect the timing and selection of life-supporting treatment decision-making. This study aimed to examine the influence of physician workload on signing a DNR order in the ICUs. Methods This is retrospective observational study. The medical records of patients, admitted to the surgical ICUs for the first time between June 1, 2011 and December 31, 2013, were reviewed. We used a multivariate Cox proportional hazards model to examine the influence of the physician’s workload on his/her writing a DNR order by adjusting for multiple factors. We then used Kaplan–Meier survival curves with log-rank test to compare the time from ICU admission to DNR orders written for patients for two groups of physicians based on the average number of patients each physician cared for per day during data collection period. Results The hazard of writing a DNR order by the attending physicians who cared for more than one patient per day significantly decreased by 41% as compared to the hazard of writing a DNR order by those caring for fewer than one patient (hazard ratio = 0.59, 95% CI 0.39—0.89, P = .01). In addition, the factors associated with writing a DNR order as determined by the Cox model were non-operative, cardiac failure/insufficiency diagnosis (hazard ratio = 1.71, 95% CI 1.00—2.91, P = .05) and the Therapeutic Intervention Scoring System score (hazard ratio = 1.02, 95% CI 1.00—1.03, P = .03). Physicians who cared for more than one patient per day were less likely to write a DNR order for their patients than those who cared for in average fewer than one patient per day (log-rank chi-square = 5.72, P = .02). Conclusions Our findings highlight the need to take multidisciplinary actions for physicians with heavy workloads. Changes in the work environmental factors along with stress management programs to improve physicians’ psychological well-being as well as the quality.
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Affiliation(s)
- Kuan-Han Lin
- Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, #1, Rd. Ren-Ai sec. 1, Taipei, 10051, Taiwan
| | - Shu-Chien Huang
- Department of Surgery, National Taiwan University Hospital, #7, Rd. Chong-Shang S, Taipei, 10002, Taiwan
| | - Chih-Hsien Wang
- Department of Surgery, National Taiwan University Hospital, #7, Rd. Chong-Shang S, Taipei, 10002, Taiwan
| | - Chau-Chung
- Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, #1, Rd. Ren-Ai sec. 1, Taipei, 10051, Taiwan.,Department of Internal Medicine, National Taiwan University Hospital, #7, Rd. Chong-Shang S, Taipei, 10002, Taiwan
| | - Tzong-Shinn Chu
- Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, #1, Rd. Ren-Ai sec. 1, Taipei, 10051, Taiwan.,Department of Medical Education, National Taiwan University Hospital, #7, Rd. Chong-Shang S, Taipei, 10002, Taiwan
| | - Yen-Yuan Chen
- Graduate Institute of Medical Education & Bioethics, National Taiwan University College of Medicine, #1, Rd. Ren-Ai sec. 1, Taipei, 10051, Taiwan.
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Chen KF, Tsai MY, Wu CC, Han ST. Effectiveness of Treatments and Diagnostic Tools and Declining Mortality in Patients With Severe Sepsis: A 12-Year Population-Based Cohort Study. J Intensive Care Med 2019; 35:1418-1425. [PMID: 30700200 DOI: 10.1177/0885066619827270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sepsis is a major cause of morbidity and mortality worldwide. With the advance of medical care, the mortality of sepsis has decreased in the past decades. Many treatments and diagnostic tools still lack supporting evidence. We conducted a retrospective population-based cohort study with propensity score matched subcohorts based on a prospectively collected national longitudinal health insurance database in Taiwan. Severe sepsis-associated hospital admissions from 2000 to 2011 based on International Classification of Diseases, Ninth Revision, Clinical Modification codes of infections and acute organ dysfunction were identified. To compare the effectiveness of treatment and diagnostic tool, propensity scores were generated to match the comparable control groups. During the 12-year period, 33 375 patients and 50 465 hospitalizations of severe sepsis were identified. The age-standardized 28-day in-hospital mortality decreased significantly from 21% in 2008 to 15% in 2011 with increasingly implemented treatment and diagnostic tool. After propensity score matching, procalcitonin (odds ratio [OR]: 0.70, 95% confidence interval [95% CI]: 0.61-0.81) and lactate testing (OR: 0.90, 95% CI: 0.84-0.97, respectively), transfusion of packed red blood cell (OR: 0.60, 95% CI: 0.52-0.69), albumin (OR: 0.72, 95% CI: 0.55-0.93), balanced crystalloid (OR: 0.29, 95% CI: 0.20-0.41), and use of dopamine (OR: 0.44, 95% CI: 0.39-0.49) were found to be significantly associated with lower mortality rate. However, inconsistent findings need to be further validated.
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Affiliation(s)
- Kuan-Fu Chen
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Keelung.,Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou.,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan.,Community Medicine Research Center, 125573Chang Gung Memorial Hospital, Keelung
| | - Meng-Ying Tsai
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou
| | - Chin-Chieh Wu
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Keelung
| | - Shih-Tsung Han
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou
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Thao PTN, Tra TT, Son NT, Wada K. Reduction in the IL-6 level at 24 h after admission to the intensive care unit is a survival predictor for Vietnamese patients with sepsis and septic shock: a prospective study. BMC Emerg Med 2018; 18:39. [PMID: 30400775 PMCID: PMC6219151 DOI: 10.1186/s12873-018-0191-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 10/23/2018] [Indexed: 12/17/2022] Open
Abstract
Background Sepsis and septic shock are common problems in intensive care units (ICUs). The mortality of patients with sepsis or septic shock is high. We investigated if reduction in the serum concentration of the cytokines tumor necrosis factor α, interleukin (IL)-6 and IL-10, and the rate of change in the IL-6 level at 24 h after ICU admission were survival predictors for patients with sepsis and septic shock in a Vietnamese population. Methods This was a prospective study conducted at an ICU in Cho Ray Hospital, Vietnam, from October 2014 to October 2016. Patients diagnosed with sepsis or septic shock using validated international guidelines were enrolled. Plasma samples were collected upon (T0) and 24 h after (T24) ICU admission for measurement of cytokine concentrations. Blood tests were done to detect organ dysfunction. The duration of ICU stays, hospital stay, APACHE II and SOFA scores, and the in-hospital mortality were compared between survival and non-survival groups. Univariate logistic regression and multivariate analysis were done to determine the association between survival and IL-6 reduction at 24 h after ICU admission. Results A total of 123 patients were enrolled. The concentration (in pg/mL) of IL-6 at To was 413.3 in survivors and 530.0 in non- survivors. At T24, the IL-6 level was 65.4 for survivors and 286.9 for non-survivors. The survival rate was 39.0%. At T24, the concentrations of IL-6 and the reduction in IL-6 level were predictors of survival in patients with sepsis and septic shock. We found a significant association between IL-6 reduction and survival at ≥86% with Odds Ratio (OR) 5.67, 95% Confidence Interval (CI); 1.27–25.3, compared with an increase in the IL-6 rate of change. Conclusions Our findings suggested that a reduction in the IL-6 level of ≥86% at 24 h from ICU admission is a survival predictor for patients with sepsis and septic shock in our population.
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Affiliation(s)
- Pham Thi Ngoc Thao
- Cho Ray Hospital, 201B Nguyen Chi Thanh Street, District 5, Ho Chi Minh City, Vietnam
| | - Ton Thanh Tra
- Cho Ray Hospital, 201B Nguyen Chi Thanh Street, District 5, Ho Chi Minh City, Vietnam.
| | - Nguyen Truong Son
- Cho Ray Hospital, 201B Nguyen Chi Thanh Street, District 5, Ho Chi Minh City, Vietnam
| | - Koji Wada
- International University of Health and Welfare, Tokyo, Japan
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Wang CH, Chang WT, Huang CH, Tsai MS, Yu PH, Wu YW, Chen WJ. Validation of the Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score in an East Asian population. PLoS One 2018; 13:e0202938. [PMID: 30138383 PMCID: PMC6107241 DOI: 10.1371/journal.pone.0202938] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 07/16/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The Cardiac Arrest Survival Postresuscitation In-hospital (CASPRI) score is a useful tool for predicting neurological outcome following in-hospital cardiac arrest (IHCA), and was derived from a cohort selected from the Get With The Guidelines-Resuscitation registry between 2000 and 2009 in the United States. In an East Asian population, we aimed to identify the factors associated with outcomes of resuscitated IHCA patients and assess the validity of the CASPRI score. METHODS A retrospective study was conducted in a single centre in Taiwan. Patients with IHCA between 2006 and 2014 were screened. RESULTS Among the 796 included patients, 94 (11.8%) patients achieved neurologically intact survival. Multivariable logistic regression analyses identified factors significantly associated with neurological outcome. Six of these factors were also components of the CASPRI score, including duration of resuscitation, neurological status before IHCA, malignant disease, initial arrest rhythms, renal insufficiency and age. In univariate logistic regression analysis, the CASPRI score was significantly associated with neurological outcome (odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.80-0.87); the area under the receiver operating characteristics curve was 0.79 (95% CI: 0.74-0.84). CONCLUSION In this retrospective study conducted in a single centre at Taiwan, we identified the common prognosticators of IHCA shared by both East Asian and Western societies. As a composite prognosticator, CASPRI score predicts outcomes with excellent accuracy among successfully resuscitated IHCA patients in an East Asian population. This tool allows accurate IHCA prognostication in an East Asian population.
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Affiliation(s)
- Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Min-Shan Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ping-Hsun Yu
- Department of Emergency Medicine, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Yen-Wen Wu
- Departments of Internal Medicine and Nuclear Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Nuclear Medicine and Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wen-Jone Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
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Abstract
Background: Intensive care unit–acquired weakness (ICU-AW) is a common complication of critical illness and is associated with increased mortality, longer mechanical ventilation and longer hospital stay. Little is known about the causes of mortality in patients with ICU-AW. In this study, we aimed to give an overview of the causes of death in a population diagnosed with ICU-AW during hospital admission. Methods: Data from a prospective cohort study in the mixed medical–surgical ICU of the Academic Medical Center in Amsterdam were used. Patients were included when mechanically ventilated for more than 48 hours. Intensive care unit–acquired weakness was defined as a mean medical research council score <4. Baseline data and data on the time of death were collected. Results: Fifty-three patients were included. Irreversible shock with multiple organ failure (MOF) was the most common cause of death (28/53 of patients; 26 patients with septic shock and 2 patients with hypovolemic shock). Most common site of sepsis was abdominal (38.5%) and pulmonary (19.2%). On admission to the ICU, 53% had a do-not-resuscitate code. In 74% of the patients, further treatment limitations were implemented during their ICU stay. Conclusion: In this cohort of patients with ICU-AW, most patients died of irreversible shock with MOF, caused by sepsis.
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Affiliation(s)
- Linda van Wagenberg
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Esther Witteveen
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands.,Department of Neurology, Academic Medical Center, Amsterdam, the Netherlands
| | - Luuk Wieske
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, Amsterdam, the Netherlands
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