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Alzoubi E, Shaheen F, Yousef K. Delirium incidence, predictors and outcomes in the intensive care unit: A prospective cohort study. Int J Nurs Pract 2024; 30:e13154. [PMID: 37044382 DOI: 10.1111/ijn.13154] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/16/2023] [Accepted: 03/19/2023] [Indexed: 04/14/2023]
Abstract
AIM The aim of this study was to investigate the incidence, predictors, and outcomes of delirium in intensive care units. BACKGROUND Delirium is a common complication in intensive care units. In developing countries, it can be misdiagnosed or unrecognised. DESIGN Prospective cohort study reported according to the strengthening the reporting of observational studies in epidemiology criteria. METHODS We included patients who were conscious, >18 years old, and admitted to the intensive care units for at least 8 h between December 2019 and February 2020. Patients with a Richmond score of -4 or -5, mental disability, receptive aphasia and/or visual or auditory impairment were excluded from the study. Delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU), whereas the functional outcome was assessed by the Katz Activity of Daily Living Index. RESULTS This study included 111 patients with a delirium incidence of 31.5%. The severity of illness was the only significant predictor of delirium. Patients with delirium had longer intensive care unit and in-hospital stays in contrast to those without delirium. Delirium was associated with in-hospital and 4-month mortality but not the activities of daily living. CONCLUSIONS Delirium is associated with increased length of stay and mortality. Further investigation to determine whether delirium management can improve outcomes is warranted.
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Affiliation(s)
- Elaf Alzoubi
- King Abdullah University Hospital, Irbid, Jordan
| | | | - Khalil Yousef
- School of Nursing, University of Jordan, Amman, Jordan
- School of Humanities, Social Science, and Health, University of Wollongong in Dubai, Dubai, United Arab Emirates
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Álvarez-Avello JM, Hernández-Pérez FJ, Herrero-Cano Á, López-Ibor JV, Aymerich M, Iranzo R, Vidal-Fernández M, Gómez-Bueno M, Gómez-Paratcha B, García-Suárez J, Martín CE, Forteza A, González-Román A, Segovia-Cubero J. Usefulness of severity scales for cardiogenic shock in-hospital mortality. Proposal for a new prognostic model. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:79-87. [PMID: 35177367 DOI: 10.1016/j.redare.2021.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/31/2021] [Indexed: 06/14/2023]
Abstract
UNLABELLED Cardiogenic shock (CS) is a condition comprising multiple etiologies, which associates high mortality rates. Some scoring systems have been shown to be good predictors of hospital mortality in patients admitted to Critical Care Units (CCU). The main objective of this study is to analyze their usefulness and validity in a cohort of CS patients. METHODS Observational unicentric study of a cohort of CS patients. SOFA, SAPS II and APACHE II scores were calculated in the first 24 h of CCU admission. RESULTS 130 patients with CS were included. SOFA, SAPS II and APACHE II scores revealed good discrimination for hospital mortality: (AUC) ROC values (AUC: 0.711, 0.752 and 0.742 respectively; P = .6). Calibration, estimated by the Hosmer-Lemeshow test, was adequate in all cases. Acute coronary syndrome, lactate serum values, SAPS II score and vasoactive inotropic score (VIS) were found to be independent predictors for mortality, upon ICU admission. With these variables, a specific prognostic indicator was developed (SAPS-2-LIVE), which improved predictive capability for mortality in our series (AUC) ROC, 0.825 (95% CI 0.752-0.89). CONCLUSION In this contemporary CS cohort, the aforementioned scores have been shown to have good predictive ability for hospital mortality. These findings could contribute to a more accurate risk stratification in CS.
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Affiliation(s)
- J M Álvarez-Avello
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Departamento de Anestesiología y Cuidados Intensivos, Clínica Universidad de Navarra, Madrid, Spain.
| | - F J Hernández-Pérez
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Á Herrero-Cano
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J V López-Ibor
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - M Aymerich
- Departamento de Anestesiología y Cuidados Intensivos, Clínica Universidad de Navarra, Madrid, Spain
| | - R Iranzo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - M Vidal-Fernández
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - M Gómez-Bueno
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - B Gómez-Paratcha
- Departamento de Anestesiología y Cuidados Intensivos, Clínica Universidad de Navarra, Madrid, Spain
| | - J García-Suárez
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - C E Martín
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - A Forteza
- Servicio de Cirugía Cardiaca, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - A González-Román
- Servicio de Anestesiología y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J Segovia-Cubero
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; Centro de Investigación en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Morris JL, Bernard F, Bérubé M, Dubé JN, Houle J, Laporta D, Morin SN, Perreault M, Williamson D, Gélinas C. Determinants of pain assessment documentation in intensive care units. Can J Anaesth 2021; 68:1176-1184. [PMID: 34105066 DOI: 10.1007/s12630-021-02022-1] [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: 10/22/2020] [Revised: 03/28/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE The underassessment of pain is a major barrier to effective pain management, and the lack of pain assessment documentation has been associated with negative patient outcomes. This study aimed to 1) describe the contextual factors related to pain assessment and management in five Québec intensive care units (ICUs); 2) describe their pain assessment documentation practices; and 3) identify sociodemographic and clinical determinants related to pain assessment documentation. METHODS A descriptive-correlational retrospective design was used. Sociodemographic data (i.e., age, sex), clinical data (i.e., diagnosis, mechanical ventilation, level of consciousness, severity of illness, opioids, sedatives), and pain assessments were extracted from 345 medical charts of ICU admissions from five teaching hospitals between 2017 and 2019. Descriptive statistics and multiple linear regression were performed. RESULTS All sites reported using the 0-10 numeric rating scale, but the implementation of a behavioural pain scale was variable across sites. A median of three documented pain assessments were performed per 24 hr, which is below the minimal recommendation of eight to 12 pain assessments per 24 hr. Overall, pain assessment was present in 70% of charts, but only 20% of opioid doses were followed by documented pain reassessment within one hour post-administration. Higher level of consciousness (β = 0.37), using only breakthrough doses (β = 0.24), and lower opioid doses (β = -0.21) were significant determinants of pain assessment documentation (adjusted R2 = 0.25). CONCLUSION Pain assessment documentation is suboptimal in ICUs, especially for patients unable to self-report or those receiving higher opioid doses. Study findings highlight the need to implement tools to optimize pain assessment and documentation.
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Affiliation(s)
- Jenna L Morris
- Ingram School of Nursing, McGill University, Montréal, QC, Canada
| | - Francis Bernard
- Faculty of Medicine, Université de Montréal, Neuro Intensive Care Unit and Research Centre, Hôpital du Sacré-Coeur de Montréal, CIUSSS Nord-Ile-Montréal, Montréal, QC, Canada
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, Québec City, QC, Canada
- CHU de Québec - Université Laval Research Center (Hôpital de l'Enfant-Jésus), Population Health and Optimal Practices Research Unit, Québec City, QC, Canada
| | - Jean-Nicolas Dubé
- Faculty of Medicine (campus Mauricie), Université de Montréal, Montréal, QC, Canada
- Department of Specialized Medicine, CIUSSS Mauricie-Centre-du-Québec, Centre hospitalier affilié universitaire régional, Trois-Rivières, QC, Canada
| | - Julie Houle
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- Medical and Clinical Research, CIUSSS Mauricie-Centre-du-Québec, Trois-Rivières, QC, Canada
| | - Denny Laporta
- Faculty of Medicine, Respiratory Division, McGill University, Department of Medicine, Division of Adult Critical Care, Jewish General Hospital, CIUSSS West-Central-Montreal, Montréal, QC, Canada
| | - Suzanne N Morin
- Department of Medicine, Center for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, McGill University, Montréal, QC, Canada
| | - Marc Perreault
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
- Department of Pharmacy, McGill University Health Center, Montréal, QC, Canada
| | - David Williamson
- Faculté de Pharmacie, Université de Montréal, Montréal, QC, Canada
- Department of Pharmacy and Research Centre, Hôpital du Sacré-Cœur de Montréal, CIUSSSS Nord-Ile-Montréal, Montréal, QC, Canada
| | - Céline Gélinas
- Ingram School of Nursing, McGill University, Montréal, QC, Canada.
- Centre for Nursing Research and Lady Davis Institute, Jewish General Hospital, CIUSSS West-Central-Montreal, Montréal, QC, Canada.
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Agrawal A, Rahman MM, Khan RA, Lozada-Martinez ID, Moscote-Salazar LR, Mishra R, Rahman S. Letter to the Editor: FOUR Score or GCS in Neurocritical Care; Modification or Adaptation. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1732790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | - Md Moshiur Rahman
- Neurosurgery Department, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| | - Robert Ahmed Khan
- Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | | | - Rakesh Mishra
- Department of Neurosurgery, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sabrina Rahman
- Department of Public Health, Independent University, Bangladesh, Dhaka, Bangladesh
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Fortis S, O'Shea AMJ, Beck Mae BF, Nair R, Goto M, Schmidt GA, Kaboli PJ, Perencevich EN, Reisinger HS, Sarrazin MV. A simplified critical illness severity scoring system (CISSS): Development and internal validation. J Crit Care 2020; 61:21-28. [PMID: 33049489 DOI: 10.1016/j.jcrc.2020.09.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To create a simplified critical illness severity scoring system with high prediction accuracy for 30-day mortality using only commonly available variables. MATERIALS AND METHODS This is a retrospective cohort study of ICU admissions 2010-2015 in 306 ICUs in 117 Veterans Affairs (VA) hospitals. We randomly divided our cohort into a training dataset (75%) and a validation dataset (25%). We created a critical illness severity scoring system (CISSS) using age, comorbidities, heart rate, mean arterial blood pressure, temperature, respiratory rate, hematocrit, white blood cell count, creatinine, sodium, glucose, albumin, bilirubin, bicarbonate, use of invasive mechanical ventilation, and whether the admission was surgical or not. We validated the performance of CISSS to predict 30-day mortality internally. RESULTS After excluding 31,743 re-admissions, we divided our sample (n = 534,001) into a training (n = 400,613) and a validation dataset (n = 133,388). In the training dataset, the area under the curve (AUC) of CISSS was 0.847(95%CI = 0.845-0.850). In the validation dataset, the AUC was 0.848 (95%CI = 0.844-0.852), the standardized mortality ratio (SMR) was 1.00 (95%CI = 0.98-1.02), and Brier's score for 30-day mortality was 0.058 (95%CI = 0.057-0.059). CISSS calibration was acceptable. CONCLUSIONS CISSS has very good performance and requires only commonly used variables that can be easily extracted by electronic health records.
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Affiliation(s)
- Spyridon Fortis
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Amy M J O'Shea
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck Mae
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Gregory A Schmidt
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather Schacht Reisinger
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary Vaughan Sarrazin
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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Comparison of the Automated Pediatric Logistic Organ Dysfunction-2 Versus Manual Pediatric Logistic Organ Dysfunction-2 Score for Critically Ill Children. Pediatr Crit Care Med 2020; 21:e160-e169. [PMID: 32091503 DOI: 10.1097/pcc.0000000000002235] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The Pediatric Logistic Organ Dysfunction-2 is a validated score that quantifies organ dysfunction severity and requires complex data collection that is time-consuming and subject to errors. We hypothesized that a computer algorithm that automatically collects and calculates the Pediatric Logistic Organ Dysfunction-2 (aPELOD-2) score would be valid, fast and at least as accurate as a manual approach (mPELOD-2). DESIGN Retrospective cohort study. SETTING Single center tertiary medical and surgical pediatric critical care unit (Sainte-Justine Hospital, Montreal, Canada). PATIENTS Critically ill children participating in four clinical studies between January 2013 and August 2018, a period during which mPELOD-2 data were manually collected. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The aPELOD-2 was calculated for all consecutive admissions between 2013 and 2018 (n = 5,279) and had a good survival discrimination with an area under the receiver operating characteristic curve of 0.84 (95% CI, 0.81-0.88). We also collected data from four single-center studies in which mPELOD-2 was calculated (n = 796, 57% medical, 43% surgical) and compared these measurements to those of the aPELOD-2. For those patients, median age was 15 months (interquartile range, 3-73 mo), median ICU stay was 5 days (interquartile range, 3-9 d), mortality was 3.9% (n = 28). The intraclass correlation coefficient between mPELOD-2 and aPELOD-2 was 0.75 (95% CI, 0.73-0.77). The Bland-Altman showed a bias of 1.9 (95% CI, 1.7-2) and limits of agreement of -3.1 (95% CI, -3.4 to -2.8) to 6.8 (95% CI, 6.5-7.2). The highest agreement (Cohen's Kappa) of the Pediatric Logistic Organ Dysfunction-2 components was noted for lactate level (0.88), invasive ventilation (0.86), and creatinine level (0.82) and the lowest for the Glasgow Coma Scale (0.52). The proportion of patients with multiple organ dysfunction syndrome was higher for aPELOD-2 (78%) than mPELOD-2 (72%; p = 0.002). The aPELOD-2 had a better survival discrimination (area under the receiver operating characteristic curve, 0.81; 95% CI, 0.72-0.90) over mPELOD-2 (area under the receiver operating characteristic curve, 0.70; 95% CI, 0.59-0.82; p = 0.01). CONCLUSIONS We successfully created a freely available automatic algorithm to calculate the Pediatric Logistic Organ Dysfunction-2 score that is less labor intensive and has better survival discrimination than the manual calculation. Use of an automated system could greatly facilitate integration of the Pediatric Logistic Organ Dysfunction-2 score at the bedside and within clinical decision support systems.
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Inter-Rater Reliability and Impact of Disagreements on Acute Physiology and Chronic Health Evaluation IV Mortality Predictions. Crit Care Explor 2020; 1:e0059. [PMID: 32166239 PMCID: PMC7063885 DOI: 10.1097/cce.0000000000000059] [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] [Indexed: 11/26/2022] Open
Abstract
Acute Physiology and Chronic Health Evaluation is a well-validated method to risk-adjust ICU patient outcomes. However, predictions may be affected by inter-rater reliability for manually entered elements. We evaluated inter-rater reliability for Acute Physiology and Chronic Health Evaluation IV manually entered elements among clinician abstractors and assessed the impacts of disagreements on mortality predictions.
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Fortis S, O'Shea AMJ, Beck BF, Nair R, Goto M, Kaboli PJ, Perencevich EN, Reisinger HS, Sarrazin MV. An automated computerized critical illness severity scoring system derived from APACHE III: modified APACHE. J Crit Care 2018; 48:237-242. [PMID: 30243204 DOI: 10.1016/j.jcrc.2018.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/04/2018] [Accepted: 09/04/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the performance of an automated computerized ICU severity scoring derived from the APACHE III. MATERIALS AND METHODS Within a retrospective cohort of patients admitted to Veterans Health Administration ICUs between 2009 and 2015, we created an automated illness severity score(modified APACHE or mAPACHE), that we extracted from the electronic health records, using the same scoring as the APACHE III excluding the Glasgow Coma Scale, urine output, arterial blood gas components of APACHE III. We assessed the mAPACHE discrimination by using the area under the curve(AUC), and calibration by using the Hosmer-Lemeshow test and calculating the difference between observed and expected mortality across equal-sized risk deciles for death. RESULTS The ICU and 30-day mortality was 5.07% of 7.82%, respectively (n = 490,955 patients). The AUC of mAPACHE for ICU and 30-day mortality was 0.771 and 0.786, respectively. The Hosmer-Lemeshow test was significant for both ICU and 30-day mortality (p < .001). The absolute difference between observed and expected mortality did not exceed ±1.53% across equal-sized deciles of risk for death. The AUC for ICU mortality was >0.7 in all admission diagnosis categories except in endocrine, respiratory, and sepsis. The AUC for 30-day mortality was >0.7 in every category. CONCLUSION mAPACHE has adequate performance to predict mortality.
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Affiliation(s)
- Spyridon Fortis
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Pulmonary, Critical Care and Occupation Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA.
| | - Amy M J O'Shea
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Brice F Beck
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
| | - Rajeshwari Nair
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA; Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Michihiko Goto
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Peter J Kaboli
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Eli N Perencevich
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Heather S Reisinger
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
| | - Mary V Sarrazin
- Center for Comprehensive Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA; Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, USA
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9
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Reith FC, Synnot A, van den Brande R, Gruen RL, Maas AI. Factors Influencing the Reliability of the Glasgow Coma Scale: A Systematic Review. Neurosurgery 2018; 80:829-839. [PMID: 28327922 DOI: 10.1093/neuros/nyw178] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 12/23/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Glasgow Coma Scale (GCS) characterizes patients with diminished consciousness. In a recent systematic review, we found overall adequate reliability across different clinical settings, but reliability estimates varied considerably between studies, and methodological quality of studies was overall poor. Identifying and understanding factors that can affect its reliability is important, in order to promote high standards for clinical use of the GCS. OBJECTIVE The aim of this systematic review was to identify factors that influence reliability and to provide an evidence base for promoting consistent and reliable application of the GCS. METHODS A comprehensive literature search was undertaken in MEDLINE, EMBASE, and CINAHL from 1974 to July 2016. Studies assessing the reliability of the GCS in adults or describing any factor that influences reliability were included. Two reviewers independently screened citations, selected full texts, and undertook data extraction and critical appraisal. Methodological quality of studies was evaluated with the consensus-based standards for the selection of health measurement instruments checklist. Data were synthesized narratively and presented in tables. RESULTS Forty-one studies were included for analysis. Factors identified that may influence reliability are education and training, the level of consciousness, and type of stimuli used. Conflicting results were found for experience of the observer, the pathology causing the reduced consciousness, and intubation/sedation. No clear influence was found for the professional background of observers. CONCLUSION Reliability of the GCS is influenced by multiple factors and as such is context dependent. This review points to the potential for improvement from training and education and standardization of assessment methods, for which recommendations are presented.
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Affiliation(s)
- Florence Cm Reith
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Preventive Medicine and Public Health, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,National Trauma Institute, Melbourne, Australia
| | - Ruben van den Brande
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Institute of Technology in Health and Medicine (NITHM), Nanyang Technological University, 637553, Singapore
| | - Andrew Ir Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Kurian GP, Korula PJ, Gowri MS. Feasibility and Accuracy of a Nonmedical Research Person in Assimilation and Calculation of Acute Physiologic Assessment and Chronic Health Evaluation Scores in an Indian Intensive Care Unit. Indian J Crit Care Med 2018; 22:524-527. [PMID: 30111928 PMCID: PMC6069310 DOI: 10.4103/ijccm.ijccm_489_17] [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] [Indexed: 11/04/2022] Open
Abstract
Background The Physiologic Assessment and Chronic Health Evaluation (APACHE) score assimilation and calculation, as well as other demographic data collection, is inherent to research and nonresearch related needs of intensive care. There may be a role for well-trained nonmedical personnel to collect this vital material to enhance research and the standard of care in the Intensive Care Units (ICUs) in countries that are poorly funded and resourced in terms of medical personnel. Aims The aim of this study is to verify the interrater reliability of a trained nonmedical personnel and ICU trainee in the collection and calculation APACHE scores. Materials and Methods In a prospective study, two raters who were blinded, one a trained nonmedical ward clerk and another an ICU trainee, assimilated data and calculated APACHE scores for 60 consecutive patients admitted to two tertiary mixed ICUs (with a total of 19 beds). Primary outcomes were to assess interrater and interclass correlation as well as the agreement of scores between the two raters. Results There was an excellent correlation of APACHE scores (Kappa coefficient of 0.92) and Bland-Altman plot depicted overall good agreement with low bias between raters. Conclusions A well-trained and supervised nonmedical research person can assimilate and calculate APACHE II scores with good agreement with an ICU trainee. This may help in deriving data from medically understaffed ICUs in India, thus promoting much-needed research from such ICUs.
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Affiliation(s)
- George Prashanth Kurian
- Division of Critical Care, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Pritish John Korula
- Division of Critical Care, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
| | - Mahasampath S Gowri
- Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu, India
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11
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Oh H, Lee K, Shin S, Seo W. Temporal Patterns and Influential Factors of Blood Glucose Levels During the First 10-Day Critical Period After Brain Injury. Clin Nurs Res 2017; 28:744-761. [PMID: 29254374 DOI: 10.1177/1054773817749725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study was conducted to document temporal patterns of blood glucose level changes during the first 10-day critical period and to identify factors that influence stress-induced hyperglycemia development in brain injury patients. The medical records of 190 brain injury patients were retrospectively reviewed. Blood glucose levels in the poor recovery group were significantly higher than in the good recovery group, particularly during the first 72 hr (158-172 mg/dl). The poor recovery group showed persistent, fluctuating hyperglycemia, whereas the good recovery group exhibited hyperglycemic peaks during the first 3 days that subsequently reduced linearly to normal. Gender, preexisting hypertension, disease severity at admission, total calorie intake, and steroid use were found to influence stress-induced hyperglycemia development significantly. In conclusion, close monitoring and adjustment are required to maintain safe blood glucose levels and the development of protocols for safe glycemic management is essential to improve critical care in brain injury patients.
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Affiliation(s)
- HyunSoo Oh
- 1 Inha University, Incheon, Republic of Korea
| | - KangIm Lee
- 1 Inha University, Incheon, Republic of Korea
| | | | - WhaSook Seo
- 1 Inha University, Incheon, Republic of Korea
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12
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Hayes K, Holland AE, Pellegrino VA, Leet AS, Fuller LM, Hodgson CL. Physical function after extracorporeal membrane oxygenation in patients pre or post heart transplantation – An observational study. Heart Lung 2016; 45:525-531. [DOI: 10.1016/j.hrtlng.2016.07.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 10/21/2022]
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13
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Robinski M, Strich F, Mau W, Girndt M. Validating a Patient-Reported Comorbidity Measure with Respect to Quality of Life in End-Stage Renal Disease. PLoS One 2016; 11:e0157506. [PMID: 27294867 PMCID: PMC4905653 DOI: 10.1371/journal.pone.0157506] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 05/31/2016] [Indexed: 12/26/2022] Open
Abstract
Purpose Medical record-derived comorbidity measures such as the Charlson Comorbidity Index (CCI) do not predict functional limitations or quality of life (QoL) in the chronically ill. Although these shortcomings are known since the 1980s, they have been largely ignored by the international literature. Recently, QoL has received growing interest as an end-point of interventional trials in Nephrology. The aim of this study is to compare a patient-reported comorbidity measure and the CCI with respect to its validity regarding QoL. Methods The German Self-Administered Comorbidity Questionnaire (SCQ-G) was completed by 780 adult end-stage renal disease-patients recruited from 55 dialysis units throughout Germany. Acceptance was evaluated via response rates. Content validity was examined by comparing the typical comorbidity pattern in dialysis patients and the pattern retrieved from our data. Convergent validity was assessed via kappa statistics. Data was compared to the CCI. Linear associations with QoL were examined (criterion validity). Results The SCQ-G was very well accepted by dialysis patients of all ages (response rate: 99%). Content validity can be interpreted as high (corresponding comorbidity items: 73.7%). Convergent validity was rather weak (.27≤ρ≤.29) but increased when comparing only concordant items (.39≤ρ≤.43). With respect to criterion validity, the SCQ-G performed better than the CCI regarding the correlation with QoL (e.g., SF-12-physical: SCQ-G total score: ρ = -.49 vs. CCI: ρ = -.36). Conclusions The patient-reported measure proved to be more valid than the external assessment when aiming at insights on QoL. Due to the inclusion of subjective limitations, the SCQ-G is more substantial with respect to patient-centered outcomes and might be used as additional measure in clinical trials.
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Affiliation(s)
- Maxi Robinski
- Institute for Rehabilitation Medicine, Medical Faculty of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Center for Health Sciences of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- * E-mail:
| | - Franz Strich
- Institute for Rehabilitation Medicine, Medical Faculty of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Center for Health Sciences of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Wilfried Mau
- Institute for Rehabilitation Medicine, Medical Faculty of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Center for Health Sciences of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Medical Faculty of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
- Center for Health Sciences of the Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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Reith FCM, Van den Brande R, Synnot A, Gruen R, Maas AIR. The reliability of the Glasgow Coma Scale: a systematic review. Intensive Care Med 2015; 42:3-15. [PMID: 26564211 DOI: 10.1007/s00134-015-4124-3] [Citation(s) in RCA: 129] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/26/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The Glasgow Coma Scale (GCS) provides a structured method for assessment of the level of consciousness. Its derived sum score is applied in research and adopted in intensive care unit scoring systems. Controversy exists on the reliability of the GCS. The aim of this systematic review was to summarize evidence on the reliability of the GCS. METHODS A literature search was undertaken in MEDLINE, EMBASE and CINAHL. Observational studies that assessed the reliability of the GCS, expressed by a statistical measure, were included. Methodological quality was evaluated with the consensus-based standards for the selection of health measurement instruments checklist and its influence on results considered. Reliability estimates were synthesized narratively. RESULTS We identified 52 relevant studies that showed significant heterogeneity in the type of reliability estimates used, patients studied, setting and characteristics of observers. Methodological quality was good (n = 7), fair (n = 18) or poor (n = 27). In good quality studies, kappa values were ≥0.6 in 85%, and all intraclass correlation coefficients indicated excellent reliability. Poor quality studies showed lower reliability estimates. Reliability for the GCS components was higher than for the sum score. Factors that may influence reliability include education and training, the level of consciousness and type of stimuli used. CONCLUSIONS Only 13% of studies were of good quality and inconsistency in reported reliability estimates was found. Although the reliability was adequate in good quality studies, further improvement is desirable. From a methodological perspective, the quality of reliability studies needs to be improved. From a clinical perspective, a renewed focus on training/education and standardization of assessment is required.
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Affiliation(s)
- Florence C M Reith
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium. .,University of Antwerp, Edegem, Belgium.
| | - Ruben Van den Brande
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
| | - Anneliese Synnot
- Australian & New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,ANZIC-RC, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Hospital, Level 6, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Russell Gruen
- Central Clinical School, Monash University, Melbourne, Australia.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Central Clinical School, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, VIC, 3004, Australia
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Wilrijkstraat 10, 2650, Edegem, Belgium.,University of Antwerp, Edegem, Belgium
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15
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When computers do the scoring, humans have to define the rules. Crit Care Med 2013; 41:335-6. [PMID: 23269137 DOI: 10.1097/ccm.0b013e318270e416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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16
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Ginn AN, Wiklendt AM, Gidding HF, George N, O’Driscoll JS, Partridge SR, O’Toole BI, Perri RA, Faoagali J, Gallagher JE, Lipman J, Iredell JR. The ecology of antibiotic use in the ICU: homogeneous prescribing of cefepime but not tazocin selects for antibiotic resistant infection. PLoS One 2012; 7:e38719. [PMID: 22761698 PMCID: PMC3382621 DOI: 10.1371/journal.pone.0038719] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 05/14/2012] [Indexed: 01/07/2023] Open
Abstract
Background Antibiotic homogeneity is thought to drive resistance but in vivo data are lacking. In this study, we determined the impact of antibiotic homogeneity per se, and of cefepime versus antipseudomonal penicillin/β-lactamase inhibitor combinations (APP-β), on the likelihood of infection or colonisation with antibiotic resistant bacteria and/or two commonly resistant nosocomial pathogens (methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa). A secondary question was whether antibiotic cycling was associated with adverse outcomes including mortality, length of stay, and antibiotic resistance. Methods We evaluated clinical and microbiological outcomes in two similar metropolitan ICUs, which both alternated cefepime with APP-β in four-month cycles. All microbiological isolates and commensal samples were analysed for the presence of antibiotic-resistant bacteria including MRSA and P. aeruginosa. Results Length of stay, mortality and overall antibiotic resistance were unchanged after sixteen months. However, increased colonisation and infection by antibiotic-resistant bacteria were observed in cefepime cycles, returning to baseline in APP-β cycles. Cefepime was the strongest risk factor for acquisition of antibiotic-resistant infection. Conclusions Ecological effects of different β-lactam antibiotics may be more important than specific activity against the causative agents or the effect of antibiotic homogeneity in selection for antibiotic resistance. This has important implications for antibiotic policy.
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Affiliation(s)
- Andrew N. Ginn
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Research Excellence in Critical Infection and Sydney Institute for Emerging Infections and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
- Westmead Millennium Institute, Westmead, New South Wales, Australia
| | - Agnieszka M. Wiklendt
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Research Excellence in Critical Infection and Sydney Institute for Emerging Infections and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
| | - Heather F. Gidding
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, New South Wales, Australia
| | - Narelle George
- Queensland Pathology, Royal Brisbane Hospital, Brisbane, Queensland, Australia
| | | | - Sally R. Partridge
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Research Excellence in Critical Infection and Sydney Institute for Emerging Infections and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
- Westmead Millennium Institute, Westmead, New South Wales, Australia
| | - Brian I. O’Toole
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rita A. Perri
- Westmead Millennium Institute, Westmead, New South Wales, Australia
- Ludwig Engel Centre for Respiratory Research, Westmead Hospital, Sydney, New South Wales, Australia
| | - Joan Faoagali
- Queensland Pathology, Royal Brisbane Hospital, Brisbane, Queensland, Australia
- Department of Microbiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - John E. Gallagher
- Intensive Care Unit, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jeffrey Lipman
- Intensive Care Unit, Royal Brisbane and Women’s Hospital, Brisbane, The University of Queensland, Brisbane, Queensland, Australia
| | - Jonathan R. Iredell
- Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Research Excellence in Critical Infection and Sydney Institute for Emerging Infections and Biosecurity, University of Sydney, Sydney, New South Wales, Australia
- Westmead Millennium Institute, Westmead, New South Wales, Australia
- * E-mail:
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Critical Care Nurses Inadequately Assess SAPS II Scores of Very Ill Patients in Real Life. Crit Care Res Pract 2012; 2012:919106. [PMID: 22548157 PMCID: PMC3323840 DOI: 10.1155/2012/919106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 12/24/2011] [Accepted: 01/13/2012] [Indexed: 12/02/2022] Open
Abstract
Background. Reliable ICU severity scores have been achieved by various healthcare workers but nothing is known regarding the accuracy in real life of severity scores registered by untrained nurses. Methods. In this retrospective multicentre audit, three reviewers independently reassessed 120 SAPS II scores. Correlation and agreement of the sum-scores/variables among reviewers and between nurses and the reviewers' gold standard were assessed globally and for tertiles. Bland and Altman (gold standard—nurses) of sum scores and regression of the difference were determined. A logistic regression model identifying risk factors for erroneous assessments was calculated. Results. Correlation for sum scores among reviewers was almost perfect (mean ICC = 0.985). The mean (±SD) nurse-registered SAPS II sum score was 40.3 ± 20.2 versus 44.2 ± 24.9 of the gold standard (P < 0.002 for difference) with a lower ICC (0.81). Bland and Altman assay was +3.8 ± 27.0 with a significant regression between the difference and the gold standard, indicating overall an overestimation (underestimation) of lower (higher; >32 points) scores. The lowest agreement was found in high SAPS II tertiles for haemodynamics (k = 0.45–0.51). Conclusions. In real life, nurse-registered SAPS II scores of very ill patients are inaccurate. Accuracy of scores was not associated with nurses' characteristics.
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Sereika SM, Tate JA, DiVirgilio-Thomas D, Hoffman LA, Swigart VA, Broyles L, Roesch T, Happ MB. The association between bathing and weaning trial duration. Heart Lung 2010; 40:41-8. [PMID: 20561879 PMCID: PMC2997168 DOI: 10.1016/j.hrtlng.2010.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Revised: 02/11/2010] [Accepted: 03/09/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To describe patterns of bath care for patients who are weaning from prolonged mechanical ventilation (PMV) and to explore the association between bathing and weaning trial duration. METHODS Descriptive correlational study. Clinical records from 439 weaning trial days for 30 patients who required PMV were abstracted for bathing occurrences during weaning trials, within 1 hour before a trial, and nocturnally. RESULTS Most baths occurred during weaning trials (30.8%) or at night (35.3%), and less frequently (16%) within 1 hour before a trial. No significant effects were found on trial duration for nocturnal bathing or bathing within 1 hour before a trial. By using random coefficient modeling, weaning duration was shown to be longer when bathing occurred during a weaning trial (P < .05), even when controlling for age, severity of illness, and days on bedrest. CONCLUSION Bathing occurred during approximately one third of PMV weaning trials. Baths during PMV weaning trials were associated with longer weaning trial duration.
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Affiliation(s)
- Susan M Sereika
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania 15261, USA
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Owen PS, Tan EC, Kiser TH, Fish DN, MacLaren R. Reliability and accuracy of practitioner-calculated Acute Physiology and Chronic Health Evaluation II scores for determining the appropriateness of drotrecogin alfa (activated). Am J Health Syst Pharm 2010; 67:136-43. [PMID: 20065268 DOI: 10.2146/ajhp090186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The reliability and accuracy of practitioner-calculated Acute Physiology and Chronic Health Evaluation (APACHE) II scores for determining the appropriateness of drotrecogin alfa (activated) in critically ill patients were evaluated. METHODS Three adjudicated clinical cases of sepsis were developed using composites of real patient scenarios. The patients' APACHE II scores were independently assessed by randomly selected critical care practitioners (physicians and nonphysicians). Each case contained at least one reason to consider withholding drotrecogin alfa (activated), but none had a definitive contraindication to drotrecogin alfa (activated). Intraobserver and interobserver variabilities were assessed using kappa correlation. Accuracy was assessed by comparing median scores to the adjudicated scores and evaluating correctly classified APACHE II scores. RESULTS A total of 21 (42%) physicians and 14 (56%) nonphysicians completed all assessments. Intraobserver and interobserver variabilities were 0.16 and 0.49 for the total APACHE II score, respectively. Median calculated APACHE II scores significantly differed for case 1 (p = 0.003) and case 3 (p < 0.0001). The percentage of error in calculating the total APACHE II score approached 85%. The main reasons for administering drotrecogin alfa (activated) were an APACHE II score of >or=25 and multiple organ failures. The main reason for therapy was a high bleeding risk or an APACHE II score of <25. CONCLUSION Weak intraobserver agreement, modest interobserver reliability, a high error rate, and low accuracy limited the clinical application of the APACHE II score by untrained practitioners, indicating that the APACHE II score should not be the only determinant for the use of drotrecogin alfa (activated).
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Affiliation(s)
- Phillip S Owen
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences Center, Mercer University (MU), Atlanta, GA, USA
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The interrater reliability of SAPS II and SAPS 3. Intensive Care Med 2010; 36:850-3. [PMID: 20130828 DOI: 10.1007/s00134-010-1772-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Accepted: 12/03/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE In this study we evaluated and compared the interrater reliability of SAPS II and SAPS 3 in order to measure the consistency of performance among different raters. METHOD Ten junior doctors working at two general ICUs were trained in the use of SAPS II and SAPS 3 using a 2.5-h training program. After training they scored 24 cases in both systems. Scores were analyzed using intraclass correlation coefficient (ICC) statistics. In order to identify variables with low reliability, subscores were analyzed using the ICC, and single-variables were compared to a template score using weighted kappa statistics. RESULTS The ICC (95% CI) of the scores was 0.84 (0.74, 0.91) in SAPS II and 0.80 (0.68, 0.89) in SAPS 3, which is considered adequate for both systems. Mean mortality predictions among the raters had a range of 0.12 in SAPS II and 0.19 in SAPS 3. Administrative data including age had high reliability, whereas variables based on diagnostic information had only moderate reliability. Laboratory data had consistently higher reliability than variables based on the interpretation of charts. CONCLUSION Both SAPS II and SAPS 3 have adequate interrater reliability, but the standardized mortality ratios are still likely to be influenced by the rater's scoring practice.
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Iyer VN, Mandrekar JN, Danielson RD, Zubkov AY, Elmer JL, Wijdicks EFM. Validity of the FOUR score coma scale in the medical intensive care unit. Mayo Clin Proc 2009; 84:694-701. [PMID: 19648386 PMCID: PMC2719522 DOI: 10.4065/84.8.694] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
OBJECTIVE To evaluate the validity of the FOUR (Full Outline of UnResponsiveness) score (ranging from 0 to 16), a new coma scale consisting of 4 components (eye response, motor response, brainstem reflexes, and respiration pattern), when used by the staff members of a medical intensive care unit (ICU). PATIENTS AND METHODS This interobserver agreement study prospectively evaluated the use of the FOUR score to describe the condition of 100 critically ill patients from May 1, 2007, to April 30, 2008. We compared the FOUR score to the Glasgow Coma Scale (GCS) score. For each patient, the FOUR score and the GCS score were determined by a randomly selected staff pair (nurse/fellow, nurse/consultant, fellow/fellow, or fellow/consultant). Pair wise weighted kappa values were calculated for both scores for each observer pair. RESULTS The interrater agreement with the FOUR score was excellent (weighted kappa: eye response, 0.96; motor response, 0.97; brainstem reflex, 0.98; respiration pattern, 1.00) and similar to that obtained with the GCS (weighted kappa: eye response, 0.96; motor response, 0.97; verbal response, 0.98). In terms of the predictive power for poor neurologic outcome (Modified Rankin Scale score, 3-6), the area under the receiver operating characteristic curve was 0.75 for the FOUR score and 0.76 for the GCS score. The mortality rate for patients with the lowest FOUR score of 0 (89%) was higher than that for patients with the lowest GCS score of 3 (71%). CONCLUSION The interrater agreement of FOUR score results was excellent among medical intensivists. In contrast to the GCS, all components of the FOUR score can be rated even when patients have undergone intubation. The FOUR score is a good predictor of the prognosis of critically ill patients and has important advantages over the GCS in the ICU setting.
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Affiliation(s)
| | | | | | | | | | - Eelco F. M. Wijdicks
- From the Division of Pulmonary and Critical Care Medicine (V.N.I.), Division of Biomedical Informatics and Biostatistics (J.N.M.), Department of Nursing (R.D.D., J.L.E.), and Division of Critical Care Neurology (A.Y.Z., E.F.M.W.), Mayo Clinic, Rochester, MN
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Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database. J Crit Care 2009; 24:401-7. [PMID: 19577415 DOI: 10.1016/j.jcrc.2009.03.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2008] [Revised: 03/17/2009] [Accepted: 03/29/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied. METHODS Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain's percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A kappa statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality. RESULTS Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by kappa statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71). CONCLUSION Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.
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