Assessment and treatment of the acutely ill patient have improved by introducing systematic assessment and accelerated protocols for specific patient groups. Triage systems are widely used, but few studies have investigated the ability of the triage systems in predicting outcome in the unselected acute population. The aim of this study was to quantify the association between the main component of the Hillerød Acute Process Triage (HAPT) system and the outcome measures; Admission to Intensive Care Unit (ICU) and in-hospital mortality, and to identify the vital signs, scored and categorized at admission, that are most strongly associated with the outcome measures.
The HAPT system is a minor modification of the Swedish Adaptive Process Triage (ADAPT) and ranks patients into five level colour-coded triage categories. Each patient is assigned a triage category for the two main descriptors; vital signs, T(vitals), and presenting complaint, T(complaint). The more urgent of the two determines the final triage category, T(final). We retrieved 6279 unique adult patients admitted through the Emergency Department (ED) from the Acute Admission Database. We performed regression analysis to evaluate the association between the covariates and the outcome measures.
The covariates, T(vitals), T(complaint) and T(final) were all significantly associated with ICU admission and in-hospital mortality, the odds increasing with the urgency of the triage category. The vital signs best predicting in-hospital mortality were saturation of peripheral oxygen (SpO(2)), respiratory rate (RR), systolic blood pressure (BP) and Glasgow Coma Score (GCS). Not only the type, but also the number of abnormal vital signs, were predictive for adverse outcome. The presenting complaints associated with the highest in-hospital mortality were 'dyspnoea' (11.5%) and 'altered level of consciousness' (10.6%). More than half of the patients had a T(complaint) more urgent than T(vitals), the opposite was true in just 6% of the patients.
The HAPT system is valid in terms of predicting in-hospital mortality and ICU admission in the adult acute population. Abnormal vital signs are strongly associated with adverse outcome, while including the presenting complaint in the triage model may result in over-triage.
The number of elderly intensive care unit (ICU) patients is increasing. We therefore assessed the long-term outcome in the elderly following intensive care.
The outcome status for 91 elderly (=75 years) and 659 nonelderly (18-74 years) ICU patients treated in the course of a one year period was obtained. A total of 36 of 37 eligible elderly survivors were interviewed about their health related quality of life (HRQOL), social services and their wish for intensive care.
The mortality (54% at follow-up and 64% after one year) was higher in the elderly ICU patients than in non-elderly ICU patients (33% and 37%, respectively, p
Recent studies of the incidence of acute kidney injury (AKI) are largely based on estimated baseline serum creatinine values. The aim of this study was to more accurately determine the incidence of AKI using the RIFLE criteria for intensive care unit (ICU) patients of a whole population.
All adult patients admitted to the ICUs of Landspitali - The National University Hospital of Iceland in 2007 (n = 1026) were studied with meticulous search for baseline creatinine. The underlying risk factors and contributing causes for AKI were defined, and survival and ratio of end-stage renal failure evaluated.
A measured baseline creatinine value was found for all but two patients with AKI. The incidence of AKI according to RIFLE criteria was 21.7% [95% confidence interval (CI): 19.0-24.1%], with 7.1% (95 CI: 5.6-8.9%), 6.8% (95 CI: 5.3-8.5%) and 7.8% (95 CI: 6.2-9.6%) in the risk, injury and failure subgroups. Using estimated baseline creatinine overestimated the incidence of AKI by 3.5%. The sensitivity and specificity of the RIFLE criteria using estimated baseline creatinine were 76% and 95%. Renal replacement therapy was required for 17% of the AKI patients. One year survival of AKI patients was 51%, but only 2.5% of patients surviving 90 days required chronic renal replacement therapy.
The incidence of AKI in the ICU was lower than previously published, perhaps due to overestimation of AKI using estimated baseline creatinine or bias from tertiary referrals. AKI patients have high mortality, but the survivors have a low incidence of end-stage renal failure.
Severe sepsis is one of the leading causes of acute kidney injury (AKI). Patients with sepsis-associated AKI demonstrate high-hospital mortality. We evaluated the incidence of severe sepsis-associated AKI and its association with outcome in intensive care units (ICUs) in Finland.
This was a predetermined sub-study of the prospective, observational, multicentre FINNAKI study conducted in 17 ICUs during 1 September 2011 and 1 February 2012. All emergency ICU admissions and elective admissions exceeding 24 hours in the ICU were screened for presence of severe sepsis and AKI up to 5 days in ICU. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria and severe sepsis according to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria.
Of the 2901 included patients, severe sepsis was diagnosed in 918 (31.6%, 95% confidence interval [CI] 29.9-33.4%) patients. Of these 918 patients, 488 (53.2% [95% CI 49.9-56.5%]) had AKI. The 90-day mortality rate was 38.1% (95% CI 33.7-42.5%) for severe sepsis patients with AKI and 24.7% (95% CI 20.5-28.8%) for those without AKI. After adjusting for covariates, KDIGO stage 3 AKI was associated with an increased risk for 90-day mortality with an adjusted odds ratio (OR) of 1.94 (95% CI 1.28-2.94), but stages 1 and 2 were not.
More than half of the patients with severe sepsis had AKI according to the KDIGO classification, and AKI stage 3 was independently associated with 90-day mortality.
Comparison of outcomes among intensive care units (ICUs) requires adjustment for patient variables. Severity of illness scores are associated with hospital mortality, but administrative databases rarely include the elements of these scores. However, these databases include the elements of comorbidity scores. The purpose of this study was to compare the value of these scores as adjustment variables in statistical models of hospital mortality and hospital and ICU length of stay after adjustment for other covariates.
We used multivariable regression to study 1808 patients admitted to a 13-bed medical-surgical ICU in a 400-bed tertiary hospital between December 1998 and August 2003.
For all patients, after adjusting for age, sex, major clinical category, source of admission, and socioeconomic determinants of health, we found that Acute Physiology and Chronic Health Evaluation (APACHE) II and comorbidity scores were significantly associated with hospital mortality and that comorbidity but not APACHE II was significantly associated with hospital length of stay. Separate analysis of hospital survivors and nonsurvivors showed that both APACHE II and comorbidity scores were significantly associated with hospital length of stay and APACHE II score was associated with ICU length of stay.
The value of APACHE II and comorbidity scores as adjustment variables depends on the outcome and population of interest.
Intensive care is advanced and highly technical, and it is essential that, despite this, patient care remains safe and of high quality. Adverse events (AEs) are supposed to be reported to internal quality control systems by health-care providers, but many are never reported. Patients on the intensive care unit (ICU) are at special risk for AEs. Our aim was to identify the incidence and characteristics of AEs in patients who died on the ICU during a 2-year period.
A structured record review according to the Global Trigger Tool (GTT) was used to review charts from patients cared for at the ICU of a middle-sized Swedish hospital during 2007 and 2008 and who died during or immediately after ICU care. All identified AEs were scored according to severity and preventability.
We reviewed 128 records, and 41 different AEs were identified in 25 patients (19.5%). Health care-associated infections, hypoglycaemia, pressure sores and procedural complications were the most common harmful events. Twenty two (54%) of the AEs were classified as being avoidable. Two of the 41 AEs were reported as complications according to the Swedish Intensive Care Registry, and one AE had been reported in the internal AE-reporting system.
Almost one fifth of the patients who died on the ICU were subjected to harmful events. GTT has the advantage of identifying more patient injuries caused by AEs than the traditional AE-reporting systems used on many ICUs.
The impact of delay in obtaining an intensive care unit (ICU) consult from inpatient wards is unclear. The goal of this study was to examine the effect of time to ICU consult from medical and surgical wards on mortality and length of stay (LOS).
This was a retrospective study of 241 adult medical and surgical inpatients admitted at 2 tertiary care ICUs in Canada between 2007 and 2009. Neither institution has medical emergency teams (METs). Patient demographics, time when the patient would have fulfilled MET calling criteria (MET time), time of ICU consult, and ICU admission were analyzed. The main outcome variables were 30-day mortality and ICU LOS.
Multivariate analysis demonstrated an increase in mortality (odds ratio, 1.8; 95% confidence interval, 1.1-2.9; P = .01) with increased duration from MET time to ICU consult for medical patients. There was no effect of this period on ICU LOS in medical patients. In contrast, in surgical patients, the MET time to ICU consult duration was associated with an increased ICU LOS (coefficient, 2.1 for delay; 95% confidence interval, 0.26-3.8; P = .02) but had no effect on mortality.
Increased duration to ICU consult from MET time is associated with adverse outcomes. These adverse outcomes are different between medical and surgical patients.
Transfusion of red blood cells (RBCs) and, in particular, older RBCs has been associated with increased short-term mortality in critically ill patients. We evaluated the association between age of transfused RBCs and acute kidney injury (AKI), hospital, and 90-day mortality in critically ill patients.
We conducted a prospective, observational, predefined sub-study within the FINNish Acute Kidney Injury (FINNAKI) study. This study included all elective ICU admissions with expected ICU stay of more than 24 hours and all emergency admissions from September to November 2011. To study the age of RBCs, we classified transfused patients into quartiles according to the age of oldest transfused RBC unit in the ICU. AKI was defined according to KDIGO (Kidney Disease: Improving Global Outcomes) criteria.
Out of 1798 patients, 652 received at least one RBC unit. The median [interquartile range] age of the oldest RBC unit transfused was 12 [11-13] days in the freshest quartile and 21 [17-27] days in the quartiles 2 to 4. On logistic regression, RBC age was not associated with the development of KDIGO stage 3 AKI. Patients in the quartile of freshest RBCs had lower crude hospital and 90-day mortality rates compared to those in the quartiles of older blood. After adjustments, older RBC age was associated with significantly increased risk for hospital mortality. Age, Simplified Acute Physiology Score II (SAPS II)-score without age points, maximum Sequental Organ Failure Assessment (SOFA) score and the total number of transfused RBC units were independently associated with 90-day mortality.
The age of transfused RBC units was independently associated with hospital mortality but not with 90-day mortality or KDIGO stage 3 AKI. The number of transfused RBC units was an independent risk factor for 90-day mortality.
Cites: Intensive Care Med. 2013 Mar;39(3):420-823291734
Cites: Anesth Analg. 2005 May;100(5):1433-8, table of contents15845701
Knowledge about the expected life years gained from intensive care unit (ICU) admission could inform priority-setting decisions across groups of ICU patients and across medical specialties. The aim of this study was to estimate expected remaining lifetime for patients admitted to ICUs during 2008-2010 and to estimate the gain in life years from ICU admission.
This is a descriptive, population modelling study of 30,712 adult mixed ICU admissions from the Norwegian Intensive Care Registry. The expected remaining lifetime for each patient was estimated using a decision-analytical model. Transition probabilities were based on registered Simplified Acute Physiology Score (SAPS) II, and standard and adjusted Norwegian life-tables.
The hospital mortality was 19.4% (n = 5,958 deaths). 24% of the patients were estimated to die within the first year after ICU admission in our model. Under an intermediate (base case), optimistic (O), and pessimistic (P) scenario with respect to long-term mortality, the average expected remaining lifetime was 19.4, 19.9, and 12.7 years. The majority of patients had a life expectancy of more than five years (84.8% in the base case, 89.4% in scenario O, and 55.6% in scenario P), and few had a life expectancy of less than one year (0.7%, 0.1%, and 12.7%). The incremental gain from ICU admission compared to counterfactual general ward care was estimated to be 0.04 (scenario P, age 85+) to 1.14 (scenario O, age
Cites: Intensive Care Med. 2012 Oct;38(10):1647-5322777516
Cites: Crit Care Med. 2012 Jan;40(1):132-822001580
Cites: Crit Care Med. 2013 May;41(5):1237-5123442988
Cites: Crit Care Med. 2013 May;41(5):1229-3623591209
Cites: Intensive Care Med. 2013 Nov;39(11):1916-2423925544
Cites: Intensive Care Med. 2014 Jan;40(1):50-624132383
This study aimed to investigate trends in first-time hospitalisations with chronic obstructive pulmonary disease (COPD) in a publicly financed healthcare system during the period from 2002 to 2008 with respect to incidence, outcome and characteristics of hospitalisations, departments, and patients.
Using health administrative data from national registers, all first-time hospitalisations with COPD in Denmark (population 5.4 million) were identified. Data based on the individual hospitalisations and patients were retrieved and analysed.
During the period 2002 to 2008 the total rate of COPD hospitalisations decreased from 460 to 410 per 100,000 person years. Among persons above 45 years of age, the age- and sex-adjusted incidence rate of first-time COPD hospitalisations decreased by 8.2% (95% CI 5.0-11.2%). The inpatient mortality increased OR 1.16 (95% CI 1.01-1.34) and the one-year mortality increased OR 1.12 (95% CI 1.03-1.21). Concurrently, significant age- and sex-adjusted increases were found in use of intensive care, comorbidity, patient travel distance, bed occupancy rate of the receiving department, prior use of oral and inhaled corticosteroids, use of outpatient clinics and encounters in general practice, while length of stay and number of receiving hospitals decreased.
Decreasing rate of first-time COPD hospitalisations combined with shorter lengths of stay and increasing severity of cases indicates that the use of hospital beds for COPD exacerbations has been gradually restricted. This may be causally related to both the centralisation into overcrowded departments and the improved outside hospital treatment of COPD, also demonstrated in this study.