Evaluation of standard and modified severity of illness scores in the obstetric patient

Purpose

To test discrimination and calibration of APACHE-II and SAPS-II risk prediction scores in a cohort of obstetric patients, and to evaluate the effect of modifying these scores for the physiological changes in pregnancy.

Materials and Methods

A retrospective review of obstetric patients, 12 weeks gestation to 48 hours postpartum, admitted to the ICU for more than 24 hours. APACHE-II and SAPS-II, and versions modified for the physiological changes of pregnancy, were evaluated by receiver operating characteristic (ROC) curves and standardized mortality ratios (SMR). Multivariable analysis identified other parameters associated with mortality.

Results

Data were obtained from 332 patients from 5 countries, with a mortality rate of 12%. Mean (± SD) APACHE-II score was 16.8 ± 6.1 and SAPS-II score 26.5 ± 15.8. Good discrimination was demonstrated with area under the ROC curves of 0.82 and 0.78 respectively, with no improvement after modification for altered maternal physiology. APACHE-II overestimated mortality, with an SMR of 0.43 (0.52 after including diagnostic weighting) compared with 0.89 for SAPS-II. Bilirubin, albumin and Glasgow Coma Scale were independently associated with mortality.

Conclusion

APACHE-II and SAPS-II are good discriminators of illness severity and may be valuable for comparing obstetric cohorts, but APACHE-II significantly over-estimates mortality.     

Predictive accuracy of severity scoring system: a prospective cohort study using APACHE III in a Korean intensive care unit

AIM: To evaluate the discrimination, calibration, and uniformity of fit by age group, operative status, and location before ICU admission of APACHE III in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a 25 bed mixed (surgical and medical) ICU of 850-bed teaching hospital in Pusan, South Korea. SUBJECTS AND METHODS: The worst values on APACHE III variables during 24h following ICU admission were collected from the patient's charts and clinical flow sheets of 284 consecutively admitted subjects. RESULTS: The mortality rate was 31.0%, and showed a strong positive correlation between APACHE III score (r=0.97, p<0.0001 for entire population, r=0.97, p<0.0001 for medical patients, r=0.91, p<0.0001 for surgical patients). Hospital mortality was significantly higher for medical patients than surgical patients (OR=7.23, 95% CI=3.76-13.88), and for patients located in the operating room than at ward before admitting ICU (OR=0.09, 95% CI=0.04-0.23). At the predicted risk of 0.5 (66 of APACHE III score), sensitivity was 0.72, specificity 0.91, and correct classification rate 0.85. Area under the ROC curve was 0.905 (95% CI=0.867-0.943). Correlation coefficient (r) between observed and expected mortality rate was 0.99. The value (chi-square) of Lemeshow-Hosmer (L-H) goodness-of-fit statistic was 6.54 (p=0.59). In patients stratified according to age groups, operative status, and location in the hospital before ICU admission, discrimination was generally good in all subgroups (area under the ROC curve >0.85), and the chi-squared of L-H goodness-of -fit statistic showed a good fit for all subgroup, especially for operative status. CONCLUSIONS: The predictive accuracy of the APACHE III scoring system showed better discrimination, as well as uniformity of fit. So, it was thought that could be utilized for the subject hospital.     

综合性医院成年住院病人的直接护理时间与自理能力、疾病严重度相关性的研究

目的比较综合性医院不同日常生活自理能力、不同疾病严重度的成年住院病人所需直接护理时间的差异,并探讨各变量之间的相关关系。方法对某综合性医院428例成年住院病人采用Barthel指数评定量表、急性生理功能和慢性健康疾病状况评估系统Ⅱ(APACHEⅡ)评价病人的自理能力和疾病严重度,用自行设计的病人基本护理需求与直接护理时间观测表观察记录成年住院病人24h所需直接护理时间。结果①不同自理能力病人所需直接护理时间不同;②不同疾病严重度病人直接护理时间不同;③直接护理时间与自理能力负相关,与疾病严重度正相关。结论①病人的直接护理时间与自理能力和疾病严重度相关;②科学地测量护理工作量和配备护理人力应考虑到病人的日常生活自理能力和疾病严重度。     

Outcome prediction in intensive care: results of a prospective, multicentre, Portuguese study

Objective: To compare the performance of the New Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE) II in an independent database, using formal statistical assessment. Design: Analysis of the database of a multicentre, prospective study. Setting: 19 intensive care units (ICUs) in Portugal. Patients: Data for 1094 patients consecutively admitted to the ICUs were collected over a period of 4 months. Following the original SAPS II and APACHE II criteria, the analysis excluded patients younger than 18 years of age, readmissions, acute myocardial infarction, burns, patients in the post-operative period after coronary artery bypass surgery, and patients with a length of stay in the ICU of less than 24 h. The group analysed comprised 982 patients. Interventions: Collection of the first 24 h admission data necessary for the calculation of SAPS II, APACHE II, Therapeutic Intervention Scoring System (TISS), Simplified TISS, organ system failure and basic demographic statistics. Vital status at discharge from the hospital was registered. Measurements and results: In this cohort, discrimination was better for SAPS II than for APACHE II (SAPS II: area under the receiver operating characteristic curve 0.817, standard error 0.015; APACHE II: 0.787, 0.015; p < 0.001); however, both models presented a poor calibration, with significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit tests H and C, p < 0.001). In a stratified analysis, this study was unable to demonstrate any definite pattern of association between the poor performance of the models and specific subgroups of patients except for the most severely ill patients, where both models overestimated mortality. Conclusions: SAPS II performed better than APACHE II in this independent database, but the results do not allow its use, at least without being customised, to analyse quality of care or performance among ICUs in the target population. Received: 2 April 1996 Accepted: 24 October 1996     

Maternal characteristics and migraine pharmacotherapy during pregnancy: cross-sectional analysis of data from a large cohort study

Little is known about factors associated with migraine pharmacotherapy during pregnancy. Of 60 435 pregnant women in a population-based cohort, 3480 (5.8%) reported having migraine during the first 5 months of pregnancy. Of these, 2525 (72.6%) reported using migraine pharmacotherapy, mostly non-narcotic analgesics (54.1%) and triptans (25.4%). After adjustment for sociodemographic factors and comorbidities in logistic regression analysis, high pregestational body mass index [odds ratio (OR) 1.3, 95% confidence interval (CI) 1.2, 1.4], sleep < 5 h (OR 1.6, 95% CI 1.3, 1.9), being on sick-leave (OR 1.3, 95% CI 1.2, 1.5) and acute back/shoulder/neck pain (OR 0.6, 95% CI 0.6, 0.7) were associated with migraine pharmacotherapy during pregnancy. Many women need drug treatment for migraine during pregnancy, and the choice of pharmacotherapy during this period may be influenced by maternal sociodemographic factors and comorbidities.     

早期肠内营养达标对不同程度重症患者预后的影响

目的 探讨早期肠内营养达标与否,对不同疾病严重程度重症患者住院时间、医疗费用以及生存率等的影响.方法 2008年1月1日至2009年6月30日入住苏州大学附属第二医院ICU的患者,满足以下标准进入本研究:(1)年龄≥18岁;(2)住院时间≥72 h;(3)入ICU 48 h内予以肠内营养.依据第3天肠内供给能量是否达到目标供给量62.7 kJ/(kg·d)的60%,分为达标组和未达标组;再根据APACHEⅡ评分将每组患者分为＜15分、15～25分和＞25分3个亚组,并比较患者不同疾病严重程度的住院时间、医疗费用及死亡率.结果 共有192例重症患者进入本研究,62例患者的早期肠内营养达标,而其余的130例患者未达标.对于APACHEⅡ评分＜15分的患者,达标组患者的总住院时间明显低于未达标组(P＜0.01);对于APACHEⅡ评分15至25分的患者,达标组患者除总住院时间(P＜0.01)外,ICU住院时间(P＜0.01)、医疗费用(P＜0.01)及死亡率(P＜0.05)均明显低于未达标组;当APACHEⅡ评分＞25分时,达标组患者医疗费用明显降低(P＜0.01).结论 早期肠内营养达标能改善重症患者的预后,并且其临床治疗价值随疾病严重程度的不同而异.     

颅脑外伤病人甲状腺激素水平与疾病严重程度及预后的关系

目的研究颅脑外伤病人甲状腺激素水平与疾病严重程度及预后的关系。方法对例颅脑外伤病人的甲状腺激素水平与疾病的严重程度及预后的关系进行前瞻性研究。疾病的严重程度及预后分别采用GCS和GOS评分。入院第二天抽血查血清甲状腺激素（TT3、FT3、TT4、FT4、rT3和TSH）的浓度。结果GCS评分与TT3（r＝0．4630,P＜0．001）、FT3（r＝0．442,P＜0．01）和TT4（r＝0．2994,P＜0．05）的水平相关,与FT4和rT3无明显相关性。根据GCS评分结果分三组：①重度组（n＝12）：GCS3～8分;②中度组（n＝11）：GCS9～12分;③轻度组（n＝24）：GCS13～15分。三组的TT3（P＜0．01）和FT3（P＜0．01）值有差别,其中重度组和中度组的TT3和FT3水平分别比轻度组降低33．3％～35．5％和33．3％～34．7％。GOS评分与TT3（r＝0．5756,P＜0．001）、FT3（r＝0．5017,P＜0．001）和TT4（r＝0．3984,P＜0．01）的水平相关,与FT4、rT3和TSH无明显相关性。根据GOS评分结果分三组：①A组（n＝8）：死亡组;②B组（n＝16）：持续植物人状态和重度残废组;③C组（n＝23）：轻度残废和恢复良好组。三组的TT3（P＜0．001）和FT3（P＜0．01）值有差别,其中A组和B组的TT3和FT3水平分别比C组降低36．4％～45．0％和31．5％～40．3％     

The Pediatric Early Warning System score: a severity of illness score to predict urgent medical need in hospitalized children

PURPOSE: We developed and performed the initial retrospective validation of a pediatric severity of illness score. The score is to preemptively identify hospitalized children who are likely to require resuscitation to treat cardiopulmonary arrest. MATERIALS AND METHODS: The Pediatric Early Warning System (PEWS) score was developed using expert opinion. The score generated contained 20 items, 16 of which were able to be retrospectively abstracted. Validation used a case-control study design in a Canadian university-affiliated pediatric hospital. Eligible patients were younger than 18 years, were admitted to a hospital ward, and had no level-of-care restrictions. Case patients had a code blue called to obtain immediate assistance for treatment of impending or actual cardiopulmonary arrest. Control patients had no code blue event and were not urgently admitted to the intensive care unit within 48 hours of study. A total of 128 controls and 87 cases were compared. RESULTS: The PEWS score area under the receiver operating characteristic curve was 0.90. The sensitivity was 78% and the specificity was 95% at a score of 5. CONCLUSIONS: Application of the score may have identified more than 3 quarters of code blue calls in our hospital with at least an hour's warning. After further refinement and validation, the PEWS score has great potential to increase the efficiency of care delivery and to improve the outcomes of care provided to hospitalized children.     

A prospective randomized trial of enteral glutamine in critical illness

Objective To assess the influence of enteral glutamine on the incidence of severe sepsis and death in critically ill patients.Design This two-armed clinical trial was triple blind (patients, attending staff, research nurse).Setting The 10 bed general ICU at Royal Perth Hospital, Western Australia.Patients This trial evaluated 363 patients requiring mechanical ventilation (median APACHE II score=14); of these, 85 had trauma.Intervention The intervention solution contained 20 g/l glutamine and the control solution was isojoulic and isonitrogenous.Measurements and results The groups had similar characteristics at baseline, and they also received equivalent amounts of protein and energy. Patients in the glutamine group received a median of 19 g/glutamine per day and 91% (332 of 363) of the patients were fed via a nasogastric tube (median duration=10 days). The outcomes were similar in the two groups: (a) death within 6 months: glutamine group 15% (27 of 179) vs control group 16% (30 of 184); p=0.75; relative risk, 0.95 (95% confidence interval, 0.71–1.28); and (b) severe sepsis: glutamine group 21% (38 of 179) vs control group 23% (43 of 184); p=0.62; relative risk, 0.94 (95% confidence interval, 0.72–1.22). There was also no discernable difference in the secondary outcomes relating to infections, febrile period, antimicrobial therapy, and consumption of inotropes.Conclusion This clinical trial did not support the use of enteral glutamine supplements in similar cohorts of critically ill patients.     

Long-term cognitive impairment and delirium in intensive care: A prospective cohort study

Background

Whilst there is a growing body of research exploring the effect of delirium in intensive care unit (ICU) patients, the relationship between patient delirium and long-term cognitive impairment has not been investigated in settings where low rates of delirium have been reported.

炎症反应器官功能不全评分评估危重病人病情的研究

目的探讨炎症反应器官功能不全评分(IRODS)在评估ICU病人病情和预后中的应用价值。方法应用新构建的IRODS回顾性地对ICU病人病情进行量化评分,考察IRODS在生存组和死亡组间的差异以及IRODS与ICU病死率的关系,比较该评分与APACHEII的评估效能。结果入院初始和24h的IRODS在生存组和死亡组间有显著性差异(P<0.001);随着IRODS增加,ICU病死率增加;入院初始及24hIRODS的接受者操纵特征曲线下面积(AUROCC)分别是0.930和0.934,APACHEII的AUROCC是0.956,两者间无显著性差异(P>0.05)。结论在入院初期,IRODS可用于评估危重病人的病情和预后,与APACHEII有相近的评估效能,但更为简便。     

A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research

The Charlson index is commonly used for risk adjustment in critical care health services research. However, the literature supporting this methodology has not been thoroughly explored. We systematically reviewed the literature related to administrative database adaptations of the Charlson index. Our review has 3 major findings. First, 2 studies compared Canadian administrative databases with chart review for obtaining Charlson comorbidity data. Agreement between the database and chart review was substantial (kappa > 0.70), and mortality prediction did not differ. Second, 5 database adaptations were identified with the Deyo and Dartmouth-Manitoba adaptations being most popular. Three studies directly compared these 2 popular adaptations and demonstrated substantial agreement (kappa > 0.70) and similar predictive ability for mortality. Third, one study validated the Charlson index for critically ill patients but demonstrated that APACHE (Acute Physiology and Chronic Health Evaluation) II better discriminates inhospital mortality (area under curve 0.67 vs 0.87). Time and cost barriers prevent widespread use of physiology-based risk adjustment in population-based research. The decreased predictive ability of the Charlson index must be weighed against the advantages of using this instrument for population-based research. Future research should focus on updating the Charlson index for recent changes in the prognosis of comorbid diseases and introduction of International Statistical Classification of Diseases, 10th Revision coding of discharge abstracts.     

Significance of new-onset prolonged sinus tachycardia in a medical intensive care unit: a prospective observational study

Objective

Few data are available on sinus tachycardia among medical intensive care unit (ICU) patients. We investigated new critical illnesses related to new-onset prolonged sinus tachycardia (NOPST) and the relationship of NOPST with ICU mortality.

Methods

The heart rate (HR) of all enrolled patients was monitored hourly over a 12-month period, and NOPST was defined as sinus tachycardia (>100 beats/min) with an increase in HR of more than 20% from the baseline value lasting longer than 6 hours.

Results

Among the 522 patients enrolled, the average mean HR was 96.1 ± 18.4 beats/min. Fifty-two (10.0%) patients met the criteria for NOPST; pneumonia, delirium, septic shock, acute respiratory distress syndrome, catheter-related infections, and mechanical ventilator–related problems were related to the occurrence of NOPST. The ICU mortality rate in patients with a NOPST duration of more than 72 hours was higher compared with other patients with NOPST (60.0% vs 18.5%; P = .002). A high daily mean HR rather than NOPST was a significant predictor of ICU mortality (odds ratio, 1.415; 95% confidence interval, 1.177-1.700).

Conclusions

Although NOPST was not associated with ICU mortality, it indicates the presence of new critical events in the medical ICU setting.     

Validation of a severity of illness score (APACHE II) in a surgical intensive care unit

The intensive care unit is an important resource for the treatment of patients needing medical and surgical care for complicated diseases. The diversity of diseases and the difference in arrangements between hospitals providing such care have limited the precision of evaluations of intensive care. We have measured the admission characteristics and hospital mortality of 598 consecutive patients admitted to our Surgical Intensive Care Unit (SICU) using a severity of disease classification system (APACHE II) on the first day of admission. Hospital outcome details were available on 87% of the SICU patients. The overall mortality was 21.7%, mean APACHE score for survivors and non-survivors was 14.2 and 22.4, and their risk of death was 21.1% and 54.1%. The APACHE II scoring system provided an excellent means of classification, with a higher sensitivity and specificity.     

Person-centred care among intensive care unit nurses: A cross-sectional study

ObjectivePractising person-centred care is crucial for nurses in the intensive care unit, as patients have high physical and psychological care needs. We aimed to identify the predictors of person-centred care among nurses working in intensive care settings.MethodsIn this cross-sectional study, 188 intensive care unit nurses at four tertiary hospitals in two cities of South Korea were included. They completed self-reported questionnaires on emotional intelligence, compassion satisfaction, secondary traumatic stress, burnout, and person-centred care. Emotional intelligence was measured using the Korean version of the Wong and Law’s emotional intelligence scale. Compassion satisfaction, secondary traumatic stress, and burnout were measured by the Professional Quality of Life questionnaire (version 5). Person-centred care was measured using the person-centred critical care nursing scale.ResultsMultiple regression identified compassion satisfaction (β = 0.49, p <.001) as the most powerful predictor of person-centred care, followed by emotional intelligence (β = 0.21, p =.004) and intensive care unit career length (β = 0.17, p =.021). These three variables accounted for 31.0 % of the variance in person-centred care.ConclusionsThis study highlights the importance of career length, emotional intelligence, and compassion satisfaction in the promotion of person-centred care among intensive care unit nurses. Nursing management should contemplate specific measures to reduce turnover among experienced intensive care unit nurses and to enhance the factors that promote person-centred care, such as compassion satisfaction and emotional intelligence.