Analysis of resource use and cost-generating factors in a German medical intensive care unit employing the Therapeutic Intervention Scoring System (TISS-28)

OBJECTIVE: Evaluation of resource use and costs of a medical intensive care unit (ICU) utilising the simplified Therapeutic Intervention Scoring System (TISS-28). DESIGN: Prospective observational study. SETTING:: Medical ICU of a tertiary care centre. PATIENTS: Consecutive patients with an ICU length of stay (LOS) more than 24 h. INTERVENTIONS: Over a 3 month period SAPS II, TISS-28 and SOFA were determined daily. Patients were retrospectively classified as receiving active (AT) or non-active (NAT) treatment according to TISS-28 variables, with AT representing a therapeutic intervention that could not be performed outside the ICU. Individual expenditure for all patients was calculated using a modified 'top-down' method. MEASUREMENTS AND RESULTS: Out of 303 consecutive patients, 241 (79.5%), including all non-survivors, were categorised AT. The hospital mortality was 14.5%. TISS-28 and ICU LOS were higher in patients receiving AT ( p<0.001). Patient-specific costs accounted for 36 EUR per TISS-point and daily treatment costs 1336 EUR for all patients. Daily costs of care were 68 EUR higher for AT, compared to NAT, patients ( p<0.001). There was no association between ICU costs and measures of severity of illness (SAPS II, SOFA). CONCLUSIONS: TISS-28 is a fast, reliable and readily applicable tool to identify patients receiving AT. Although total and daily costs of care were significantly higher in patients receiving AT, the difference of the daily costs was, albeit statistically significant, economically negligible. The main difference in ICU costs was attributable to ICU LOS. Therefore cost-saving strategies must aim at reducing ICU LOS, without compromising quality of care.     

Validation of “nine equivalents of nursing manpower use score” on an independent data sample

Objective: To compare the recently developed “nine equivalents of nursing manpower use score” (NEMS) with the simplified Therapeutic Intervention Scoring System (TISS-28). Design: Prospective single centre study. Setting: Adult 30-bed medical-surgical intensive care unit (ICU) in a tertiary care university hospital. Patients: Data from all patients admitted in 1997 to the ICU were included in the study. Methods and results: NEMS and TISS-28 items were recorded prospectively for each nursing shift. There were three shifts per day. The Simplified Acute Physiology Score (SAPS) II was calculated for the first 24 h of ICU stay and each patient's basic demographic data were collected. The agreement between NEMS and TISS-28 was assessed by calculating the mean difference and the standard deviation of the differences between the two measures. Further, regression techniques and Pearson's correlation were used. Altogether, 2743 patients with a total of 28'220 nursing shifts were included; 62 % of the shifts were used for postoperative/trauma patients and 38 % for medical patients. Mean NEMS was 26.0 ± 8.1 and mean TISS-28 was 26.5 ± 7.9. The scores differed by K 3 points in 49 % of all shifts. The bias was −0.5 ± 5.3 (95 % confidence interval −0.47 to −0.60) and the limits of agreement were −11.1 to +10.1. The relation between the two systems was NEMS = 4.7 ± 0.8 · TISS-28 (r = 0.78, r ² = 0.62, p < 0.001). Including postoperative/trauma patients only: NEMS = 1.9 + 0.9 · TISS-28, for medical patients this equation was: NEMS = 6.0 + 0.8 · TISS-28. First-day SAPS II explained 11 % of the variability in first-shift NEMS and 5 % of the variability in first-shift TISS-28. Conclusions: This study confirms a good agreement between TISS-28 and NEMS in a large, independent sample. However, as shown by the differences between medical and postoperative/trauma patients, a change in case mix may result in different regression equations. Further, wide limits of agreement indicate that there may be a rather large variability between the two measures at the individual level. Received: 9 October 1998 Accepted: 16 March 1999     

Nine equivalents of nursing manpower use score (NEMS)

Objectives: To develop a simplified Therapeutic Intervention Scoring System (TISS) based on the TISS-28 items and to validate the new score in an independent database. Design: Retrospective statistical analysis of a database and a prospective multicentre study. Setting: Development in the database of the Foundation for Research on Intensive Care in Europe with external validation in 64 intensive care units (ICUs) of 11 European countries. Measurements and results: Development of NEMS on a random sample of TISS-28 items, cross validation on another random sample of TISS-28, and external validation of NEMS in comparison with TISS-28 scored by two independent raters on the day of the visit to the ICUs participating in an international study. Multivariable regression techniques, Pearson's correlation, and paired sample t-tests were used (significance at p < 0.05 level). Intraclass correlation, rate of agreement, and kappa statistics were used for interrater reliability tests. The TISS-28 items were reduced to NEMS (9 items) in a random sample of 2000 records; the means of the two scores were no different: TISS-28 26.23 ± 10.38, NEMS 26.19 ± 9.12, NS. Cross-validation in a random sample of 996 records; mean TISS-28 26.13 ± 10.38, NEMS 26.17 ± 9.38, NS; R ² = 0.76. External validation on 369 pairs of TISS-28 and NEMS has shown that the means of the two scores were no different: TISS-28 27.56 ± 11.03, NEMS 27.02 ± 8.98, NS; R ² = 0.59. Reliability tests have shown an “almost perfect” interrater correlation. Similar to studies correlating TISS with Simplified Acute Physiology Score (SAPS)-I and/or Acute Physiology and Chronic Health Evaluation II scores, the value of NEMS scored on the first day accounts for 30.4 % of the variation of SAPS-II score. Conclusions: NEMS is a suitable therapeutic index to measure nursing workload at the ICU level. The use of NEMS is indicated for: (a) multicentre ICU studies; (b) management purposes in the general (macro) evaluation and comparison of workload at the ICU level; (c) the prediction of workload and planning of nursing staff allocation at the individual patient level.     

Usefulness of a clinical diagnosis of ICU-acquired paresis to predict outcome in patients with SIRS and acute respiratory failure

Purpose

Neuromuscular abnormalities are common in ICU patients. We aimed to assess the incidence of clinically diagnosed ICU-acquired paresis (ICUAP) and its impact on outcome.

Methods

Forty-two patients with systemic inflammatory response syndrome on mechanical ventilation for ≥48 h were prospectively studied. Diagnosis of ICUAP was defined as symmetric limb muscle weakness in at least two muscle groups at ICU discharge without other explanation. The threshold Medical Research Council (MRC) Score was set at 35 (of 50) points. Activities in daily living were scored using the Barthel Index 28 and 180 days after ICU discharge.

Results

Three patients died before sedation was stopped. ICUAP was diagnosed in 13 of the 39 patients (33%). Multivariate regression analysis yielded five ICUAP-predicting variables (P < 0.05): SAPS II at ICU admission, treatment with steroids, muscle relaxants or norepinephrine, and days with sepsis. Patients with ICUAP had lower admission SAPS II scores [37 ± 13 vs. 49 ± 15 (P = 0.018)], lower Barthel Index at 28 days and lower survival at 180 days after ICU discharge (38 vs. 77%, P = 0.033) than patients without ICUAP. Daily TISS-28 scores were similar but cumulative TISS-28 scores were higher in patients with ICUAP (664 ± 275) than in patients without ICUAP (417 ± 236; P = 0.008). The only independent risk factor for death before day 180 was the presence of ICUAP.

Conclusions

A clinical diagnosis of ICUAP was frequently established in this patient group. Despite lower SAPS II scores, these patients needed more resources and had high mortality and prolonged recovery periods after ICU discharge.     

Nursing Activities Score in the intensive care unit: analysis of the related factors.

BACKGROUND: High costs of intensive care as well as quality of care and patient safety demand measurement of nursing workload in order to determine nursing staff requirements. It is also important to be aware of the factors related to high patient care demands in order to help forecast staff requirements in intensive care units (ICUs). OBJECTIVES: To describe nursing workload using the Nursing Activities Score (NAS); to explore the association between NAS and patients variables, i.e. gender, age, length of stay (LOS), ICU discharge, treatment in the ICU, Simplified Acute Physiology Score II (SAPS II) and Therapeutic Interventions Scoring System-28 (TISS-28). METHODS: NAS, demographic data, SAPS II and TISS-28 were analysed among 200 patients from four different ICUs in a private hospital in S?o Paulo, Brazil. RESULTS: NAS median were 66.4%. High NAS scores (> 66.4%) were associated with death (p-value 0.006) and LOS (p-value 0.015). Logistic regression analysis demonstrated that TISS-28 scores above 23 and SAPS II scores above 46.5 points, classified as high, increased 5.45 and 2.78 times, respectively, the possibility of a high workload as compared to lower values of the same indexes. CONCLUSION: This study shows that the highest NAS scores were associated with increased mortality, LOS, severity of the patient illness (SAPS II), and particularly to TISS-28 in the ICU.     

Nursing workload in intensive care units: a study using the Therapeutic Intervention Scoring System-28 (TISS-28).

The Therapeutic Intervention Scoring System-28 (TISS-28) is an instrument that has been used to measure severity of illness and nursing workload in intensive care units (ICUs). OBJECTIVES: To characterize the severity of illness and nursing workload using the TISS-28 in 11 ICUs of a university hospital in the city of S?o Paulo, Brazil. METHODS: In a prospective study, data were collected from 271 patients admitted to the ICUs in December 2000 and the patients were followed up for 1 week. RESULTS AND CONCLUSIONS: Most of the patients were males (60.0%) and their mean age was 51(+20.6) years. Surgical treatment (66.8%) and admissions from the operating room were predominant. The mortality rate was 25.0% and the average length of stay was 7.7 (+10.4) days. The mean TISS-28 score was 23 (range: 14-32 points). The lowest mean score was observed for patients from the Burn ICU and the highest mean score was obtained for patients from the Liver Transplant ICU. A change in TISS-28 scores was observed in the same ICU over the 7-day study period. Units differed in terms of severity of illness and nursing workload. Patients who died received a higher TISS-28 score than patients who survived (p=0.00). As the nursing staff are the largest economic investment in an ICU, so measuring nursing workload in different ICUs from different centres can contribute to the estimation of nursing staff required according to the specific demands of the units.     

Validation of the simplified therapeutic intervention scoring system on an independent database

Objective: To evaluate the performance of the Simplified Therapeutic Intervention Scoring System on an independent database and determine its relation with the Therapeutic Intervention Scoring System in the quantification of nursing workload in intensive care. Design: Analysis of the database of a multicenter prospective Portuguese study. Setting: 19 intensive care units (ICUs) in Portugal. Patients: Data on 1094 patients consecutively admitted to the ICUs were collected during a period of 3 months. Methods: Collection of the data necessary for the calculation of the Therapeutic Intervention Scoring System (TISS-76) and the Simplified Therapeutic Intervention Scoring System (TISS-28) during the first 24 h in the ICU. Basic demographic statistics and all the variables necessary for the computation of the Simplified Acute Physiology Score II were also collected. Vital status at discharge from the hospital was registered. Regression techniques, Pearson's correlation and paired sample t-test were used. Results are presented as mean ± standard deviation except when stated otherwise. Reliability was evaluated by the use of intraclass correlation coefficients in a 5 % random sample. Measurements and results: After exclusion of all the patients with missing data, 1080 patients were analysed. The overall mean TISS-28 (29.82 ± 10.64) was significantly lower than the mean TISS-76 (31.14 ± 11.95). Both systems showed very significant differences between ICUs (p < 0.001). The correlation between the two was good, with TISS-28 explaining 72 % of the variation of TISS-76 (r = 0.85, r ² = 0.72). The relation between the two systems was TISS-28 = 6.22 + 0.85 TISS-76. In this cohort, reliability of data collection was very high, with intraclass correlation coefficients greater than 0.90 for both systems. Conclusions: TISS-28 was validated on this independent population. The results indicate that TISS-28 can replace TISS-76 for the measurement of the nursing workload in Portuguese ICUs Received: 29 October 1996 Accepted: 27 February 1997     

Evaluation of the SOFA score: a single-center experience of a medical intensive care unit in 303 consecutive patients with predominantly cardiovascular disorders

Objective: To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score, the total maximum SOFA (TMS) score, and a derived variable, the ΔSOFA (TMS score minus total SOFA score on day 1) in medical, cardiovascular patients as a means for describing the incidence and severity of organ dysfunction and the prognostic value regarding outcome. Design: Prospective, clinical study. Setting: Medical intensive care unit in a university hospital. Patients: A total of 303 consecutive patients were included (216 men, 87 women; mean age 62 ± 12.6 years; SAPS II 26.2 ± 12.7). They were evaluated 24 h after admission and thereafter every 24 h until ICU discharge or death between November 1997 and March 1998. Readmissions and patients with an ICU stay shorter than 12 h were excluded. Main outcome measure: Survival status at hospital discharge, incidence of organ dysfunction/failure. Interventions: Collection of clinical and demographic data and raw data for the computation of the SOFA score every 24 h until ICU discharge. Measurements and main results: Length of ICU stay was 3.7 ± 4.7 days. ICU mortality was 8.3 % and hospital mortality 14.5 %. Nonsurvivors had a higher total SOFA score on day 1 (5.9 ± 3.7 vs. 1.9 ± 2.3, p < 0.001) and thereafter until day 8. High SOFA scores for any organ system and increasing number of organ failures (SOFA score ≥ 3) were associated with increased mortality. Cardiovascular and neurological systems (day 1) were related to outcome and cardiovascular and respiratory systems, and admission from another ICU to length of ICU stay. TMS score was higher in nonsurvivors (1.76 ± 2.55 vs. 0.58 ± 1.39, p < 0.01), and ΔSOFA/total SOFA on day 1 was independently related to outcome. The area under the receiver-operating characteristic curve was 0.86 for TMS, 0.82 for SOFA on day 1, and 0.77 for SAPS II. Conclusions: The SOFA, TMS, and ΔSOFA scores provide the clinician with important information on degree and progression of organ dysfunction in medical, cardiovascular patients. On day 1 both SOFA score and TMS score had a better prognostic value than SAPS II score. The model is closely related to outcome and identifies patients who are at increased risk for prolonged ICU stay. Received: 6 August 1999 Final revision received: 3 January 2000 Accepted: 28 March 2000     

Evaluation of an interdisciplinary data set for national intensive care unit assessment.

OBJECTIVES: To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN: A prospective, multicentric study. SETTING: Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS: A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS: Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS: The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS: Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.     

Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study

Introduction

The inflammatory response to an invading pathogen in sepsis leads to complex alterations in hemostasis by dysregulation of procoagulant and anticoagulant factors. Recent treatment options to correct these abnormalities in patients with sepsis and organ dysfunction have yielded conflicting results. Using thromboelastometry (ROTEM^®), we assessed the course of hemostatic alterations in patients with sepsis and related these alterations to the severity of organ dysfunction.

Methods

This prospective cohort study included 30 consecutive critically ill patients with sepsis admitted to a 30-bed multidisciplinary intensive care unit (ICU). Hemostasis was analyzed with routine clotting tests as well as thromboelastometry every 12 hours for the first 48 hours, and at discharge from the ICU. Organ dysfunction was quantified using the Sequential Organ Failure Assessment (SOFA) score.

Results

Simplified Acute Physiology Score II and SOFA scores at ICU admission were 52 ± 15 and 9 ± 4, respectively. During the ICU stay the clotting time decreased from 65 ± 8 seconds to 57 ± 5 seconds (P = 0.021) and clot formation time (CFT) from 97 ± 63 seconds to 63 ± 31 seconds (P = 0.017), whereas maximal clot firmness (MCF) increased from 62 ± 11 mm to 67 ± 9 mm (P = 0.035). Classification by SOFA score revealed that CFT was slower (P = 0.017) and MCF weaker (P = 0.005) in patients with more severe organ failure (SOFA ≥ 10, CFT 125 ± 76 seconds, and MCF 57 ± 11 mm) as compared with patients who had lower SOFA scores (SOFA <10, CFT 69 ± 27, and MCF 68 ± 8). Along with increasing coagulation factor activity, the initially increased International Normalized Ratio (INR) and prolonged activated partial thromboplastin time (aPTT) corrected over time.

Conclusions

Key variables of ROTEM^® remained within the reference ranges during the phase of critical illness in this cohort of patients with severe sepsis and septic shock without bleeding complications. Improved organ dysfunction upon discharge from the ICU was associated with shortened coagulation time, accelerated clot formation, and increased firmness of the formed blood clot when compared with values on admission. With increased severity of illness, changes of ROTEM^® variables were more pronounced.     

Retrospective evaluation of the simplified Therapeutic Intervention Scoring System (TISS-28) in a surgical intensive care unit

OBJECTIVE: To compare the simplified Therapeutic Intervention Scoring System (TISS-28) with its original version, to provide reference values of daily TISS-28 assessment and to describe its association with severity of illness in surgical patients. DESIGN: Retrospective evaluation of prospectively collected audit data; four documentation periods. Setting: Ten-bed intensive care unit (ICU) in a surgical university hospital. PATIENTS: One thousand nine hundred eighty-six consecutive admissions (1,808 patients; 10,448 observation days) who stayed on ICU for at least 6 h. Patients were in hospital for abdominal, vascular or trauma surgery. The average age was 61.5 years, the mean APACHE II score on admission 10.3 points. INTERVENTIONS: None. MEASUREMENTS: Raw data for APACHE II score and TISS were recorded daily. TISS-28 was calculated retrospectively from the original TISS data. RESULTS: Average TISS-28 values (28.7 points; SD = 9.7) do not differ substantially from the original TISS values (28.2 points, SD = 10.9) and overall correlation is high (r = 0.935). Of the patients, 57.3 % left the ICU after 1-2 days as survivors with a mean daily TISS-28 of 20.0 points. Variability between documentation periods was higher with the original TISS. On average, patients with increasing severity of disease require an increasing amount of care. Survivors have lower TISS-28 values than non-survivors (27.6 vs 34.9). CONCLUSIONS: In a surgical ICU the simplified version of TISS with 28 items (TISS-28) sufficiently reflects the amount of intensive care provided and may provide useful additional information on severity of disease and prognosis. It should replace the original index, at least in these cases.     

Therapeutic intervention scoring system-28 (TISS-28): directions for application

Therapeutic Intervention Scoring System-28 (TISS-28) is a tool that enables the measurement of the nursing work load in Intensive Care Units and the estimate of how grave the disease is. In this study are presented the operational definitions for its application, proposed by a group of specialists in the area, with the aim of rendering uniform the meaning of each of the items and preventing interpretation biases.     

Is the routine use of antipseudomonal antibiotics in acutely exacerbated COPD patients indicated: A retrospective analysis in 437 ICU patients.

PurposeChronic obstructive pulmonary disease (COPD) is a risk factor for acquiring multiple drug resistant bacteria. The main objective of this analysis was to question a beneficial outcome in the routine use of antipseudomonal antibiotics in the empiric treatment of severe AECOPD in Intensive Care Unit patients.Material and methodsWe report a retrospective, observational cohort study in adult patients with severe AECOPD admitted to ICU at a tertiary care university hospital. Antibiotic treatment on admission as well as microbiology samples were analyzed. The influence of SOFA score at admission, age, sex and antibiotic choice upon survival was investigated by multivariable analysis.Results437 patients were included. Mean age was 68 years (±10), 46.5% were female. 271/437 patients (62%) were initially treated with antibiotics covering Pseudomonas aeruginosa. Overall, positive microbiology samples were found in 107 patients (24.5%). P. aeruginosa was only found in 3.7%. There was no significant difference in 30-day ICU mortality after adjusting for age, sex and severity of illness (20.4% ± 11.6 in patients with Pseudomonas inactive antibiotics versus 29.3% ± 10.8 in patients with PAA, p=0.113).ConclusionsEmpiric use of antipseudomonal antibiotics did not result in improved ICU survival in this retrospective analysis.     

Filière de soins et devenir des patients présentant une défaillance d’organe admis en unité de soins continus

Aims

To describe the outcome of patients with organ failure admitted to an intermediate care unit located in a general hospital.

Methods

Retrospective monocenter cohort study conducted from 2011/01/01 to 2011/07/01. Patients admitted with coma, shock, renal failure, acute respiratory failure or requiring mechanical ventilation, vasopressors, fluid challenge and transfusion were enrolled. The clinical characteristics on admission were collected including age, sex ratio, origin (emergency department, transfer), typology (medicine, surgery), diagnosis on admission, SAPS II score, length of stay, subsequent ICU (intensive care unit) transfer, care limitation, mortality in the unit and on day 28.

Results

Among the 485 admitted patients, 87 (18%) were enrolled in the study with the following characteristics: age: 78±12 years (median±SD), sex ratio: 1.23, SAPS II 41±21, SAPSII without age 24±21. Patients were referred for heart failure (23%), septic shock (20%), respiratory failure (14%), invasive (32%) or non invasive mechanical ventilation (32%), and vasopressors (57%). The mean length of stay was 4 days [range: 1–26]. For 18 patients (20%), care was limited. Mortality rate was 25% in the unit and 32% on day 28, respectively. A call for an intensivist was notified in the medical record for 17 patients (20%). Nine patients (11%) were further admitted to the ICU.

Conclusion

A small number of patients with organ failure admitted to an intermediate care unit is further admitted to an ICU. Pre-triage, age and comorbidities may explain the absence of ICU referral or refusal. Benefit of ICU admission in the elderly critically ill patients remains to be assessed.

     

Tiss 76 and Tiss 28: correlation of two therapeutic activity indices on a Spanish multicenter icu database

Objectives: To evaluate the performance of the Simplified Therapeutic Intervention Scoring System (TISS 28) on an independent database and to determine its relation to the original Therapeutic Intervention Scoring System (TISS 76).¶Design: Analysis of the database of the Spanish prospective multicenter study PAEEC (Project for the Epidemiological Analysis of Critical Care Patients).¶Setting: 86 intensive care units (ICUs) in Spain.¶Patients: Data on 8838 patients admitted to the ICUs.¶Measurements and results: Administrative data, main diagnostic category, severity score [Acute Physiology and Chronic Health Evaluation (APACHE) II and III] and data for the calculation of the TISS 76 and TISS 28 were collected during the first 24 h after the patient's ICU admission. TISS 76 and TISS 28 scores were calculated and analyzed on how they varied according to other variables (diagnostic group, severity level, hospital size and age).The association between TISS 76 and TISS 28 was studied.¶ The TISS 76 score was 21 ± 10.5 points and the TISS 28 score 23.3 ± 8.8 points. There was a good correlation between TISS 76 and TISS 28 (r = 0.85). The regression equation was: TISS 28 = 8.35 + (0.712 × TISS 76). The TISS 28 score behaved similarly to the TISS 76 score in relation to the other variables, with a positive correlation between the therapeutic and the severity level (APACHE II and III) and a negative correlation between therapeutic activity and age, with very similar correlation coefficients. Both TISS 28 and TISS 76 scores were higher in larger hospitals.¶Conclusions: There is a strong correlation between TISS 28 and TISS 76 scores in the PAEEC database and TISS 28 works correctly in our setting.     

3种评分系统在ICU护士个人管床分配中的应用及效果评价

目的 探讨3种评分系统,即改良版护理活动评分系统、治疗干预评分系统-28、急性生理与慢性健康状况评分系统-IV比较预测重症监护室中每个护士在不同班次合理准确的患者管理数量,并评价其应用效果.为重症监护室护理管理者能够科学、准确、公平、公正的分配每个护士在各班次的患者管理数量提供参考依据.方法 分别采用3种评分系统,于2016年12月-2017年6月对贵州省某大型三级甲等医院内的重症监护室共计360个班次的护理工作量进行评分,共评估患者330例,根据各量表的评估分数计算各班次每个护士合理的患者管理数量.结果 改良版护理活动评分系统与治疗干预评分系统-28所评估得分差异有统计学意义(P<0.001);改良版护理活动评分系统在重症监护室护士的患者管理分配上优于治疗干预评分-28以及急性生理与慢性健康状况评分-IV,即改良版护理活动评分系统预测分数段在40.9～52.8可参考护患比为1.0:2.5,分数段在52.9～62.3可参考1.0:2.0,分数段在62.4～67.9可参考1.0:1.5,分数段在68.0～98.4可参考1.0:1.0.结论 基础护理工作在重症监护室护理工作量中占有较大比例,改良版护理活动评分系统更好地反映了直接和间接护理工作量,包含了更详细的基础护理评分条目,且护患比计算方法相对简便,因此改良版护理活动评分系统对护理内容评估更广泛,在评估重症监护室护士的患者管理分配上更具有适用性.     

Application of SOFA score to trauma patients

Objective: To assess the ability of the SOFA score (Sequential Organ Failure Assessment) to describe the evolution of organ dysfunction/failure in trauma patients over time in intensive care units (ICU). Design: Retrospective analysis of a prospectively collected database. Setting: 40 ICUs in 16 countries. Patients: All trauma patients admitted to the ICU in May 1995. Main outcome measures and results: Incidence of dysfunction/failure of different organs during the first 10 days of stay and the relation between the dysfunction, outcome, and length of stay. Included in the SOFA study were 181 trauma patients (140 males and 41 females).The non-survivors were significantly older than the survivors (51 years ± 20 vs 38 ± 16 years, p < 0.05) and had a higher global SOFA score on admission (8 ± 4 vs 4 ± 3, p < 0.05) and throughout the 10-day stay. On admission, the non-survivors had higher scores for respiratory ( > 3 in 47 % of non-survivors vs 17 % of survivors), cardiovascular ( > 3 in 24 % of non-survivors vs 5.7 % of survivors), and neurological systems ( > 4 in 41 % of non-survivors vs 16 % of survivors); although the trend was maintained over the whole study period, the differences were greater during the first 4–5 days. After the first 4 days, only respiratory dysfunction was significantly related to outcome. A higher SOFA score, admission to the ICU from the same hospital, and the presence of infection on admission were the three major variables associated with a longer length of stay in the ICU (additive regression coefficients: 0.85 days for each SOFA point, 4.4 for admission from the same hospital, 7.26 for infection on admission). Conclusions: The SOFA score can reliably describe organ dysfunction/failure in trauma patients. Regular and repeated scoring may be helpful for identifying categories of patients at major risk of prolonged ICU stay or death. Received: 3 March 1998 Accepted: 21 December 1998     

Prognostication of critically ill patients with acute-on-chronic liver failure using the Chronic Liver Failure–Sequential Organ Failure Assessment: A Canadian retrospective study

PurposeWe evaluated the Chronic Liver Failure–Sequential Organ Failure Assessment (CLIF-SOFA) score to predict survival in a Canadian critically ill cohort with acute-on-chronic liver failure.MethodsWe retrospectively examined 274 acute-on-chronic liver failure patients admitted to a quaternary level intensive care unit (ICU) between April 1, 2000, and April 30, 2011. We evaluated severity of illness scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), SOFA, and CLIF-SOFA.ResultsOn ICU admission, patients had the following median (interquartile range): APACHE II, 23 (19-28); MELD, 26 (19-35); CTP, 12 (10-13); SOFA, 15 (11-18); and CLIF-SOFA, 17 (13-21). In-hospital survival was 40%. There were no significant differences in survival for cirrhosis etiology, reason, or year of admission. The CLIF-SOFA score had the greatest area under receiver operating curve of 0.865 (95% confidence interval, 0.820-0.909) and outperformed the CTP, MELD, SOFA, and APACHE II scores. Sequential Organ Failure Assessment score performance improved on the third day of ICU admission (area under receiver operating curve, 0.935; 95% confidence interval, 0.895-0.975).ConclusionsThe CLIF-SOFA and SOFA scores during the first 3 days of ICU admission appear to be highly predictive of in-hospital mortality.     

Validation of the SAPS 3 admission prognostic model in patients with cancer in need of intensive care

Objectives To validate the SAPS 3 admission prognostic model in patients with cancer admitted to the intensive care unit (ICU).Design Cohort study.Setting Ten-bed medical–surgical oncologic ICU.Patients and participants Nine hundred and fifty-two consecutive patients admitted over a 3-year period.Interventions None.Measurements and results Data were prospectively collected at admission of ICU. SAPS II and SAPS 3 scores with respective estimated mortality rates were calculated. Discrimination was assessed by area under receiver operating characteristic (AUROC) curves and calibration by Hosmer–Lemeshow goodness-of-fit test. The mean age was 58.3 ± 23.1 years; there were 471 (49%) scheduled surgical, 348 (37%) medical and 133 (14%) emergency surgical patients. ICU and hospital mortality rates were 24.6% and 33.5%, respectively. The mean SAPS 3 and SAPS II scores were 52.3 ± 18.5 points and 35.3 ± 20.7 points, respectively. All prognostic models showed excellent discrimination (AUROC ≥ 0.8). The calibration of SAPS II was poor (p < 0.001). However, the calibration of standard SAPS 3 and its customized equation for Central and South American (CSA) countries were appropriate (p > 0.05). SAPS II and standard SAPS 3 prognostic models tended somewhat to underestimate the observed mortality (SMR > 1). However, when the customized equation was used, the estimated mortality was closer to the observed mortality [SMR = 0.95 (95% CI = 0.84–1.07)]. Similar results were observed when scheduled surgical patients were excluded.Conclusions The SAPS 3 admission prognostic model at ICU admission, in particular its customized equation for CSA, was accurate in our cohort of critically ill patients with cancer.This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. Financial support: institutional departmental funds. Conflicts of interest: none.