Analysis of Risk Factors to Predict Intensive Care Unit Transfer in Medical in-Patients
28 Nov 2014-Vol. 16, Iss: 4, pp 259-266
TL;DR: It is suggested that early prediction and treatment of patients with high risk of ICU transfer may improve the prognosis of patients.
Abstract: Purpose: The purpose of this study was to analyze risk factors in predicting medical patients transferred to Intensive Care Unit (ICU) on the general ward. Methods: We reviewed retrospectively clinical data of 120 medical patients on the general ward and a Modified Early Warning Score (MEWS) between ICU group and general ward group. Data were analyzed with multivariate logistic regression and the area under the receiver operating characteristic curves using SPSS/WIN 18.0 program. Results: Fifty-two ICU patients and 68 general ward patients were included. In multivariate logistic regression, the MEWSs (Odds Ratio [OR], 1.91; 95% confidence interval [CI], 1.32-2.76), sequential organ failure assessment score (OR, 1.28; 95% CI, 1.10-1.72), PaO2/FiO2 ratio (OR, 0.98; 95% CI, 0.98-0.99), and saturation (OR, 0.93; 95% CI, 0.88-0.99) were predictive of ICU transfer. The sensitivity and the specificity of the MEWSs used with a cut-off value of six were 80.8% and 70.6% respectively for ICU transfer. Conclusion: These findings suggest that early prediction and treatment of patients with high risk of ICU transfer may improve the prognosis of patients.
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TL;DR: It is suggested that early prediction and treatment of patients with high risk of ICU transfer may improve the prognosis of patients.
Additional excerpts
...선행연구에서 제시한 중환 자실 전동 위험요인 중 PF ratio [12]는 산소분압 값을 산출하기 위해서는 동맥혈 가스분석이 필요하다....
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...여러 선행연구에서 병동 악화 환자가 치명적 사건이 발생하기 이전 활력징후의 변화가 나타난다고 하였다 [12, 20, 24]....
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...선행연구 에서 일반병동에서 중환자실로 전동 된 환자들의 위험요 인은 증가된 수축기압, 호흡수와 심박동수, 감소 된 의식 수준, 산소 포화도 및 동맥혈 산소분압/투여산소분획비 (PaO2/FiO2, PF ratio) 이었다[2, 12, 20]....
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...이와 같 은 혈액검사는 결과가 나오기까지 시간이 경과해야 하므 로 중환자실 전동이 필요한 병동 악화환자에게 일반적으 로 사용하는데 제한이 있다[12, 15]....
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...신속대응팀에 의뢰된 환자의 65% 이상의 악화원인은 호흡문제로[12], Viglino 등[13]은 호흡문제를 가진 환 자에서 저산소증은 악화 환자를 예측할 수 있는 인자로 서 산소요구량을 고려하지 않고 단독으로 제공된 SpO2 또는 PaO2 값은 호흡 문제를 가진 환자의 질병 증증도 를 평가하는데 유용하지 않다고 보고하였다....
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References
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TL;DR: In this paper, the authors evaluated the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients in ICU.
Abstract: ObjectiveTo evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients.DesignProspective, multicenter study.SettingForty intensive care units (ICUs) in 16 countries.PatientsPatients admitted to the
2,958 citations
TL;DR: In this article, the authors evaluated the usefulness of repeated measurement of the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients.
Abstract: ContextEvaluation of trends in organ dysfunction in critically ill patients
may help predict outcome.ObjectiveTo determine the usefulness of repeated measurement the Sequential Organ
Failure Assessment (SOFA) score for prediction of mortality in intensive care
unit (ICU) patients.DesignProspective, observational cohort study conducted from April 1 to July
31, 1999.SettingA 31-bed medicosurgical ICU at a university hospital in Belgium.PatientsThree hundred fifty-two consecutive patients (mean age, 59 years) admitted
to the ICU for more than 24 hours for whom the SOFA score was calculated on
admission and every 48 hours until discharge.Main Outcome MeasuresInitial SOFA score (0-24), Δ-SOFA scores (differences between
subsequent scores), and the highest and mean SOFA scores obtained during the
ICU stay and their correlations with mortality.ResultsThe initial, highest, and mean SOFA scores correlated well with mortality.
Initial and highest scores of more than 11 or mean scores of more than 5 corresponded
to mortality of more than 80%. The predictive value of the mean score was
independent of the length of ICU stay. In univariate analysis, mean and highest
SOFA scores had the strongest correlation with mortality, followed by Δ-SOFA
and initial SOFA scores. The area under the receiver operating characteristic
curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score
during the first 96 hours, regardless of the initial score, the mortality
rate was at least 50% when the score increased, 27% to 35% when it remained
unchanged, and less than 27% when it decreased. Differences in mortality were
better predicted in the first 48 hours than in the subsequent 48 hours. There
was no significant difference in the length of stay among these groups. Except
for initial scores of more than 11 (mortality rate >90%), a decreasing score
during the first 48 hours was associated with a mortality rate of less than
6%, while an unchanged or increasing score was associated with a mortality
rate of 37% when the initial score was 2 to 7 and 60% when the initial score
was 8 to 11.ConclusionsSequential assessment of organ dysfunction during the first few days
of ICU admission is a good indicator of prognosis. Both the mean and highest
SOFA scores are particularly useful predictors of outcome. Independent of
the initial score, an increase in SOFA score during the first 48 hours in
the ICU predicts a mortality rate of at least 50%.
2,190 citations
TL;DR: The ability of a modified Early Warning Score (MEWS) to identify medical patients at risk of catastrophic deterioration in a busy clinical area was investigated and could be created, using nurse practitioners and/or critical care physicians, to respond to high scores and intervene with appropriate changes in clinical management.
Abstract: The Early Warning Score (EWS) is a simple physiological scoring system suitable for bedside application. The ability of a modified Early Warning Score (MEWS) to identify medical patients at risk of catastrophic deterioration in a busy clinical area was investigated. In a prospective cohort study, we applied MEWS to patients admitted to the 56-bed acute Medical Admissions Unit (MAU) of a District General Hospital (DGH). Data on 709 medical emergency admissions were collected during March 2000. Main outcome measures were death, intensive care unit (ICU) admission, high dependency unit (HDU) admission, cardiac arrest, survival and hospital discharge at 60 days. Scores of 5 or more were associated with increased risk of death (OR 5.4, 95%CI 2.8-10.7), ICU admission (OR 10.9, 95%CI 2.2-55.6) and HDU admission (OR 3.3, 95%CI 1.2-9.2). MEWS can be applied easily in a DGH medical admission unit, and identifies patients at risk of deterioration who require increased levels of care in the HDU or ICU. A clinical pathway could be created, using nurse practitioners and/or critical care physicians, to respond to high scores and intervene with appropriate changes in clinical management.
1,423 citations
TL;DR: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal, with major consequences may include increased morbidity and mortality and requirement for intensive care.
Abstract: Objective: To examine the prevalence, nature, causes, and consequences of suboptimal care before admission to intensive care units, and to suggest possible solutions. Design: Prospective confidential inquiry on the basis of structured interviews and questionnaires. Setting: A large district general hospital and a teaching hospital. Subjects: A cohort of 100 consecutive adult emergency admissions, 50 in each centre. Main outcome measures: Opinions of two external assessors on quality of care especially recognition, investigation, monitoring, and management of abnormalities of airway, breathing, and circulation, and oxygen therapy and monitoring. Results: Assessors agreed that 20 patients were well managed (group 1) and 54 patients received suboptimal care (group 2). Assessors disagreed on quality of management of 26 patients (group 3). The casemix and severity of illness, defined by the acute physiology and chronic health evaluation (APACHE II) score, were similar between centres and the three groups. In groups 1, 2, and 3 intensive care mortalities were 5 (25%), 26 (48%), and 6 (23%) respectively (P=0.04) (group 1 versus group 2, P=0.07). Hospital mortalities were 7 (35%), 30 (56%), and 8 (31%) (P=0.07) and standardised hospital mortality ratios (95% confidence intervals) were 1.23 (0.49 to 2.54), 1.4 (0.94 to 2.0), and 1.26 (0.54 to 2.48) respectively. Admission to intensive care was considered late in 37 (69%) patients in group 2. Overall, a minimum of 4.5% and a maximum of 41% of admissions were considered potentially avoidable. Suboptimal care contributed to morbidity or mortality in most instances. The main causes of suboptimal care were failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice. Conclusions: The management of airway, breathing, and circulation, and oxygen therapy and monitoring in severely ill patients before admission to intensive care units may frequently be suboptimal. Major consequences may include increased morbidity and mortality and requirement for intensive care. Possible solutions include improved teaching, establishment of medical emergency teams, and widespread debate on the structure and process of acute care. Key messages Suboptimal management of oxygen therapy, airway, breathing, circulation, and monitoring before admission to intensive care occurred in over half of a consecutive cohort of acute adult emergency patients. This may be associated with increased morbidity, mortality, and avoidable admissions to intensive care At least 39% of acute adult emergency patients were admitted to intensive care late in the clinical course of the illness Major causes of suboptimal care included failure of organisation, lack of knowledge, failure to appreciate clinical urgency, lack of supervision, and failure to seek advice A medical emergency team may be useful in responding pre-emptively to the clinical signs of life threatening dysfunction of airway, breathing, and circulation, rather than relying on a cardiac arrest team The structure and process of acute care and their importance require major re-evaluation and debate
943 citations
TL;DR: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital.
Abstract: Objectives: To determine whether earlier clinical intervention by a medical emergency team prompted by clinical instability in a patient could reduce the incidence of and mortality from unexpected cardiac arrest in hospital. Design: A non-randomised, population based study before (1996) and after (1999) introduction of the medical emergency team. Setting: 300 bed tertiary referral teaching hospital. Participants: All patients admitted to the hospital in 1996 (n=19 317) and 1999 (n=22 847). Interventions: Medical emergency team (two doctors and one senior intensive care nurse) attended clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response activated by the bedside nurse or doctor according to predefined criteria. Main outcome measures: Incidence and outcome of unexpected cardiac arrest. Results: The incidence of unexpected cardiac arrest was 3.77 per 1000 hospital admissions (73 cases) in 1996 (before intervention) and 2.05 per 1000 admissions (47 cases) in 1999 (after intervention), with mortality being 77% (56 patients) and 55% (26 patients), respectively. After adjustment for case mix the intervention was associated with a 50% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.50, 95% confidence interval 0.35 to 0.73). Conclusions: In clinically unstable inpatients early intervention by a medical emergency team significantly reduces the incidence of and mortality from unexpected cardiac arrest in hospital. What is already known on this topic In most studies mortality from unexpected cardiac arrest in hospital exceeds 50% Such events are usually preceded by signs of clinical deterioration in the hours before cardiac arrest What this paper adds Early intervention by a medical emergency team significantly reduced the incidence of and mortality from unexpected cardiac arrest in hospital
810 citations
Additional excerpts
...여(Buist et al., 2002), MET 의뢰 8시간 전 시점을 악화 상태가 나타나 기 전 시점으로 간주하여 자료를 수집하였다....
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...MET는 일반병동에서 악화상태 의 환자를 조기 발견하여 치료하는 팀이며 동시에 MET 의뢰시점에 서 중환자실 전동 유무가 결정되기 때문에 본 연구에서 MET 의뢰 시점은 중환자실 전동 직전인 시점으로 간주하였고, 6-8시간 전 심 정지 환자의 활력징후의 변화가 나타난다고 한 선행연구에 근거하 여(Buist et al., 2002), MET 의뢰 8시간 전 시점을 악화 상태가 나타나 기 전 시점으로 간주하여 자료를 수집하였다....
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...등의 활력징후의 변화가 나타난다고 한 선행 연구와 일치하는 결과 이다(Buist et al., 2002; Goldhill et al., 1999; Hillman et al., 2002; Kause et al., 2004)....
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...이는 일반병동 환자에서 악화 상태가 나타나기 6-8 시간 전에 호흡 수 및 심박동 수가 증가하고, 수축기압이 감소하는 등의 활력징후의 변화가 나타난다고 한 선행 연구와 일치하는 결과 이다(Buist et al., 2002; Goldhill et al., 1999; Hillman et al., 2002; Kause et al., 2004)....
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...의 변화가 나타나는 것이 관찰되면서 조기 발견 및 중재의 필요성 이 더욱 강조되었다(Buist et al., 2002; Kause et al., 2004)....
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