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Lu Y, Ren C, Wu C. In-Hospital Mortality Prediction Model for Critically Ill Older Adult Patients Transferred from the Emergency Department to the Intensive Care Unit. Risk Manag Healthc Policy 2023; 16:2555-2563. [PMID: 38024492 PMCID: PMC10676667 DOI: 10.2147/rmhp.s442138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose Studies on the prognosis of critically ill older adult patients admitted to the emergency department (ED) but requiring immediate admission to the intensive care unit (ICU) remain limited. This study aimed to develop an in-hospital mortality prediction model for critically ill older adult patients transferred from the ED to the ICU. Patients and Methods The training cohort was taken from the Medical Information Mart for Intensive Care IV (version 2.2) database, and the external validation cohort was taken from the Affiliated Dongyang Hospital of Wenzhou Medical University. In the training cohort, class balance was addressed using Random Over Sampling Examples (ROSE). Univariate and multivariate Cox regression analyses were performed to identify independent risk factors. These were then integrated into the predictive nomogram. In the validation cohort, the predictive performance of the nomogram was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, calibration curve, clinical utility decision curve analysis (DCA), and clinical impact curve (CIC). Results In the ROSE-balanced training cohort, univariate and multivariate Cox regression analysis identified that age, sex, Glasgow coma scale score, malignant cancer, sepsis, use of mechanical ventilation, use of vasoactive agents, white blood cells, potassium, and creatinine were independent predictors of in-hospital mortality in critically ill older adult patients, and were included in the nomogram. The nomogram showed good predictive performance in the ROSE-balanced training cohort (AUC [95% confidence interval]: 0.792 [0.783-0.801]) and validation cohort (AUC [95% confidence interval]: 0.780 [0.727-0.834]). The calibration curves were well-fitted. DCA and CIC demonstrated that the nomogram has good clinical application value. Conclusion This study developed a predictive model for early prediction of in-hospital mortality in critically ill older adult patients transferred from the ED to the ICU, which was validated by external data and has good predictive performance.
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Affiliation(s)
- Yan Lu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaoxiang Ren
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
| | - Chaolong Wu
- Clinical Laboratory, Affiliated Dongyang Hospital of Wenzhou Medical University, Dongyang, Zhejiang, 322100, People’s Republic of China
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Osman AD, Howell J, Smithies L, Wilson D, Lam L, Moran J, Jones D, Taylor DM. Assessment of emergency department staff awareness, access and utilisation of advance care directives and goals of care: A cross-sectional survey. Australas Emerg Care 2021; 25:235-240. [PMID: 34906442 DOI: 10.1016/j.auec.2021.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Emergency department staff awareness, access and implementation of advance care directives and goals of care documents and the related patient consent processes are important but not well understood. METHODS A cross-sectional survey using purposive sampling was undertaken at a tertiary hospital's Emergency Department from 15th March to 26th April 2021. Participants were recruited through online platforms. Pre-validated questionnaires were distributed by email or as QR codes on bulletin boards. Data collected included staff: demographics, knowledge, access and implementation of advance care directives and goals of care documentation. RESULTS One hundred thirty-four (28%) of 476 targeted participants responded with nursing forming largest group. Results showed that previous attendance of advance care planning education was low at 20%. Familiarity with advance care directive documentations was only 19% while with goals of care document was average. 61 (48%) respondents reported ease of accessing electronic documents and 21 (19%) reported feeling very comfortable discussing and setting goals of care with patients (p = <0.01). CONCLUSIONS Staff awareness of advance care directive was poor, while awareness of goals of care was average. There was no association between advance care directives awareness and staff age group, gender, length of: - professional practice, practice at the study site.
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Affiliation(s)
- Abdi D Osman
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; School of Health, Federation University Australia, Victoria, Australia.
| | - Jocelyn Howell
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Lisa Smithies
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; Faculty of Arts, University of Melbourne, Parkville, Victoria, Australia
| | - Damian Wilson
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia
| | - Louisa Lam
- School of Health, Federation University Australia, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Victoria, Australia
| | - Juli Moran
- Department of Palliative Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Daryl Jones
- School of Public Health and Preventive Medicine, Monash University, Victoria, Australia; Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - David M Taylor
- Emergency Department, Austin Hospital, Heidelberg, Victoria, Australia; Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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Andersen SK, Montgomery CL, Bagshaw SM. Early mortality in critical illness - A descriptive analysis of patients who died within 24 hours of ICU admission. J Crit Care 2020; 60:279-284. [PMID: 32942163 DOI: 10.1016/j.jcrc.2020.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To describe patients who die within 24 h of ICU admission in order to better optimize care delivery. METHODS This was a retrospective cohort study of patients ≥18 years old admitted to 17 adult ICUs in Alberta, Canada from January 1, 2016 and June 30, 2017. Data were obtained from a provincial clinical information system and data repository. The primary outcome was incidence of ICU death within 24 h of admission. Secondary outcomes were patient and system factors associated with early death. Variables of interest were identified a priori and examined using multivariable logistic regression. RESULTS Of 19,556 patients admitted to ICU in an 18-month period, 3.3% died within 24 h, representing 29.8% of ICU deaths. Factors associated with early death were age (adjusted-OR 0.99, 95% CI, 0.9-1.0), acuity (adjusted-OR 1.3, 95% CI, 1.3-1.4), admission from the Emergency Department (ED; adjusted-OR 1.5, 95% CI, 1.1-1.9) and surgical (adjusted-OR 2.27, 95% CI, 1.4-3.6), neurologic (adjusted-OR 4.6, 95% CI, 3.1-6.9) or trauma diagnosis (adjusted-OR 6.1, 95% CI, 2.4-15.6). CONCLUSION Patients who die within 24 h constitute one third of ICU deaths. Age, acuity, admission from the ED and surgical, neurologic or trauma-related admission diagnosis correlate with early death.
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Affiliation(s)
- Sarah K Andersen
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
| | - Carmel L Montgomery
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2J2.00 WC Mackenzie Health Sciences Centre, 8440 112 St. NW, Edmonton, Alberta T6G 2R7, Canada; Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada; Alberta Health Services Critical Care Strategic Clinical Network, Alberta Health Services, Seventh Street Plaza 14th Floor, North Tower 10030 - 107 Street NW, Edmonton, Alberta T5J 3E4, Canada.
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Wilcox SR, Richards JB, Stevenson EK. Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making. J Emerg Med 2020; 58:11-17. [PMID: 31708311 DOI: 10.1016/j.jemermed.2019.09.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Research has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care. OBJECTIVES The purpose of this study was to assess the influence of code status on emergency residents' decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts. METHODS We conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents. RESULTS Three hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001). CONCLUSIONS In a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.
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Ferraro K, Sanchez-Reilly S. Palliative Volume Resuscitation in a Patient with Cancer and Hypercalcemia: Why Bother? J Palliat Med 2019; 23:871-873. [PMID: 31509060 DOI: 10.1089/jpm.2019.0343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypercalcemia of malignancy affects 2%-2.8% of cancer patients and is associated with an increased risk of mortality and other symptom-related complications. Standard treatment consists of fluid resuscitation, intravenous bisphosphonates, and calcitonin. Little is known, however, about the benefits of treatment of malignant hypercalcemia in patients with late-stage terminal cancer. We present a case of a hospice patient with squamous cell lung cancer brought to our hospital with newly altered mental status who was found to have hypercalcemia of malignancy. Our discussion centers on the diagnostic dilemma of deciding which patients seeking comfort-focused care may benefit from fluid resuscitation for symptoms of hypercalcemia of malignancy while maintaining the unambiguous goal of comfort care.
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Affiliation(s)
- Kelly Ferraro
- South Texas Veterans Health Care System, University of Texas Health, San Antonio, Texas, USA
| | - Sandra Sanchez-Reilly
- South Texas Veterans Health Care System, University of Texas Health, San Antonio, Texas, USA
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Update and recommendations in decision making referred to limitation of advanced life support treatment. Med Intensiva 2019; 44:101-112. [PMID: 31472947 DOI: 10.1016/j.medin.2019.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/16/2019] [Accepted: 07/14/2019] [Indexed: 12/18/2022]
Abstract
The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.
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Abbott J. The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life Wishes in the Emergency Department. Ann Emerg Med 2018; 73:294-301. [PMID: 30503382 DOI: 10.1016/j.annemergmed.2018.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 10/06/2018] [Accepted: 10/12/2018] [Indexed: 11/29/2022]
Abstract
Physician Orders for Life-Sustaining Treatment forms convert patient wishes into physician orders to direct care patients receive near the end of life. Recent evidence of the challenges and opportunities for honoring patient end-of-life wishes in the emergency department (ED) is presented. The forms can be very helpful in directing whether cardiopulmonary resuscitation and intubation are desired in the first few minutes of a patient's presentation. After initial stabilization, understanding the intent of end-of-life orders and the scope of further interventions requires discussion with the patient or a surrogate. The emergency medicine provider must be committed both to honoring initial resuscitation orders and to the conversations required to narrow the gap between ED care and patient wishes so that people receive care best aligned with their wishes.
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Affiliation(s)
- Jean Abbott
- Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora, CO.
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