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Salluh JIF, Quintairos A, Dongelmans DA, Aryal D, Bagshaw S, Beane A, Burghi G, López MDPA, Finazzi S, Guidet B, Hashimoto S, Ichihara N, Litton E, Lone NI, Pari V, Sendagire C, Vijayaraghavan BKT, Haniffa R, Pisani L, Pilcher D. National ICU Registries as Enablers of Clinical Research and Quality Improvement. Crit Care Med 2024; 52:125-135. [PMID: 37698452 DOI: 10.1097/ccm.0000000000006050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
OBJECTIVES Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement. DATA SOURCES English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix. STUDY SELECTION Original research, review articles, letters, and commentaries, were considered. DATA EXTRACTION Data from relevant literature were identified, reviewed, and integrated into a concise narrative review. DATA SYNTHESIS CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs. CONCLUSIONS ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.
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Affiliation(s)
- Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Post-Graduation Program, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amanda Quintairos
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Critical and Intensive Care Medicine, Academic Hospital Fundación Santa Fe de Bogota, Bogota, Colombia
| | - Dave A Dongelmans
- Amsterdam UMC location University of Amsterdam, Department of Intensive Care Medicine, Amsterdam, The Netherlands
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, The Netherlands
| | - Diptesh Aryal
- National Coordinator, Nepal Intensive Care Research Foundation, Kathmandu, Nepal
| | - Sean Bagshaw
- Department of Medicine, Faculty of Medicine and Dentistry (Ling, Bagshaw), University of Alberta and Alberta Health Services, Edmonton, AB, Canada
- Division of Internal Medicine (Villeneuve), Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta and Grey Nuns Hospitals, Edmonton, AB, Canada
| | - Abigail Beane
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Maria Del Pilar Arias López
- Argentine Society of Intensive Care (SATI). SATI-Q Program, Buenos Aires, Argentina
- Intermediate Care Unit, Hospital de Niños Ricardo Gutierrez, Buenos Aires, Argentina
| | - Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, service de réanimation, Paris, France
| | - Satoru Hashimoto
- Division of Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA
- The University of Western Australia, Perth, WA
| | - Nazir I Lone
- Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
- Scottish Intensive Care Society Audit Group, United Kingdom
| | - Vrindha Pari
- Chennai Critical Care Consultants, Pvt Ltd, Chennai, India
| | - Cornelius Sendagire
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
- Anesthesia and Critical Care, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Rashan Haniffa
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Crit Care Asia, Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Luigi Pisani
- Critical Care, Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - David Pilcher
- University College Hospital, London, United Kingdom
- Department of Intensive Care, Alfred Health, Prahran, VIC, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation, Camberwell, Australia
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Kvåle R, Möller MH, Porkkala T, Varpula T, Enlund G, Engerstrôm L, Sigurdsson MI, Thormar K, Garde K, Christensen S, Buanes EA, Sverrisson K. The Nordic perioperative and intensive care registries-Collaboration and research possibilities. Acta Anaesthesiol Scand 2023. [PMID: 37096912 DOI: 10.1111/aas.14255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/10/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND The Nordic perioperative and intensive care registries have been built up during the last 25 years to improve quality in intensive and perioperative care. We aimed to describe the Nordic perioperative and intensive care registries and to highlight possibilities and challenges in future research collaboration between these registries. MATERIAL AND METHOD We present an overview of the following Nordic registries: Swedish Perioperative Registry (SPOR), the Danish Anesthesia Database (DAD), the Finnish Perioperative Database (FIN-AN), the Icelandic Anesthesia Database (IS-AN), the Danish Intensive Care Database (DID), the Swedish Intensive Care Registry (SIR), the Finnish Intensive Care Consortium, the Norwegian Intensive Care and Pandemic Registry (NIPaR), and the Icelandic Intensive Care Registry (IS-ICU). RESULTS Health care systems and patient populations are similar in the Nordic countries. Despite certain differences in data structure and clinical variables, the perioperative and intensive care registries have enough in common to enable research collaboration. In the future, even a common Nordic registry could be possible. CONCLUSION Collaboration between the Nordic perioperative and intensive care registries is both possible and likely to produce research of high quality. Research collaboration between registries may have several add-on effects and stimulate international standardization regarding definitions, scoring systems, and benchmarks, thereby improving overall quality of care.
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Affiliation(s)
- Reidar Kvåle
- The Norwegian Intensive Care and Pandemic Registry (NIPaR), Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Morten Hylander Möller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Timo Porkkala
- Department of Cardiac Anesthesia and Intensive Care, Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Tero Varpula
- The Finnish Intensive Care Consortium (FICC), Department of Anaesthesia and Critical Care, Helsinki University Hospital, Espoo, Finland
| | - Gunnar Enlund
- The Swedish Perioperative Registry (SPOR), Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Uppsala, Sweden
| | - Lars Engerstrôm
- The Swedish Intensive care Registry (SIR), Department of Cardiothoracic Surgery, Anaesthesia and Intensive care; Linköping University Hospital, Linköping and Department of Anaesthesia and Intensive care, Vrinnevi Hospital, Norrköping, Sweden
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Critical Care, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Katrin Thormar
- Department of Anaesthesia and Critical Care, Landspitali University Hospital, Reykjavik, Iceland
| | - Kim Garde
- Chief Quality Officer The Danish Anaesthesia Database (DAD) Dept. of Quality Improvement, Copenhagen University Hospital, Copenhagen, Denmark
| | - Steffen Christensen
- The Danish Intensive Care Database (DID), Dept. of Anesthesia and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Eirik Alnes Buanes
- The Norwegian Intensive Care and Pandemic Registry (NIPaR), Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Kristinn Sverrisson
- Department of Anaesthesia and Critical Care, Landspitali University Hospital, Reykjavik, Iceland
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Holmqvist J, Brynolf A, Zhao J, Halmin M, Hollenberg J, Mårtensson J, Bell M, Block L, Edgren G. Patterns and determinants of blood transfusion in intensive care in Sweden between 2010 and 2018: A nationwide, retrospective cohort study. Transfusion 2022; 62:1188-1198. [PMID: 35638740 PMCID: PMC9328318 DOI: 10.1111/trf.16942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/28/2022] [Accepted: 03/28/2022] [Indexed: 11/30/2022]
Abstract
Background Intensive care unit (ICU) patients are transfused with blood products for a number of reasons, from massive ongoing hemorrhage, to mild anemia following blood sampling, combined with bone marrow depression due to critical illness. There's a paucity of data on transfusions in ICUs and most studies are based on audits or surveys. The aim of this study was to provide a complete picture of ICU‐related transfusions in Sweden. Methods We conducted a register based retrospective cohort study with data on all adult patient admissions from 82 of 84 Swedish ICUs between 2010 and 2018, as recorded in the Swedish Intensive Care Register. Transfusions were obtained from the SCANDAT‐3 database. Descriptive statistics were computed, characterizing transfused and nontransfused patients. The distribution of blood use comparing different ICUs was investigated by computing the observed proportion of ICU stays with a transfusion, as well as the expected proportion. Results In 330,938 ICU episodes analyzed, at least one transfusion was administered for 106,062 (32%). For both red‐cell units and plasma, the fraction of patients who were transfused decreased during the study period from 31.3% in 2010 to 24.6% in 2018 for red‐cells, and from 16.6% in 2010 to 9.4% in 2018 for plasma. After adjusting for a range of factors, substantial variation in transfusion frequency remained, especially for plasma units. Conclusion Despite continuous decreases in utilization, transfusions remain common among Swedish ICU patients. There is considerable unexplained variation in transfusion rates. More research is needed to establish stronger critiera for when to transfuse ICU patients.
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Affiliation(s)
- Jacob Holmqvist
- Department of Anaestesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Anne Brynolf
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden
| | - Jingcheng Zhao
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden
| | - Märit Halmin
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Cardiology, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Center for Resuscitation Science, Karolinska Institutet, Södersjukhuset, Stockholm, Sweden
| | - Johan Mårtensson
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Linda Block
- Department of Anaestesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Anesthesia and Intensive Care, Sahlgrenska Academy, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Gustaf Edgren
- Department of Medicine, Solna, Clinical Epidemiology Division, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
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Inghammar M, Sunden-Cullberg J. Prognostic significance of body temperature in the emergency department vs the ICU in Patients with severe sepsis or septic shock: A nationwide cohort study. PLoS One 2020; 15:e0243990. [PMID: 33373376 PMCID: PMC7771849 DOI: 10.1371/journal.pone.0243990] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/01/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Increased body temperature in the Emergency Department (BT-ED) and the ICU (BT-ICU) is associated with lower mortality in patients with sepsis. Here, we compared how well BT-ED and BT-ICU predict mortality; investigated mortality in various combinations of BT-ED and BT-ICU, and; compared degree of fever in the ED and ICU and associated quality of care. METHODS 2385 adults who were admitted to an ICU within 24 hours of ED arrival with severe sepsis or septic shock were included. RESULTS Thirty-day mortality was 23.6%. Median BT-ED and BT-ICU was 38.1 and 37.6°C. Crude mortality decreased more than 5% points per°C increase for both BT-ED and BT-ICU. Adjusted OR for mortality was 0.82/°C increase for BT-ED (0.76-0.88, p < 0.001), and 0.89 for BT-ICU (0.83-0.95, p<0.001). Patients who were at/below median temperature in both the ED and in the ICU had the highest mortality, 32%, and those with over median in the ED and at/below in the ICU had the lowest, 16%, (p<0.001). Women had 0.2°C lower median BT-ED (p = 0.03) and 0.3°C lower BT-ICU (p<0.0001) than men. Older patients had lower BT in the ICU, but not in the ED. Fever was associated with a higher rate of sepsis bundle achievement in the ED, but lower nurse workload in the ICU. CONCLUSIONS BT-ED was more useful to prognosticate mortality than BT-ICU. Despite better prognosis in patients with elevated BT, fever was associated with higher quality of care in the ED. Future studies should assess how BT-ED can be used to improve triage of infected patients, assigning higher priority to patients with low-grade/no fever and vice versa. Patients with at/below median BT in both ED and ICU have the highest mortality and should receive special attention. Different BT according to sex and age also needs further study.
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Affiliation(s)
- Malin Inghammar
- Department of Clinical Sciences, Section for Infection Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Jonas Sunden-Cullberg
- Division of Infectious Diseases and Center for Infectious Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- * E-mail:
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5
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Kavaliunas A, Ocaya P, Mumper J, Lindfeldt I, Kyhlstedt M. Swedish policy analysis for Covid-19. HEALTH POLICY AND TECHNOLOGY 2020; 9:598-612. [PMID: 32904437 PMCID: PMC7455549 DOI: 10.1016/j.hlpt.2020.08.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged health care systems and put societies to the test in the world beyond expectations. OBJECTIVE Our aim is to describe and analyze the Swedish approach in combating the pandemic. METHODS We present and discuss data collated from various sources - published scientific studies, pre-print material, agency reports, media communication, public surveys, etc. - with specific focus on the approach itself, Covid-19 trends, healthcare system response, policy and measures overview, and implications. RESULTS The main intervention to manage the curve has been the general recommendations to adhere to good hand hygiene, beware of physical distance to others, to refrain from large gatherings and restrain from non-essential travel. Persons with suspected Covid-19 infection were recommended to stay at home and avoid social contacts. Additionally, visits to the elderly care homes and meetings with more than 50 people were forbidden. As a result, the healthcare system in the country has so far, never been overwhelmed. However, the relatively high mortality among the elderly, together with the vulnerability of some migrants, points out the drawbacks. CONCLUSIONS Many countries have both marvelled and criticized the Swedish strategy that is formed in a close partnership between the government and the society based on a mutual trust giving the responsibility to individuals. It already highlights how much can be achieved with voluntary measures (recommendations) - something that was noticed and proposed as a future model by the World Health Organization.
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Affiliation(s)
- Andrius Kavaliunas
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Pauline Ocaya
- Department of Clinical Microbiology, Section of Infection and Immunology, University Hospital of Umeå, Umeå, Sweden
| | - Jim Mumper
- Independent Consultant, Norrköping, Sweden
| | - Isis Lindfeldt
- Department of Sociology and Uppsala Antibiotic Center, Uppsala University, Uppsala, Sweden
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Jawad M, Baigi A, Chew M. Exposure to surgery is associated with better long-term outcomes in patients admitted to Swedish intensive care units. Acta Anaesthesiol Scand 2020; 64:1154-1161. [PMID: 32297658 DOI: 10.1111/aas.13604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/24/2020] [Accepted: 04/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Long-term outcomes of patients admitted to intensive care units (ICUs) after surgery are unknown. We investigated the long-term effects of surgical exposure prior to ICU admission. METHODS Registry-based cohort study. The adjusted effect of surgical exposure for mortality was examined using Cox regression. Secondary analysis with conditional logistic regression in a case-control subpopulation matched for age, gender, and Simplified Acute Physiology Score III (SAPS3) was also conducted. RESULTS 72 242 adult patients (56.9% males, median age 66 years [IQR 50-76]), admitted to Swedish ICUs in 3-year (2012-2014) were followed for a median of 2026 days (IQR 1745-2293). Cardiovascular diseases (17.5%), respiratory diseases (15.8%), trauma (11.2%), and infections (11.4%) were the leading causes for ICU admission. Mortality at longest follow-up was 49.4%. Age; SAPS3; admissions due to malignancies, respiratory, cardiovascular and renal diseases; and transfer to another ICU were associated with increased mortality. Surgical exposure prior to ICU admission (adjusted hazard ratio [aHR] 0.90; 95% CI 0.87-0.94; P < .001), admissions from the operation theatre (aHR 0.94; CI 0.90-0.99; P = .022) or post-anaesthesia care unit (aHR 0.92; CI 0.87-0.97; P = .003) were associated with decreased mortality. Conditional logistic regression confirmed the association between surgical exposure and decreased mortality (adjusted odds ratio 0.82; CI 0.75-0.91; P < .001). CONCLUSIONS Long-term ICU mortality was associated with known risk factors such as age and SAPS3. Transfer to other ICUs also appeared to be a risk factor and requires further investigation. Prior surgical exposure was associated with better outcomes, a noteworthy observation given limited ICU admissions after surgery in Sweden.
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Affiliation(s)
- Monir Jawad
- Central Hospital in Kristianstad Kristianstad Sweden
- Lund University Lund Sweden
| | | | - Michelle Chew
- Department of Anaesthesia and Intensive Care Medical and Health Sciences, Linköping University Linköping Sweden
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Zhao J, Rostgaard K, Hjalgrim H, Edgren G. The Swedish Scandinavian donations and transfusions database (SCANDAT3-S) - 50 years of donor and recipient follow-up. Transfusion 2020; 60:3019-3027. [PMID: 32827155 PMCID: PMC7754339 DOI: 10.1111/trf.16027] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/04/2020] [Accepted: 07/04/2020] [Indexed: 01/12/2023]
Abstract
Background The two previous versions of the Scandinavian donations and transfusions (SCANDAT) databases, encompassing data on blood donors, blood components, transfusions, and transfused patients linked to national health registers in Sweden and Denmark up until 2012, have been used to study donor health, disease transmission, the role of donor characteristics, and more. Study Design and Methods Here we describe the creation of the Swedish portion of the third iteration of SCANDAT – SCANDAT3‐S – with follow‐up from 1968 to the end of 2017, resulting in up to 50 years of uninterrupted follow‐up for donors and recipients. The database now also includes non‐transfused non‐donors with a blood typing result, increased temporal resolution for transfusions, and linkages to laboratory and drug prescription data. Results After data cleaning, the database contained 23 579 863 donation records, 21 383 317 transfusion records, and 8 071 066 unique persons with valid identification. In total, the database offers 28 638 436 person‐years of follow‐up for donors, 13 582 350 person‐years of follow‐up for transfusion recipients, and 65 613 639 person‐years of follow‐up for non‐recipient non‐donors, with possibility for future extension. Additionally, the database includes 167 820 412 dispense records for prescribed drugs and 316,338,442 laboratory test results. Since the latest update in 2012, >99.9% of all donations were traceable to a donor with valid identification, and >97% of all transfusions to a recipient with valid identification. Conclusion With extended follow‐up and more clinical detail, the Swedish portion of the third and latest iteration of the SCANDAT database should allow for more comprehensive analysis of donation and transfusion‐related research questions.
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Affiliation(s)
- Jingcheng Zhao
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden
| | - Klaus Rostgaard
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Hjalgrim
- Department of Clinical Immunology, Aalborg University Hospital, Aalborg, Denmark.,Department of Hematology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gustaf Edgren
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institutet, Stockholm, Sweden.,Department of Cardiology, Södersjukhuset, Stockholm, Sweden
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Litton E, Guidet B, de Lange D. National registries: Lessons learnt from quality improvement initiatives in intensive care. J Crit Care 2020; 60:311-318. [PMID: 32977140 DOI: 10.1016/j.jcrc.2020.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/29/2020] [Accepted: 08/11/2020] [Indexed: 01/01/2023]
Abstract
National clinical quality registries (CQRs) are effective tools for improving the outcomes of patients admitted to the intensive care unit (ICU), and are increasingly important as healthcare needs evolve. A high-quality ICU CQR is built from a foundation of common requirements and challenges. First, performance indicators of the structure, process, or outcomes of patient care should measure what is important. Second, high data quality is essential and can be collected and curated through standardized processes. Third, standardized mortality ratio (SMR) is a cornerstone for benchmarking ICU performance, but application requires a comprehensive understanding of its context and potential pitfalls. Fourth, data collection alone is insufficient. Quality improvement comes from closing the feedback loop by identifying and managing unwarranted practice variation. Fifth, the process of improving healthcare is fundamentally a human enterprise, subject to behavioural change, including those that modify performance. Sixth, ICU CQRs must be dynamic to meet the needs of an evolving healthcare system and stakeholders. Finally, these lessons are far from comprehensive. Sharing perspectives on the development of ICU CQRs can help maximise their value as a powerful platform for informing policy development and improving the outcomes of patients admitted to the ICU.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Perth 6065, Australia; St John of God Hospital, Salvado Road, Subiaco, Perth 6009, Australia.
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint-Antoine, Service de Réanimation, Paris F75012, France
| | - Dylan de Lange
- Intensive Care Unit, University Medical Centre, Utrecht 85500, Netherlands
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Sex-based differences in ED management of critically ill patients with sepsis: a nationwide cohort study. Intensive Care Med 2020; 46:727-736. [PMID: 31974918 PMCID: PMC7103003 DOI: 10.1007/s00134-019-05910-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 12/19/2019] [Indexed: 01/06/2023]
Abstract
Purpose To compare management and outcomes for critically ill women and men with sepsis in the emergency medical services (EMS), the emergency department (ED) and the ICU. Methods We used two prospectively compiled Swedish national quality registers, the National Quality Sepsis Registry and the Swedish Intensive Care Registry to identify a nationwide cohort of 2720 adults admitted to an ICU within 24 h of arrival to any of 32 EDs, with a diagnosis of severe sepsis or septic shock between 2008 and 2015. Results Patients were 44.5% female. In the EMS, a higher fraction of men had all vital signs recorded—54.4 vs 49.9% (p = 0.02) and received IV fluids and oxygen—40.0 vs 34.8% (p = 0.02). In the ED, men had completed 1-h sepsis bundles in 41.5% of cases compared to 30.0% in women (p < 0.001), and shorter time to antibiotics—65 (IQR 30–136) vs 87 min (IQR 39–172) (p = 0.0001). There was no significant difference between men and women regarding ICU nursing workload, mechanical ventilation or ICU length of stay. In severity-adjusted multivariable analysis, OR for women achieving a completed sepsis bundle, compared to men was 0.64 (CI 0.51–0.81). Thirty-day mortality was 25.0% for women and 23.1% for men (p = 0.24). Adjusted OR for female death was 1.28 (CI 1.00–1.64), but the increased mortality was not mediated by differential bundle completion. Conclusions Women and men with severe sepsis or septic shock received differential care in the ED, but this did not explain higher odds of death in women. Electronic supplementary material The online version of this article (10.1007/s00134-019-05910-9) contains supplementary material, which is available to authorized users.
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Emilsson L, Lindahl B, Köster M, Lambe M, Ludvigsson JF. Review of 103 Swedish Healthcare Quality Registries. J Intern Med 2015; 277:94-136. [PMID: 25174800 DOI: 10.1111/joim.12303] [Citation(s) in RCA: 254] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVES In the past two decades, an increasing number of nationwide, Swedish Healthcare Quality Registries (QRs) focusing on specific disorders have been initiated, mostly by physicians. Here, we describe the purpose, organization, variables, coverage and completeness of 103 Swedish QRs. METHODS From March to September 2013, we examined the 2012 applications of 103 QRs to the Swedish Association of Local Authorities and Regions (SALAR) and also studied the annual reports from the same QRs. After initial data abstraction, the coordinator of each QR was contacted at least twice between June and October 2013 and asked to confirm the accuracy of the data retrieved from the applications and reports. RESULTS About 60% of the QRs covered ≥80% of their target population (completeness). Data recorded in Swedish QRs include aspects of disease management (diagnosis, clinical characteristics, treatment and lead times). In addition, some QRs retrieve data on self-reported quality of life (EQ5D, SF-36 and disease-specific measures), lifestyle (smoking) and general health status (World Health Organization performance status, body mass index and blood pressure). CONCLUSION Detailed clinical data available in Swedish QRs complement information from government-administered registries and provide an important source not only for assessment and development of quality of care but also for research.
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Affiliation(s)
- L Emilsson
- Primary Care Research Unit, Vårdcentralen Värmlands Nysäter, Värmland County, Sweden; School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Department of Health Management and Health Economy, Institute of Health and Society, University of Oslo, Oslo, Norway
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Bingold TM, Lefering R, Zacharowski K, Waydhas C, Scheller B. [Eleven years of core data set in intensive care medicine. Severity of disease and workload are increasing]. Anaesthesist 2014; 63:942-50. [PMID: 25376445 DOI: 10.1007/s00101-014-2389-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 09/24/2014] [Accepted: 09/24/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the year 2000 a working group of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) defined a core data set on quality assurance for the first time. In the following years the participating intensive care units sent data to the registry on a voluntary basis and received an annual report on benchmarking data. Alterations in the quality in the field of intensive care medicine have so far only been published to a very low extent. AIM This study analyzed the core date set of the DIVI between 2000 and 2010 in respect to changes in disease severity using the simplified acute physiology score (SAPS II), the sequential organ failure assessment (SOFA), the need for therapeutic interventions with the therapeutic intervention scoring system (TISS 28) and intensive care unit (ICU) mortality. MATERIAL AND METHODS Inclusion criteria were participation in the registry for at least 4 years, SAPS II, SOFA, TISS28 scores available and data on ICU discharge. A standardized mortality rate (SMR) was calculated for each year. RESULTS The mean SAPS II score including 94,398 patients increased by 0.23 points/year with a standard error (SE) of 0.02 to 26.9 ± 12 points (p < 0.001). Similarly, the SOFA score on admission to the ICU increased by 0.14 points/year (SE 0.04) to 3.4 ± 2.7 points (p < 0.001), the proportion of patients with a two organ failure doubled to 7.1 % and the number of patients dependent on ventilation increased by 13.6 % to 59.8 %. The mean time on ventilation increased by 0.17 ventilator days/year (SE 0.01, p < 0.001) to 3.1 ± 7.5 days/patient. The mean number of therapeutic interventions increased by 8.7 % to 26.3 ± 8.3 TISS 28 points/day. The mean length of stay on the ICU (4.3 ± 8 days) and the age of the patients (63.2 ± 17.0 years) remained unchanged. The readmission rate showed no significant changes between the years 2004 and 2010. The readmission rate to the ICU within 48 h after primary discharge was 3.1 % with a 95 % confidence interval (CI) of 3.0-3.3 in contrast to 1.5 % (95 % CI 1.4-1.6) for readmission to the ICU after 48 h. The length of stay in hospital before admission to the ICU decreased for patients with scheduled surgery (6.3 ± 9.7 days vs. 4.2 ± 6.9 days), increased slightly for patients with medically indicated admission to the ICU (2.4 ± 8.2 days 3.1 ± 8.6 days) and remained unchanged for patients with unscheduled admission to the ICU after surgery (4.1 ± 8.6 days). The SMR decreased between 2000 and 2004 from 0.97 to 0.72 and increased again thereafter to 0.99 (ICU mortality 8.5 %). CONCLUSION The severity of disease on admission to the ICU, the proportion of patients on ventilation and the workload of therapeutic interventions increased between 2000 and 2010 in German ICUs but the length of stay of patients in the ICU remained unchanged. The SMR decreased until 2005 and increased thereafter to return to the initial values. The overall ICU mortality was low compared to international data.
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Affiliation(s)
- T M Bingold
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinik Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt a. M., Deutschland,
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Nordberg P, Hollenberg J, Rosenqvist M, Herlitz J, Jonsson M, Järnbert-Petterson H, Forsberg S, Dahlqvist T, Ringh M, Svensson L. The implementation of a dual dispatch system in out-of-hospital cardiac arrest is associated with improved short and long term survival. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 3:293-303. [PMID: 24739955 DOI: 10.1177/2048872614532415] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIMS To determine the impact of a dual dispatch system, using fire fighters as first responders, in out-of-hospital cardiac arrest (OHCA) on short (30 days) and long term (three years) survival, and, to investigate the potential differences regarding in-hospital factors and interventions between the patient groups, such as the use of therapeutic hypothermia and cardiac catheterization. METHODS AND RESULTS OHCAs from 2004 (historical controls) and 2006-2009 (intervention period) were included. During the intervention period, fire fighters equipped with automated external defibrillators (AEDs) were dispatched in suspected OHCA. Logistic regression analyses of outcome data included: the intervention with dual dispatch, sex, age, location, aetiology, witnessed status, bystander-cardiopulmonary resuscitation, first rhythm and therapeutic hypothermia. In total, 2581 OHCAs were included (historical controls n=620, intervention period n=1961). Fire fighters initiated cardiopulmonary resuscitation and connected an AED before emergency medical services' arrival in 41% of the cases. The median time from dispatch to arrival of first responder or emergency medical services shortened from 7.7 in the control period to 6.7 min in the intervention period (p<0.001). The 30-day survival improved from 3.9% to 7.6% (p=0.001), adjusted odds ratio 2.8 (confidence interval 1.6-4.9). Survival to three years increased from 2.4% to 6.5% (p<0.001), adjusted odds ratio 3.8 (confidence interval 1.9-7.6). In the logistic regression analysis including in-hospital factors we found no outcome benefit of therapeutic hypothermia. CONCLUSIONS The implementation of a dual dispatch system using fire fighters in OHCA was associated with increased 30-day and three-year survival. No major differences in the in-hospital treatment were seen between the studied patient groups.
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Affiliation(s)
- Per Nordberg
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Mårten Rosenqvist
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Herlitz
- Institute of Internal Medicine, Department of Metabolism and Cardiovascular Research, Sahlgrenska University Hospital, Gothenburg, Sweden The Prehospital Research Centre Western Sweden, Prehospen University College of Borås, Sweden
| | - Martin Jonsson
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Hans Järnbert-Petterson
- Department of Clinical Science and Education Karolinska Institutet, Södersjukhuset Stockholm, Sweden
| | - Sune Forsberg
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Tobias Dahlqvist
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Mattias Ringh
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
| | - Leif Svensson
- Department of Clinical Science and Education Karolinska Institutet, Section of Cardiology, Södersjukhuset Stockholm, Sweden
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Koetsier A, Peek N, de Jonge E, Dongelmans D, van Berkel G, de Keizer N. Reliability of in-hospital mortality as a quality indicator in clinical quality registries. A case study in an intensive care quality register. Methods Inf Med 2013; 52:432-40. [PMID: 23807704 DOI: 10.3414/me12-02-0070] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 04/09/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Errors in the registration or extraction of patient outcome data, such as in-hospital mortality, may lower the reliability of the quality indicator that uses this (partly) incorrect data. Our aim was to measure the reliability of in-hospital mortality registration in the Dutch National Intensive Care Evaluation (NICE) registry. METHODS We linked data of the NICE registry with an insurance claims database, resulting in a list of discrepancies in in-hospital mortality. Eleven Intensive Care Units (ICUs) were visited where local data sources were investigated to find the true in-hospital mortality status of the discrepancies and to identify the causes of the data errors in the NICE registry. Original and corrected Standardized Mortality Ratios (SMRs) were calculated to determine if conclusions about quality of care changed compared to the national benchmark. RESULTS In eleven ICUs, 23,855 records with 460 discrepancies were identified of which 255 discrepancies (1.1% of all linked records) were due to incorrect in-hospital mortality registration in the NICE registry. Two programming errors in computer software of six ICUs caused 78% of errors, the remainder was caused by manual transcription errors and failure to record patient outcomes. For one ICU the performance became concordant with the national benchmark after correction, instead of being better. CONCLUSIONS The reliability of in-hospital mortality registration in the NICE registry was good. This was reflected by the low number of data errors and by the fact that conclusions about the quality of care were only affected for one ICU due to systematic data errors. We recommend that registries frequently verify the software used in the registration process, and compare mortality data with an external source to assure consistent quality of data.
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Affiliation(s)
- A Koetsier
- Antonie Koetsier, MSc Department of Medical Informatics, Academic Medical Center, Room J1b-115-2, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands, E-mail:
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