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Predicting sepsis using prehospital data from the ambulance service: A linked data cohort study
Papers and Poster Abstracts / Australian Critical Care 29 (2016) 110–123
Predicting sepsis using prehospital data from the ambulance service: A linked data cohort study
Health-related quality of life – Conceptualisation and prioritisation in decision-making by critical care physicians
Teresa Williams 1,∗ , Judith Finn 1 , Daniel Fatovich 2 , Hideo Tohira 1 , Deon Brink 3 , Gavin D. Perkins 4 , Kwok M. Ho 5
Kimberley Haines 1,2,∗ , Louisa Remedios 2 , Sue Berney 1 , Cameron Knott 1 , Linda Denehy 2
1
1
Prehospital Resuscitation and Emergency Care Research Unit, Curtin University; St John Ambulance-Western Australia; Royal Perth Hospital, Bentley, Australia 2 Emergency Medicine Royal Perth Hospital, and the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia 3 St John Ambulance-Western Australia, Belmont, Australia 4 Critical Care Medicine, Warwick Medical School, University of Warwick and Honorary Consultant Physician in Critical Care at Heart of England NHS Foundation Trust, UK, Warwick, United Kingdom 5 Intensive Care Unit Royal Perth Hospital; School of Population Health, The University of Western Australia, Perth, Australia Introduction: Early identification of sepsis may facilitate prealerting the emergency department (ED) enabling prompt initiation of antibiotics and source control. Whether sepsis can be reliably predicted using prehospital data recorded by paramedics remains uncertain. Study objectives: (1) To determine the predictive ability of prehospital factors to predict a subsequent diagnosis of sepsis; (2) To examine the ability of the New Early Warning Score (NEWS) to predict a subsequent diagnosis of sepsis. Methods: This retrospective cohort study linked the prehospital data of patients aged 16 years and older, transported by the metropolitan St John Ambulance Service in Perth, between July 2012 and June 2014, with data from the ED Information System. Air transports, inter-facility transfers, patients with cardiac arrest, trauma and overdoses were excluded. Apart from the predictive ability of each individual demographic and vital physiological variable, the ability of the National Early Warning Score (NEWS) to predict a subsequent diagnosis of sepsis was also assessed. NEWS is a composite score: scores of 5+ are predictive of increased risk of death or ICU admission. Logistic regression and area under the operating-receiving-operating characteristic curves (AUROC) were used to identify prehospital predictors of sepsis and their discriminatory power, respectively. Results: Of 92,362 patients included in the study, 4565 (4.9%) had a diagnosis of sepsis subsequently in ED. Significant prehospital factors associated with sepsis: OR (95% CI) per 1 unit increment were age 1.08 (1.02–1.03), temperature 2.38 (2.00–2.51), systolic blood pressure 0.98 (0.97–0.98), respiratory rate 0.97 (0.94–0.99), heart rate 1.01 (1.01–1.02), and AVPU (alert = 1/verbal = 2/pain = 3/unresponsive = 4) 1.27 (1.13–1.42). The NEWS in the prehospital setting only had a moderate ability to differentiate between patients with and without sepsis (AUROC 0.74, 95% CI 0.72–0.77) and this predictive ability was no better than individual physiological parameters alone. Conclusion: Sepsis cannot be reliably predicted using prehospital data recorded by paramedics. http://dx.doi.org/10.1016/j.aucc.2015.12.024
119
2
Austin Health, Victoria, Australia The University of Melbourne, Victoria, Australia
Introduction: Clinical decision-making is an important yet complex process when evaluating patient health related quality of life (HRQoL) and making subsequent care decisions. However little is known about this process. The aim was to explore how intensive care physicians conceptualise and prioritise HRQoL in their decision-making. Methods: Qualitative inquiry using Grounded Theory and Case Study. Semi-structured interviews conducted with critical care physicians, at a large closed intensive care unit in a university affiliated hospital. Grounded Theory was used to generate themes from the data, identifying illustrative quotes. Results: Three key themes emerged: (1) Multi-dimensionality of HRQoL – it was difficult to understand and estimate HRQoL, with the patient viewed as the best informant. Proxies commonly provided pre-morbid patient HRQoL information and future health preferences’; contributing to perceived subjectivity and this information was used to direct patient care. (2) Prioritisation of HRQoL within decision-making – different aspects were prioritised more highly at various time points of the patient’s healthcare trajectory. Premorbid HRQoL was prioritised highly when making admission decisions and used to predict future HRQoL. During critical illness the patients’ health state was viewed as tolerable “suffering” if the patient had a good outcome in the opinion of the physicians, but was less acceptable if they considered the patient’s survival or HRQol to be poor. (3) Role of physician in decision-making – physicians described their role as representing society with peers influencing their decision-making. Physicians regarded their practice as similar to peers and as “middle of the road”. Ultimately, decisionmaking was underpinned by physician values, assisting them in their clinical judgements. Conclusions: Critical care physicians conceptualize HRQoL as a complex, subjective construct. Patient voice (or proxy representation) was integral in establishing premorbid HRQoL and future health preferences. HRQoL became more important in high stakes decision-making including initiating invasive and burdensome therapies or in redirecting therapeutic goals. Funding source: NHMRC Dora Lush Scholarship. http://dx.doi.org/10.1016/j.aucc.2015.12.025 Decompressive craniectomy and the disability paradox Stephen Honeybul 1,∗ , Courtney Janzen 1 , Kate Kruger 1 , Kwok Ho 2 1 2
Sir Charles Gairdner Hospital, Perth, Australia Royal Perth Hospital, Perth, Australia
Introduction: Many patients survive with severe disability following decompressive craniectomy for severe traumatic brain injury. The acceptability or otherwise of this outcome has yet to determined.
Predicting sepsis using prehospital data from the ambulance service: A linked data cohort study
Health-related quality of life – Conceptualisation and prioritisation in decision-making by critical care physicians
Teresa Williams 1,∗ , Judith Finn 1 , Daniel Fatovich 2 , Hideo Tohira 1 , Deon Brink 3 , Gavin D. Perkins 4 , Kwok M. Ho 5
Kimberley Haines 1,2,∗ , Louisa Remedios 2 , Sue Berney 1 , Cameron Knott 1 , Linda Denehy 2
1
1
Prehospital Resuscitation and Emergency Care Research Unit, Curtin University; St John Ambulance-Western Australia; Royal Perth Hospital, Bentley, Australia 2 Emergency Medicine Royal Perth Hospital, and the Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Australia 3 St John Ambulance-Western Australia, Belmont, Australia 4 Critical Care Medicine, Warwick Medical School, University of Warwick and Honorary Consultant Physician in Critical Care at Heart of England NHS Foundation Trust, UK, Warwick, United Kingdom 5 Intensive Care Unit Royal Perth Hospital; School of Population Health, The University of Western Australia, Perth, Australia Introduction: Early identification of sepsis may facilitate prealerting the emergency department (ED) enabling prompt initiation of antibiotics and source control. Whether sepsis can be reliably predicted using prehospital data recorded by paramedics remains uncertain. Study objectives: (1) To determine the predictive ability of prehospital factors to predict a subsequent diagnosis of sepsis; (2) To examine the ability of the New Early Warning Score (NEWS) to predict a subsequent diagnosis of sepsis. Methods: This retrospective cohort study linked the prehospital data of patients aged 16 years and older, transported by the metropolitan St John Ambulance Service in Perth, between July 2012 and June 2014, with data from the ED Information System. Air transports, inter-facility transfers, patients with cardiac arrest, trauma and overdoses were excluded. Apart from the predictive ability of each individual demographic and vital physiological variable, the ability of the National Early Warning Score (NEWS) to predict a subsequent diagnosis of sepsis was also assessed. NEWS is a composite score: scores of 5+ are predictive of increased risk of death or ICU admission. Logistic regression and area under the operating-receiving-operating characteristic curves (AUROC) were used to identify prehospital predictors of sepsis and their discriminatory power, respectively. Results: Of 92,362 patients included in the study, 4565 (4.9%) had a diagnosis of sepsis subsequently in ED. Significant prehospital factors associated with sepsis: OR (95% CI) per 1 unit increment were age 1.08 (1.02–1.03), temperature 2.38 (2.00–2.51), systolic blood pressure 0.98 (0.97–0.98), respiratory rate 0.97 (0.94–0.99), heart rate 1.01 (1.01–1.02), and AVPU (alert = 1/verbal = 2/pain = 3/unresponsive = 4) 1.27 (1.13–1.42). The NEWS in the prehospital setting only had a moderate ability to differentiate between patients with and without sepsis (AUROC 0.74, 95% CI 0.72–0.77) and this predictive ability was no better than individual physiological parameters alone. Conclusion: Sepsis cannot be reliably predicted using prehospital data recorded by paramedics. http://dx.doi.org/10.1016/j.aucc.2015.12.024
119
2
Austin Health, Victoria, Australia The University of Melbourne, Victoria, Australia
Introduction: Clinical decision-making is an important yet complex process when evaluating patient health related quality of life (HRQoL) and making subsequent care decisions. However little is known about this process. The aim was to explore how intensive care physicians conceptualise and prioritise HRQoL in their decision-making. Methods: Qualitative inquiry using Grounded Theory and Case Study. Semi-structured interviews conducted with critical care physicians, at a large closed intensive care unit in a university affiliated hospital. Grounded Theory was used to generate themes from the data, identifying illustrative quotes. Results: Three key themes emerged: (1) Multi-dimensionality of HRQoL – it was difficult to understand and estimate HRQoL, with the patient viewed as the best informant. Proxies commonly provided pre-morbid patient HRQoL information and future health preferences’; contributing to perceived subjectivity and this information was used to direct patient care. (2) Prioritisation of HRQoL within decision-making – different aspects were prioritised more highly at various time points of the patient’s healthcare trajectory. Premorbid HRQoL was prioritised highly when making admission decisions and used to predict future HRQoL. During critical illness the patients’ health state was viewed as tolerable “suffering” if the patient had a good outcome in the opinion of the physicians, but was less acceptable if they considered the patient’s survival or HRQol to be poor. (3) Role of physician in decision-making – physicians described their role as representing society with peers influencing their decision-making. Physicians regarded their practice as similar to peers and as “middle of the road”. Ultimately, decisionmaking was underpinned by physician values, assisting them in their clinical judgements. Conclusions: Critical care physicians conceptualize HRQoL as a complex, subjective construct. Patient voice (or proxy representation) was integral in establishing premorbid HRQoL and future health preferences. HRQoL became more important in high stakes decision-making including initiating invasive and burdensome therapies or in redirecting therapeutic goals. Funding source: NHMRC Dora Lush Scholarship. http://dx.doi.org/10.1016/j.aucc.2015.12.025 Decompressive craniectomy and the disability paradox Stephen Honeybul 1,∗ , Courtney Janzen 1 , Kate Kruger 1 , Kwok Ho 2 1 2
Sir Charles Gairdner Hospital, Perth, Australia Royal Perth Hospital, Perth, Australia
Introduction: Many patients survive with severe disability following decompressive craniectomy for severe traumatic brain injury. The acceptability or otherwise of this outcome has yet to determined.