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Erratum: Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum. 勘误:非创伤性成人院内心脏骤停抢救过程中的心包穿刺术、胸导管插入术和针刺胸腔造口术:回顾性队列研究:勘误。
Q4 Medicine Pub Date : 2024-09-17 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001158

[This corrects the article DOI: 10.1097/CCE.0000000000001130.].

[此处更正了文章 DOI:10.1097/CCE.0000000000001130]。
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引用次数: 0
Pericardiocentesis, Chest Tube Insertion, and Needle Thoracostomy During Resuscitation of Nontraumatic Adult In-Hospital Cardiac Arrest: A Retrospective Cohort Study: Erratum. 非创伤性成人院内心脏骤停抢救过程中的心包穿刺、胸腔置管和针刺胸腔造口术:回顾性队列研究:勘误。
Q4 Medicine Pub Date : 2024-09-17 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001158
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引用次数: 0
Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study. 急性呼吸衰竭患者使用限时试验的特点:一项前瞻性单中心观察研究。
Q4 Medicine Pub Date : 2024-09-16 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001148
Joy X Moy, Anica C Law, Lily N Stalter, Michael D Peliska, Geralyn Palmer, Bret M Hanlon, Sean Mortenson, Elizabeth M Viglianti, Douglas A Wiegmann, Jacqueline M Kruser

Importance: A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.

Objectives: To characterize TLT use in patients with acute respiratory failure (ARF).

Design, setting, and participants: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.

Main outcomes and measures: Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.

Results: Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).

Conclusions and relevance: In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

重要性:有时间限制的试验(TLT)是临床医生、患者和家属之间的一项合作计划,在规定的时间内使用维持生命疗法,之后根据患者的反应决定是继续以康复为目标的护理,还是将重点转向舒适。TLT是一种很有前景的方法,有助于应对危重病中的不确定性,但人们对其目前的使用情况知之甚少:描述急性呼吸衰竭(ARF)患者使用 TLT 的情况:美国一家学术医疗中心对接受有创机械通气超过或等于 48 小时的急性呼吸衰竭成人 ICU 患者进行了为期 12 个月的前瞻性队列观察研究:主要暴露是参与 TLT,由患者的 ICU 医生确定。从电子病历中提取患者特征、护理服务要素和住院结果:在 176 名符合条件的患者中,36 人(20.5%)参加了 TLT。在 18 位重症监护室主治医生中,有 9 位(50%)参与了大于或等于 1 次 TLT(频率为所护理患者的 0-39%)。TLT 的中位持续时间为 3.0 天(四分位数间距 [IQR],3.0-4.5 天)。TLT患者的平均年龄较高(67.4 岁 [sd,12.0 岁] vs. 60.0 岁 [sd,16.0 岁];P < 0.01),Charlson合并症指数较高(5.1 [sd,2.2] vs. 3.8[sd,2.6];p < 0.01),与非 TLT 患者相比,器官功能衰竭序列评估评分相似(9.6 [sd, 3.3] vs. 9.5 [sd, 3.7];p = 0.93)。TLT患者更有可能死亡或出院接受临终关怀(80.6% vs. 42.1%;p < 0.05),ICU住院时间更短(中位数,5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d];p < 0.01):在这项研究中,约五分之一的 ARF 患者参加了 TLT。我们的研究结果表明,TLT 主要用于临近生命末期的患者,但医生的使用情况存在很大差异,因此需要证据来指导最佳使用。
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引用次数: 0
Utility of Skin Tone on Pulse Oximetry in Critically Ill Patients: A Prospective Cohort Study. 重症患者肤色对脉搏氧饱和度的影响:一项前瞻性队列研究
Q4 Medicine Pub Date : 2024-09-13 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001133
Sicheng Hao, Katelyn Dempsey, João Matos, Christopher E Cox, Veronica Rotemberg, Judy W Gichoya, Warren Kibbe, Chuan Hong, An-Kwok Ian Wong

Objective: Pulse oximetry, a ubiquitous vital sign in modern medicine, has inequitable accuracy that disproportionately affects minority Black and Hispanic patients, with associated increases in mortality, organ dysfunction, and oxygen therapy. Previous retrospective studies used self-reported race or ethnicity as a surrogate for skin tone which is believed to be the root cause of the disparity. Our objective was to determine the utility of skin tone in explaining pulse oximetry discrepancies.

Design: Prospective cohort study.

Setting: Patients were eligible if they had pulse oximetry recorded up to 5 minutes before arterial blood gas (ABG) measurements. Skin tone was measured using administered visual scales, reflectance colorimetry, and reflectance spectrophotometry.

Participants: Admitted hospital patients at Duke University Hospital.

Interventions: None.

Measurements and main results: Sao2-Spo2 bias, variation of bias, and accuracy root mean square, comparing pulse oximetry, and ABG measurements. Linear mixed-effects models were fitted to estimate Sao2-Spo2 bias while accounting for clinical confounders.One hundred twenty-eight patients (57 Black, 56 White) with 521 ABG-pulse oximetry pairs were recruited. Skin tone data were prospectively collected using six measurement methods, generating eight measurements. The collected skin tone measurements were shown to yield differences among each other and overlap with self-reported racial groups, suggesting that skin tone could potentially provide information beyond self-reported race. Among the eight skin tone measurements in this study, and compared with self-reported race, the Monk Scale had the best relationship with differences in pulse oximetry bias (point estimate: -2.40%; 95% CI, -4.32% to -0.48%; p = 0.01) when comparing patients with lighter and dark skin tones.

Conclusions: We found clinical performance differences in pulse oximetry, especially in darker skin tones. Additional studies are needed to determine the relative contributions of skin tone measures and other potential factors on pulse oximetry discrepancies.

目的:脉搏血氧仪是现代医学中无处不在的生命体征,但其准确性不公平,对黑人和西班牙裔少数群体患者的影响尤为严重,死亡率、器官功能障碍和氧疗的相关费用也随之增加。以往的回顾性研究使用自我报告的种族或民族作为肤色的替代物,这被认为是造成差异的根本原因。我们的目标是确定肤色在解释脉搏血氧饱和度差异方面的效用:前瞻性队列研究:在动脉血气 (ABG) 测量前 5 分钟记录脉搏氧饱和度的患者均符合条件。肤色测量采用管理视觉量表、反射比色法和反射分光光度法进行:干预措施:无:测量和主要结果比较脉搏血氧仪和 ABG 测量的 Sao2-Spo2 偏差、偏差变化和准确度均方根。在考虑临床混杂因素的同时,拟合线性混合效应模型以估计 Sao2-Spo2 偏差。采用六种测量方法前瞻性地收集了肤色数据,共产生了八种测量结果。结果显示,所收集的肤色测量值之间存在差异,并与自我报告的种族群体重叠,这表明肤色有可能提供自我报告的种族以外的信息。在本研究的八种肤色测量方法中,与自我报告的种族相比,当比较浅肤色和深肤色患者时,蒙克量表与脉搏氧饱和度偏差差异的关系最好(点估计值:-2.40%;95% CI,-4.32% 至 -0.48%;p = 0.01):我们发现脉搏氧饱和度的临床表现存在差异,尤其是肤色较深的患者。需要进行更多的研究来确定肤色测量和其他潜在因素对脉搏血氧饱和度差异的相对影响。
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引用次数: 0
Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study. 成人长期重症患者质量改进工具的代码设计:改良德尔菲共识研究。
Q4 Medicine Pub Date : 2024-09-12 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001146
Laura Allum, Natalie Pattison, Bronwen Connolly, Chloe Apps, Katherine Cowan, Emily Flowers, Nicholas Hart, Louise Rose

Objectives: Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.

Design: Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.

Setting: Carried out in the United Kingdom.

Patients/subjects: Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.

Interventions: None.

Measurements and main results: We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted "critically important" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.

Conclusions: Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.

目的:越来越多的患者需要长期接受重症监护。然而,用于提高安全性和规范护理的现有质量改进(QI)工具并不是针对他们的特殊需求而设计的。这可能会导致错失护理机会,并造成更坏的结果。根据基于经验的编码设计流程,我们的目标是就最重要的可操作护理流程达成共识,以便将其纳入针对长期重症成人患者的 QI 工具:设计:从之前的系统性回顾以及对既往患者、其护理伙伴和临床医生的访谈中确定项目。进行了两轮在线改良德尔菲调查,要求参与者对每个项目进行评分,根据其对有效护理的重要性从 1 到 9 分进行评分;其中 1-3 分不重要,4-6 分重要但不关键,7-9 分非常重要,可纳入 QI 工具。然后由一名独立主持人主持召开最后的共识会议,进一步讨论并确定项目的优先次序:患者/研究对象:在英国进行:干预措施:无:测量和主要结果我们招募了 116 名参与者:在德尔菲第一轮中,我们招募了 63 名医护人员(54%)、45 名患者(39%)和 8 名亲属(7%),并在第二轮中保留了 91 人(78%)。在最初确定的 39 个项目中,有 32 个项目被超过 70% 的德尔菲参与者评为 "极其重要",可纳入 QI 工具。在与 15 名重症监护室临床医生、4 名既往患者和 1 名家属举行的共识会议上,这些项目被进一步排序,最终的 QI 工具包含 25 个项目,其中包括促进患者和家属参与决策、提供连续性护理以及结构化呼吸机断奶和康复:通过基于经验的编码设计和严格的建立共识方法,我们确定了针对长期危重症成人患者的 QI 工具的重要内容。了解工具的可接受性和最佳实施策略的工作正在进行中。
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引用次数: 0
The Discover In-Hospital Cardiac Arrest (Discover IHCA) Study: An Investigation of Hospital Practices After In-Hospital Cardiac Arrest. 发现院内心脏骤停(Discover IHCA)研究:院内心脏骤停后医院实践调查。
Q4 Medicine Pub Date : 2024-09-11 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001149
Luke Andrea, Nathaniel S Herman, Jacob Vine, Katherine M Berg, Saiara Choudhury, Mariana Vaena, Jordan E Nogle, Saleem M Halablab, Aarthi Kaviyarasu, Jonathan Elmer, Gabriel Wardi, Alex K Pearce, Conor Crowley, Micah T Long, J Taylor Herbert, Kipp Shipley, Brittany D Bissell Turpin, Michael J Lanspa, Adam Green, Shekhar A Ghamande, Akram Khan, Siddharth Dugar, Aaron M Joffe, Michael Baram, Cooper March, Nicholas J Johnson, Alexander Reyes, Krassimir Denchev, Michael Loewe, Ari Moskowitz

Importance: In-hospital cardiac arrest (IHCA) is a significant public health burden. Rates of return of spontaneous circulation (ROSC) have been improving, but the best way to care for patients after the initial resuscitation remains poorly understood, and improvements in survival to discharge are stagnant. Existing North American cardiac arrest databases lack comprehensive data on the post-resuscitation period, and we do not know current post-IHCA practice patterns. To address this gap, we developed the Discover In-Hospital Cardiac Arrest (Discover IHCA) study, which will thoroughly evaluate current post-IHCA care practices across a diverse cohort.

Objectives: Our study collects granular data on post-IHCA treatment practices, focusing on temperature control and prognostication, with the objective of describing variation in current post-IHCA practice.

Design, setting, and participants: This is a multicenter, prospectively collected, observational cohort study of patients who have suffered IHCA and have been successfully resuscitated (achieved ROSC). There are 24 enrolling hospital systems (23 in the United States) with 69 individual enrolling hospitals (39 in the United States). We developed a standardized data dictionary, and data collection began in October 2023, with a projected 1000 total enrollments. Discover IHCA is endorsed by the Society of Critical Care Medicine.

Interventions, outcomes, and analysis: The study collects data on patient characteristics including pre-arrest frailty, arrest characteristics, and detailed information on post-arrest practices and outcomes. Data collection on post-IHCA practice was structured around current American Heart Association and European Resuscitation Council guidelines. Among other data elements, the study captures post-arrest temperature control interventions and post-arrest prognostication methods. Analysis will evaluate variations in practice and their association with mortality and neurologic function.

Conclusions: We expect this study, Discover IHCA, to identify variability in practice and outcomes following IHCA, and be a vital resource for future investigations into best-practice for managing patients after IHCA.

重要性:院内心脏骤停 (IHCA) 是一项重大的公共卫生负担。自发性循环(ROSC)的恢复率一直在提高,但人们对最初复苏后护理患者的最佳方法仍然知之甚少,出院后存活率的提高也停滞不前。现有的北美心脏骤停数据库缺乏复苏后的全面数据,我们也不知道目前的心脏骤停复苏后实践模式。为了填补这一空白,我们开展了 "发现院内心脏骤停"(Discover IHCA)研究,该研究将对不同人群目前的院内心脏骤停后护理实践进行全面评估:我们的研究收集有关院内心脏骤停后处理方法的详细数据,重点是温度控制和预后,目的是描述当前院内心脏骤停后处理方法的差异:这是一项多中心、前瞻性、观察性队列研究,研究对象是发生 IHCA 并成功复苏(达到 ROSC)的患者。共有 24 个医院系统(美国有 23 个)和 69 家单个参与医院(美国有 39 家)。我们开发了标准化的数据字典,数据收集工作于 2023 年 10 月开始,预计总注册人数为 1000 人。发现 IHCA 得到了重症医学会的认可:该研究收集患者特征数据,包括逮捕前的虚弱程度、逮捕特征以及逮捕后做法和结果的详细信息。根据美国心脏协会和欧洲复苏委员会的现行指南,对心肺复苏术后的实践进行了数据收集。除其他数据元素外,该研究还收集了心跳骤停后的体温控制干预措施和心跳骤停后的预后方法。分析将评估实践中的差异及其与死亡率和神经功能的关系:我们希望通过这项研究发现 IHCA 后的实践和结果差异,并为今后研究 IHCA 后患者管理的最佳实践提供重要资源。
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引用次数: 0
Utility of Skin Tone on Pulse Oximetry in Critically Ill Patients: A Prospective Cohort Study. 重症患者肤色对脉搏氧饱和度的影响:一项前瞻性队列研究
Q4 Medicine Pub Date : 2024-09-11 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001133
Sicheng Hao, Katelyn Dempsey, João Matos, Christopher E Cox, Veronica Rotemberg, Judy W Gichoya, Warren Kibbe, Chuan Hong, An-Kwok Ian Wong

Objective: Pulse oximetry, a ubiquitous vital sign in modern medicine, has inequitable accuracy that disproportionately affects minority Black and Hispanic patients, with associated increases in mortality, organ dysfunction, and oxygen therapy. Previous retrospective studies used self-reported race or ethnicity as a surrogate for skin tone which is believed to be the root cause of the disparity. Our objective was to determine the utility of skin tone in explaining pulse oximetry discrepancies.

Design: Prospective cohort study.

Setting: Patients were eligible if they had pulse oximetry recorded up to 5 minutes before arterial blood gas (ABG) measurements. Skin tone was measured using administered visual scales, reflectance colorimetry, and reflectance spectrophotometry.

Participants: Admitted hospital patients at Duke University Hospital.

Interventions: None.

Measurements and main results: Sao2-Spo2 bias, variation of bias, and accuracy root mean square, comparing pulse oximetry, and ABG measurements. Linear mixed-effects models were fitted to estimate Sao2-Spo2 bias while accounting for clinical confounders.One hundred twenty-eight patients (57 Black, 56 White) with 521 ABG-pulse oximetry pairs were recruited. Skin tone data were prospectively collected using six measurement methods, generating eight measurements. The collected skin tone measurements were shown to yield differences among each other and overlap with self-reported racial groups, suggesting that skin tone could potentially provide information beyond self-reported race. Among the eight skin tone measurements in this study, and compared with self-reported race, the Monk Scale had the best relationship with differences in pulse oximetry bias (point estimate: -2.40%; 95% CI, -4.32% to -0.48%; p = 0.01) when comparing patients with lighter and dark skin tones.

Conclusions: We found clinical performance differences in pulse oximetry, especially in darker skin tones. Additional studies are needed to determine the relative contributions of skin tone measures and other potential factors on pulse oximetry discrepancies.

目的:脉搏血氧仪是现代医学中无处不在的生命体征,其准确性不公平,对黑人和西班牙裔少数群体患者的影响尤为严重,死亡率、器官功能障碍和氧疗的相关费用也随之增加。以往的回顾性研究使用自我报告的种族或民族作为肤色的替代物,这被认为是造成差异的根本原因。我们的目标是确定肤色在解释脉搏血氧饱和度差异方面的效用:前瞻性队列研究:在动脉血气 (ABG) 测量前 5 分钟记录脉搏氧饱和度的患者均符合条件。肤色测量采用管理视觉量表、反射比色法和反射分光光度法进行:干预措施:无:测量和主要结果比较脉搏血氧仪和 ABG 测量的 Sao2-Spo2 偏差、偏差变化和准确度均方根。在考虑临床混杂因素的同时,拟合线性混合效应模型来估计 Sao2-Spo2 偏差。采用六种测量方法前瞻性地收集了肤色数据,共产生了八种测量结果。结果显示,所收集的肤色测量值之间存在差异,并与自我报告的种族群体重叠,这表明肤色有可能提供自我报告的种族以外的信息。在本研究的八种肤色测量方法中,与自我报告的种族相比,当比较浅肤色和深肤色患者时,蒙克量表与脉搏氧饱和度偏差差异的关系最好(点估计值:-2.40%;95% CI,-4.32% 至 -0.48%;p = 0.01):我们发现脉搏氧饱和度的临床表现存在差异,尤其是肤色较深的患者。需要进行更多的研究来确定肤色测量和其他潜在因素对脉搏血氧饱和度差异的相对影响。
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引用次数: 0
Development and Validation of a Deep Learning Model for Prediction of Adult Physiological Deterioration. 开发和验证用于预测成人生理退化的深度学习模型。
Q4 Medicine Pub Date : 2024-09-11 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001151
Supreeth P Shashikumar, Joshua Pei Le, Nathan Yung, James Ford, Karandeep Singh, Atul Malhotra, Shamim Nemati, Gabriel Wardi

Background: Prediction-based strategies for physiologic deterioration offer the potential for earlier clinical interventions that improve patient outcomes. Current strategies are limited because they operate on inconsistent definitions of deterioration, attempt to dichotomize a dynamic and progressive phenomenon, and offer poor performance.

Objective: Can a deep learning deterioration prediction model (Deep Learning Enhanced Triage and Emergency Response for Inpatient Optimization [DETERIO]) based on a consensus definition of deterioration (the Adult Inpatient Decompensation Event [AIDE] criteria) and that approaches deterioration as a state "value-estimation" problem outperform a commercially available deterioration score?

Derivation cohort: The derivation cohort contained retrospective patient data collected from both inpatient services (inpatient) and emergency departments (EDs) of two hospitals within the University of California San Diego Health System. There were 330,729 total patients; 71,735 were inpatient and 258,994 were ED. Of these data, 20% were randomly sampled as a retrospective "testing set."

Validation cohort: The validation cohort contained temporal patient data. There were 65,898 total patients; 13,750 were inpatient and 52,148 were ED.

Prediction model: DETERIO was developed and validated on these data, using the AIDE criteria to generate a composite score. DETERIO's architecture builds upon previous work. DETERIO's prediction performance up to 12 hours before T0 was compared against Epic Deterioration Index (EDI).

Results: In the retrospective testing set, DETERIO's area under the receiver operating characteristic curve (AUC) was 0.797 and 0.874 for inpatient and ED subsets, respectively. In the temporal validation cohort, the corresponding AUC were 0.775 and 0.856, respectively. DETERIO outperformed EDI in the inpatient validation cohort (AUC, 0.775 vs. 0.721; p < 0.01) while maintaining superior sensitivity and a comparable rate of false alarms (sensitivity, 45.50% vs. 30.00%; positive predictive value, 20.50% vs. 16.11%).

Conclusions: DETERIO demonstrates promise in the viability of a state value-estimation approach for predicting adult physiologic deterioration. It may outperform EDI while offering additional clinical utility in triage and clinician interaction with prediction confidence and explanations. Additional studies are needed to assess generalizability and real-world clinical impact.

背景:以预测为基础的生理机能衰退策略为尽早采取临床干预措施、改善患者预后提供了可能。目前的策略存在局限性,因为它们对病情恶化的定义不一致,试图将一种动态和渐进的现象二分法,而且效果不佳:深度学习恶化预测模型(Deep Learning Enhanced Triage and Emergency Response for Inpatient Optimization [DETERIO])基于一致的恶化定义(成人住院病人失代偿事件 [AIDE] 标准),并将恶化作为一个状态 "价值估计 "问题来处理,该模型的性能能否优于市售的恶化评分?推导队列:推导队列包含从加利福尼亚大学圣地亚哥分校医疗系统内两家医院的住院部和急诊部收集的病人回顾性数据。患者总数为 330,729 人,其中 71,735 人为住院患者,258,994 人为急诊患者。其中 20% 的数据被随机抽样作为回顾性 "测试集"。共有 65,898 名患者,其中 13,750 人为住院患者,52,148 人为急诊患者:DETERIO 利用 AIDE 标准生成综合评分,并在这些数据上进行了开发和验证。DETERIO 的结构建立在以前工作的基础上。将 DETERIO 在 T0 前 12 小时内的预测性能与 Epic Deterioration Index (EDI) 进行了比较:结果:在回顾性测试集中,DETERIO 在住院病人和急诊室子集中的接收器操作特征曲线下面积(AUC)分别为 0.797 和 0.874。在时间验证队列中,相应的 AUC 分别为 0.775 和 0.856。DETERIO 在住院病人验证队列中的表现优于 EDI(AUC, 0.775 vs. 0.721; p < 0.01),同时保持了较高的灵敏度和相当的误报率(灵敏度,45.50% vs. 30.00%;阳性预测值,20.50% vs. 16.11%):结论:DETERIO 证明了预测成人生理恶化的状态值估计方法的可行性。它可能优于 EDI,同时在分诊和临床医生与预测信心和解释的互动中提供额外的临床实用性。还需要进行更多的研究来评估其通用性和实际临床影响。
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引用次数: 0
Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study. 成人长期重症患者质量改进工具的代码设计:改良德尔菲共识研究。
Q4 Medicine Pub Date : 2024-09-10 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001146
Laura Allum, Natalie Pattison, Bronwen Connolly, Chloe Apps, Katherine Cowan, Emily Flowers, Nicholas Hart, Louise Rose

Objectives: Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.

Design: Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.

Setting: Carried out in the United Kingdom.

Patients/subjects: Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.

Interventions: None.

Measurements and main results: We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted "critically important" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.

Conclusions: Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.

目的:越来越多的患者需要长期接受重症监护。然而,用于提高安全性和规范护理的现有质量改进(QI)工具并不是针对他们的特殊需求而设计的。这可能会导致错失护理机会,并造成更坏的结果。根据基于经验的编码设计流程,我们的目标是就最重要的可操作护理流程达成共识,以便将其纳入针对长期重症成人患者的 QI 工具:设计:从之前的系统性回顾以及对既往患者、其护理伙伴和临床医生的访谈中确定项目。进行了两轮在线改良德尔菲调查,要求参与者对每个项目进行评分,根据其对有效护理的重要性从 1 到 9 分进行评分;其中 1-3 分不重要,4-6 分重要但不关键,7-9 分非常重要,可纳入 QI 工具。然后由一名独立主持人主持召开最后的共识会议,进一步讨论并确定项目的优先次序:患者/研究对象:在英国进行:干预措施:无:测量和主要结果我们招募了 116 名参与者:在德尔菲第一轮中,我们招募了 63 名医护人员(54%)、45 名患者(39%)和 8 名亲属(7%),并在第二轮中保留了 91 人(78%)。在最初确定的 39 个项目中,有 32 个项目被超过 70% 的德尔菲参与者评为 "极其重要",可纳入 QI 工具。在与 15 名重症监护室临床医生、4 名既往患者和 1 名家属举行的共识会议上,这些项目被进一步排序,最终的 QI 工具包含 25 个项目,其中包括促进患者和家属参与决策、提供连续性护理以及结构化呼吸机断奶和康复:利用基于经验的编码设计和严格的建立共识方法,我们确定了针对长期危重症成人患者的 QI 工具的重要内容。了解工具的可接受性和最佳实施策略的工作正在进行中。
{"title":"Codesign of a Quality Improvement Tool for Adults With Prolonged Critical Illness: A Modified Delphi Consensus Study.","authors":"Laura Allum, Natalie Pattison, Bronwen Connolly, Chloe Apps, Katherine Cowan, Emily Flowers, Nicholas Hart, Louise Rose","doi":"10.1097/CCE.0000000000001146","DOIUrl":"10.1097/CCE.0000000000001146","url":null,"abstract":"<p><strong>Objectives: </strong>Increasing numbers of patients experience a prolonged stay in intensive care. Yet existing quality improvement (QI) tools used to improve safety and standardize care are not designed for their specific needs. This may result in missed opportunities for care and contribute to worse outcomes. Following an experience-based codesign process, our objective was to build consensus on the most important actionable processes of care for inclusion in a QI tool for adults with prolonged critical illness.</p><p><strong>Design: </strong>Items were identified from a previous systematic review and interviews with former patients, their care partners, and clinicians. Two rounds of an online modified Delphi survey were undertaken, and participants were asked to rate each item from 1 to 9 in terms of importance for effective care; where 1-3 was not important, 4-6 was important but not critical, and 7-9 was critically important for inclusion in the QI tool. A final consensus meeting was then moderated by an independent facilitator to further discuss and prioritize items.</p><p><strong>Setting: </strong>Carried out in the United Kingdom.</p><p><strong>Patients/subjects: </strong>Former patients who experienced a stay of over 7 days in intensive care, their family members and ICU staff.</p><p><strong>Interventions: </strong>None.</p><p><strong>Measurements and main results: </strong>We recruited 116 participants: 63 healthcare professionals (54%), 45 patients (39%), and eight relatives (7%), to Delphi round 1, and retained 91 (78%) in round 2. Of the 39 items initially identified, 32 were voted \"critically important\" for inclusion in the QI tool by more than 70% of Delphi participants. These were prioritized further in a consensus meeting with 15 ICU clinicians, four former patients and one family member, and the final QI tool contains 25 items, including promoting patient and family involvement in decisions, providing continuity of care, and structured ventilator weaning and rehabilitation.</p><p><strong>Conclusions: </strong>Using experience-based codesign and rigorous consensus-building methods we identified important content for a QI tool for adults with prolonged critical illness. Work is underway to understand tool acceptability and optimum implementation strategies.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11390055/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Effects of Post-Hospital Arrival Factors on Out-of-Hospital Cardiac Arrest Outcomes During the COVID-19 Pandemic. 在 COVID-19 大流行期间,到达医院后的因素对院外心脏骤停结果的影响。
Q4 Medicine Pub Date : 2024-09-10 eCollection Date: 2024-09-01 DOI: 10.1097/CCE.0000000000001154
Yasuyuki Kawai, Koji Yamamoto, Keita Miyazaki, Hideki Asai, Hidetada Fukushima

Importance: The relationship between post-hospital arrival factors and out-of-hospital cardiac arrest (OHCA) outcomes remains unclear.

Objectives: This study assessed the impact of post-hospital arrival factors on OHCA outcomes during the COVID-19 pandemic using a prediction model.

Design, setting, and participants: In this cohort study, data from the All-Japan Utstein Registry, a nationwide population-based database, between 2015 and 2021 were used. A total of 541,781 patients older than 18 years old who experienced OHCA of cardiac origin were included.

Main outcomes and measures: The primary exposure was trends in COVID-19 cases. The study compared the predicted proportion of favorable neurologic outcomes 1 month after resuscitation with the actual outcomes. Neurologic outcomes were categorized based on the Cerebral Performance Category score (1, good cerebral function; 2, moderate cerebral function).

Results: The prediction model, which had an area under the curve of 0.96, closely matched actual outcomes in 2019. However, a significant discrepancy emerged after the pandemic began in 2020, where outcomes continued to deteriorate as the virus spread, exacerbated by both pre- and post-hospital arrival factors.

Conclusions and relevance: Post-hospital arrival factors were as important as pre-hospital factors in adversely affecting the prognosis of patients following OHCA during the COVID-19 pandemic. The results suggest that the overall response of the healthcare system needs to be improved during infectious disease outbreaks to improve outcomes.

重要性:入院后因素与院外心脏骤停(OHCA)结果之间的关系仍不清楚:本研究使用预测模型评估了 COVID-19 大流行期间入院后因素对院外心脏骤停结果的影响:在这项队列研究中,使用了 2015 年至 2021 年期间来自全日本 Utstein 登记处(一个基于全国人口的数据库)的数据。共纳入了 541781 名 18 岁以上、经历过心脏源性 OHCA 的患者:主要暴露是 COVID-19 病例的趋势。该研究比较了复苏后 1 个月有利神经系统结果的预测比例与实际结果。神经系统结果根据脑功能分类得分进行分类(1,脑功能良好;2,脑功能中等):预测模型的曲线下面积为 0.96,与 2019 年的实际结果非常吻合。然而,在 2020 年大流行开始后出现了明显的差异,随着病毒的传播,结果继续恶化,而到达医院前后的因素都加剧了这种恶化:在 COVID-19 大流行期间,在对 OHCA 患者的预后产生不利影响方面,入院后因素与入院前因素同样重要。结果表明,在传染病爆发期间,医疗保健系统的整体应对措施需要改进,以改善预后。
{"title":"Effects of Post-Hospital Arrival Factors on Out-of-Hospital Cardiac Arrest Outcomes During the COVID-19 Pandemic.","authors":"Yasuyuki Kawai, Koji Yamamoto, Keita Miyazaki, Hideki Asai, Hidetada Fukushima","doi":"10.1097/CCE.0000000000001154","DOIUrl":"https://doi.org/10.1097/CCE.0000000000001154","url":null,"abstract":"<p><strong>Importance: </strong>The relationship between post-hospital arrival factors and out-of-hospital cardiac arrest (OHCA) outcomes remains unclear.</p><p><strong>Objectives: </strong>This study assessed the impact of post-hospital arrival factors on OHCA outcomes during the COVID-19 pandemic using a prediction model.</p><p><strong>Design, setting, and participants: </strong>In this cohort study, data from the All-Japan Utstein Registry, a nationwide population-based database, between 2015 and 2021 were used. A total of 541,781 patients older than 18 years old who experienced OHCA of cardiac origin were included.</p><p><strong>Main outcomes and measures: </strong>The primary exposure was trends in COVID-19 cases. The study compared the predicted proportion of favorable neurologic outcomes 1 month after resuscitation with the actual outcomes. Neurologic outcomes were categorized based on the Cerebral Performance Category score (1, good cerebral function; 2, moderate cerebral function).</p><p><strong>Results: </strong>The prediction model, which had an area under the curve of 0.96, closely matched actual outcomes in 2019. However, a significant discrepancy emerged after the pandemic began in 2020, where outcomes continued to deteriorate as the virus spread, exacerbated by both pre- and post-hospital arrival factors.</p><p><strong>Conclusions and relevance: </strong>Post-hospital arrival factors were as important as pre-hospital factors in adversely affecting the prognosis of patients following OHCA during the COVID-19 pandemic. The results suggest that the overall response of the healthcare system needs to be improved during infectious disease outbreaks to improve outcomes.</p>","PeriodicalId":93957,"journal":{"name":"Critical care explorations","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11390052/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142303492","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
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Critical care explorations
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