Mortality

The prognostic implication of the SOFA score on acutely admitted medical patients

Original Articles, Volume 17, Issue 4, Pages 173 – 240 (2018)

Objectives: To investigate the prognostic implication of the SOFA score on all acutely admitted medical patients, to see how well it could predict 30-day mortality and ICU- admission.

Main outcome measures: Discriminatory power was calculated as AUROC. Calibration was assessed using Hosmer-Lemeshow goodness-of-fit.

Results: AUROC for 30-day mortality was 0.68, (95% CI, 0.64 to 0.71) and ICU admission 0.71, (95% CI, 0.66 to 0.76). Goodness of fit for 30-day mortality and ICU admission was acceptable.

Conclusions: The SOFA score showed average ability to predict 30-day mortality and ICU admission with acceptable calibration. When substituting GCS with AVPU the performance of the SOFA score was unacceptable.

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Direct and delayed admissions to ICU in older medical patients

Original Articles, Volume 17, Issue 2, Pages 57 – 116 (2018)

Abstract

The aims of this retrospective cohort study were to retrieve characteristics and outcomes of older (65+) medical patients who are directly admitted to ICU from the ED and to compare these with those admitted to ICU from a ward.

Of 1396 patients, 21 (1.5%) were directly admitted to ICU and 54 (3.9%) after a delay. Blood pressure was lower and respiratory rate higher in the direct than in the delayed group. The direct group had lower mortality (28-day: 19.0 vs.

38.9%, p=0.14; 1-year: 42.9 vs. 66.7%; p=0.06), shorter length-of-stay and returned more frequently to independent living than the delayed group.

Only a fraction of older patients are admitted to ICU; directly admitted patients tend to have better outcomes.

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Acute Medical Ward for better care coordination of patients admitted with infection – evidence from a tertiary hospital in Singapore

Research Audit and Clinical Practice, Volume 16, Issue 4, Pages 153 – 212 (2017)

Abstract

Coordination and consolidation of care provided in acute care hospitals need reconfiguration and reorganization to meet the demand of large number of acute admissions. We report on the effectiveness of an Acute Medical Ward AMW (AMW) receiving cases that were suspected to have infection related diagnosis on admission by Emergency Department (ED), addressing this in a large tertiary hospital in South East Asia. Mean Length of Stay (LOS) was compared using Gamma Generalized Linear Models with Log-link while odds of readmissions and mortality were compared using logistic regression models. The LOS (mean: 5.8 days, SD: 9.1 days) of all patients admitted to AMW was similar to discharge diagnosis-matched general ward (GW) patients admitted before AMW implementation, readmission rates were lower (15-day: 5.3%, 30-day: 8.1%). Bivariate and multivariate models revealed that mean LOS after AMW implementation was not significantly different from before AMW implementation (Ratio: 0.99, p=0.473). Our AMW had reduced readmission rates for patients with infection but has not made an overall impact on the LOS and readmission rates for the epartment as a whole.

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Long-term health related quality of life in patients with sepsis after intensive care stay: A systematic review

Research Audit and Clinical Practice, Volume 16, Issue 4, Pages 153 – 212 (2017)

Abstract

Sepsis is a major health care issue and sepsis survivors are often confronted with long-term complications after admission to the intensive care unit (ICU) which may negatively influence their health related quality of life (HRQOL). This study aimed to systematically evaluate the outcome in terms of HRQOL in patients with sepsis after ICU discharge.

A literature search was conducted in the bibliographic databases PubMed, EMBASE, and CINAHL, including reference lists of published guidelines, reviews and associated articles.

Sixteen studies were included, thirteen (81.3%) reported that sepsis survivors suffer from impaired HRQOL in physical and mental domains which persist from months to years after a sepsis episode.

More focus on improving long-term outcomes for patients surviving sepsis and the ICU is needed.

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Characteristics and outcome of acute medical admissions with hyponatremia: even mild hyponatremia is associated with higher mortality

Research Audit and Clinical Practice, Volume 16, Issue 4, Pages 153 – 212 (2017)

Abstract

Hyponatremia is a common finding in hospitalized patients. In this retrospective cohort study we assessed the characteristics and outcome of acute medical admissions with hyponatremia. Compared to the normal sodium group, those with hyponatremia were significantly older and the Charlson Comorbidity Index (CCI) was higher. The number of admissions to MCU/ICU between both groups was similar, but hyponatremic patients had a longer length of stay and both 28-day and one-year mortality were higher, even in patients with mild hyponatremia. Hyponatremia was independently associated with mortality after adjustment for age, CCI and polypharmacy, as was found in the subgroup with mild hyponatremia.

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Profiling the medical admissions of the homeless

Research Audit and Clinical Practice, Volume 11, Issue 4, Pages 193 - 264 (2012)

Abstract

Aim: to describe the characteristics and outcomes of homeless people admitted to our Internal Medicine service in St. James’s Hospital, Dublin (Ireland), between 2002 and 2011.

Methods: we interrogated an anonymized in-patient database.

Results: there were 1,460 homeless admissions (623 unique patients; 39% admitted more than once). Most patients were young, male, and had low comorbidity levels. Thirty-seven percent of the admissions were alcohol-related and 27% substance abuse-related. Thirteen percent had an active psychiatric illness. Their in-patient mortality rate was 5%. Seventy two percent were discharged without the residential arrangement being explicitly documented, 15% self-discharged or absconded, and 8% were discharged to a residential facility.

Conclusion: results are novel in our context and will be relevant for local policy and practice.

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The increased mortality associated with a weekend emergency admission is due to increased illness severity and altered case-mix

Research Audit and Clinical Practice, Volume 10, Issue 4, Pages 173 - 232 (2011)

Abstract

Background: A weekend emergency medical admission has been associated with a higher mortality. We have examined all weekend admissions to St James’ Hospital, Dublin between 2002 and 2009.

Methods: We divided admissions by weekday or weekend (Saturday or Sunday) presentation. We utilised a multivariate logistic model, to determine whether a weekend admission was independently predictive of 30 day outcome.

Results: There were 49337 episodes recorded in 25883 patients; 30-day inhospital mortality at the weekend (9.9% vs. 9.0%) had an unadjusted Odds Ratio of 1.11 (95% CI 0.99, 1.23: p=0.057). In the full risk (unlike the univariate) model, a weekend admission was not independently predictive (OR 1.05; 95% CI: 0.88, 1.24). The case-mix for a weekend admission differed; with more neurological diagnoses (22.8% vs 20.4% : p = 0.001) and less gastrointestinal disease (18.3% vs 21.1% : p = 0.001). A biochemistry only illness severity score predicted a higher mortality for weekend admissions.

Conclusion: Patients admitted at the weekend had an approximate 11% increased 30-day in-hospital mortality, compared with a weekday admission. However, admission at the weekend was not independently predictive in a risk model that included Illness Severity (age and biochemical markers) and co-morbidity. Sicker patients, with a worse outcome, are admitted over the weekend; these considerations should inform the allocation of healthcare resources.

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Does admission via an Acute Medical Unit influence hospital mortality? 12 years’ experience in a large Dublin Hospital

Research Audit and Clinical Practice, Volume 13, Issue 4, Pages 149 - 194 (2014)

Abstract

Background: Following an emergency medical admission, patients may be admitted an acute medical assessment unit (AMAU) or directly into a ward. An AMAU provides a structured environment for their initial assessment and treatment.

Methods: All emergency admissions (66,933 episodes in 36,271 patients) to an Irish hospital over an 12-year period (2002-2013) were studied with 30-day in-hospital mortality as the outcome measure. Univariate Odds Ratios, by initial patient allocation, and the fully adjusted Odds Ratios were calculated, using a validated logistic regression model.

Results: Patients, by design, were intended to be admitted initially to the AMAU (<= 5 day stay). Capacity constraints dictated that only 39.8% of patients were so admitted; the remainder bypassed the AMAU to a ward (60.2%). All patients remained under the care of the admitting consultant/team. We computed the risk profile for each group, using a multiple variable validated model of 30-day in-hospital mortality; the model indicated the same risk profile between these groups. The univariate OR of an in-hospital death by day 30 for a patient initially allocated to the AMAU, compared with an initial ward allocation was 0.76 (95% CI: 0.71, 0.82- p<0.001). The fully adjusted risk for patients was 0.67 (95% CI: 0.62, 0.73- p<0.001). Conclusion: Patients, with equivalent mortality risk, allocated initially to AMAU or a more traditional ward, appeared to have substantially different outcomes.

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A Risk Index for Geriatric Acute Medical Admissions (RIGAMA)

Research Audit and Clinical Practice, Volume 13, Issue 1, Pages 1 - 52 (2014)

Abstract

Aim: to create and validate a Risk Index for Geriatric Acute Medical Admissions (RIGAMA) for those aged ≥ 65, based on accumulation of deficits.

Methods: we retrospectively validated a 30-item RIGAMA against inpatient mortality, length of stay (LOS), discharge to long-term care (LTC) and 30-day readmission, adjusted for age.

Results: ≥ 1 RIGAMA deficit was superior to age in predicting mortality and prolonged LOS, with a clear incremental effect. The latter was true for ≥3 deficits in predicting 30-day readmission. Three to 5 deficits predicted discharge to LTC better than age.

Conclusion: RIGAMA is easy to collect by the admitting junior doctor and may help trigger early senior support and inform the appropriate use of hospital resources by older patients.

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Measuring Hospital Mortality

Research Audit and Clinical Practice, Volume 12, Issue 3, Pages 125 - 184 (2013)

Abstract

The hospital standardised mortality ratio (HSMR) and the summary hospital mortality index (SHMI) are both in current use in the UK as measures of the performance of acute hospitals. Characteristics of both the acute hospital itself and of its local healthcare environment influence these indices. Whilst many hope that measures of mortality can be used as a surrogate for healthcare quality, this is an evolving area.

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