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Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database
Peter A Hampshire, Catherine A Welch, Lawrence A McCrossan, Katharine Francis, David A Harrison
Critical Care , 2009, DOI: 10.1186/cc8016
Abstract: A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival).There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO2:FiO2, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC model had the best discrimination of the three scores analysed, as assessed by the area under the receiver operating characteristic curve of 0.78, but all scores were poorly calibrated. APACHE II had the highest accuracy at predicting hospital mortality, with a standardised mortality ratio of 1.01. SAPS II and the ICNARC score both underestimated hospital mortality.Increased hospital mortality is associated with the length of hospital stay prior to ICU admission and with severe sepsis, suggesting that, if appropriate, such patients should be treated aggressively with early ICU admission. A low haematocrit was associated with higher mortality and this relationship require
Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database
Jonathan A Hyam, Catherine A Welch, David A Harrison, David K Menon
Critical Care , 2006, DOI: 10.1186/cc5066
Abstract: A secondary analysis was conducted of data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme, a high quality clinical database, of 374,594 admissions to 171 adult critical care units across England, Wales and Northern Ireland from 1995 to 2005. The discrimination and calibration of five risk prediction models, SAPS II, MPM II, APACHE II and III and the ICNARC model plus raw Glasgow Coma Score (GCS) were compared.There were 11,021 admissions following traumatic brain injury identified (3% of all database admissions). Mortality in ICU was 23.5% and in-hospital was 33.5%. Median ICU and hospital lengths of stay were 3.2 and 24 days, respectively, for survivors and 1.6 and 3 days, respectively, for non-survivors. The ICNARC model, SAPS II and MPM II discriminated best between survivors and non-survivors and were better calibrated than raw GCS, APACHE II and III in 5,393 patients eligible for all models.Traumatic brain injury requiring intensive care has a high mortality rate. Non-survivors have a short length of ICU and hospital stay. APACHE II and III have poorer calibration and discrimination than SAPS II, MPM II and the ICNARC model in traumatic brain injury; however, no model had perfect calibration.Traumatic brain injury is a common and potentially fatal condition. In the United States, 50,000 people die annually after head injury and 80,000 to 90,000 suffer long-term disability [1]. Head injury accounted for more than 120,000 admissions in England during 2000 to 2001, utilising over 320,000 bed days [2]. Ninety percent of head injuries seen in UK Accident and Emergency departments are mild, defined by the Royal Society of Rehabilitation Physicians as Glasgow Coma Score (GCS) 13 to 15 [3], 5% are moderate (GCS 9 to 12) and 5% are severe (GCS 3 to 8) [4].Patients with severe head injury, in whom treatment is not deemed futile, are cared for in general or specialist intensive care units (ICUs). This is for a variety of reasons, mo
Case mix, outcome, and activity for admissions to UK critical care units with severe acute pancreatitis: a secondary analysis of the ICNARC Case Mix Programme Database
David A Harrison, Giovanna D'Amico, Mervyn Singer
Critical Care , 2007, DOI: 10.1186/cc5682
Abstract: We conducted a secondary analysis of the ICNARC (Intensive Care National Audit & Research Centre) Case Mix Programme Database of 219,468 admissions to 159 adult, general critical care units in England, Wales, and Northern Ireland for the period of 1995 to 2003 to identify admissions with SAP. The ability of the modified Glasgow criteria to discriminate hospital survivors from non-survivors was compared to that of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and a number of individual physiological parameters.A total of 2,677 admissions with SAP were identified (1.2% of all admissions). Mortality for these admissions was 31% in the critical care unit and 42% in hospital. The median length of stay in the critical care unit was 3.8 days and was similar for survivors and non-survivors. Increasing numbers of modified Glasgow criteria were associated with increasing hospital mortality, but better discrimination was provided by the APACHE II score and by several physiological parameters.SAP requiring critical care is associated with high mortality and long length of stay. The modified Glasgow criteria represent a simple measure of severity but were not designed to predict hospital mortality. It may be possible to develop a specific model for risk prediction in patients with SAP requiring critical care.Acute pancreatitis affects approximately 10 to 20 per million of the UK population per year [1] and approximately 25% of these require some form of critical care [2]. Severe acute pancreatitis (SAP) requiring admission to a critical care unit is associated with high mortality [1,3]. Management of SAP on the critical care unit is resource-intensive [4], and admissions have long stays in critical care [5]. However, data on outcomes and activity are sparse and predominantly from single specialist centres with limited numbers of patients.A number of severity scoring approaches exist for acute pancreatitis, the most commonly used being the criteria of Ranso
Characteristics and outcome for admissions to adult, general critical care units with acute severe asthma: a secondary analysis of the ICNARC Case Mix Programme Database
Dheeraj Gupta, Brian Keogh, Kian Chung, Jon G Ayres, David A Harrison, Caroline Goldfrad, Anthony R Brady, Kathy Rowan
Critical Care , 2004, DOI: 10.1186/cc2835
Abstract: We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995–2001.Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score.ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.Asthma is a common and chronic disorder with very good outcome in the great majority of patients with appropriate maintenance therapy, of which inhaled corticosteroids and long-acting β-agonists are the mainstay. The natural history of asthma is punctuated by acute exacerbations, most of which respond to conventional treatment using bronchodilators, steroids and oxygen [1]. Deterioration or failure to respond to these
Case mix and outcomes for admissions to UK adult, general critical care units with chronic obstructive pulmonary disease: a secondary analysis of the ICNARC Case Mix Programme Database
Martin J Wildman, David A Harrison, Anthony R Brady, Kathy Rowan
Critical Care , 2005, DOI: 10.1186/cc3719
Abstract: We conducted a secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database, of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland for the period from 1995 to 2001.Nonsurgical admissions with COPD accounted for 3752 admissions (2.9% of all admissions). Patients were acidotic (median pH 7.26, interquartile range [IQR] 7.18–7.33), hypercapnic (median arterial CO2 tension 8.7, IQR 6.9–10.7) and hypoxic (median arterial O2 tension/fractional inspired oxygen gradient 22.9, IQR 17.2–29.6). Overall, 2775 (73.9%) were definitely intubated and 278 (7.4%) were probably intubated in the first 24 hours in the ICU. The median (IQR) ICU length of stay was 4.0 (1.6–9.4) days and the hospital length of stay was 16 (9–29) days. a total of 827 patients (23.1%) died in the admitting ICU and 1322 (38.3%) died during hospital admission. Age, presence of severe respiratory disease, length of stay in hospital before critical care admission, cardiopulmonary resuscitation within 24 hours before admission, intubation status in first 24 hours in critical care, pH, arterial oxygen tension/fractional inspired oxygen gradient, albumin, cardiovascular organ failure, neurological organ failure and renal organ failure all had independent associations with hospital mortality. Respiratory organ failure had a significant independent association with decreased hospital mortality.Nonsurgical patients with COPD represent an important group of patients admitted to UK ICUs. The presence of single organ respiratory failure in the first 24 hours in critical care identifies patients with a 70% chance of surviving to leave hospital.The prevalence of chronic obstructive pulmonary disease (COPD) in the UK has been estimated to be 1%, increasing to 5% in men aged 65–74 years and 10% in men older than 75 years [1]. COPD accounted for more than 100,000 hospital admissions in England in 2000/2001 and is the fifth most common cause
Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database
David A Harrison, Anthony R Brady, Kathy Rowan
Critical Care , 2005, DOI: 10.1186/cc3745
Abstract: The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.This artcle was previously published in this journal as: Critical Care 8:R99-R111, see: http://ccforum.com/content/8/2/R99 webciteHigh-quality clinical databases are of value in comparative audit, clinical practice, in managing services and in evaluating health technologies [1,2]. The use of inappropriate, unrepresentative or poor-quality data can, however, lead to inaccurate conclusions. The Directory of Clinical Databases (DoCDat) was established to inform researchers and clinicians of what clinical databases exist and to provide an inde
Case mix, outcome and length of stay for admissions to adult, general critical care units in England, Wales and Northern Ireland: the Intensive Care National Audit & Research Centre Case Mix Programme Database
David A Harrison, Anthony R Brady, Kathy Rowan
Critical Care , 2004, DOI: 10.1186/cc2834
Abstract: The CMP collects data on consecutive admissions to adult, general critical care units in England, Wales and Northern Ireland. Explicit steps are taken to ensure the accuracy of the data, including use of a dataset specification, of initial and refresher training courses, and of local and central validation of submitted data for incomplete, illogical and inconsistent values. Criteria for evaluating clinical databases developed by the Directory of Clinical Databases were applied to the CMPD. The case mix, outcome and activity for all admissions were briefly summarised.The mean quality level achieved by the CMPD for the 10 Directory of Clinical Databases criteria was 3.4 (on a scale of 1 = worst to 4 = best). The CMPD contained validated data on 129,647 admissions to 128 units. The median age was 63 years, and 59% were male. The mean Acute Physiology and Chronic Health Evaluation II score was 16.5. Mortality was 20.3% in the CMP unit and was 30.8% at ultimate discharge from hospital. Nonsurvivors stayed longer in intensive care than did survivors (median 2.0 days versus 1.7 days in the CMP unit) but had a shorter total hospital length of stay (9 days versus 16 days). Results for the CMPD were comparable with results from other published reports of UK critical care admissions.The CMP uses rigorous methods to ensure data are complete, valid and reliable. The CMP scores well against published criteria for high-quality clinical databases.High-quality clinical databases are of value in comparative audit, clinical practice, in managing services and in evaluating health technologies [1,2]. The use of inappropriate, unrepresentative or poor-quality data can, however, lead to inaccurate conclusions. The Directory of Clinical Databases (DoCDat) was established to inform researchers and clinicians of what clinical databases exist and to provide an independent assessment of their scope and quality [3]. This information is provided through a website [4]. An expert group was convene
Characteristics and outcome for admissions to adult, general critical care units with acute severe asthma: a secondary analysis of the ICNARC Case Mix Programme Database
Dheeraj Gupta, Brian Keogh, Kian Chung, Jon G Ayres, David A Harrison, Caroline Goldfrad, Anthony R Brady, Kathy Rowan
Critical Care , 2005, DOI: 10.1186/cc3746
Abstract: We conducted a secondary analysis of data from a high-quality clinical database (the Intensive Care National Audit and Research Centre [ICNARC] Case Mix Programme Database) of 129,647 admissions to 128 adult, general critical care units across England, Wales and Northern Ireland over the period 1995–2001.Asthma accounted for 2152 (1.7%) admissions, and in 57% mechanical ventilation was employed during the first 24 hours in the ICU. A total of 147 (7.1%) patients died in intensive care and 199 (9.8%) died before discharge from hospital. The mean age was 43.6 years, and the ratio of women to men was 2:1. Median length of stay was 1.5 days in the ICU and 8 days in hospital. Older age, female sex, having received cardiopulmonary resuscitation (CPR) within 24 hours before admission, having suffered a neurological insult during the first 24 hours in the ICU, higher heart rate, and hypercapnia were associated with greater risk for in-hospital death after adjusting for Acute Physiology and Chronic Health Evaluation II score. CPR before admission, neurological insult, hypoxaemia and hypercapnia were associated with receipt of mechanical ventilation after adjusting for Acute Physiology and Chronic Health Evaluation II score.ICU admission for asthma is relatively uncommon but remains associated with appreciable in-hospital mortality. The greatest determinant of poor hospital survival in asthma patients was receipt of CPR within 24 hours before admission to ICU. Clinical management of these patients should be directed at preventing cardiac arrest before admission.This artcle was previously published in this journal as: Critical Care 8:R112-R121, see: http://ccforum.com/content/8/2/R112 webciteAsthma is a common and chronic disorder with very good outcome in the great majority of patients with appropriate maintenance therapy, of which inhaled corticosteroids and long-acting β-agonists are the mainstay. The natural history of asthma is punctuated by acute exacerbations, most of w
Case mix, outcome and activity for patients admitted to intensive care units requiring chronic renal dialysis: a secondary analysis of the ICNARC Case Mix Programme Database
Colin A Hutchison, Alex V Crowe, Paul E Stevens, David A Harrison, Graham W Lipkin
Critical Care , 2007, DOI: 10.1186/cc5785
Abstract: This was a secondary analysis of a high-quality clinical database, namely the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, which includes 276,731 admissions to 170 adult ICUs across England, Wales and Northern Ireland from 1995 to 2004.During the eight year study period, 1.3% (n = 3,420) of all patients admitted to ICU were receiving chronic renal dialysis before ICU admission. This represents an estimated ICU utilization of six admissions (32 bed-days) per 100 dialysis patient-years. The ESRF group was younger (mean age 57.3 years versus 59.5 years) and more likely to be male (60.2% versus 57.9%) than those without ESRF. Acute Physiology and Chronic Health Evaluation II score and Acute Physiology Score revealed greater severity of illness on admission in patients with ESRF (mean 24.7 versus 16.6 and 17.2 versus 12.6, respectively). Length of stay in ICU was comparable between groups (median 1.9 days versus 1.8 days) and ICU mortality was only slightly elevated in the ESRF group (26.3% versus 20.8%). However, the ESRF group had protracted overall hospital stay (median 25 days versus 17 days), and increased hospital mortality (45.3% versus 31.2%) and ICU readmission (9.0% vs. 4.7%). Multiple logistic regression analysis adjusted for case mix identified the increased hospital mortality to be associated with increasing age, emergency surgery and nonsurgical cases, cardiopulmonary resuscitation before ICU admission and extremes of physiological norms. The adjusted odds ratio for ultimate hospital mortality associated with chronic renal dialysis was 1.24 (95% confidence interval 1.13 to 1.37).Patients with ESRF admitted to UK ICUs are more likely to be male and younger, with a medical cause of admission, and to have greater severity of illness than the non-ESRF population. Outcomes on the ICU were comparable between the two groups, but those patients with ESRF had greater readmission rates, prolonged post-ICU hospital stay and inc
Community-acquired pneumonia on the intensive care unit: secondary analysis of 17,869 cases in the ICNARC Case Mix Programme Database
Mark Woodhead, Catherine A Welch, David A Harrison, Geoff Bellingan, Jon G Ayres
Critical Care , 2006, DOI: 10.1186/cc4927
Abstract: We conducted a secondary analysis of a high quality clinical database, the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, of 301,871 admissions to 172 adult ICUs across England, Wales and Northern Ireland, 1995 to 2004. Cases of CAP were identified from pneumonia admissions excluding nosocomial pneumonias and the immuno-compromised. It was not possible to review data from the time of hospital admission; therefore, some patients who developed hospital-acquired/nosocomial pneumonia may have been included.We identified 17,869 cases of CAP (5.9% of all ICU admissions). There was a 128% increase in admissions for CAP from 12.8 per unit to 29.2 per unit during the study period compared to only a 24% rise in total ICU admissions (p < 0.001). Eighty-five percent of admissions were from within the same hospital. Fifty-nine percent of cases were admitted to the ICU <2 days, 21.5% between 2 and 7 days, and 19.5% >7 days after hospital admission. Between 1995 and 1999 and 2000 and 2004 there was a rise in admissions from accident and emergency (14.8% to 16.8%; p < 0.001) and high dependency units (6.9% to 11.9%; p < 0.001) within the same hospital, those aged >74 (18.5 to 26.1%; p < 0.001), and mean APACHE II score (6.83 to 6.91; p < 0.001). There was a fall in past history of severe respiratory problems (8.7% to 6.4%; p < 0.001), renal replacement therapy (1.6% to 1.2%; p < 0.01), steroid treatment (3.4% to 2.8%; p < 0.05), sedation/paralysis (50.2% to 40.4%; p < 0.001), cardiopulmonary resuscitation prior to admission (7.5% to 5.5%; p < 0.001), and septic shock (7.3% to 6.6%; p < 0.001). ICU mortality was 34.9% and ultimate hospital mortality 49.4%. Mortality was 46.3% in those admitted to the ICU within 2 days of hospital admission rising to 50.4% in those admitted at 2 to 7 days and 57.6% in those admitted after 7 days following hospital admission.CAP makes up a small, but important and rising, proportion of adult ICU admissions. Survi
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