ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The use of clinical outcomes data to evaluate how well intensive care units (ICUs) are performing, especially data provided by severity scoring systems, has received increasing attention as both a method to help consumers choose between available providers and a method to improve delivery of health care. Although the use of outcomes for these purposes offers important insights, and has advantages over other possible approaches, it is not necessarily the most appropriate method to accomplish either purpose. This presentation examines the use of outcomes for the purposes of ICU evaluation and improvement. Theoretical and practical strengths and weaknesses of an outcomes-centered approach to ICU evaluation are discussed. A more comprehensive conceptual framework, which includes the use of performance variables to evaluate and improve ICU performance, is presented.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Almost 10 years ago, the third generation of outcome prediction models, Acute Physiology and Chronic Health Evaluation (APACHE) III, Simplified Acute Physiology Score (SAPS) II, and Mortality Prediction Model (MPM) II were published. These systems proved better than their predecessors, and are considered the state of the art in this field.Their role was challenged recently by the reappearance of organ dysfunction/failure scores, which are viewed today as having am important role in patient description. Although we do not have a definitive answer about their role, data seem to indicate that they must be used to complement classical scores but not to replace them. In addition, debate continues about the advantages and disadvantages of disease-specific versus general scores as triage instruments, especially in the pre-intensive care unit setting.Although there have been 20 years of research in the fields of severity stratification and outcome prediction in intensive care, several development and application problems remain. It is time for researchers to combine their efforts to address them.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The traditional approach to the severity of illness systems in the critically ill has relied on clinical variables. These systems, although increasingly refined and improved, continue to have difficulties. After the investigation of the pathogenesis of diseases in the critically ill it is becoming more apparent that patient response to disease and eventual outcome is strongly influenced by genetic predisposition. Although this ability is in the early stages of development, it may be possible in the future not only to predict patient outcome but also to preempt clinical management through knowledge of a patient’s genetic susceptibility.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The goal of devising a severity of illness scoring system that reflects long-term outcomes in survivors of critical illness is a laudable one. However, several obstacles must be overcome before it can be achieved. We need to determine which morbid outcomes are most informative in critically ill populations, how best to measure these outcomes, and how they influence the subsequent pattern and cost of health care use. This review suggests a reevaluation of our approach to outcome studies in survivors of critical illness. We need to abandon the traditional, compartmentalized view of critical illness as an intensive care unit-centered phenomenon. Instead, we need to adopt the concept of a continuum from premorbid disease to critical illness and ultimately to a debilitated patient in need of physical and psychological rehabilitation. This longitudinal model for outcomes research in critical care can be achieved only through rigorous ambulatory follow-up of survivors of critical illness. This detailed follow-up data may facilitate the development of predictors that might prove valuable in future scoring system models.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

The goal of intensive care is to provide the highest quality care to achieve the best outcomes for patients. Although the random allocation of patients to receive intensive care as part of a randomized controlled trial might in theory be the best method to evaluate its effectiveness, the practical application of such a study design is deemed unethical. The alternative in such a situation is to use observational methods in which the outcome of care patients receive as part of their “natural” treatment is studied. Before drawing inferences from the outcomes of treatment for such groups of patients, the characteristics of the patients admitted to intensive care must be taken into account. The purpose of scoring systems in intensive care, as for many other areas of health care, is to take into account the characteristics of patients that could affect their risk of a particular outcome, irrespective of the effect of the care they receive. Clearly, accounting for such factors, which are outside the control of those providing the care, is essential before any comparison of the outcome of care is possible. For each scoring system, the association between the independent variables (patient characteristics) and the dependent variable (death before discharge from hospital after intensive care) is described in the form of a mathematical model, known as a multiple logistic regression model. To assess any scoring system and model, four steps must be undertaken. First, the goodness-of-fit of the model should be assessed on the development dataset. Second, the goodness-of-fit of the model should be assessed on a subset of the dataset different from the subset used to develop the model. Third, the goodness-of-fit of the model should be assessed on an entirely new dataset. Fourth, the given model should be compared with other existing models on the same dataset. This article briefly describes the concept of scoring systems and their roles, and outlines the requirements for assessment in terms of model validation and goodness-of-fit. It concludes with the outstanding methodological issues in this area.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Severity of illness scores in intensive care may be used to assess intensive care unit (ICU) performance and to support clinical decision-making. The derivation of a standardized mortality ratio, based on hospital mortality, provides one indicator of ICU performance, but must be interpreted with care. In particular, it must be interpreted in the context of the health care system within which it is being employed. Derivation of complementary predictions, such as length of stay, offers the potential to better understand cost effectiveness, but at the present time their value is uncertain and their availability is restricted. Sequential prediction of mortality risk, derived from data collected beyond the first 24 hours after admission to the intensive care unit, appears to have a limited impact on clinical decision-making. Improvements in quality of care, derived from standardized mortality ratios, will require an integrated approach encompassing both audit and research techniques.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Public access defibrillation is a sound theoretical concept to improve the time of defibrillation for out-of-the hospital cardiac arrest victims. New smaller, lighter, and less expensive automatic external defibrillators have set the stage for wider public involvement in the definitive treatment of cardiac arrest. Increasing experience with these devices in the public sector supports their effectiveness and utility. Successful experiences with automatic external defibrillator use have been reported by firefighters, police officers, airline personnel, security guards, and employees of the Chicago Airport Authority. The necessary training needed by laypersons to successfully save a life with these devices may be less than first anticipated. A long-awaited randomized, controlled trial of their use by nonmedical first responders is now under way.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID

摘要:

Several studies in laboratory animals and in human victims of cardiac arrest have showed that ventricular fibrillation median frequency, dominant frequency, and voltage amplitude can be used as noninvasive tools to monitor efficacy of ongoing cardiopulmonary resuscitation efforts and guide countershock therapy. Due to the lower absolute values of fibrillation frequency in patients in comparison with animals, filters that effectively eliminate interference to closed-chest cardiopulmonary resuscitation deteriorate the predictive power of fast Fourier transform analysis. Further large prospective clinical trials and alternative methods of electrocardiogram spectral analysis for improved prediction of countershock success are warranted before this tool can be widely employed for the management of cardiac arrest.

ISSN:1070-5295    

出版商:OVID    

年代:2000

数据来源: OVID