mHOMR: a prospective observational study of an automated mortality prediction model to identify patients with unmet palliative needs

2021 ◽  
pp. bmjspcare-2020-002870
Author(s):  
Pete Wegier ◽  
Allison Kurahashi ◽  
Stephanie Saunders ◽  
Bhadra Lokuge ◽  
Leah Steinberg ◽  
...  
Keyword(s):  
Observational Study ◽  
Mortality Risk ◽  
Prospective Observational Study ◽  
Symptom Assessment ◽  
Mortality Prediction ◽  
Healthcare Facilities ◽  
Palliative Approach ◽  
General Internal ◽  
Hospitalised Patients ◽  
Edmonton Symptom Assessment Scale

ObjectiveIdentification of patients with shortened life expectancy is a major obstacle to delivering palliative/end-of-life care. We previously developed the modified Hospitalised-patient One-year Mortality Risk (mHOMR) model for the automated identification of patients with an elevated 1-year mortality risk. Our goal was to investigate whether patients identified by mHOMR at high risk for mortality in the next year also have unmet palliative needs.MethodWe conducted a prospective observational study at two quaternary healthcare facilities in Toronto, Canada, with patients admitted to general internal medicine service and identified by mHOMR to have an expected 1-year mortality risk of 10% or more. We measured patients’ unmet palliative needs—a severe uncontrolled symptom on the Edmonton Symptom Assessment Scale or readiness to engage in advance care planning (ACP) based on Sudore’s ACP Engagement Survey.ResultsOf 518 patients identified by mHOMR, 403 (78%) patients consented to participate; 87% of those had either a severe uncontrolled symptom or readiness to engage in ACP, and 44% had both. Patients represented frailty (38%), cancer (28%) and organ failure (28%) trajectories were admitted for a median of 6 days, and 94% survived to discharge.ConclusionsA large majority of hospitalised patients identified by mHOMR have unmet palliative needs, regardless of disease, and are identified early enough in their disease course that they may benefit from a palliative approach to their care. Adoption of such a model could improve the timely introduction of a palliative approach for patients, especially those with non-cancer illness.

scholarly journals The performance of the EMS triage (RETTS-p) and the agreement between the field assessment and final hospital diagnosis: a prospective observational study among children < 16 years

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Carl Magnusson ◽  
Johan Herlitz ◽  
Thomas Karlsson ◽  
Maria Jiménez-Herrera ◽  
Christer Axelsson
Keyword(s):  
Observational Study ◽  
Prospective Observational Study ◽  
Hospital Setting ◽  
Risk Of Death ◽  
Computerised Decision Support System ◽  
Field Assessment ◽  
Hospitalised Patients ◽  
Increased Risk ◽  
Life Threatening ◽  
Triage Level

Abstract Background The rapid triage and treatment system for paediatrics (RETTS-p) has been used by the emergency medical services (EMS) in the west of Sweden since 2014. The performance of the RETTS-p in the pre-hospital setting and the agreement between the EMS nurse’s field assessment and the hospital diagnosis is unknown. The aim of this study was to evaluate the performance of the RETTS-p in the EMS and the agreement between the EMS field assessment and the hospital diagnosis. Methods A prospective observational study was conducted among 454 patients < 16 years of age who were assessed and transported to the PED. Two instruments were used for comparison: 1) Classification of an emergent patient according to predefined criteria as compared to the RETTS-p and 2) Agreement between the EMS nurse’s field assessment and the hospital diagnosis. Results Among all children, 11% were identified as having vital signs associated with an increased risk of death and 7% were diagnosed in hospital with a potentially life-threatening condition. Of the children triaged with RETTS-p (85.9%), 149 of 390 children (38.2%) were triaged to RETTS-p red or orange (life-threatening, potentially life-threatening), of which 40 (26.8%) children were classified as emergent. The hospitalised children were triaged with the highest frequency to level yellow (can wait; 41.5%). In children with RETTS-p red or orange, the sensitivity for a defined emergent patient was 66.7%, with a corresponding specificity of 67.0%. The EMS field assessment was in agreement with the final hospital diagnosis in 80% of the cases. Conclusions The RETTS-p sensitivity in this study is considered moderate. Two thirds of the children triaged to life threatening or potentially life threatening were later identified as non-emergent. Of those, one in six was discharged from the PED without any intervention. Further, one third of the children were under triaged, the majority were found in the yellow triage level (can wait). The highest proportion of hospitalised patients was found in the yellow triage level. Our result is in agreement with previous studies using other triage instruments. A computerised decision support system might help the EMS triage to increase sensitivity and specificity.

scholarly journals The utility of a shortened palliative care screening tool to predict death within 12 months – a prospective observational study in two south African hospitals with a high HIV burden

2019 ◽  
Vol 18 (1) ◽  
Author(s):  
Peter J. Raubenheimer ◽  
Cascia Day ◽  
Faried Abdullah ◽  
Katherine Manning ◽  
Clint Cupido ◽  
...  
Keyword(s):  
South Africa ◽  
Observational Study ◽  
Predictive Value ◽  
Prospective Observational Study ◽  
Screening Tool ◽  
Young Patients ◽  
Public Hospitals ◽  
Mortality Data ◽  
Hospitalised Patients ◽  
Identification Tool

Abstract Background Timely identification of people who are at risk of dying is an important first component of end-of-life care. Clinicians often fail to identify such patients, thus trigger tools have been developed to assist in this process. We aimed to evaluate the performance of a identification tool (based on the Gold Standards Framework Prognostic Indicator Guidance) to predict death at 12 months in a population of hospitalised patients in South Africa. Methods Patients admitted to the acute medical services in two public hospitals in Cape Town, South Africa were enrolled in a prospective observational study. Demographic data were collected from patients and patient notes. Patients were assessed within two days of admission by two trained clinicians who were not the primary care givers, using the identification tool. Outcome mortality data were obtained from patient folders, the hospital electronic patient management system and the Western Cape Provincial death registry which links a unique patient identification number with national death certificate records and system wide electronic records. Results 822 patients (median age of 52 years), admitted with a variety of medical conditions were assessed during their admission. 22% of the cohort were HIV-infected. 218 patients were identified using the screening tool as being in the last year of their lives. Mortality in this group was 56% at 12 months, compared with 7% for those not meeting any criteria. The specific indicator component of the tool performed best in predicting death in both HIV-infected and HIV-uninfected patients, with a sensitivity of 74% (68–81%), specificity of 85% (83–88%), a positive predictive value of 56% (49–63%) and a negative predictive value of 93% (91–95%). The hazard ratio of 12-month mortality for those identified vs not was 11.52 (7.87–16.9, p < 0.001). Conclusions The identification tool is suitable for use in hospitals in low-middle income country setting that have both a high communicable and non-communicable disease burden amongst young patients, the majority under age 60.

scholarly journals A prospective, observational study of fidaxomicin use for Clostridioides difficile infection in France

2021 ◽  
Vol 49 (6) ◽  
pp. 030006052110212
Author(s):  
Benoit Guery ◽  
Pierre Berger ◽  
Remy Gauzit ◽  
Magali Gourdon ◽  
Frédéric Barbut ◽  
...  
Keyword(s):  
Observational Study ◽  
Clinical Cure ◽  
Prospective Observational Study ◽  
Adverse Outcomes ◽  
High Rate ◽  
Clostridioides Difficile ◽  
Real World Setting ◽  
Hospitalised Patients ◽  
Clostridioides Difficile Infection ◽  
Cure Rates

Objective To describe the characteristics, management and outcomes of hospitalised patients with Clostridioides difficile infection (CDI) treated with and without fidaxomicin. Methods This prospective, multicentre, observational study (DAFNE) enrolled hospitalised patients with CDI, including 294 patients treated with fidaxomicin (outcomes recorded over a 3-month period) and 150 patients treated with other CDI therapies during three 1-month periods. The primary endpoint was baseline and CDI characteristics of fidaxomicin-treated patients. Results At baseline, the fidaxomicin-treated population included immunocompromised patients (39.1%) and patients with severe (59.2%) and recurrent (36.4%) CDI. Fidaxomicin was associated with a high rate of clinical cure (92.2%) and low CDI recurrence (16.3% within 3 months). Clinical cure rates were ≥90% in patients aged ≥65 years, those receiving concomitant antibiotics and those with prior or severe CDI. There were 121/296 (40.9%) patients with adverse events (AEs), 5.4% with fidaxomicin-related AEs and 1.0% with serious fidaxomicin-related AEs. No fidaxomicin-related deaths were reported. Conclusions Fidaxomicin is an effective and well-tolerated CDI treatment in a real-world setting in France, which included patients at high risk of adverse outcomes. Trial registration: Description of the use of fidaxomicin in hospitalised patients with documented Clostridium difficile infection and the management of these patients (DAFNE), NCT02214771, www.ClinicalTrials.gov.

Accuracy for mortality prediction with additive biomarkers including interleukin-6 in critically ill patients: a multicenter prospective observational study

2020 ◽  
Author(s):  
Ryo Yamamoto ◽  
Junichi Sasaki ◽  
Takayuki Shibusawa ◽  
Taka-aki Nakada ◽  
Toshihiko Mayumi ◽  
...  
Keyword(s):  
Observational Study ◽  
Critically Ill ◽  
Sofa Score ◽  
Critically Ill Patients ◽  
Prospective Observational Study ◽  
Characteristic Curve ◽  
Univariate Analysis ◽  
Mortality Prediction ◽  
University Hospitals ◽  
Discrimination Power

Abstract Background: Several inflammation markers have been reported to be associated with unfavorable clinical outcomes in critically ill patients. We aimed to elucidate whether serum IL-6 concentration considered with sequential organ failure assessment (SOFA) score can better predict mortality in critically ill patients.Methods: A prospective observational study was conducted at five university hospitals in 2016–2018. Critically ill adult patients who met ≥2 systemic inflammatory response syndrome criteria on admission were included, and those who died or discharged within 48 hours were excluded. Inflammatory biomarkers including interleukin (IL) -6, -8, and -10, tumor necrosis factor-α, and procalcitonin were blindly measured daily for 3 days. Area under the receiver operating characteristic curve (AUROC) for SOFA score at Day 2 according to 28-day mortality was calculated as a baseline. Combination models of SOFA score and additional biomarkers were developed using logistic regression, and AUROC calculated in each model was compared with the baseline.Results: Among 161 patients included in the study, 18 (11.2%) did not survive at Day 28. Univariate analysis for each biomarker identified that the IL-6 (Days 1–3), IL-8 (Days 0–3), and IL-10 (Days 1–3) were higher in non-survivors versus survivors. Analyses of 28-day mortality prediction by a single biomarker showed IL-6, -8, and -10 at Days 1–3 had a significant discrimination power, and the IL-6 at Day 3 had the highest AUROC (0.766 [0.656–0.876]). Baseline AUROC for SOFA score predicting 28-day mortality was 0.776 (0.672–0.880). The combination model using additional IL-6 concentration at Day 3 had higher AUROC than baseline (AUROC = 0.844, AUROC improvement = 0.068 [0.002–0.133]), whereas other biomarkers did not improve accuracy in predicting 28-day mortality.Conclusions: Accuracy for 28-day mortality prediction was improved by adding serum IL-6 concentration to SOFA score.Trial registration: N/A (This study did not include any health-related interventions)

scholarly journals Comparing the predictive ability of a commercial artificial intelligence early warning system with physician judgement for clinical deterioration in hospitalised general internal medicine patients: a prospective observational study

BMJ Open ◽  
2019 ◽  
Vol 9 (10) ◽  
pp. e032187
Author(s):  
Jonathan Arnold ◽  
Alex Davis ◽  
Baruch Fischhoff ◽  
Emmanuelle Yecies ◽  
Jon Grace ◽  
...  
Keyword(s):  
Internal Medicine ◽  
Observational Study ◽  
General Internal Medicine ◽  
Early Warning ◽  
Early Warning System ◽  
Prospective Observational Study ◽  
Warning System ◽  
Clinical Deterioration ◽  
Receiver Operating Curve ◽  
General Internal

ObjectiveOur study compares physician judgement with an automated early warning system (EWS) for predicting clinical deterioration of hospitalised general internal medicine patients.DesignProspective observational study of clinical predictions made at the end of the daytime work-shift for an academic general internal medicine floor team compared with the risk assessment from an automated EWS collected at the same time.SettingInternal medicine teaching wards at a single tertiary care academic medical centre in the USA.ParticipantsIntern physicians working on the internal medicine wards and an automated EWS (Rothman Index by PeraHealth).OutcomeClinical deterioration within 24 hours including cardiac or pulmonary arrest, rapid response team activation or unscheduled intensive care unit transfer.ResultsWe collected predictions for 1874 patient days and saw 35 clinical deteriorations (1.9%). The area under the receiver operating curve (AUROC) for the EWS was 0.73 vs 0.70 for physicians (p=0.571). A linear regression model combining physician and EWS predictions had an AUROC of 0.75, outperforming physicians (p=0.016) and the EWS (p=0.05).ConclusionsThere is no significant difference in the performance of the EWS and physicians in predicting clinical deterioration at 24 hours on an inpatient general medicine ward. A combined model outperformed either alone. The EWS and physicians identify partially overlapping sets of at-risk patients suggesting they rely on different cues or decision rules for their predictions.Trial registration numberNCT02648828.

Tactile massage reduces rescue doses for pain and anxiety: an observational study

2017 ◽  
Vol 8 (1) ◽  
pp. 30-33 ◽  
Author(s):  
Karina Pedersen ◽  
Linda Björkhem-Bergman
Keyword(s):  
Palliative Care ◽  
Observational Study ◽  
Symptom Assessment ◽  
Well Being ◽  
Control Groups ◽  
Edmonton Symptom Assessment Scale ◽  
Before And After ◽  
Parallel Control ◽  
Symptom Assessment Scale ◽  
Harmful Effects

ObjectivesThe aim of this study was to evaluate the effect of tactile massage (TM) on palliative care patients.MethodAn observational study at a hospice ward in Sweden was carried out. Forty-one palliative patients were offered TM, at an average of three treatments per patient. Before and after every treatment, self-assessed pain, well-being and anxiety according to the Edmonton Symptom Assessment Scale (0–10) were recorded. In addition, the number of rescue doses for pain and anxiety was monitored 24 hours before and after the treatment and in two consecutive days before the patients were offered TM (control data).ResultsTM resulted in improvement of self-assessed pain by 1.7 points (SD 1.6), anxiety by 2.3 points (SD 2.0) and well-being by 2.6 points (SD 1.4). The number of rescue doses for pain was reduced from 1.6 to 0.84 doses/patient (P<0.001) and for anxiety from 0.52 to 0.24 doses/patient (P<0.01). The number of rescue doses was not changed in the same patients in two consecutive days before the patients were offered TM. The effect was evident already after the first treatment and did not increase further with repeated treatments. No patients reported any harmful effects of the treatment.ConclusionTM reduced the need for administration of rescue doses for pain and anxiety and improved well-being in palliative care patients. Larger randomised studies with parallel control groups are needed to confirm the findings from this observational pilot study.

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