Evaluation of ICU Risk Models Adapted for Use as Continuous Markers of Severity of Illness Throughout the ICU Stay*
Evaluation of ICU Risk Models Adapted for Use as Continuous Markers of Severity of Illness Throughout the ICU Stay*
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DOI：
10.1097/ccm.0000000000002904
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发表时间：
2018-03-01
影响因子：
8.8
通讯作者：
Swami, Sunil
中科院分区：
文献类型：
--
作者：
Badawi, Omar;Liu, Xinggang;Swami, Sunil
目的：评估不同ICU风险模型作为疾病严重程度连续标记物的准确性。设计：非干预性队列研究。设置：EICU研究所ICU使用Tele-ICU软件计算2013年1月至2016年3月期间连续的ICU出院准备情况评分。患者：561478名住院时间在4小时至30天之间的成年ICU患者。干预：不可用。测量和主要结果：计算每小时急性生理学和慢性健康评估IV、顺序器官衰竭评估和出院准备情况评分。主要结果是受试者操作特征曲线下的面积作为ICU死亡率的平均评分。次要结果包括ICU住院死亡率、中位数、最高分和末次评分以及24小时内死亡的受试者操作特征曲线下面积。每个分数的轨迹通过绘制每小时平均与在ICU的时间的关系图来可视化，按死亡率和住院时间分层。受试者工作特征曲线下面积分别为0.90(0.89~0.90)分、0.86(0.86~0.86)分和0.94(0.94~0.94)分。每小时急性生理学和慢性健康评估、序贯器官衰竭评估和出院准备评分预测24小时死亡率的受试者操作特征曲线下面积分别为0.81(0.81~0.81)、0.76(0.76~0.76)和0.86(0.86~0.86)。出院准备情况评分在受试者操作特征曲线下的区域高于每个指标的急性生理学和慢性健康评估和序贯器官衰竭评估。急性生理学与慢性健康评估和序贯器官衰竭评分在存活和死亡的前24小时内均呈上升趋势；存活患者的出院就绪性评分持续下降，住院时间较长的死亡者的出院就绪性评分在36小时后上升。结论：急性生理学和慢性健康评估、序贯器官衰竭评估和出院就绪性评分在连续使用时对ICU死亡率具有较高的区分性；出院就绪性评分在每个终点的受试者操作特征曲线下的区域略高。这些发现验证了在人群水平上使用这些模型在ICU进行持续的风险调整，尽管急性生理学和慢性健康评估和顺序器官衰竭评估似乎比出院准备分数对患者状况的改善反应更慢，出院准备分数可能反映干预后的生理改善，可能低估了风险。
Objectives: Evaluate the accuracy of different ICU risk models repurposed as continuous markers of severity of illness.Design: Nonintervention cohort study.Setting: eICU Research Institute ICUs using tele-ICU software calculating continuous ICU Discharge Readiness Scores between January 2013 and March 2016.Patients: Five hundred sixty-one thousand four hundred seventy-eight adult ICU patients with an ICU length of stay between 4 hours and 30 days.Interventions: Not available.Measurements and Main Results: Hourly Acute Physiology and Chronic Health Evaluation IV, Sequential Organ Failure Assessment, and Discharge Readiness Scores were calculated beginning hour 4 of the ICU stay. Primary outcome was the area under the receiver operating characteristic curve for the mean score with ICU mortality. Secondary outcomes included area under the receiver operating characteristic curves for ICU mortality with admission, median, maximum and last scores, and for death within 24 hours. The trajectories of each score were visualized by plotting the hourly averages against time in the ICU, stratified by mortality and length of stay. The area under the receiver operating characteristic curves for mean Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores were 0.90 (0.89-0.90), 0.86 (0.86-0.86), and 0.94 (0.94-0.94), respectively. The area under the receiver operating characteristic curves for hourly Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores predicting 24-hour mortality were 0.81 (0.81-0.81), 0.76 (0.76-0.76), and 0.86 (0.86-0.86). Discharge Readiness Scores had a higher area under the receiver operating characteristic curve than both Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment for each metric. Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores increased throughout the first 24 hours in both survivors and nonsurvivors; Discharge Readiness Scores continuously decreased in survivors and temporarily decreased before increasing by hour 36 in nonsurvivors with longer length of stays.Conclusions: Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment, and Discharge Readiness Scores all have relatively high discrimination for ICU mortality when used continuously; Discharge Readiness Scores tended to have slightly higher area under the receiver operating characteristic curves for each endpoint. These findings validate the use of these models on a population level for continuous risk adjustment in the ICU, although Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment appear slower to respond to improvements in patient status than Discharge Readiness Scores, and Discharge Readiness Scores may reflect physiologic improvement from interventions, potentially underestimating risk.