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The Swedish Intensive Care Registry: New (?) insights for the surgeon

Source for research!

http://www.icuregswe.org

Sten Walther, MDChairman, Swedish Intensive Care RegistryLinköping University Hospital

http://www.icuregswe.org/

Member Non-member

Regional hospital County hospital Local hospital

Outline: Basics

– Data sources– Coverage and accuracy

Case studies– GI-bleeding and AAA– Time to death in the ICU– Timing of tracheotomy– Life after ICU-care

The Swedish Intensive Care Registry: New (?) insights for the surgeon

Source for research!

Data sources

Data sources Data coupling possible using Unique admission identifier Unique person identifier

National Quality Registry legislation Person identifier permitted if purpose is audit and benchmarking Written information to the patient must be provided Consent presumed Active withdrawal of consent possible

Definition: The ICU patient

A patient with an acute, sometimes life threatening condition who needs monitoring, diagnostics and treatment

The post-operative patient is sometimes an ICU patient: need for prolonged (+ 6hrs) organ support or > 24 hrs ICU stay

Thresholds for admission vary between hospitals and within hospitals over time

Consult

Admit Treat Discharge

Follow upCritical care outreach

ICU outcome

Withdrawal / Withholding

Adverse eventsSOFA

Nursing workloadDiagnosis

Key diagnosis

Renal RT

Ventilator therapy

Procedures

ICU-care aftercare

SAPS 3

ICU-Higgins

APACHE II

PIM 2

Reason for admission

Minimal dataset

CardioThor ICU

Pediatric ICU

ICU

Which data?

My ICU

Swedish Intensive Care Registry

Swedish Population Registry

Data transfer: interaction over time

My ICU

No errorErrors




My ICU




Old admissionsCorrected errorsNew admissions

My ICU


Preferably weeklyAt least monthly



My ICU


Preferably weeklyAt least monthly


Weekly

Vital status update


Registry metrics (DocDAT stuk)

Criteria for assessing coverage and accuracy

Registry metrics (DocDAT stuk)

Criteria for assessing coverage and accuracy

Vital status

Health relatedQuality of Life

Criteria …. (cont’d)

Black et al, Qual Saf Health Care 2003 12: 348-352

http://www.icuregswe.org

http://www.icuregswe.org/

Admission types in the ICU: SIR 2010

Intensive careGeneral incl. neuro

– 37 071Cardiothoracic

– 3 863Specialized pediatric

– 1 651

Other care typesPost-operative

– 12 367Other

– 10 493Coronary

– 5 321

70 766

42 585 28 181

Case study ISurvival: ICU admissions from General surgery

No surgeryElective surgery

Emergency surgery

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

0 1 2 3Survival (yrs)

Swedish Intensive Care Registry 2008-2011, N=46 382

Survival: Gastrointestinal bleeding(Principal diagnosis, Primary admission only)

Surgery

No surgery

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

396 260 193 137 86Surgery2716 1816 1359 974 674No surgery

Number at risk

0 .5 1 1.5 2Survival (yrs)

Swedish Intensive Care Registry 2008-2011

Kaplan-Meier survival estimates

Survival: Gastrointestinal bleeding(Principal diagnosis, Primary ICU admission only)

Surgery

No surgery

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

396 260 193 137 86Surgery2716 1816 1359 974 674No surgery

Number at risk




No surgery Surgery

Age (yrs) 69 (SD 15) 67 (SD 16)

Male / Female 64 % / 36 % 60 % / 40 %

SAPS3 risk estimate

Median 0.26 (IQR 0.16 – 0.42)

Median 0.36 (IQR 0.16 – 0.45)

Length of ICU stay(days)

Median 0.9 (IQR 0.5 – 1.6)

Median 1.0 (IQR 0.6 – 1.9)

Dead in ICU 5.5 % 5.7 %

Dead < 30 days 17 % 19 %

Risk adjustment with SAPS3GI-bleeding (N=1282).Survival 30 days after admission to ICU

0.00

0.25

0.50

0.75

1.00

Sen

sitiv

ity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.8433

Discrimination is good:aROC = 0.84

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

234 131 88 53 333rd adm702 441 313 210 1452nd adm3113 2076 1552 1111 7601st adm

Number at risk




Survival: Gastrointestinal bleeding(Repeated admissions)

Survival: Gastrointestinal bleeding and gender(Primary ICU admission)

1.00

0.90

0.80

0.70

0.60

0.50

0.40

Pro

porti

on a

live

1991 1337 993 707 479Male1122 739 559 404 281Female

Number at risk




Similar also after risk adjustment

Survival: Abdominal aortic aneurysm

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

961 426 222 64Ruptured1283 764 394 122Not ruptured

Number at risk




Not ruptured

Ruptured


1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

961 426 222 64Ruptured1283 764 394 122Not ruptured

Number at risk




Not ruptured Ruptured

Dead < 30dSIR2010 5.5 % 34.7 %

Dead < 30dSwedvasc 2010 2.4 % 35.1 %

1.00

0.90

0.80

0.70

0.60

0.50

Pro

porti

on a

live

248 120 42 15Local1168 651 352 110County828 419 222 61Regional

Number at risk


Regional

County

Local




1.00

0.90

0.80

0.70

0.60

0.50

Pro

porti

on a

live

248 120 42 15Local1168 651 352 110County828 419 222 61Regional

Number at risk


Regional

County

Local



Differences remain favoring County ICUsafter adjustment for risk (SAPS3) and rupture


Gui

delin

es …

..

Case study II Time to death in the ICU: Operative vs. Non-operative admissions

Operative

Non-operative

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

0 10 20 30 40 50 60Time to death (days)

Swedish Intensive Care Registry 2008-2011 (N: Op=1632, Non-op=7356)

Time to death in the ICU: Operative vs. Non-operative admissions

Operative

Non-operative

1.00

0.80

0.60

0.40

0.20

0.00

Pro

porti

on a

live

0 10 20 30 40 50 60Time to death (days)

Swedish Intensive Care Registry 2008-2011 (N: Op=1632, Non-op=7356)

50th percentile

75th percentile

Operative 2.0 days 6.0 days

Non-operative 1.4 days 4.0 days

Case study IIIProcedures in the ICU: Tracheotomy

Umeå IVA

ÖrnsköldsvikSollefteå

Sundsvall

Östersund

Hudiksvall

GävleFalun

Torsby

Arvika

KarlstadVästerås

Lindesberg

Karlskoga

Örebro IVA

Nyköping

Eskilstuna

NorrtäljeDanderyd

K Solna CIVA

St GöranSÖS IVASödertälje

K Huddinge IVANorrköping

Linköping IVA

Linköping TIVA

Linköping NIVA

Jönköping

Eksjö

Värnamo

Skövde

LidköpingAlingsås

Kungälv

Borås

Varberg

Halmstad

Kristianstad

Helsingborg

Lund IVA

Lund BIVA

Malmö IVAMalmö Inf

Ystad

0

.2

.4

.6

.8

1

Pro

porti

on w

ith tr

ache

osto

my

0 50 100 150 200

Number of admissions with mechanical ventilation >72 hrs

Tracheotomy: Technique and timing

0

50

100

150

200

Ope

n tra

cheo

tom

y

0 7 14 21Days with mechanical ventilation

0

50

100

150

200

Per

cuta

neou

s tra

cheo

tom

y


Open technique Percutaneous technique

OpenN=1630

PercutaneousN=1201

Age 61 (SD 16) yrs 63 (SD 15) yrs

Male / Female 77 % / 23 % 81 % / 19 %

SAPS3 risk estimate

Median 0.45 (IQR 0.26 – 0.62)

Median 0.44 (IQR 0.28 – 0.62)

Days to procedure

Median 5.1 (IQR 2.7 – 8.1)

Median 4.2 (IQR 2.4 – 7.7)

0

50

100

150

200

Ope

n tra

cheo

tom

y


0

50

100

150

200

Per

cuta

neou

s tra

cheo

tom

y


Open technique Percutaneous technique



ICU length of stay increases by 1.3 days for every day tracheostomy is ‘delayed’

y=1.3x + 11 (adjusted for SAPS3 and technique)

0

7

14

21

28Le

ngth

of I

CU

sta

y (d

ays)

0 7 14

Duration of mechanical ventilation before tracheotomy (days)

Gui

delin

es …

..

Assessing health related quality of life may give important insights You only manage what you measure

Case study IVHealth related quality of life after ICU

Assessing health related quality of life may give important insights You only manage what you measure

Are there important differences in HRQoL related to – illness severity? – length of ICU-stay? – treatment protocols?– diagnoses?– gender?

Is there anything we can do about it? Designing and exploring interventions

Health related quality of life after ICU


PF

RP

BP

GH

VT

SF

RE

MH

20

40

60

80

100

PF Physical FunctioningRP Role - PhysicalBP Bodily PainGH General HealthVT VitalitySF Social FunctioningRE Role - EmotionalMH Mental Health

Reference2 months, N=9826 months, N=70112 months, N=302

At 2 months (N=982):Age 61 (17 – 99) yrsICU LOS 9 (2 – 48) days

SF-36: All assessments (27 ICUs)

SIR data from 2009-2010


SF-36: Admissions after surgery

What is the appropriate reference?

For how long should we measure?

Can we accelerate recovery?

Designing and exploring interventions

PF

RP

BP

GH

VT

SF

RE

MH

20

40

60

80

100

PF Physical FunctioningRP Role - PhysicalBP Bodily PainGH General HealthVT VitalitySF Social FunctioningRE Role - EmotionalMH Mental Health

Reference2 months, N=666 months, N=6612 months, N=66

SIR data from 2009-2010

The Swedish Intensive Care Registry Not a database Large group of people devoted to audit and benchmarking to be able to deliver the very best care

SIR 10th AnniversarySaltsjöbaden 2011

www.icuregswe.org(with link to my presentation coming shortly)

[email protected]

010 209 41 00

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