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Member Non-member
Regional hospital County hospital Local hospital
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
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
Swedish Intensive Care Registry
Critical care outreach
ICU-care aftercare
Swedish population
registryMicrobiology lab
data
Many other ICUs
Your ICU
My ICU
Data sources
Swedish Intensive Care Registry
Critical care outreach
ICU-care aftercare
Swedish population
registryMicrobiology lab
data
Many other ICUs
Your ICU
My ICU
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 workload
Diagnosis
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
Swedish Intensive Care Registry
Swedish Population Registry
Data transfer: interaction over time
My ICU
Swedish Intensive Care Registry
Swedish Population Registry
Data transfer: interaction over time
Old admissionsCorrected errorsNew admissions
My ICU
Swedish Intensive Care Registry
Preferably weeklyAt least monthly
Swedish Population Registry
Data transfer: interaction over time
My ICU
Swedish Intensive Care Registry
Preferably weeklyAt least monthly
Swedish Population Registry
Weekly
Vital status update
Data transfer: interaction over time
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
Admission types in the ICU: SIR 2010
Intensive careGeneral incl. neuro
– 37 071
Cardiothoracic– 3 863
Specialized pediatric– 1 651
Other care typesPost-operative
– 12 367
Other – 10 493
Coronary– 5 321
70 766
42 585 28 181
Case study ISurvival: ICU admissions from General surgery
No surgery
Elective surgery
Emergency surgery
1.00
0.80
0.60
0.40
0.20
0.00
Pro
po
rtio
n 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
port
ion
aliv
e
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
port
ion
aliv
e
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
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
0.0
00
.25
0.5
00
.75
1.0
0S
ens
itivi
ty
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
port
ion
aliv
e
234 131 88 53 333rd adm702 441 313 210 1452nd adm3113 2076 1552 1111 7601st adm
Number at risk
0 .5 1 1.5 2Survival (yrs)
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
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
port
ion
aliv
e
1991 1337 993 707 479Male1122 739 559 404 281Female
Number at risk
0 .5 1 1.5 2Survival (yrs)
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
Similar also after risk adjustment
Survival: Abdominal aortic aneurysm
1.00
0.80
0.60
0.40
0.20
0.00
Pro
port
ion
aliv
e
961 426 222 64Ruptured1283 764 394 122Not ruptured
Number at risk
0 1 2 3Survival (yrs)
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
Not ruptured
Ruptured
Survival: Abdominal aortic aneurysm
1.00
0.80
0.60
0.40
0.20
0.00
Pro
port
ion
aliv
e
961 426 222 64Ruptured1283 764 394 122Not ruptured
Number at risk
0 1 2 3Survival (yrs)
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
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
port
ion
aliv
e
248 120 42 15Local1168 651 352 110County828 419 222 61Regional
Number at risk
0 1 2 3Survival (yrs)
Regional
County
Local
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
Survival: Abdominal aortic aneurysm
1.00
0.90
0.80
0.70
0.60
0.50
Pro
port
ion
aliv
e
248 120 42 15Local1168 651 352 110County828 419 222 61Regional
Number at risk
0 1 2 3Survival (yrs)
Regional
County
Local
Swedish Intensive Care Registry 2008-2011
Kaplan-Meier survival estimates
Differences remain favoring County ICUsafter adjustment for risk (SAPS3) and rupture
Survival: Abdominal aortic aneurysm
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
port
ion
aliv
e
0 10 20 30 40 50 60Time to death (days)
Swedish Intensive Care Registry 2008-2011 (N: Op=1632, Non-op=7356)
“Intensive care is about saving the salvageable,comfort the dying and don’t mix them up”
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
port
ion
aliv
e
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
Norrtälje
Danderyd
K Solna CIVA
St GöranSÖS IVASödertälje
K Huddinge IVANorrköping
Linköping IVA
Linköping TIVA
Linköping NIVA
Jönköping
Eksjö
Värnamo
Skövde
Lidköping
Alingsås
Kungälv
Borås
Varberg
Halmstad
Kristianstad
Helsingborg
Lund IVA
Lund BIVA
Malmö IVAMalmö Inf
Ystad
0
.2
.4
.6
.8
1
Pro
po
rtio
n w
ith t
rach
eo
sto
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 tr
ach
eo
tom
y
0 7 14 21Days with mechanical ventilation
0
50
100
150
200
Pe
rcut
aneo
us tr
ach
eoto
my
0 7 14 21Days with mechanical ventilation
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 tr
ach
eo
tom
y
0 7 14 21Days with mechanical ventilation
0
50
100
150
200
Pe
rcut
aneo
us tr
ach
eoto
my
0 7 14 21Days with mechanical ventilation
Open technique Percutaneous technique
Tracheotomy: Technique and timing
Tracheotomy: Technique and timing
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
28L
engt
h o
f IC
U s
tay
(da
ys)
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
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
Reference
2 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
Health related quality of life after ICU
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
Reference
2 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