Physiological Severity Score Research Articles

How Effective is Frailty and Comprehensive Geriatric Assessment to Predict the Long-Term Mortality After General Surgery?

Introduction: This study investigated the effect of preoperative comprehensive geriatric assessment(CGA) and frailty assessment on long-term mortality.Methods: This study which evaluated a total of 81 older patients underwent the CGA prior to general surgery. Katz ADL, the Lawton Brody IADL, the Mini-Nutrition Assessment test (MNAsf), the Mini-Mental State Examination (MMSE), and Yesavage Geriatric Depression Scale (GDS) were performed. Fried criteria were utilized for the assessment of frailty. The Physiological and Operative Severity Scores for the Enumeration of Mortality and Morbidity (POSSUM) score, and the Charlson Comorbidity Index (CCI) were used for operative risk assessment. The patients were screened for 3-year mortality. Results: The median age of the patients was 71 years (range, 65-84 years). 58.02% of the patients were female and 24.69% were in the frail group. The mortality rate of the frail group was significantly higher than those of the pre-frail and robust groups (p: 0.030). The Cox regression analyses revealed that MMSE (p: 0.020), Physiological Severity Score (PSS) (p: 0.034), BUPA score (p: 0.030) and educational background (p: 0.031) were independently correlated with mortality in Model 1, while MNA (p: 0.003), PSS score (p: 0.080) and educational background (p: 0.002) were correlated with mortality in Model 2. ADL, MMSE, CDT, MNA-SF, Fried score, length of hospital stay, PSS score, and BUPA score were the best predictors of mortality (AUC values: 0.61, 0.74, 0.72, 0.73, 0.69, 0.74, 0.64, and 0.66respectively). Conclusion: The results of the study demonstrated that CGA components and frailty predicted long-term mortality in general surgery patients.

Evaluation of possum scoring system in patients undergoing laparotomy

Background: Prediction of complications is an essential part of risk management in surgery. Knowing which patient is at risk of developing complications contributes to the quality of surgical care and cost reduction in surgery. Among the variety of scoring systems used to identify the “high risk” patient POSSUM scoring is the most widely used.Methods: Patients undergoing laparotomy were selected serially and their physiological severity score on admission and operative severity scored at the end of 30days and compared with the POSSUM predicted score.Results: In the elective surgery group, patients with morbidity correlated with high POSSUM scores but due to low overall morbidity conclusions could not be drawn while in the emergency group predicted morbidity correlated well with observed results. The low overall mortality in the study group precluded meaningful analysis.Conclusions: POSSUM scoring system has an undeniable advantage in this set up for better patient counseling, improving the surgical outcomes in both emergency and elective wards and for better management of limited resources and manpower.

Severity scores in trauma patients admitted to ICU. Physiological and anatomic models

IntroductionThe goals of this project were to compare both the anatomic and physiologic severity scores in trauma patients admitted to intensive care unit (ICU), and to elaborate mixed statistical models to improve the precision of the scores. MethodsA prospective study of cohorts. The combined medical/surgical ICU in a secondary university hospital. Seven hundred and eighty trauma patients admitted to ICU older than 16 years of age. Anatomic models (ISS and NISS) were compared and combined with physiological models (T-RTS, APACHE II [APII], and MPM II). The probability of death was calculated following the TRISS method. The discrimination was assessed using ROC curves (ABC [CI 95%]), and the calibration using the Hosmer–Lemeshow's H test. The mixed models were elaborated with the tree classification method type Chi Square Automatic Interaction Detection. ResultsA 14% global mortality was recorded. The physiological models presented the best discrimination values (APII of 0.87 [0.84–0.90]). All models were affected by bad calibration (p<0.01). The best mixed model resulted from the combination of APII and ISS (0.88 [0.83–0.90]). This model was able to differentiate between a 7.5% mortality for elderly patients with pathological antecedents and a 25% mortality in patients presenting traumatic brain injury, from a pool of patients with APII values ranging from 10 to 17 and an ISS threshold of 22. ConclusionsThe physiological models perform better than the anatomical models in traumatic patients admitted to the ICU. Patients with low scores in the physiological models require an anatomic analysis of the injuries to determine their severity.

The Comparison of Reliabilities of Nutritional Risk Scoring and Physiological Severity Score in Critical Care Patients

The Comparison of Reliabilities of Nutritional Risk Scoring and Physiological Severity Score in Critical Care Patients

Physiological and operative severity score for the enumeration of mortality and morbidity scoring systems for assessment of patient outcome and impact of surgeons' and anesthesiologists' performance in hepatopancreaticobiliary surgery.

Context:The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) is a scoring system used to predict morbidity and mortality.Aims:We compared the physiological and operative risk, the expected morbidity and mortality, and the observed postoperative mortality among patients operated by different surgeons and anesthetized by different anesthesiologists.Settings and Design:This was a retrospective, single center study.Subjects and Methods:The anesthetic records of 159 patients who underwent hepatopancreaticobiliary surgery were analyzed for the physiological and operative severity, POSSUM morbidity, POSSUM and Portsmouth POSSUM (P-POSSUM) mortality scoring systems, observed mortality in 30-days, 3, 6, and 12 months postoperatively, duration of surgery, and units of packed red blood cells (PRBC) transfused. These variables were compared among patients operated by five different surgeons and anesthetized by seven different anesthesiologists.Statistical Analysis:One-way analysis of variance was used for normally and Kruskal–Wallis test for nonnormally distributed responses. Differences in percentages of postoperative mortality were assessed by Chi-squared test.Results:The physiological severity, POSSUM morbidity, POSSUM and P-POSSUM mortality scores, and observed mortality at 1, 3, 6, and 12 months postoperatively did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. Duration of surgery (P < 0.001), PRBC units transfused (P = 0.002), and operative severity (P = 0.001) differed significantly among patients operated by different surgeons.Conclusions:The physiological severity score, POSSUM and P-POSSUM scores did not differ among patients operated by different surgeons and anesthetized by different anesthesiologists. The different operative severity scores did not influence the observed mortality in the postoperative period.

Layperson trauma training in low- and middle-income countries: a review

BackgroundPrehospital trauma systems are rudimentary in many low- and middle-income countries (LMICs) and require laypersons to stabilize and transport injured patients. The World Health Organization recommends educating layperson first responders as an essential step in the development of Emergency Medical Services systems in LMICs. This systematic review examines trauma educational initiatives for layperson first responders in resource-poor settings. Materials and methodsLayperson first-responder training and education program publications were identified using PubMed MEDLINE and Scopus databases. Articles addressing physicians, professional Emergency Medical Services training, or epidemiologic descriptions were excluded. Publications were assessed by independent reviewers, and those included underwent thematic analysis. ResultsThirteen publications met inclusion criteria. Four themes emerged regarding the development of layperson first-responder training programs: (1) An initial needs assessment of a region's existing trauma system of care and laypersons' baseline emergency care knowledge focuses subsequent educational interventions; (2) effective programs adapt to and leverage existing resources; (3) training methods should anticipate participants with low levels of education and literacy; and (4) postimplementation evaluation allows for curriculum improvement. Technology, such as online and remote learning platforms, can be used to operationalize each theme. ConclusionsSuccessful training programs for layperson first responders in LMICs identify and maximize existing resources are adaptable to learners with little formal education and are responsive to postimplementation evaluation. Educational platforms that leverage technology to deliver content may facilitate first-responder trauma education in underresourced areas. Themes identified can inform the development of trauma systems of care to decrease mortality and physiological severity scores in trauma patients in LMICs.

Prehospital trauma systems reduce mortality in developing countries

The majority of trauma deaths in the developing world occur outside of the hospital. In the mid-1990s, preliminary studies of prehospital trauma systems showed improvements in mortality. However, no empirical data are available to assess the overall benefit of these systems. We undertook a systematic review and meta-analysis to assess the effectiveness of prehospital trauma systems in developing countries. We conducted multiple database and bibliography searches (from inception until December 2010) to identify articles assessing the effectiveness of prehospital trauma systems in developing countries. The primary outcome was mortality. Secondary outcomes were physiologic severity score, Injury Severity Score, and prehospital time. We calculated relative risks (95% confidence intervals [CIs]), performed a sensitivity analysis, and pooled estimates using a fixed effects method. Fourteen studies met our inclusion criteria for qualitative analysis. Eight studies representing seven countries (n = 5,607) were included in the meta-analysis. Our pooled estimates show a 25% decreased risk of dying from trauma in areas that have prehospital trauma systems (relative risk [RR], 0.75; 95% CI, 0.66-0.85), with no significant heterogeneity (χ = 3.71, p = 0.72). Rural settings showed slightly enhanced treatment effect compared with urban settings (RR, rural 0.71; 95% CI, 0.59-0.86 vs. urban 0.79; 95% CI, 0.65-0.94). In-field response time was reduced in both rural (without an ambulance system, 66 minutes, 95% CI: 24-108) and urban (with an ambulance system, 6 minutes, 95% CI: 5.47 to 6.53, p < 0.0005) settings. Prehospital trauma systems in developing countries, particularly middle-income countries, reduce mortality. These data should inform and encourage developing countries to adopt prehospital trauma systems at the policy level. Meta-analysis, level III+.

Rural trauma in Iran: are the data reliable?

An Iranian team has reported the results of a rural prehospital trauma system. In a previous comment to their article I asked the team to come forward with additional information in order to validate the accuracy of the main variable in their study, the physiological severity score (PSS) 2 . The Iranian colleagues responded promptly 3 and thus opened an important discussion on quality standards for trauma registry analysis.

Reply to comment on: Improving trauma care in rural Iran by training existing treatment chains

We thank Hans Husum for his interest for our article 1 . The correlation between Injury Severity Score (ISS) and Physiological Severity Score (PSS) was calculated as Spearman’s rho, because the ISS is a discontinuous variable. Spearman’s rho was ÷0.401, p <0.0005. This indicates that when the anatomical injury severity increases the physiological derangement is increased, which should be of no surprise.

Improving trauma care in rural Iran by training existing treatment chains

Iran has a major land mine injury problem in its border areas. Mine injuries have a high mortality and morbidity, and the injuries generally occur in remote areas. Iran has a well developed system of rural health workers and clinics, covering most border areas. These have mainly had prevention, immunization and curative treatment for medical conditions as their focus. We hypothesized that adding a short training in trauma care to the already existing system of rural health workers would improve the care for trauma victims. The objective of the present study was to describe the training and evaluate its effect using mortality and change in physiological function of victims after prehospital treatment as outcome measures. The training was arranged in villages and clinics in the border area. Physicians, nurses and emergency technicians from a local emergency clinic, the Mehran Clinic, were given a two-day course with monthly refreshers; while rural healthcare workers and lay people were given shorter training courses in their villages. All patients treated were registered and patients were followed up. Physiological changes after treatment was assessed with a modified three-component 'revised trauma score'. Patients entered the system directly through the local emergency clinic (some with prehospital treatment before arriving at the local emergency clinic). Some were transferred to the referral university hospital, and there they could be compared with a convenience comparison group of patients transported directly to the referral university hospital without treatment during transportation. During the three-year study period 109 physicians, nurses and 76 emergency technicians (behwarses) were trained, while 4649 lay persons had first-responder training. A total of 366 patients were treated by the system. Prehospital support was given to 238 victims before admission to the primary clinic. We found no difference in mortality between patients with and without first-responder treatment. In all, 226 of these patients were transferred to the university hospital. During the period a group of 245 other victims of injury was admitted directly to the university hospital. The physiological status of the transferred victims improved significantly by treatment from the emergency clinic to the university hospital with a mean improvement in the Physiological Severity Score (PSS) of 1.11 (95% CI 0.98-1.24). The PSS of the intervention group was significantly higher than the status of the group brought directly to the university hospital without treatment during transportation (difference 0.73, 95% CI difference 0.55-.91, p < 0.0005). We found that the existing rural healthcare system in Iran's western border area could be upgraded to care for mine victims and victims of other injuries by using available resources. This system improved the physiological status of the victims during transportation, and was able to handle penetrating as well as blunt injury. The use of existing health structures should be considered when planning improvements.

The role of performing life support courses in rural areas in improving pre-hospital physiologic conditions of patients with penetrating injuries.

To evaluate the impact of animal model based medical training courses for village healthcare workers on prehospital physiologic condition and prognosis of patients with penetrating injuries. Experimental study. This study was carried out in Mehran city and its neighbouring rural districts in western part of Iran from 2002 to 2004. Seventy-six village healthcare workers were trained and equipped to deliver in-field medical first cares. First group (226 patients) consisted of those who received this cares by the trained group and second group (245 patients) were those who received no in-field cares and were transported directly to the trauma center in provincial capital, Ilam. Physiologic Severity Score (PSS) was calculated to determine the physiologic condition of patients in both groups. The most prevalent cause of trauma in both groups was car accidents (61.6%). Controlling of hemorrhage was the most frequent provided initial medical care (40.6%). A significant improvement regarding the PSS score was observed in the first group of patients compared to the second group (7.505 vs. 6.799, 95% CI for difference: 0.3 to 0.9). The mortality rates of the first and second group of patients were 3% and 7.3%, respectively (p=0.051). Performing life support courses in rural areas of low-income countries where there is no pre-hospital triage and emergency medical system and provision of classic resuscitative measures are limited, has a significant impact on improvement of pre-hospital physiologic condition and prognosis of patients with penetrating injuries.

Optimal Surgical Performance Attenuates Physiologic Risk in High-Acuity Operations

The interplay between baseline physiology, operative performance, and postoperative recovery is poorly defined. We describe the beneficial effect of a successful operation on outcomes across the full spectrum of physiologic risk for an elective high-acuity procedure. Four hundred twelve consecutive pancreatic resections, performed between 2001 and 2008, were analyzed according to the Physiologic and Operative Severity Score for the Enumeration of Mortality and Morbidity. Baseline physiology was classified according to the Physiologic Severity Score: minor (< or = 16); intermediate (17 to 23); vulnerable (> or = 24). Surgical performance was assigned by the Operative Severity Score: class I (< or = 14); class II (15 to 17); class III (> or = 18). Physiologic and operative predictions were independently correlated with actual clinical and economic outcomes and then merged to measure the influence of surgical performance beyond baseline physiology. As baseline physiology declines, patients suffer more complications and require more therapeutic and invasive interventions. Within each physiologic risk grade, class I operations (optimal surgical performances) were associated with lower rates of morbidity, shorter hospital stays, and improved cost efficiency. Deeper analysis reveals that intraoperative blood loss is the most variable and influential factor affecting physiologic risk. Each additional unit (375 mL) of blood loss increases the odds of morbidity by 45%, prolongs hospital stay by 1 day, and costs an additional $4,000 per patient. Predictive risk assessment accurately demonstrates that escalating physiologic risk worsens postoperative morbidity, prolongs hospital duration, and increases costs after such high-acuity operations. These effects are attenuated by improved operative performance.

Unification of the Revised Trauma Score

The Revised Trauma Score (RTS) calculated with Major Outcome Trauma Study weights (MTOS-RTS) is currently the standard physiologic severity score in trauma research and quality control. It is often confused with the Triage-RTS (T-RTS), a version that is easier to calculate but only intended for clinical triage. To compare the accuracy of the MTOS-RTS to the RTS calculated with weights derived from the study population (POP-RTS) and the T-RTS, for predicting mortality in a trauma population. The study population consists of 22,388 patients, drawn from the trauma registries of three Level I trauma centers. The predictive accuracy of the MTOS-RTS, POP-RTS, and the T-RTS were compared using measures of discrimination and model fit from logistic regression models. The MTOS-RTS, the POP-RTS, and the T-RTS had the same discrimination (Area under the Receiver Operating Curve [AUC] = 0.841). The POP-RTS and the T-RTS had a slightly better model fit than the MTOS-RTS (AIC = 8010, 8010, and 8067, respectively). The T-RTS had equal discrimination and equal or better model fit than the MTOS-RTS in the whole sample, in each of the three trauma centers and in the population of patients with severe head trauma. The T-RTS was also equivalent to the POP-RTS in all of these population sub-groups. The T-RTS could replace the MTOS-RTS as the standard physiologic severity score for trauma outcome prediction. The advantages of using the T-RTS over the MTOS-RTS are ease of calculation, the need for only one measure for triage and mortality prediction purposes and universal adaptation to a broad range of trauma populations.

Mortality after acute surgery for complications of diverticular disease of the sigmoid colon is almost exclusively due to patient related factors

Auditing the outcome of surgery for complicated diverticulitis of the sigmoid colon is difficult. A comparison of studies is hardly possible because risk factors both in terms of the severity of diverticulitis and patient-related risk factors are neither well described nor standardized. The purpose of this study was to define morbidity and mortality of primary surgery for acute complications of diverticular disease of the sigmoid colon and to identify the relation between risk factors and morbidity and mortality. In a prospective computerized morbidity and mortality registration from 1990 to 2002, 114 patients, who underwent surgery on an acute or urgent base for acute complications of diverticular disease of the sigmoid colon, were identified. In all patients the POSSUM score was calculated. To audit mortality rates a POSSUM based scoring system was introduced. Mortality was 16.7%, and morbidity 71.1%. Higher morbidity rates were significantly related to a higher POSSUM physiological score (P = 0.012) and to older age (P < 0.001). Higher mortality rates also were significantly related to a higher POSSUM physiological score (P < 0.001) and older age (P = 0.003). Patients who died had significantly more sepsis (P < 0.001), multiple organ failure (P = 0.027), cardiac (P < 0.001) and pulmonary (P = 0.013) complications. Gender, operation indication and type of neither surgery nor surgeon had a significant relation with morbidity or mortality. Surgery for acute complications of diverticular disease of the sigmoid colon carries a high morbidity rate and a substantial mortality rate. The majority of deceased patients had severe comorbidity. Post-operative mortality and morbidity are to a large extent driven by patient related factors. Elevated physiological severity scores and a lack of peri-operative management failures express this in the majority of deceased patients.

POSSUM scoring for laparoscopic cholecystectomy in the elderly

Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) scoring is a validated scoring system in the audit of surgical outcomes; however, evaluation of this system has mostly been applied to open surgical techniques. The present study examines the validity of POSSUM in predicting morbidity and mortality in patients undergoing laparoscopic cholecystectomy (LC) with the recognized risk factor for postoperative mortality of advanced age. All patients aged 80 years or over undergoing LC in one surgical unit between January 1993 and December 1999 were identified from the surgical operations database of the hospital. Case-note review was used to collate data in terms of clinical and operative factors as described in POSSUM. Observed/POSSUM estimated (O/E) ratio of morbidity and 30-day mortality were calculated. Laparoscopic cholecystectomy was performed in 76 patients aged 80 years or over during the study period. Of these patients, case notes for 70 patients (92%) were available for review. Median (range) age was 83 years (80-93 years) and median (range) American Society of Anesthesiologists score was 2 (2-4). Twenty-six (34%) of 70 patients underwent cholecystectomy during an acute admission. The mean physiology severity score was 23 and operative severity score, 8. A significant postoperative morbidity was observed in 15 (22%) of 70 patients. There was no 30-day mortality. Using exponential analysis, POSSUM predicted morbidity in 15 patients and mortality in seven patients. Thus, O/E ratios for morbidity and mortality were 1 and 0, respectively. POSSUM scoring performs well in predicting morbidity, but overpredicts mortality, after LC in patients aged over 80 years. An assessment of its application to other laparoscopic procedures merits evaluation.

Respiratory rate as a prehospital triage tool in rural trauma.

Where trauma systems do not exist, such as in low-income countries, the aim of prehospital triage is identification of trauma victims with high priority for forward resuscitation. The present pilot study explored the accuracy of simple prehospital triage tools in the hands of nongraduate trauma care providers in the minefields of North Iraq and Cambodia. Prehospital prediction of trauma death and major trauma victims (Injury Severity Score > 15) was studied in 737 adult patients with penetrating injuries and long evacuation times (mean, 6.1 hours). Both the respiratory rate and the full Physiologic Severity Score predicted trauma death with high accuracy (area under the curve for receiver-operating characteristic plots at 0.9) and significantly better than other physiologic indicators. The accuracy in major trauma victim identification was moderate for all physiologic indicators (area under the receiver-operating characteristic curve, 0.7-0.8). Respiratory rate > 25 breaths/min may be a useful triage tool for nongraduate trauma care providers where the scene is chaotic and evacuations long. Further studies on larger cohorts are necessary to validate the results.