Predictors Of Hospital Death Research Articles

The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units

Assessment of different hospitals' performance in neonatal intensive care has tended to rely on risk of mortality adjusted only for birthweight. We have developed a neonatal scoring system, CRIB (clinical risk index for babies), to take account of other factors. Scores are given for birthweight, gestational age, maximum and minimum fraction of inspired oxygen and maximum base excess during the first 12 h, and presence of congenital malformations. CRIB was developed retrospectively in a cohort of 812 infants of birthweight 1500 g or less or gestational age less than 31 weeks treated in four UK tertiary hospitals between 1988 and 1990. The scoring system was then validated by comparing its value as a predictor of hospital death with that of birthweight in a separate cohort of 488 similar infants. The area under the receiver operating characteristic (ROC) curve for predicting death in this validation cohort (a measure of the predictor's accuracy) was significantly greater for CRIB than for birthweight alone (0·90 [SE 0·05] vs 0·78 [0·03], p=0·03). Both indices of initial risk were used to assess the performance of nine tertiary and four non-tertiary hospitals in the UK. We looked at hospital mortality among the 1300 infants in the development and validation cohorts plus 248 other infants of birthweight 1500 g or less or gestational age less than 31 weeks. Without adjustment for initial risk, there was no clear difference in group mortality between the tertiary and non-tertiary hospitals. However, calculation of risk- adjusted mortality by means of CRIB showed that babies were twice as likely to die in the non-tertiary hospitals as in the tertiary hospitals (odds ratio 2·12 [95% Cl 1·39-3·24]). Adjustment for birthweight alone also showed higher odds of death in non-tertiary hospitals (1·45 [1·01-2·11]). CRIB is a robust index of initial neonatal risk that is more accurate than birthweight and simple enough for routine use. International comparisons of staffing policy and organisation of neonatal intensive care units are needed to investigate the reasons for variations in performance.

Multivariate analysis in the prediction of death in hospital after acute myocardial infarction.

Prognostic factors in patients with acute myocardial infarction based on clinical and investigative data on admission were evaluated prospectively in 111 consecutive patients. Seventeen patients (15.3%) died during hospital stay. Age, a previous infarct, high Killip class, cardiomegaly, high serum concentrations of cardiac enzymes, a low ejection fraction, and a high wall motion score index correlated significantly with in-hospital mortality; whereas sex, risk factors, and pericardial effusion did not. Multivariate analysis showed that age and the wall motion score index were the best predictors of death in hospital. Wall motion detected by cross sectional echocardiography may reflect the extent of myocardial involvement. Age and wall motion score index predicted in-hospital mortality with a sensitivity of 76.5%, a specificity of 91.5%, and a predictive accuracy of 89.2%. Age and the wall motion score index can be determined on admission and are useful for identifying patients at high risk of cardiac death who might benefit from early intervention.

Risk factors for pulmonary thromboendarterectomy

Pulmonary thromboendarterectomy is being performed with increasing frequency for incapacitating pulmonary hypertension caused by chronic large-vessel pulmonary embolism. However, patient-related risk factors and procedural complications associated with morbidity and mortality have not been fully defined. From Oct. 1, 1984, to April 10, 1989, we performed pulmonary thromboendarterectomy using deep hypothermia and circulatory arrest in 127 consecutive patients (62.2% male, mean age 50 +/- 16 [standard deviation], range 20 to 82 years) in whom the exposure and dissection of the pulmonary arteries and methods for myocardial protection have been standardized. End points for univariate and multivariate analyses of risk factors were reperfusion pulmonary edema leading to respiratory insufficiency as defined by ventilator dependency (greater than or equal to 5 days) (31.5%, 39/124) and hospital mortality (12.6%, 16/127). Multivariate analyses showed that ascites and need for 4 units of blood or more predicted ventilator dependency (p less than 0.03). Increased cardiopulmonary bypass times predicted both end points (p less than 0.03 to less than 0.0001), and failure to achieve at least a 50% reduction in pulmonary vascular resistance strongly predicted hospital death (p less than 0.0001). However, other factors that exhibited trends for association with one of the end points may prove important with a larger sample size. A hospital mortality rate of 12.6% for pulmonary thromboendarterectomy is acceptable when compared with approximately 25% for heart-lung transplantation, which is the only therapeutic alternative. Increased ventilator dependency and hospital mortality can be anticipated with longer cardiopulmonary bypass times and inadequate reduction of pulmonary vascular resistance.

Coronary angioplasty in acute myocardial infarction: Should it be done? to whom? when?

In this issue of the Journal, Ellis et al. (1) describe the results of primary coronary angioplasty without prior thrombolytic therapy performed in the setting of acute myocardial infarction. The study patients were classified into 139 patients who received angioplasty 6 to 48 h after the onset of chest pain (late group) and 117 patients treated with angioplasty within 6 h of chest pain (early group). All patients underwent angioplasty on the basis of clinical evidence of ongoing ischemia or hemodynamic compromise. Patients with left main coronary artery disease or combination disease of the proximal left anterior descending and left circumflex coronary arteries were excluded, as were patients with lesions not suitable for attempted angioplasty. The late group had more patients with diabetes mellitus (19.4% versus 7.4%, p = 0.003), multivessel disease (61.2% versus 48.7%, p = 0.05) and a lower ejection fraction (44% versus 49%, p = 0.001). Successful coronary angioplasty was accomplished in 78.4% of the late group and 71.8% of the early group (hospital mortality rate 13.7% in both groups). Successful angioplasty was associated with a 5.5% hospital mortality rate, whereas unsuccessful angioplasty was associated with a 43.3% hospital mortality rate (p < 0.001). The predictors of hospital death were cardiogenic shock, low ejection fraction, unsuccessful angioplasty and older age. The time to angioplasty was not a predictor of outcome. The authors conclude that late emergency angioplasty may be justified when the likelihood of angioplasty success is very high. Assessing the role of coronary angioplasty. This large experience of early primary angioplasty in the absence of prior thrombolytic therapy is noteworthy and points to the difficulty in assessing the role of angioplasty in acute myocardial infarction. As the authors correctly note, the patients