Risk Of Hospital Death Research Articles

Mortality associated with delay in operation after hip fracture: observational study

Objective To estimate the number of deaths and readmissions associated with delay in operation after femoral fracture.Design Analysis of inpatient hospital episode statistics.Setting NHS hospital trusts in England with at...

The use of routine laboratory data to predict in-hospital death in medical admissions

The ability to predict clinical outcomes in the early phase of a patient's hospital admission could facilitate the optimal use of resources, might allow focused surveillance of high-risk patients and might permit early therapy. We investigated the hypothesis that the risk of in-hospital death of general medical patients can be modelled using a small number of commonly used laboratory and administrative items available within the first few hours of hospital admission. Matched administrative and laboratory data from 9497 adult hospital discharges, with a hospital discharge specialty of general medicine, were divided into two subsets. The dataset was split into a single development set, Q 1 ( n = 2257), and three validation sets, Q 2, Q 3 and Q 4 ( n 1 = 2335, n 2 = 2361, n 3 = 2544). Hospital outcome (survival/non-survival) was obtained for all discharges. An outcome model was constructed from binary logistic regression of the development set data. The goodness-of-fit of the model for the validation sets was tested using receiver–operating characteristics curves ( c-index) and Hosmer–Lemeshow statistics. Application of the model to the validation sets produced c-indices of 0.779 (Q 2), 0.764 (Q 3) and 0.757 (Q 4), respectively, indicating good discrimination. Hosmer–Lemeshow analysis gave χ 2 = 9.43 (Q 2), χ 2 = 7.39 (Q 3) and χ 2 = 8.00 (Q 4) ( p-values of 0.307, 0.495 and 0.433) for 8 degrees of freedom, indicating good calibration. The finding that the risk of hospital death can be predicted with routinely available data very early on after hospital admission has several potential uses. It raises the possibility that the surveillance and treatment of patients might be categorised by risk assessment means. Such a system might also be used to assess clinical performance, to evaluate the benefits of introducing acute care interventions or to investigate differences between acute care systems.

Disturbed consciousness, old age and less institutional experience predict increased mortality in people thrombolysed for ischaemic stroke

QuestionWhat factors predict death during hospitalisation in people receiving intravenous tissue plasminogen activator (tPA) for ischaemic stroke?Study designProspective cohort study.Main results166 people died after receiving tPA in hospital for ischemic stroke. 42% of deaths occurred within 3 days and 68% within 1 week. Older age and disturbed levels of consciousness increased the risk of death during hospitalisation (see results table). The highest mortality was seen for people with a disturbance of consciousness aged over 74 years or more. Mortality was higher in hospitals with less experience with tPA (see results table)Authors’ conclusionsOlder age and disturbed levels of consciousness increase the risk of death in hospital from tPA administration in people with ischemic stroke. Risk of death decreased with increased experience in tPA administration of the treating hospital.

Evaluating hospital care for individuals with Alzheimer's disease using inpatient quality indicators.

The purpose of this study was to determine whether persons with Alzheimer's disease (AD) were at greater risk for in-hospital mortality than non-AD patients as a result of poor quality of care. The study focused on six common medical conditions that result in hospital mortality. Using 1995 to 2000 data from New York state (n = 7,021,065), analysts compared mortality risk for individuals with and without AD. Among men, adjusted odds of death were greater for those with AD for gastrointestinal (GI) hemorrhage (+52 percent), congestive heart failure (CHF) (+42 percent), hip fracture (+35 percent), and acute myocardial infarction (AMI) (+30 percent) (all p < .0001). Among women, AD did not affect risks for most conditions. The results of the study show that men with AD are at higher risk of hospital mortality for common medical conditions, which may indicate poor quality of care. Their risk of hospital death was greater than that of men without AD for AMI, CHF, hip fracture, and GI hemorrhage. Their risk was also greater than that of women with AD for CHF, pneumonia, hip fracture, and GI hemorrhage. With the exception of pneumonia, this risk difference notably exceeded the analogous difference between women and men without AD. Hospital staff should be alerted to greater mortality risk for men with AD, as this risk may indicate lower quality of care.

The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study

IntroductionCompliance with the ventilator care bundle affects the rate of ventilator-associated pneumonia. It was not known, however, whether compliance with sepsis care bundles has an impact on outcome. The aims of the present study were to determine the rate of compliance with 6-hour and 24-hour sepsis bundles and to determine the impact of the compliance on hospital mortality in patients with severe sepsis or septic shock.MethodsWe conducted a prospective observational study on 101 consecutive adult patients with severe sepsis or septic shock on medical or surgical wards, or in accident and emergency areas at two acute National Health Service Trust Teaching hospitals in England. The main outcome measures were: the rate of compliance with 6-hour and 24-hour sepsis care bundles adapted from the Surviving Sepsis Campaign guidelines on patients' clinical care; and the difference in hospital mortality between the compliant and the non-compliant groups.ResultsThe median age of the patients was 69 years (interquartile range 51 to 78), and 53% were male. The sources of infection were sought and confirmed in 87 of 101 patients. The chest was the most common source (50%), followed by the abdomen (22%). The rate of compliance with the 6-hour sepsis bundle was 52%. Compared with the compliant group, the non-compliant group had a more than twofold increase in hospital mortality (49% versus 23%, relative risk (RR) 2.12 (95% confidence interval (CI) 1.20 to 3.76), P = 0.01) despite similar age and severity of sepsis. Compliance with the 24-hour sepsis bundle was achieved in only 30% of eligible candidates (21/69). Hospital mortality was increased in the non-compliant group from 29% to 50%, with a 76% increase in risk for death, although the difference did not reach statistical significance (RR 1.76 (95% CI 0.84 to 3.64), P = 0.16).ConclusionNon-compliance with the 6-hour sepsis bundle was associated with a more than twofold increase in hospital mortality. Non-compliance with the 24-hour sepsis bundle resulted in a 76% increase in risk for hospital death. All medical staff should practise these relatively simple, easy and cheap bundles within a strict timeframe to improve survival rates in patients with severe sepsis and septic shock.

Surgical patients are at lower risk of death in hospitals with more degree-educated nurses

Question What is the relationship between the education level of hospital nurses and risk-adjusted 30-day mortality in surgical patients? Study design Outcomes analysis using questionnaire and hospital discharge data. Main results Risk of 30-day mortality reduced by 5% when the proportion of degree-educated nurses increased by 10% ( p⩽0.02). A mean workload increase of one patient per nurse increased risk of 30-day mortality by 5% ( p⩽0.03). Hospitals with more degree-educated nurses were: larger, more likely to undertake advanced surgical techniques ( p<0.001), more commonly teaching hospitals and had lower mean work loads ( p<0.001). Length of nursing experience was not found to be a predictor of mortality ( p>0.52). Authors’ conclusions People were less likely to die after surgery in hospitals with a higher proportion of degree-educated nurses.

Mortalidad intrahospitalaria tras el alta de una unidad de cuidados intensivos en pacientes que han precisado ventilación mecánica

Our goal was to determine the hidden mortality (HM) in patients who underwent an episode of mechanical ventilation (MV). We also analyzed the factors associated with an increase in the risk of hidden mortality. Prospective cohort study. Patients admitted to an ICU who required MV and who were monitored until their discharge from hospital. We performed a multivariate study with a logistic regression model including all the variables that were present in a univariate analysis p < 0.20. Forty-one of the 215 patients who were discharged from the ICU died when they were admitted to hospital, which represents a hidden mortality rate of 19% (CI 95% 11%-27%). A mean period of 9 days elapsed between discharge from the ICU and patient's death, with 25% of patients dying within the first two days. Commonest cause of death was respiratory failure (37%). Factors independently associated with an increase in the risk of hidden mortality were (values expressed as adjusted odds ratio (CI 95%): age > 74 years 1.15 (1.01 to 1.26) (p = 0.02); APACHE II > 29 1.14 (1.01 to 1.27) (p = 0.04); reason for MV being coma 1.21 (1.07 to 1.37) (p = 0.002); reason for MV being cardiopulmonary arrest 1.28 (1.18 to 1.68) (p < 0.001); tracheotomy in ICU 1.31 (1.19 to 1.68) (p < 0.001) and stay in the ICU longer than 16 days 1.35 (1.01 to1.70) (p = 0.04). An important number of patients discharged from the ICU after an episode of MV die in hospital. Risk factors associated with an increased risk of death in hospital identify a group of patients who, after excluding those with non-cardiopulmonary resuscitation orders, would possibly benefit from high surveillance or intermediate care units.

¿Se puede identificar mediante el EuroSCORE a los pacientes con mortalidad mínima en cirugía cardíaca?

Risk of hospital death is one of the key factors considered by the clinical cardiologist when weighting indications for surgery. Risk estimation scales establish distinct levels of risk in quantitative terms. The aim of the present study was to investigate whether a low EuroSCORE value corresponds to low mortality in our setting. During 1999-2000 we prospectively calculated the EuroSCORE for all patients who underwent isolated coronary (CS) or valvular (VS) surgery. We then analyzed intrahospital mortality of patients with a low EuroSCORE. The validation group consisted of patients who underwent surgery in 2001 and obtained a low EuroSCORE. During 1999-2000 we identified 116 patients (16.2% of all patients treated with isolated CS or CV) with a low EuroSCORE (50 8.6 years; 65% male). Fifty-seven of these patients underwent isolated CS, and 59 of them isolated VS. Intrahospital mortality was zero. In 2001 we identified 59 (16.1%) such patients (49 8.7 years; 68% male), of whom 35 underwent isolated CS and 24 underwent isolated VS. Intrahospital mortality during this period was again zero. A low EuroSCORE identifies a population of patients with minimum risk of mortality after isolated coronary or valve surgery. The score may be useful as a sentinel indicator in analyses of the complex issue of quality of cardiac surgery.

Role of coronary interventional procedures in improved postinfarction survival in the 1990s

The contribution of increased use of same-admission percutaneous coronary interventional procedures to recent improvements in hospital survival of patients with acute myocardial infarction (AMI) remains unclear. Patients with International Classification of Diseases codes for AMI (code 410), who were admitted to the emergency coronary care unit and underwent an initial episode of treatment, were studied over the 9-year period 1990 to 1998 (n = 2,628). Three triennia between 1990 and 1998 were compared. Trends in risk, the use of procedures, and hospital outcomes were analyzed. Hospital mortality was 33% lower (p <0.02) in the third triennium (5.8%) than in the earlier 2 triennia (8.7%), equivalent to an absolute reduction of 29 hospital deaths/1,000 patients treated. The lower hospital mortality was not due to: (1) shorter hospital stays (reduction in mortality was primarily in the first 3 hospital days), (2) treatment of lower risk subjects (a risk score based on age, gender, and presence of diabetes increased between the first and third triennia), or (3) use of in-hospital interventional procedures (although the use of percutaneous coronary intervention more than doubled in the third triennium, most procedures were performed in patients with a 1% risk of hospital death). We conclude from this study that there has been a substantial improvement over a 9-year period in early case fatality after AMI, but that this cannot be attributed to the increased use of in-hospital coronary interventions, which were largely performed on low-risk patients.

Extravasation of radiographic contrast is an independent predictor of death in primary intracerebral hemorrhage.

Hematomas that enlarge following presentation with primary intracerebral hemorrhage (ICH) are associated with increased mortality, but the mechanisms of hematoma enlargement are poorly understood. We interpreted the presence of contrast extravasation into the hematoma after CT angiography (CTA) as evidence of ongoing hemorrhage and sought to identify the clinical significance of contrast extravasation as well as factors associated with the risk of extravasation. We reviewed the clinical records and radiographic studies of all patients with intracranial hemorrhage undergoing CTA from 1994 to 1997. Only patients with primary ICH were included in this study. Univariate and multivariate logistic regression analyses were performed to determine the associations between clinical and radiological variables and the risk of hospital death or contrast extravasation. Data were available for 113 patients. Contrast extravasation was seen in 46% of patients at the time of CTA, and the presence of contrast extravasation was associated with increased fatality: 63.5% versus 16.4% in patients without extravasation (P=0.011). There was a trend toward a shorter time (median+/-SD) from symptom onset to CTA in patients with extravasation (4.6+/-19 hours) than in patients with no evidence of extravasation (6.6+/-28 hours; P=0.065). Multivariate analysis revealed that hematoma size (P=0.022), Glasgow Coma Scale (GCS) score (P=0.016), extravasation of contrast (P=0.006), infratentorial ICH (P=0.014), and lack of surgery (P<0.001) were independently associated with hospital death. Variables independently associated with contrast extravasation were hematoma size (P=0.024), MABP >120 mm Hg (P=0.012), and GCS score of </=8 (P<0.005). Contrast extravasation into the hematoma after ICH is associated with increased fatality. The risk of contrast extravasation is increased with extreme hypertension, depressed consciousness, and large hemorrhages. If contrast extravasation represents ongoing hemorrhage, the findings in this study may have implications for therapy of ICH, particularly with regard to blood pressure management.

Mortality, Risk Indicators, Mode and Place of Death and Symptoms of Angina Pectoris in the Five Years after Coronary Artery Bypass Grafting in Patients With and Without a History of Hypertension

Aim: To describe mortality, risk indicators for death, place and mode of death, and symptoms of angina pectoris among survivors in the 5 years after coronary artery bypass grafting (CABG) in patients with and without a history of hypertension. Methods: All patients in western Sweden who underwent CABG without concomitant valve surgery and without previously performed CABG between June 1988 and June 1991. Results: A total of 1997 patients were included in the analysis, 740 (37%) of whom had a history of hypertension. Patients with no history had a 5-year mortality of 12.4%. The corresponding relative risk for hypertensives was 1.4 (95% CI 1.1-1.8). Risk factors for death appeared similar in patients with and without a history of hypertension. Patients with hypertension had an increased risk of death in hospital and an increased risk of a non-cardiac death. Among survivors after 5 years, patients with a history of hypertension tended to have a higher prevalence of symptoms equivalent to angina pectoris. Conclusions: Patients with a history of hypertension have an increased risk of death in the 5 years after CABG. Risk factors for death appear similar in patients with and without a history of hypertension. Patients with hypertension have a particularly increased risk of death in hospital and of death judged as non-cardiac.

Mortality Risk and Patterns of Practice in 2,070 Patients With Acute Myocardial Infarction, 1987-92: Relative Importance of Age, Sex, and Medical Therapy

<h3>Objective</h3> To define contemporary age- and sex-related mortality risks and patterns of medical practice in acute myocardial infarction (AMI). <h3>Design</h3> Retrospective comparison of demographic and clinical variables, including the use of proven effective AMI medical therapy, among AMI patient cohorts from 1987 to 1992. <h3>Patients/Setting</h3> Of a total of 2,070 AMI patients, 629 were women and 1,441, men; 951 patients were managed in university hospitals, 641 in a regional hospital, and 478 in community hospitals. <h3>Interventions</h3> No direct study interventions; results of practice patterns and risk analyses of the earlier (1987-90) AMI cohorts, however, were published concurrently with the actual practices of the more recent (1991-92) cohorts and may have had some indirect effect on the recent practice patterns. <h3>Results</h3> Univariate analysis showed that mortality was higher (p<0.0001) and use of thrombolysis, beta blockers, and acetylsalicylic acid was lower (p<0.0001) in patients 70 years of age and older, compared with younger patients, and in women, compared with men. Multivariate analysis of the entire patient sample revealed age of 75 years or older (154 percent) and age 70 to 74 years (141 percent) to be associated with the highest relative risk of death in hospital. The increased relative risk associated with previous AMI was 45 percent. Acetylsalicylic acid use was associated with the greatest decrease in relative risk of death (—69 percent), followed by beta blockers (—36 percent) and thrombolysis (—31 percent). These patterns of relative risk were the same for men and women. <h3>Conclusions</h3> Among contemporary AMI patients, advanced age and female sex are associated with relative under-utilization of proven effective medical therapy and increased risk of dying in the hospital. Although the contribution of age to AMI risk appears greater than that of gender, survival in any high risk group would likely be improved by increased use of proven medical therapy. (<i>Chest 1994; 105:1687-92</i>)

Combined valve and coronary artery bypass surgery: early and late results.

Determinants of early, late and event-free survival of combined valve and coronary artery bypass graft (CABG) surgery were studied in 420 patients using multivariate analysis. It was found that the risk of hospital death increases 5 times when the preoperative NYHA class was > or = IV, 3 times when left ventricular (LV) function is significantly impaired and is double when mitral regurgitation is present. The survival probability of hospital survivors was 91% (87.3-94.5%) at 5 years. Late mortality was determined by advanced preoperative NYHA class ( > or = IV) and the presence of mitral regurgitation. The event-free survival probability of hospital survivors, i.e. total events including death, valve-related complications, ischemic complications and recurrent NYHA class > or = IV, was 73.0% (66.7-79.5%) at 5 years. Postoperative events were determined by the presence of preoperative NYHA class > or = IV, impaired ventricular function, mitral regurgitation and non-sinus rhythm. It is concluded that these parameters can be considered as the most important predictors of clinical outcome after combined valve and CABG surgery.

Evaluation of Definitions for Sepsis

To evaluate the current definitions for sepsis and clarify and quantify the risk for intensive care unit (ICU) patients with sepsis. A prospective cohort analysis of 519 patients with a primary clinical diagnosis of sepsis treated in the ICUs of 40 US hospitals drawn from a nationally representative sample of 17,440 admissions. Patient's age, treatment location prior to ICU admission, comorbidities, origin of sepsis, daily physiologic measurements, therapeutic intensity, and subsequent hospital mortality rate. Patients were categorized into subgroups by important risk factors and into current clinical definitions of sepsis. Patients also were provided an individual risk of hospital mortality based on their individual predicted risk by using the first ICU day APACHE III score, treatment location prior to ICU admission, and etiology of sepsis. Patients with a designated urinary source of sepsis had a significantly lower baseline risk of death (30 percent) than patients with other causes (54 percent, p less than 0.01). Patients admitted to the ICU from the emergency department also had significantly lower mortality (37 percent) than patients admitted from hospital wards, other units within the hospital, or transferred from other hospitals (55 percent, p less than 0.01). Recognized definitions such as "sepsis syndrome" and "septic shock" identified groups of patients with significantly different mortality rates, 40 percent and 64 percent, respectively (p less than 0.01), but the range of individual patient risks within these groups were indistinguishable from the 211 patients (41 percent) that did not meet these definitions during the initial seven days of ICU treatment. Multivariate analysis using initial APACHE III score, etiology (urosepsis or other), and treatment location prior to ICU admission provided the greatest degree of discrimination (ROC = 0.82) of patients by risk of hospital death. Sepsis is a complex clinical entity and could be viewed as a continuum with substantial variation in initial severity and risk of hospital death. One accurate description of sepsis is the continuous measure of hospital mortality risk estimated primarily from physiologic abnormalities.

Epidemiology in Anaesthesia

Data on 13 043 operations were abstracted from 108 878 anaesthetic records in the Cardiff Anaesthetic Record System. Nine groups of surgical operations with high mortality in hospital were identified. These records were analysed using a logistic regression model to determine the probability of death in hospital. Variables included in the model were age, sex, elective or emergency operation and five intercurrent diseases. The significance of individual variables was assessed: age was the most important single variable in six of the nine operation groups. The model was used to calculate the risk of death in hospital for individuals with specific characteristics. With further development, this technique might be used by clinicians at other centres to predict the outcome for patients under their care.

Prosthetic fitting in lower limb amputees.

A series of 320 patients with lower limb amputations was analyzed. Among patients admitted from home the risk of death in hospital, was 24 per cent (28/119) following AK amputation, as compared to 14 per cent (6/43) after TK amputation and 12 per cent (12/103) after BK amputation. Successful prosthetic fitting was achieved in 41 per cent (43/91) after AK amputation, 75 per cent (28/37) after TK amputation and 70 per cent (64/91) after BK amputation, including the 21 per cent (45/219) of patients discharged to a nursing home.

Incremental risk factors in hospital mortality rate after repair of ventricular septal defect

A total of 312 patients with single or multiple ventricular septal defects (VSD) with or without major associated lesions underwent surgical repair between 1967 and 1979. In the overall experience in patients without major associated defects, six hospital deaths (3.6%) occurred among 166 patients undergoing primary repair of single large VSDs, but in the last 5 years, one death (1.1%) occurred among 94 patients. Among the 29 patients with multiple VSDs, nine deaths (31%) occurred, but only one (7%) among the 14 operated upon in the last 5 years. In both groups, young age was an incremental risk factor for hospital death overall, but not in the last 5 years. Neither the location of the VSD nor the surgical approach were risk factors. Among 58 patients with major associated lesions and either single or multiple VSDs, 14 (24%) died after operation. In this subset, risk of hospital death did not decline during the 12 year period, and young age remained a significant incremental risk factor throughout. Of 261 patients with a single VSD and without a straddling tricuspid valve, one (0.4%) developed complete heart block, as did two (4%) of 47 patients with multiple VSDs. The decrease in hospital mortality rate with time and the neutralization of young age and multiplicity of VSDs as important incremental risk factors resulted from improvements such as more precise preoperative diagnosis of location and number of VSDs and improved intraoperative and postoperative care. The incremental risk of major associated lesions, especially in the very young and in those with multiple VSDs, should be neutralized in the future by-further research and development. However, in the meantime, management in most subsets should be individualized.

Classic Shunting Operations as Part of Two-Stage Repair for Tetralogy of Fallot

One hundred forty-nine consecutive patients with tetralogy of Fallot, with or without pulmonary atresia, underwent Blalock-Taussig or Waterston operation for initial palliation. Of these patients, 45 were less than 6 months old, and 63 were less than 1 year old. The type of shunt, and the presence or absence of pulmonary atresia did not have a significant effect ( p > 0.2) on hospital mortality. Parametric analysis showed a significant effect of age ( p = 0.03), the risk of hospital death being 6% at 1 month of age, 4% at 3 months, 3% at 6 months, and 2.5% at 12 months. No late deaths occurred before the age of 3 years. Six patients (4.2% of the hospital survivors) required another operation before they were 3 years old. Severe arm ischemia occurred after a Blalock-Taussig shunt in 1 infant with Down's syndrome.