Machine learning-based clinical decision support for infection risk prediction

BackgroundHealthcare-associated infection (HAI) remains a significant risk for hospitalized patients and a challenging burden for the healthcare system. This study presents a clinical decision support tool that can be used in clinical workflows to proactively engage secondary assessments of pre-symptomatic and at-risk infection patients, thereby enabling earlier diagnosis and treatment.MethodsThis study applies machine learning, specifically ensemble-based boosted decision trees, on large retrospective hospital datasets to develop an infection risk score that predicts infection before obvious symptoms present. We extracted a stratified machine learning dataset of 36,782 healthcare-associated infection patients. The model leveraged vital signs, laboratory measurements and demographics to predict HAI before clinical suspicion, defined as the order of a microbiology test or administration of antibiotics.ResultsOur best performing infection risk model achieves a cross-validated AUC of 0.88 at 1 h before clinical suspicion and maintains an AUC >0.85 for 48 h before suspicion by aggregating information across demographics and a set of 163 vital signs and laboratory measurements. A second model trained on a reduced feature space comprising demographics and the 36 most frequently measured vital signs and laboratory measurements can still achieve an AUC of 0.86 at 1 h before clinical suspicion. These results compare favorably against using temperature alone and clinical rules such as the quick sequential organ failure assessment (qSOFA) score. Along with the performance results, we also provide an analysis of model interpretability via feature importance rankings.ConclusionThe predictive model aggregates information from multiple physiological parameters such as vital signs and laboratory measurements to provide a continuous risk score of infection that can be deployed in hospitals to provide advance warning of patient deterioration

Frequency of Laboratory Test Utilization in the Intensive Care Unit and Its Implications for Large-Scale Data Collection Efforts

Objective: Mapping local use names to standardized nomenclatures such as LOINC (Logical Observation Identifiers Names and Codes) is a time-consuming task when done retrospectively or during the configuration of new information systems. The author sought to identify a subset of intensive care unit (ICU) laboratory tests, which, because of their frequency of use, should be the focus of efforts to standardize test names in ICU information systems. Design: The author reviewed the ordering practices in medical, surgical, and pediatric ICUs within a large university teaching hospital to identify the subset of laboratory tests that represented the majority of tests performed in these settings. The author compared the results of his findings with the laboratory tests required to complete several of the most frequently used ICU acuity scoring systems. Results: It was found that between 104 and 202 tests and profiles represented 99% of all testing in the three ICUs. All the laboratory studies needed for six commonly used ICU scoring systems fell into the top 21 laboratory studies and profiles performed in each ICU. Conclusion: The author identified a small subset of the LOINC database that should be the focus of efforts to standardize test names in ICU information systems. Mapping this subset of laboratory tests and profiles to LOINC vocabulary will simplify the process of collecting data for large-scale databases such as ICU scoring systems and the configuration of new ICU information systems

Cardiovascular abnormalities in infants prenatally exposed to cocaine

This study utilized a historical cohort to examine the relationship between maternal cocaine use during pregnancy and the occurrence of congenital cardiovascular abnormalities. All neonatal drug screens performed at Boston City Hospital during an 18-month period were reviewed (n=554); for 214 (39%) screened high-risk neonates, results of toxicologic screens were positive for cocaine, and 340 (61%) neonates had no detectable cocaine. We compared the occurrence of cardio vascular malformations and electrocardiographic abnormalities in these two groups. Matches were sought between these 554 infants and our pediatric cardiology data base, which consisted of inpatient consultation, outpatient consultation, and electrocardiography. Forty-nine patients had drug screens and were also entered into our cardiology data base: 25 had both consultations and electrocardiograms, and 24 had electrocardiograms only. The rate of cardiac anomalies among the cocaine-positive infants was significantly higher (relative risk=3.7; 95% confidence interval:(1.4, 9.4)) than the rate of these anomalies among the cocaine-negative comparison group (65/1000 vs 18/1000); the rate for cocaine-positive infants was also significantly higher than published rates for general populations of infants. Several electrocardiographic abnormalities, high-grade ventricular ectopy, and cardiorespiratory arrests were also noted in our study population. We conclude that cocaine exposure during prenatal life appears to predispose infants to structural cardiovascular maiformations, electrocardiographic abnormalities, and, possibly, cardiopulmonary autonomic dysfunction

Tracheal bronchus: a cause of prolonged atelectasis in intubated children

Tracheal bronchus is a common anomaly that occurs in approximately 2% of people. Two children with multiple medical problems which led to endotracheal intubation are described. The hospital course for each child was complicated by persistent right upper lobe atelectasis. The presence of a tracheal bronchus was not recognized in either case initially; identification of this anatomic variant allowed appropriate changes in airway management. The potential for tracheal bronchus to cause, or be associated with, localized pulmonary problems is reviewed. The diagnosis of tracheal bronchus should be considered early in the course of intubated patients with right upper lobe complications

An unusual cause of respiratory distress in a neonate

Congenital nasolacrimal duct obstruction with cystic extension into the nasopharynx (dacryocystocele) is a rare cause of respiratory distress in the neonate. We describe the pediatric intensive care unit (PICU) course of a newborn with this disorder who had severe distress and in whom the diagnosis was originally missed

Arrhythmias in Children Prenatally Exposed to Cocaine

OBJECTIVES: To describe the time of detection, electrophysiologic mechanism, and severity of hemodynamic sequelae of arrhythmias in infants and children prenatally exposed to cocaine and to determine whether the incidence of severe neonatal arrhythmia is related to prenatal exposure to cocaine. DESIGN: Characteristics of arrhythmias are described for all significant arrhythmias detected at Boston (Mass) City Hospital in infants and children with known cocaine exposure, as well as a convenience sample of children from Children's Hospital, Boston. A historical cohort was used to calculate the rates of cardiac consultation for arrhythmia among children prenatally exposed to cocaine and among children with no known cocaine exposure. STUDY POPULATION: Characterization of the arrhythmias is based on case studies of 18 children. The rate of arrhythmia consultation was calculated from 554 infants who had urine toxic screens for cocaine and from 13 arrhythmias detected between 1988 and 1991. OUTCOME MEASURES: Prenatal cocaine exposure; the time of detection, electrophysiologic mechanism, and severity of hemodynamic sequelae of arrhythmias; and the incidence of cardiology consultation for arrhythmia in infants and children prenatally exposed to cocaine. RESULTS: Fetal arrhythmia persisted into the neonatal period in three cocaine-exposed infants; two were delivered via emergency cesarean sections for presumed fetal bradycardia and were subsequently found to have asymptomatic frequent and blocked atrial premature beats. Including these three infants, arrhythmia was observed in 13 cocaine-exposed neonates; 12 had a variety of supraventricular arrhythmias and four had low-grade ventricular ectopy. Arrhythmia resulted in congestive heart failure in five (38%) of 13 neonates. Six occurrences of arrhythmia were observed beyond the neonatal period among five cocaine-exposed infants. Late arrhythmias included high-grade ventricular arrhythmias and resulted in two cardiorespiratory arrests. In addition, neonates with known exposure to cocaine were more likely to have a consultation for arrhythmia than neonates without known exposure. CONCLUSIONS: Sustained arrhythmias may result from an increased number of potential initiating premature beats in children prenatally exposed to cocaine. These effects persist beyond the period of exposure and are associated in some children with congestive heart failure, cardiorespiratory arrest, and death. Prenatal cocaine exposure increases the incidence of consultation for atrial and ventricular arrhythmias.(Arch Pediatr Adolesc Med. 1994;148:1163-1169