Prospective validation of a checklist to predict short-term death in older patients after emergency department admission in Australia and Ireland

Abstract Background Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end-of-life discussions. Methods Prospective cohorts of >65-year-old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose-trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow-up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in-hospital death was the secondary outcome. Results A total of 1,182 patients, with median age 76 to 80 years (IRE-AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7–8.6) versus 5.7 (95% CI = 5.1–6.2) and Irish mean of 7.7 (95% CI = 6.9–8.5) versus 5.7 (95% CI = 5.1–6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver-operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short-term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in-hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. Conclusions The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation

Temporal and Spatial Clustering of Bacterial Genotypes

Genotypic characterization of bacterial isolates provides valuable information for epidemiological surveillance and microbial population biology. In particular, the ability to discern clonal relatedness among isolates can be used to identify links and sites of transmission, some of which are not easily traced using conventional contact investigation. The spatial and temporal clustering of isolates that share the same or closely related genotypes can add further value to the use of molecular fingerprinting in the detection and management of infectious disease outbreaks. This chapter reviews and discusses the use of both spatio-temporal clustering and bacterial genotypes in public health biosurveillance and includes examples of temporal and spatial clustering of bacterial genotypes that allow for the integration of bacterial genotyping into public health decision making

HazeWatch : a participatory sensor system for monitoring air pollution in Sydney

This paper describes our experiences with building and deploying a low-cost participatory system for urban air pollution monitoring in Sydney. Though air pollution imposes significant health costs on the urban community globally, today's published data on pollution concentrations is spatially too sparse, and does not allow for sufficiently accurate estimation of exposures for (potentially mobile) individuals in order to make medical inferences. The HazeWatch project described in this paper uses several low-cost mobile sensor units attached to vehicles to measure air pollution concentrations, and users' mobile phones to tag and upload the data in real time. The greater spatial granularity of data thus collected enables creation of pollution maps of metropolitan Sydney viewable in real-time over the web, as well as personalized apps that show the individual's exposure history and allow for route planning to reduce future exposure. We share the insights we obtained from building and trialling such a system in Sydney, and highlight challenges that can be addressed collaboratively by groups developing similar systems world-wide.9 page(s

The relationship between hyperglycaemia on admission and patient outcome is modified by hyperlactatemia and diabetic status: a retrospective analysis of the eICU collaborative research database

Abstract Both blood glucose and lactate are well-known predictors of organ dysfunction and mortality in critically ill patients. Previous research has shown that concurrent adjustment for glucose and lactate modifies the relationship between these variables and patient outcomes, including blunting of the association between blood glucose and patient outcome. We aim to investigate the relationship between ICU admission blood glucose and hospital mortality while accounting for lactate and diabetic status. Across 43,250 ICU admissions, weighted to account for missing data, we assessed the predictive ability of several logistic regression and generalised additive models that included blood glucose, blood lactate and diabetic status. We found that inclusion of blood glucose marginally improved predictive performance in all patients: AUC-ROC 0.665 versus 0.659 (p = 0.005), with a greater degree of improvement seen in non-diabetics: AUC-ROC 0.675 versus 0.663 (p < 0.001). Inspection of the estimated risk profiles revealed the standard U-shaped risk profile for blood glucose was only present in non-diabetic patients after controlling for blood lactate levels. Future research should aim to utilise observational data to estimate whether interventions such as insulin further modify this effect, with the goal of informing future RCTs of interventions targeting glycaemic control in the ICU

What is inappropriate hospital use for elderly people near the end of life? : a systematic review

Background: Older people with advance chronic illness use hospital services repeatedly near the end of life. Some of these hospitalizations are considered inappropriate. Aim: To investigate extent and causes of inappropriate hospital admission among older patients near the end of life. Methods: English language publications in Medline, EMBASE, PubMed, Cochrane library, and the grey literature (January 1995–December 2016) covering community and nursing home residents aged ≥ 60 years admitted to hospital. Outcomes: measurements of inappropriateness. A 17-item quality score was estimated independently by two authors. Results: The definition of ‘Inappropriate admissions’ near the end of life incorporated system factors, social and family factors. The prevalence of inappropriate admissions ranged widely depending largely on non-clinical reasons: poor availability of alternative sites of care or failure of preventive actions by other healthcare providers (1.7–67.0%); family requests (up to 10.5%); or too late an admission to be of benefit (1.7–35.0%). The widespread use of subjective parameters not routinely collected in practice, and the inclusion of non-clinical factors precluded the true estimation of clinical inappropriateness. Conclusions: Clinical inappropriateness and system factors that preclude alternative community care must be measured separately. They are two very different justifications for hospital admissions, requiring different solutions. Society has a duty to ensure availability of community alternatives for the management of ambulatory-sensitive conditions and facilitate skilling of staff to manage the terminally ill in non-acute settings. Only then would the evaluation of local variations in clinically inappropriate admissions and inappropriate length of stay be possible to undertake

Pre-existing risk factors for in-hospital death among older patients could be used to initiate end-of-life discussions rather than Rapid Response System calls : a case-control study

Aim: To investigate associations between clinical parameters – beyond the evident physiological deterioration and limitations of medical treatment – with in-hospital death for patients receiving Rapid Response System (RRS) attendances. Methods: Retrospective case-control analysis of clinical parameters for 328 patients aged 60 years and above at their last RRS call during admission to a single teaching hospital in the 2012–2013 calendar years. Generalised estimating equation modelling was used to compare the deceased with a randomly selected sample of those who had RRS calls and survived admission (controls), matched by age group, sex, and hospital ward. Results: In addition to a pre-existing order for limitation of treatment or cardiac arrest (OR 6.92; 95%CI 4.61–10.27), nursing home residence, proteinuria, advanced malignancy, acute myocardial infarction, chronic kidney disease, cognitive impairment and frailty were associated with high risk of death. After adjusting for all the clinical indicators investigated, the strongest risk factors for in-hospital death for patients with a RRS call were advanced malignancy (OR 3.95; 95%CI 2.16–7.21) and new myocardial infarction (OR 2.79; 95%CI 1.86–4.20). Patients with cognitive impairment, frailty indicator or chronic kidney disease were twice as likely to die as patients without those risk factors. Conclusion: In a sample of older deteriorated patients requiring a RRS attendance, multiple indicators of chronic illness, cognitive impairment and frailty were significantly associated with high risk of death. These clinical features beyond the evident orders for limitation of medical treatment should signal the need for clinicians to initiate end-of-life discussions that may prevent futile interventions.5 page(s