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. 2022 Apr 1;4(4):e0677.
doi: 10.1097/CCE.0000000000000677. eCollection 2022 Apr.

Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation

Oscar J L Mitchell  1   2   3 , Maya Dewan  4 , Heather A Wolfe  3   5   6 , Karsten J Roberts  7 , Stacie Neefe  1 , Geoffrey Lighthall  8 , Nathaniel A Sands  2 , Gary Weissman  1   3   9 , Jennifer Ginestra  1   3   9 , Michael G S Shashaty  1   10 , William D Schweickert  1 , Benjamin S Abella  2   11
Affiliations

Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation

Oscar J L Mitchell et al. Crit Care Explor. .

Abstract

Objectives: Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated.

Design: We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania.

Setting: Quaternary academic medical center.

Patients: Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020.

Interventions: None.

Measurements and main results: Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, "An acute worsening of a patient's clinical status that poses a substantial increase to an individual's short-term risk of death or serious harm." Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5-6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2-30.0]).

Conclusions: Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria.

Keywords: Delphi study; cardiac arrest; mechanical ventilation; outcomes assessment; quality improvement; rapid response team.

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Conflict of interest statement

Dr. Abella holds equity and research funding from VOC Health, a company developing novel COVID testing. He also holds research funding and has received speaking honoraria from Zoll and Becton Dickinson. Dr. Wolfe receives personal fees from The Debriefing Academy Educator and personal fees from Zoll Medical Foundation Speakers Bureau outside the submitted work. Dr. Dewan receives career development support from the Agency for Healthcare Research and Quality (K08-HS026975). Drs. Mitchell and Ginestra are supported by T32 grants from the National Institute of Health (T32 5T32HL098054 and 5T32HL007891, respectively). Dr. Wolfe receives funding from the National Institute of Health: R01 HL131544-01. The remaining authors have disclosed that they do not have any potential conflicts of interest.

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