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Observational Study
. 2022 Apr 19;26(1):112.
doi: 10.1186/s13054-022-03986-2.

The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients

Bart G J Candel  1   2 , Wouter Raven  3 , Heleen Lameijer  4 , Wendy A M H Thijssen  5 , Fabian Termorshuizen  6   7   8 , Christiaan Boerma  9 , Nicolette F de Keizer  6   7   8 , Evert de Jonge  10 , Bas de Groot  3
Affiliations
Observational Study

The effect of treatment and clinical course during Emergency Department stay on severity scoring and predicted mortality risk in Intensive Care patients

Bart G J Candel et al. Crit Care. .

Erratum in

Abstract

Background: Treatment and the clinical course during Emergency Department (ED) stay before Intensive Care Unit (ICU) admission may affect predicted mortality risk calculated by the Acute Physiology and Chronic Health Evaluation (APACHE)-IV, causing lead-time bias. As a result, comparing standardized mortality ratios (SMRs) among hospitals may be difficult if they differ in the location where initial stabilization takes place. The aim of this study was to assess to what extent predicted mortality risk would be affected if the APACHE-IV score was recalculated with the initial physiological variables from the ED. Secondly, to evaluate whether ED Length of Stay (LOS) was associated with a change (delta) in these APACHE-IV scores.

Methods: An observational multicenter cohort study including ICU patients admitted from the ED. Data from two Dutch quality registries were linked: the Netherlands Emergency department Evaluation Database (NEED) and the National Intensive Care Evaluation (NICE) registry. The ICU APACHE-IV, predicted mortality, and SMR based on data of the first 24 h of ICU admission were compared with an ED APACHE-IV model, using the most deviating physiological variables from the ED or ICU.

Results: A total of 1398 patients were included. The predicted mortality from the ICU APACHE-IV (median 0.10; IQR 0.03-0.30) was significantly lower compared to the ED APACHE-IV model (median 0.13; 0.04-0.36; p < 0.01). The SMR changed from 0.63 (95%CI 0.54-0.72) to 0.55 (95%CI 0.47-0.63) based on ED APACHE-IV. Predicted mortality risk changed more than 5% in 321 (23.2%) patients by using the ED APACHE-IV. ED LOS > 3.9 h was associated with a slight increase in delta APACHE-IV of 1.6 (95% CI 0.4-2.8) compared to ED LOS < 1.7 h.

Conclusion: Predicted mortality risks and SMRs calculated by the APACHE IV scores are not directly comparable in patients admitted from the ED if hospitals differ in their policy to stabilize patients in the ED before ICU admission. Future research should focus on developing models to adjust for these differences.

Keywords: APACHE III; Benchmarking; Data quality; Intensive care; Medical registries.

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Conflict of interest statement

All authors declare no conflicts of interest.

Figures

Fig. 1
Fig. 1
Patient flow diagram throughout the study. Patients from the National Intensive Care Evaluation (NICE) registry were linked with patients from the Netherlands Emergency department Evaluation Database (NEED)
Fig. 2
Fig. 2
In panel A the median Emergency Department Acute Physiology and Chronic Health Evaluation (ED APACHE-IV) score is presented per quartile Emergency Department Length of Stay (ED-LOS), with 95% Confidence intervals. The ED APACHE-IV score uses the most deviated physiological variables from ED admission until 24 h after ICU admission, which differs from the ICU APACHE-IV score which only contains the most deviated physiological variables from the first 24 h of ICU admission. Panel B shows the mean delta APACHE-IV per quartile ED-LOS. The delta APACHE-IV is calculated as follows: ED APACHE-IV score—ICU APACHE-IV score
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