Member Non-member Regional hospital County hospital Local hospital The Swedish Intensive Care Registry: New (?) insights for the surgeon Source for research! Sten Walther, MD Chairman, Swedish Intensive Care Registry Linköping University Hospital

Member Non-member Regional hospital County hospital Local hospital Outline: Basics –Data sources –Coverage and accuracy Case studies –GI-bleeding and AAA –Time to death in the ICU –Timing of tracheotomy –Life after ICU-care The Swedish Intensive Care Registry: New (?) insights for the surgeon Source for research!

Data sources Swedish Intensive Care Registry Critical care outreach ICU-care aftercare Swedish population registry Microbiology lab data Many other ICUs Your ICU My ICU

Data sources Swedish Intensive Care Registry Critical care outreach ICU-care aftercare Swedish population registry Microbiology lab data Many other ICUs Your ICU My ICU Data coupling possible using Unique admission identifier Unique person identifier National Quality Registry legislation Person identifier permitted if purpose is audit and benchmarking Written information to the patient must be provided Consent presumed Active withdrawal of consent possible

Definition: The ICU patient A patient with an acute, sometimes life threatening condition who needs monitoring, diagnostics and treatment The post-operative patient is sometimes an ICU patient: need for prolonged (+ 6hrs) organ support or > 24 hrs ICU stay Thresholds for admission vary between hospitals and within hospitals over time

Consult Admit Treat Discharge Follow up Critical care outreach ICU outcome Withdrawal / Withholding Adverse events SOFA Nursing workload Diagnosis Key diagnosis Renal RT Ventilator therapy Procedures ICU-care aftercare SAPS 3 ICU-Higgins APACHE II PIM 2 Reason for admission Minimal dataset CardioThor ICU Pediatric ICU ICU Which data?

My ICU Swedish Intensive Care Registry Swedish Population Registry Data transfer: interaction over time

My ICU No error Errors Swedish Intensive Care Registry Swedish Population Registry Data transfer: interaction over time

My ICU Swedish Intensive Care Registry Swedish Population Registry Data transfer: interaction over time Old admissions Corrected errors New admissions

My ICU Swedish Intensive Care Registry Preferably weekly At least monthly Swedish Population Registry Data transfer: interaction over time

My ICU Swedish Intensive Care Registry Preferably weekly At least monthly Swedish Population Registry Weekly Vital status update Data transfer: interaction over time

Registry metrics (DocDAT stuk) Criteria for assessing coverage and accuracy

Registry metrics (DocDAT stuk) Criteria for assessing coverage and accuracy Vital status Health related Quality of Life

Criteria …. (contd) Black et al, Qual Saf Health Care :

Admission types in the ICU: SIR 2010 Intensive care General incl. neuro – Cardiothoracic –3 863 Specialized pediatric –1 651 Other care types Post-operative – Other – Coronary –

Case study I Survival: ICU admissions from General surgery

Survival: Gastrointestinal bleeding (Principal diagnosis, Primary admission only)

Survival: Gastrointestinal bleeding (Principal diagnosis, Primary ICU admission only) No surgerySurgery Age (yrs)69 (SD 15)67 (SD 16) Male / Female64 % / 36 %60 % / 40 % SAPS3 risk estimate Median 0.26 (IQR 0.16 – 0.42) Median 0.36 (IQR 0.16 – 0.45) Length of ICU stay (days) Median 0.9 (IQR 0.5 – 1.6) Median 1.0 (IQR 0.6 – 1.9) Dead in ICU5.5 %5.7 % Dead < 30 days 17 %19 %

Risk adjustment with SAPS3 GI-bleeding (N=1282). Survival 30 days after admission to ICU Discrimination is good: aROC = 0.84

Survival: Gastrointestinal bleeding (Repeated admissions)

Survival: Gastrointestinal bleeding and gender (Primary ICU admission) Similar also after risk adjustment

Survival: Abdominal aortic aneurysm Not ruptured Ruptured

Survival: Abdominal aortic aneurysm Not ruptured Ruptured Dead < 30d SIR %34.7 % Dead < 30d Swedvasc %35.1 %

Survival: Abdominal aortic aneurysm

Differences remain favoring County ICUs after adjustment for risk (SAPS3) and rupture Survival: Abdominal aortic aneurysm

Guidelines …..

Case study II Time to death in the ICU: Operative vs. Non-operative admissions Intensive care is about saving the salvageable, comfort the dying and dont mix them up

Time to death in the ICU: Operative vs. Non-operative admissions 50 th percentile 75 th percentile Operative 2.0 days6.0 days Non- operative 1.4 days4.0 days

Case study III Procedures in the ICU: Tracheotomy

Tracheotomy: Technique and timing Open technique Percutaneous technique

Open N=1630 Percutaneous N=1201 Age61 (SD 16) yrs63 (SD 15) yrs Male / Female 77 % / 23 %81 % / 19 % SAPS3 risk estimate Median 0.45 (IQR 0.26 – 0.62) Median 0.44 (IQR 0.28 – 0.62) Days to procedure Median 5.1 (IQR 2.7 – 8.1) Median 4.2 (IQR 2.4 – 7.7) Open technique Percutaneous technique Tracheotomy: Technique and timing

ICU length of stay increases by 1.3 days for every day tracheostomy is delayed

Guidelines …..

Assessing health related quality of life may give important insights You only manage what you measure Case study IV Health related quality of life after ICU

Assessing health related quality of life may give important insights You only manage what you measure Are there important differences in HRQoL related to –illness severity? –length of ICU-stay? –treatment protocols? –diagnoses? –gender? Is there anything we can do about it? Designing and exploring interventions Health related quality of life after ICU

At 2 months (N=982): Age 61 (17 – 99) yrs ICU LOS 9 (2 – 48) days SF-36: All assessments (27 ICUs) SIR data from

Health related quality of life after ICU SF-36: Admissions after surgery What is the appropriate reference? For how long should we measure? Can we accelerate recovery? Designing and exploring interventions SIR data from

The Swedish Intensive Care Registry Not a database Large group of people devoted to audit and benchmarking to be able to deliver the very best care SIR 10 th Anniversary Saltsjöbaden 2011

(with link to my presentation coming shortly)