Kathryn M Rowan

Intensive Care National Audit & Research Centre ICNARC, Londinium, England, United Kingdom

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Publications (69)628.21 Total impact

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    ABSTRACT: Population: patients admitted to all adult general ICUs during 2005 surviving to hospital discharge identified from the Scottish Intensive Care Society Audit Group (SICSAG) registry; matched (1:1) to similar hospital controls. Five-year outcomes: mortality, hospital resource use. Confounder adjustment: multivariable regression and pre-post within-individual analyses. Measurements and Main results 5259 from 7656 ICU patients survived to hospital discharge (5215(99.2%) matched to hospital controls). Factors present pre-ICU admission (comorbidities/pre-ICU hospitalisations) were stronger predictors of hospital resource use than acute illness factors. In the five years after the initial hospital discharge compared with hospital controls, the ICU cohort had higher mortality (32.3% versus 22.7%, hazard ratio 1.33,95%CI 1.22 to 1.46,p<0.001), used more hospital resources (mean hospital admission rate 4.8 versus 3.3/person/5years) and had 51% higher mean five-year hospital costs ($25608 versus $16913/patient). Increased resource use persisted after confounder adjustment (p<0.001) and using pre-post analyses (p<0.001). Excess resource use and mortality was greatest for younger patients without significant comorbidity. Conclusions This complete, national study demonstrates that ICU survivorship is associated with higher five-year mortality and hospital resource utilisation than hospital controls representing a substantial burden on individuals, care-givers and society.
    No preview · Article · Jan 2016 · American Journal of Respiratory and Critical Care Medicine
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    ABSTRACT: The use of cardiac output monitoring to guide intra-venous fluid and inotropic therapies may improve peri-operative outcomes, but uncertainty exists regarding clinical effectiveness and robust cost-effectiveness evidence is lacking. The objective of the study was to evaluate the cost-effectiveness of peri-operative cardiac output-guided haemodynamic therapy versus usual care in high-risk patients undergoing major gastrointestinal surgery. The study undertook a cost-effectiveness analysis using data from a multi-centre randomised trial that recruited patients from 17 hospitals in the United Kingdom. The trial compared cardiac output-guided, haemodynamic therapy algorithm for intra-venous fluid and inotrope (dopexamine) infusion during and 6 h following surgery, with usual care. Resource use and outcome data on 734 high-risk trial patients aged over 50 years undergoing major gastrointestinal surgery were used to report cost-effectiveness at 6 months and to project lifetime cost-effectiveness. The cost-effectiveness analysis used information on health-related quality of life (QoL) at randomisation, 30 days, and 6 months combined with information on vital status to report quality-adjusted life years (QALYs). Each QALY was valued using the National Institute for Health and Care Excellence (NICE) recommended threshold of willingness to pay (£20,000 per QALY) in conjunction with the costs of each group to report the incremental net monetary benefits (INB) of the treatment algorithm versus usual care. The mean [SD] quality of life at 30 days and 6 months was similar between the treatment groups (at 6 months, intervention group 0.73 [0.28] versus usual care group 0.71 [0.30]; mean gain 0.03 [95 % confidence interval (CI) -0.01 to 0.08]). At 6 months, survival, mean QALYs and mean healthcare costs (intervention group £8574 versus usual care group £8974) were also similar. At the cost-effectiveness threshold of £20,000 per QALY gained, the incremental net benefit of haemodynamic therapy over the patients' lifetime was positive (£4168 [95 % CI -£3063 to £11,398]). This corresponds to an 87 % probability that this intervention is cost-effective. Cardiac output-guided haemodynamic therapy algorithm was associated with an average cost reduction and improvement in QALY and is likely to be cost-effective. Further research is needed to confirm the clinical and cost-effectiveness of this treatment. ISRCTN04386758.
    Preview · Article · Dec 2015
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    ABSTRACT: Background Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events. Objective To describe IHCA demographics during three day/time periods—weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)—and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care. Methods We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals. Results Risk-adjusted outcomes (OR (95% CI)) were worse (p<0.001) for both weekend daytime (ROSC>20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses. Conclusions IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at night and weekends, rather than patient case mix, appear to be responsible.
    Full-text · Article · Dec 2015 · BMJ quality & safety
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    ABSTRACT: To improve care it is necessary to feed back experiences of those receiving care. Of patients admitted to intensive care units (ICUs), approximately one-quarter die, and few survivors recollect their experiences, so family members have a vital role. The most widely validated tool to seek their views is the Family Satisfaction in the Intensive Care Unit questionnaire (FS-ICU). Objectives To test face and content validity and comprehensibility of the FS-ICU (phase 1). To establish internal consistency, construct validity and reliability of the FS-ICU; to describe family satisfaction and explore how it varies by family member, patient, unit/hospital and other contextual factors and by country; and to model approaches to sampling for future use in quality improvement (phase 2). Design Mixed methods: qualitative study (phase 1) and cohort study (phase 2). Setting NHS ICUs ( n = 2, phase 1; n = 20, phase 2). Participants Health-care professionals, ex-patients, family members of ICU patients ( n = 41, phase 1). Family members of ICU patients ( n = 12,303, phase 2). Interventions None. Main outcome measures Key themes regarding each item of the 24-item FS-ICU (FS-ICU-24) (phase 1). Overall family satisfaction and domain scores of the FS-ICU-24 (phase 2). Results In phase 1, face validity, content validity and comprehensibility were good. Adaptation to the UK required only minor edits. In phase 2, one to four family members were recruited for 60.6% of 10,530 patients (staying in ICU for 24 hours or more). Of 12,303 family members, 7173 (58.3%) completed the questionnaire. Psychometric assessment of the questionnaire established high internal consistency and criterion validity. Exploratory factor analysis indicated new domains: satisfaction with care , satisfaction with information and satisfaction with the decision-making process . All scores were high with skewed distributions towards more positive scores. For family members of ICU survivors, factors associated with increased/decreased satisfaction were age, ethnicity, relationship to patient, and visit frequency, and patient factors were acute severity of illness and invasive ventilation. For family members of ICU non-survivors, average satisfaction was higher but no family member factors were associated with increased/decreased satisfaction; patient factors were age, acute severity of illness and duration of stay. Neither ICU/hospital factors nor seasonality were associated. Funnel plots confirmed significant variation in family satisfaction across ICUs. Adjusting for family member and patient characteristics reduced variation, resulting in fewer ICUs identified as potential outliers. Simulations suggested that family satisfaction surveys using short recruitment windows can produce relatively unbiased estimates of average family satisfaction. Conclusions The Family-Reported Experiences Evaluation study has provided a UK-adapted, psychometrically valid questionnaire for overall family satisfaction and three domains. The large sample size allowed for robust multilevel multivariable modelling of factors associated with family satisfaction to inform important adjustment of any future evaluation. Limitations Responses to three free-text questions indicate the questionnaire may not be sensitive to all aspects of family satisfaction. Future work Reservations remain about the current questionnaire. While formal analysis of the free-text questions did not form part of this proposal, brief analysis suggested considerable scope for improvement of the FS-ICU-24. Study registration Current Controlled Trials ISRCTN47363549. Funding details The National Institute for Health Research Health Services and Delivery Research programme.
    Full-text · Article · Dec 2015
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    ABSTRACT: When assessing health-related quality of life (HRQL), critical care outcomes research generally uses generic measures in the absence of a suitable critical care–specific measure. Our aims were to construct a conceptual framework of survivors' HRQL and assess the extent to which the 2 most commonly used generic measures (the Short Form 36 Health Survey and EuroQol-5D) covered the framework.
    Full-text · Article · Nov 2015
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    ABSTRACT: Early goal-directed therapy (EGDT) is recommended in international guidance for the resuscitation of patients presenting with early septic shock. However, adoption has been limited and uncertainty remains over its clinical effectiveness and cost-effectiveness. Objectives The primary objective was to estimate the effect of EGDT compared with usual resuscitation on mortality at 90 days following randomisation and on incremental cost-effectiveness at 1 year. The secondary objectives were to compare EGDT with usual resuscitation for requirement for, and duration of, critical care unit organ support; length of stay in the emergency department (ED), critical care unit and acute hospital; health-related quality of life, resource use and costs at 90 days and at 1 year; all-cause mortality at 28 days, at acute hospital discharge and at 1 year; and estimated lifetime incremental cost-effectiveness. Design A pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation. Setting Fifty-six NHS hospitals in England. Participants A total of 1260 patients who presented at EDs with septic shock. Interventions EGDT ( n = 630) or usual resuscitation ( n = 630). Patients were randomly allocated 1 : 1. Main outcome measures All-cause mortality at 90 days after randomisation and incremental net benefit (at £20,000 per quality-adjusted life-year) at 1 year. Results Following withdrawals, data on 1243 (EGDT, n = 623; usual resuscitation, n = 620) patients were included in the analysis. By 90 days, 184 (29.5%) in the EGDT and 181 (29.2%) patients in the usual-resuscitation group had died [ p = 0.90; absolute risk reduction −0.3%, 95% confidence interval (CI) −5.4 to 4.7; relative risk 1.01, 95% CI 0.85 to 1.20]. Treatment intensity was greater for the EGDT group, indicated by the increased use of intravenous fluids, vasoactive drugs and red blood cell transfusions. Increased treatment intensity was reflected by significantly higher Sequential Organ Failure Assessment scores and more advanced cardiovascular support days in critical care for the EGDT group. At 1 year, the incremental net benefit for EGDT versus usual resuscitation was negative at −£725 (95% CI −£3000 to £1550). The probability that EGDT was more cost-effective than usual resuscitation was below 30%. There were no significant differences in any other secondary outcomes, including health-related quality of life, or adverse events. Limitations Recruitment was lower at weekends and out of hours. The intervention could not be blinded. Conclusions There was no significant difference in all-cause mortality at 90 days for EGDT compared with usual resuscitation among adults identified with early septic shock presenting to EDs in England. On average, costs were higher in the EGDT group than in the usual-resuscitation group while quality-adjusted life-years were similar in both groups; the probability that it is cost-effective is
    Full-text · Article · Nov 2015 · Health technology assessment (Winchester, England)
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    ABSTRACT: National clinical audit has a key role in ensuring quality in health care. When comparing outcomes between providers, it is essential to take the differing case mix of patients into account to make fair comparisons. Accurate risk prediction models are therefore required. Objectives To improve risk prediction models to underpin quality improvement programmes for the critically ill (i.e. patients receiving general or specialist adult critical care or experiencing an in-hospital cardiac arrest). Design Risk modelling study nested within prospective data collection. Setting Adult (general/specialist) critical care units and acute hospitals in the UK. Participants Patients admitted to an adult critical care unit and patients experiencing an in-hospital cardiac arrest attended by the hospital-based resuscitation team. Interventions None. Main outcome measures Acute hospital mortality (adult critical care); return of spontaneous circulation (ROSC) greater than 20 minutes and survival to hospital discharge (in-hospital cardiac arrest). Data sources The Case Mix Programme (adult critical care) and National Cardiac Arrest Audit (in-hospital cardiac arrest). Results The current Intensive Care National Audit & Research Centre (ICNARC) model was externally validated using data for 29,626 admissions to critical care units in Scotland (2007–9) and outperformed the Acute Physiology And Chronic Health Evaluation (APACHE) II model in terms of discrimination (c-index 0.848 vs. 0.806) and accuracy (Brier score 0.140 vs. 0.157). A risk prediction model for cardiothoracic critical care was developed using data from 17,002 admissions to five units (2010–12) and validated using data from 10,238 admissions to six units (2013–14). The model included prior location/urgency, blood lactate concentration, Glasgow Coma Scale (GCS) score, age, pH, platelet count, dependency, mean arterial pressure, white blood cell (WBC) count, creatinine level, admission following cardiac surgery and interaction terms, and it had excellent discrimination (c-index 0.904) and accuracy (Brier score 0.055). A risk prediction model for admissions to all (general/specialist) adult critical care units was developed using data from 155,239 admissions to 232 units (2012) and validated using data from 90,017 admissions to 216 units (2013). The model included systolic blood pressure, temperature, heart rate, respiratory rate, partial pressure of oxygen in arterial blood/fraction of inspired oxygen, pH, partial pressure of carbon dioxide in arterial blood, blood lactate concentration, urine output, creatinine level, urea level, sodium level, WBC count, platelet count, GCS score, age, dependency, past medical history, cardiopulmonary resuscitation, prior location/urgency, reason for admission and interaction terms, and it outperformed the current ICNARC model for discrimination and accuracy overall (c-index 0.885 vs. 0.869; Brier score 0.108 vs. 0.115) and across unit types. Risk prediction models for in-hospital cardiac arrest were developed using data from 14,688 arrests in 122 hospitals (2011–12) and validated using data from 7791 arrests in 143 hospitals (2012–13). The models included age, sex (for ROSC > 20 minutes), prior length of stay in hospital, reason for attendance, location of arrest, presenting rhythm, and interactions between rhythm and location. Discrimination for hospital survival exceeded that for ROSC > 20 minutes (c-index 0.811 vs. 0.720). Limitations The risk prediction models developed were limited by the data available within the current national clinical audit data sets. Conclusions We have developed and validated risk prediction models for cardiothoracic and adult (general and specialist) critical care units and for in-hospital cardiac arrest. Future work Future development should include linkage with other routinely collected data to enhance available predictors and outcomes. Funding details The National Institute for Health Research Health Services and Delivery Research programme.
    No preview · Article · Oct 2015

  • No preview · Article · Oct 2015
  • Meghan Prin · David Harrison · Kathryn Rowan · Hannah Wunsch
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    ABSTRACT: Purpose: High-dependency care units (HDUs) are a focus of research to optimize critical care resource allocation. HDUs provide a level of care between the general ward and the intensive care unit (ICU). However, few data report on the case mix and outcomes of patients in these units. Methods: Retrospective observational cohort study of patients admitted to 11 stand-alone HDUs in the UK from 2008 to 2011. We stratified patients by location prior to HDU admission and location on discharge from HDU, and we summarized the case mix, transitions of care, and mortality. Results: Of 9008 patients admitted to 11 stand-alone HDUs, 56.5 % were male and the mean age was 62.7 ± 17.9 years. The majority of patients admitted to HDUs were non-surgical (59.3 %), with 22.4 and 20.1 % admitted from the ICU and general ward, respectively; 41.3 % were admitted from the operating room or recovery suite. The median length of stay in HDU was 1.8 days (IQR 0.9-3.5) and in-HDU mortality was 5.1 %. Among HDU survivors (n = 8551), 8.5 % were discharged to an ICU, 80.9 % to a general ward, and 10.6 % to other care areas. For patients admitted to HDU from an ICU, only 5.8 % were readmitted to ICU. Hospital mortality for the HDU population was 14.8 %; for patients discharged to an ICU, hospital mortality was 43.6 %. Conclusions: In a sample of 11 stand-alone HDUs in the UK, patients are from many different hospital locations. Hospital mortality for patients requiring HDU care is high, particularly for patients who require transfer to an ICU.
    No preview · Article · Sep 2015 · Intensive Care Medicine
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    ABSTRACT: Evidence of variation in mortality after surgery may indicate preventable postoperative death. We sought to determine if regional differences in outcome were present in surgical patients admitted to critical care in the UK. We extracted data on admission characteristics, case mix and outcome of all patients admitted to UK critical care units following surgery for the calendar year of 2009. We also used publicly held data on regional population, volume of surgery and bed provision. Multilevel regression analysis was used to adjust for the effects of case mix and regional critical care bed provision on acute hospital mortality. A total of 16,147 patients admitted to critical care following surgery were included in this analysis. Median odds ratio (MOR) was used to describe regional-level variance in acute hospital mortality. Significant variation was identified (MOR 1.14; 95 % CI 1.07, 1.28) and persisted following adjustment for case mix (MOR 1.10; 95 % CI 1.04, 1.25) and regional critical care bed provision (MOR 1.09; 95 % CI 1.04, 1.24). Critical care bed utilisation (surgical critical care admissions per 100,000 surgical procedures) seemed to better explain this observation (MOR 1.03; 95 % CI 1.00, 29.26) and was associated with statistically significant reduction in mortality (OR 0.91; 95 % CI 0.85, 0.97; p = 0.01). Significant regional variation in hospital mortality for patients admitted to critical care following surgery was observed. Critical care bed utilisation seemed to better explain this observation and was associated with improved outcome.
    No preview · Article · Jul 2015 · Intensive Care Medicine
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    ABSTRACT: This study validates risk prediction models for acute traumatic brain injury (TBI) in critical care units in the United Kingdom (UK) and recalibrates the models to this population. The Risk Adjustment In Neurocritical care (RAIN) Study was a prospective, observational cohort study in 67 adult critical care units. Adult patients admitted to critical care following acute TBI with a last pre-sedation Glasgow Coma Score (GCS) less than 15 were recruited. The primary outcomes were mortality and unfavourable outcome (death or severe disability, assessed using the Extended Glasgow Outcome Scale) at six months following TBI. Of 3,626 critical care unit admissions, 2,975 were analysed. Following imputation of missing outcomes, mortality at six months was 25.7% and unfavourable outcome 57.4%. Ten risk prediction models were validated from Hukkelhoven et al, the MRC CRASH Trial Collaborators and the IMPACT group. The model with the best discrimination was the IMPACT 'Lab' model (c-index 0.779 for mortality, 0.713 for unfavourable outcome). This model was well calibrated for mortality at six months but substantially under-predicted the risk of unfavourable outcome. Recalibration of the models resulted in small improvements in discrimination and excellent calibration for all models. The risk prediction models demonstrated sufficient statistical performance to support their use in research and audit but fell below the level required to guide individual patient decision-making. The published models for unfavourable outcome at six months had poor calibration in the UK critical care setting and the models recalibrated to this setting should be used in future research.
    No preview · Article · Apr 2015 · Journal of neurotrauma
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    ABSTRACT: Background: Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and uncertainty about its effectiveness remains. Methods: We conducted a pragmatic randomized trial with an integrated cost-effectiveness analysis in 56 hospitals in England. Patients were randomly assigned to receive either EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was all-cause mortality at 90 days. Results: We enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90 days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients (29.2%) in the usual-care group had died (relative risk in the EGDT group, 1.01; 95% confidence interval [CI], 0.85 to 1.20; P=0.90), for an absolute risk reduction in the EGDT group of -0.3 percentage points (95% CI, -5.4 to 4.7). Increased treatment intensity in the EGDT group was indicated by increased use of intravenous fluids, vasoactive drugs, and red-cell transfusions and reflected by significantly worse organ-failure scores, more days receiving advanced cardiovascular support, and longer stays in the intensive care unit. There were no significant differences in any other secondary outcomes, including health-related quality of life, or in rates of serious adverse events. On average, EGDT increased costs, and the probability that it was cost-effective was below 20%. Conclusions: In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment Programme; ProMISe Current Controlled Trials number, ISRCTN36307479.).
    No preview · Article · Mar 2015 · New England Journal of Medicine
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    ABSTRACT: BACKGROUND Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and uncertainty about its effectiveness remains. METHODS We conducted a pragmatic randomized trial with an integrated cost-effectiveness analysis in 56 hospitals in England. Patients were randomly assigned to receive either EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was all-cause mortality at 90 days. RESULTS We enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90 days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients (29.2%) in the usual-care group had died (relative risk in the EGDT group, 1.01; 95% confidence interval [CI], 0.85 to 1.20; P=0.90), for an absolute risk reduction in the EGDT group of −0.3 percentage points (95% CI, −5.4 to 4.7). Increased treatment intensity in the EGDT group was indicated by increased use of intravenous fluids, vasoactive drugs, and red-cell transfusions and reflected by significantly worse organ-failure scores, more days receiving advanced cardiovascular support, and longer stays in the intensive care unit. There were no significant differences in any other secondary outcomes, including health-related quality of life, or in rates of serious adverse events. On average, EGDT increased costs, and the probability that it was cost-effective was below 20%. CONCLUSIONS In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment Programme; ProMISe Current Controlled Trials number, ISRCTN36307479.)
    No preview · Article · Mar 2015 · New England Journal of Medicine
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    ABSTRACT: Fever suppression may be beneficial for patients with traumatic brain injury (TBI) and stroke, but for patients with meningitis or encephalitis [central nervous system (CNS) infection], the febrile response may be advantageous. To evaluate the relationship between peak temperature in the first 24 h of intensive care unit (ICU) admission and all-cause hospital mortality for acute neurological diseases. Retrospective cohort design from 2005 to 2013, including 934,159 admissions to 148 ICUs in Australia and New Zealand (ANZ) and 908,775 admissions to 236 ICUs in the UK. There were 53,942 (5.8 %) patients in ANZ and 56,696 (6.2 %) patients in the UK with a diagnosis of TBI, stroke or CNS infection. For both the ANZ (P = 0.02) and UK (P < 0.0001) cohorts there was a significant interaction between early peak temperature and CNS infection, indicating that the nature of the relationship between in-hospital mortality and peak temperature differed between TBI/stroke and CNS infection. For patients with CNS infection, elevated peak temperature was not associated with an increased risk of death, relative to the risk at 37-37.4 °C (normothermia). For patients with stroke and TBI, peak temperature below 37 °C and above 39 °C was associated with an increased risk of death, compared to normothermia. The relationship between peak temperature in the first 24 h after ICU admission and in-hospital mortality differs for TBI/stroke compared to CNS infection. For CNS infection, increased temperature is not associated with increased risk of death.
    Full-text · Article · Feb 2015 · Intensive Care Medicine
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    ABSTRACT: Risk prediction models are used in critical care for risk stratification, summarising and communicating risk, supporting clinical decision-making and benchmarking performance. However, they require validation before they can be used with confidence, ideally using independently collected data from a different source to that used to develop the model. The aim of this study was to validate the Intensive Care National Audit & Research Centre (ICNARC) model using independently collected data from critical care units in Scotland. Data were extracted from the Scottish Intensive Care Society Audit Group (SICSAG) database for the years 2007 to 2009. Recoding and mapping of variables was performed, as required, to apply the ICNARC model (2009 recalibration) to the SICSAG data using standard computer algorithms. The performance of the ICNARC model was assessed for discrimination, calibration and overall fit and compared with that of the Acute Physiology And Chronic Health Evaluation (APACHE) II model. There were 29,626 admissions to 24 adult, general critical care units in Scotland between 1 January 2007 and 31 December 2009. After exclusions, 23,269 admissions were included in the analysis. The ICNARC model outperformed APACHE II on measures of discrimination (c index 0.848 versus 0.806), calibration (Hosmer-Lemeshow chi-squared statistic 18.8 versus 214) and overall fit (Brier's score 0.140 versus 0.157; Shapiro's R 0.652 versus 0.621). Model performance was consistent across the three years studied. The ICNARC model performed well when validated in an external population to that in which it was developed, using independently collected data.
    Full-text · Article · Dec 2014 · BMC Anesthesiology
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    ABSTRACT: Rationale: Little is known about the utility of provision of high-dependency care (HDC) that is in a geographically separate location from a primary intensive care unit (ICU). Objectives: To determine whether the availability of HDC in a geographically separate unit affects patient flow or mortality for critically ill patients. Methods: Admissions to ICUs in the UK, from 2009-2011, who received Level 3 intensive care in the first 24 hours after admission and subsequently Level 2 HDC. We compared differences in patient flow and outcomes for patients treated in hospitals providing some HDC in a geographically separate unit (dual HDC) versus patients treated in hospitals providing all HDC in the same unit as intensive care (integrated HDC) using multi-level mixed effects models. Measurements and Main Results: In 192 adult general ICUs, 21.4% provided dual HDC. Acute hospital mortality was no different for patients cared for in ICUs with dual HDC versus those with integrated HDC (adjusted odds ratio (AOR) 0.94 (0.86-1.03) p=0.16). Dual HDC was associated with a decreased likelihood of a delayed discharge from the primary unit. But, total duration of critical care and the likelihood of discharge from the primary unit at night were increased with dual HDC. Conclusions: Availability of HDC in a geographically separate unit does not impact acute hospital mortality. The potential benefit of decreasing delays in discharge should be weighed against the increased total duration of critical care and greater likelihood of a transfer out of the primary unit at night.
    No preview · Article · Dec 2014 · American Journal of Respiratory and Critical Care Medicine
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    ABSTRACT: The CALORIES trial is a pragmatic, open, multicentre, randomised controlled trial (RCT) of the clinical effectiveness and cost-effectiveness of early nutritional support via the parenteral route compared with early nutritional support via the enteral route in unplanned admissions to adult general critical care units (CCUs) in the United Kingdom. The trial derives from the need for a large, pragmatic RCT to determine the optimal route of delivery for early nutritional support in the critically ill. To describe the proposed statistical analyses for the evaluation of the clinical effectiveness in the CALORIES trial. With the primary and secondary outcomes defined precisely and the approach to safety monitoring and data collection summarised, the planned statistical analyses, including prespecified subgroups and secondary analyses, were developed and are described. The primary outcome is all-cause mortality at 30 days. The primary analysis will be reported as a relative risk and absolute risk reduction and tested with the Fisher exact test. Prespecified subgroup analyses will be based on age, degree of malnutrition, acute severity of illness, mechanical ventilation at admission to the CCU, presence of cancer and time from CCU admission to commencement of early nutritional support. Secondary analyses include adjustment for baseline covariates. In keeping with best trial practice, we have developed, described and published a statistical analysis plan for the CALORIES trial and are placing it in the public domain before inspecting data from the trial.
    No preview · Article · Dec 2014 · Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
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    ABSTRACT: IntroductionPrior to investing in a large, multicentre randomised controlled trial (RCT), the National Institute for Health Research in the UK called for an evaluation of the feasibility and value for money of undertaking a trial on intravenous immunoglobulin (IVIG) as an adjuvant therapy for severe sepsis/septic shock.Methods In response to this call, this paper assessed the clinical and cost-effectiveness of IVIG (using a decision model), and evaluated the value of conducting an RCT (using expected value of information (EVI) analysis). The evidence informing such assessments was obtained through a series of systematic reviews and meta-analyses. Further primary data analyses were also undertaken using the Intensive Care National Audit & Research Centre Case Mix Programme Database, and a Scottish Intensive Care Society research study.ResultsWe found a large degree of statistical heterogeneity in the clinical evidence on treatment effect, and the source of such heterogeneity was unclear. The incremental cost effectiveness ratio of IVIG is within the borderline region of estimates considered to represent value for money, but results appear highly sensitive to the choice of model used for clinical effectiveness. This was also the case with EVI estimates, with maximum payoffs from conducting a further clinical trial between £137 and £1,011 million.Conclusions Our analyses suggest that there is a need for a further RCT. Results on the value of conducting such research, however, were sensitive to the clinical effectiveness model used, reflecting the high level of heterogeneity in the evidence base.
    Full-text · Article · Dec 2014 · Critical care (London, England)
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    ABSTRACT: Background: Uncertainty exists about the most effective route for delivery of early nutritional support in critically ill adults. We hypothesized that delivery through the parenteral route is superior to that through the enteral route. Methods: We conducted a pragmatic, randomized trial involving adults with an unplanned admission to one of 33 English intensive care units. We randomly assigned patients who could be fed through either the parenteral or the enteral route to a delivery route, with nutritional support initiated within 36 hours after admission and continued for up to 5 days. The primary outcome was all-cause mortality at 30 days. Results: We enrolled 2400 patients; 2388 (99.5%) were included in the analysis (1191 in the parenteral group and 1197 in the enteral group). By 30 days, 393 of 1188 patients (33.1%) in the parenteral group and 409 of 1195 patients (34.2%) in the enteral group had died (relative risk in parenteral group, 0.97; 95% confidence interval, 0.86 to 1.08; P=0.57). There were significant reductions in the parenteral group, as compared with the enteral group, in rates of hypoglycemia (44 patients [3.7%] vs. 74 patients [6.2%]; P=0.006) and vomiting (100 patients [8.4%] vs. 194 patients [16.2%]; P<0.001). There were no significant differences between the parenteral group and the enteral group in the mean number of treated infectious complications (0.22 vs. 0.21; P=0.72), 90-day mortality (442 of 1184 patients [37.3%] vs. 464 of 1188 patients [39.1%], P=0.40), in rates of 14 other secondary outcomes, or in rates of adverse events. Caloric intake was similar in the two groups, with the target intake not achieved in most patients. Conclusions: We found no significant difference in 30-day mortality associated with the route of delivery of early nutritional support in critically ill adults. (Funded by the United Kingdom National Institute for Health Research; CALORIES Current Controlled Trials number, ISRCTN17386141.).
    Preview · Article · Oct 2014 · New England Journal of Medicine
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    ABSTRACT: In many countries, treatment of life-threatening neurological conditions takes place in specialised Neuro-Critical Care Units (NCCU). In the UK most patients are treated on general intensive care units (GICU) with varying levels neurological support. We used the Intensive Care National Audit and Research Centre (ICNARC) database to analyse mortality for ICH, MG and GBS between 1996 and 2009 in NCCU and ICUs in the UK. For ICH (n=10,313), overall ICU mortality was 42.4% and acute hospital mortality 62.1%. In NCCU length of stay was longer, but mortality lower, and over time, mortality from ICH decreased faster. For MG (n=1,064) and GBS (n=1,906) there was no association between acute hospital mortality unit type–overall mortality was relatively high (MG: 8.7% ICU mortality and 22% acute hospital mortality; GBS: 7.7 and 16.7% respectively). Overall mortality did not decrease over time. The first large-scale analysis of outcome in acute neurological disease in UK shows specialised NCCU care alone is associated with increased survival in conditions requiring highly specialised intensive care techniques. The high mortality seen after ICU discharge particularly in MG and GBS suggests that high quality step-down care and neurorehabilitation is pivotal in others.
    No preview · Article · Sep 2014 · Journal of Neurology Neurosurgery & Psychiatry

Publication Stats

2k Citations
628.21 Total Impact Points

Institutions

  • 2000-2015
    • Intensive Care National Audit & Research Centre ICNARC
      Londinium, England, United Kingdom
  • 2005-2009
    • Columbia University
      • Department of Anesthesiology
      New York City, NY, United States