Trauma intensive care unit survival: How good is an educated guess?

Claudia E. Goettler, Brett H. Waibel, Joel Goodwin, Frank Watkins, Eric A. Toschlog, Scott G. Sagraves, Paul J. Schenarts, Michael R. Bard, Mark A. Newell, Michael F. Rotondo

Research output: Contribution to journalArticle

11 Citations (Scopus)

Abstract

Background: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. Methods: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. Results: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. Conclusions: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.

Original languageEnglish (US)
Pages (from-to)1279-1287
Number of pages9
JournalJournal of Trauma - Injury, Infection and Critical Care
Volume68
Issue number6
DOIs
StatePublished - Jun 1 2010

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Intensive Care Units
Survival
Wounds and Injuries
Patient Care
Aptitude
Critical Care
Nurses
Patient Care Team
Nutritionists
Patient Discharge
Trauma Centers
Research Ethics Committees
Certification
Medical Students
Pharmacists
Observational Studies
Survivors
Consensus
Observation
Medicine

Keywords

  • Mortality
  • Outcomes.
  • Prediction
  • Survival
  • Trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Goettler, C. E., Waibel, B. H., Goodwin, J., Watkins, F., Toschlog, E. A., Sagraves, S. G., ... Rotondo, M. F. (2010). Trauma intensive care unit survival: How good is an educated guess? Journal of Trauma - Injury, Infection and Critical Care, 68(6), 1279-1287. https://doi.org/10.1097/TA.0b013e3181de3b99

Trauma intensive care unit survival : How good is an educated guess? / Goettler, Claudia E.; Waibel, Brett H.; Goodwin, Joel; Watkins, Frank; Toschlog, Eric A.; Sagraves, Scott G.; Schenarts, Paul J.; Bard, Michael R.; Newell, Mark A.; Rotondo, Michael F.

In: Journal of Trauma - Injury, Infection and Critical Care, Vol. 68, No. 6, 01.06.2010, p. 1279-1287.

Research output: Contribution to journalArticle

Goettler, CE, Waibel, BH, Goodwin, J, Watkins, F, Toschlog, EA, Sagraves, SG, Schenarts, PJ, Bard, MR, Newell, MA & Rotondo, MF 2010, 'Trauma intensive care unit survival: How good is an educated guess?', Journal of Trauma - Injury, Infection and Critical Care, vol. 68, no. 6, pp. 1279-1287. https://doi.org/10.1097/TA.0b013e3181de3b99
Goettler, Claudia E. ; Waibel, Brett H. ; Goodwin, Joel ; Watkins, Frank ; Toschlog, Eric A. ; Sagraves, Scott G. ; Schenarts, Paul J. ; Bard, Michael R. ; Newell, Mark A. ; Rotondo, Michael F. / Trauma intensive care unit survival : How good is an educated guess?. In: Journal of Trauma - Injury, Infection and Critical Care. 2010 ; Vol. 68, No. 6. pp. 1279-1287.
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T1 - Trauma intensive care unit survival

T2 - How good is an educated guess?

AU - Goettler, Claudia E.

AU - Waibel, Brett H.

AU - Goodwin, Joel

AU - Watkins, Frank

AU - Toschlog, Eric A.

AU - Sagraves, Scott G.

AU - Schenarts, Paul J.

AU - Bard, Michael R.

AU - Newell, Mark A.

AU - Rotondo, Michael F.

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N2 - Background: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. Methods: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. Results: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. Conclusions: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.

AB - Background: Resource utilization in medicine is becoming a more and more urgent issue with ongoing national discussions on healthcare coverage. In the management of a trauma system, large amounts of resources and money are expended on individual patients in hope of a "great save." In addition, those of us caring for these patients are required to estimate outcomes daily to the family in an effort to choose the best course of care for an individual patient. Hence, we undertook a study to analyze the accuracy of outcomes predictions of various members of the healthcare team. Methods: During a period of 38 months (July 2005 to August 2008), an observational study of patients admitted to a Level I Trauma Center Intensive Care Unit (ICU) was undertaken. Institutional Review Board permission was obtained before starting the study. Only patients older than 18 years were included. Patients who were moribund or expected discharge within 72 hours were excluded.Our traumatized ICU patients are cared for by a multidisciplinary team consisting of a trauma/ICU attending, all of whom have additional certification in surgical critical care and who rotate through the ICU on a weekly basis, a surgical ICU fellow, residents and medical students of several levels of training who rotate on a monthly basis, trauma advanced-level practitioners who rotate weekly, and bedside ICU nurses who work routine shifts. Respiratory therapists, nutritionists, ICU pharmacists, and other members of the rounding team were not included in the study because they do not provide global patient care. Regardless of admitting physician, the patients are managed by the team, and our practice of care is similar across the group, based on protocols and consensus.For each of the study patients, a survey tool was filled out by the ICU rounding team on hospital day 1 and hospital day 3. The tool was completed by members of the team providing global care to the patient and varied depending on the members of the group at each day's rounds. All current and admission data on injuries, study and laboratory results, and current patient status were available to all members of the team. Each member was expected to fill out the survey tool independently, and the results of the tool were not discussed during rounds.Concurrently, data were collected by the ICU fellow and research nurse. These data and the results of the survey tools were entered in a database for analysis after patient discharge. A retrospective analysis was undertaken to analyze the relative accuracy of the care, team members' assessment, and actual survival. Statistical analysis was done using by-chance accuracy comparisons. Results: Two hundred twenty-three patients had 326 observations performed. Day 3 accuracy improved for most groups. In all groups, accuracy was found to be statistically significantly better than by-chance accuracy. Given that the majority of patients in the trauma population are survivors, sensitivity and positive predictive value of the observer's ability to predict death were also evaluated. Conclusions: Although significantly better than chance prediction, the ability of members of the ICU team to predict survival of trauma patients remains poor, particularly on initial evaluation. A period of clinical observation improves the accuracy. Unfortunately, experience of the observer does not seem to improve accuracy of survival prediction. This data indicate that care must be taken when describing likely outcomes to patient family members.

KW - Mortality

KW - Outcomes.

KW - Prediction

KW - Survival

KW - Trauma

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