 Member  Non-member  Regional hospital  County hospital  Local hospital

1. The Swedish Intensive Care Registry: New (?) insights for the surgeon Source for research! Member Non-member  Regional hospital  County hospital  Local hospital Sten Walther, MD Chairman, Swedish Intensive Care Registry Linköping University Hospital http://www.icuregswe.org

2. The Swedish Intensive Care Registry: New (?) insights for the surgeon Source for research! 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 Member Non-member  Regional hospital  County hospital  Local hospital

3. Data sources

4. Data sources • 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

5. 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

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

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

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

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

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

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

12. Criteria for assessing coverage and accuracy Registry metrics (DocDATstuk)      

13. Criteria for assessing coverage and accuracy Registry metrics (DocDATstuk)    Health related Quality of Life   Vital status 

14. Criteria …. (cont’d)      Black et al, QualSaf Health Care 2003 12: 348-352

15. http://www.icuregswe.org

17. Admissiontypes in the ICU: SIR 2010 Intensive care General incl. neuro 37 071 Cardiothoracic 3 863 Specializedpediatric 1 651 Othercaretypes Post-operative 12 367 Other 10 493 Coronary 5 321  42 585  28 181 70 766

18. Case study ISurvival: ICU admissions from General surgery

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

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

21. Risk adjustment with SAPS3GI-bleeding (N=1282).Survival 30 days after admission to ICU Discrimination is good: aROC = 0.84

22. Survival: Gastrointestinal bleeding(Repeated admissions)

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

24. Survival: Abdominal aortic aneurysm Not ruptured Ruptured

25. Survival: Abdominal aortic aneurysm

26. Survival: Abdominal aortic aneurysm

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

28. Guidelines …..

29. 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 don’t mix them up”

30. Time to death in the ICU: Operative vs. Non-operative admissions

31. Case study IIIProcedures in the ICU: Tracheotomy

32. Tracheotomy: Technique and timing Open technique Percutaneous technique

33. Tracheotomy: Technique and timing Open technique Percutaneous technique

34. Tracheotomy: Technique and timing • ICU length of stay increases by 1.3 days for every day tracheostomy is ‘delayed’

35. Guidelines …..

36. Case study IVHealth related quality of life after ICU • Assessing health related quality of life may give important insights • You only manage what you measure

37. 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

38. Health related quality of life after ICU SF-36: All assessments (27 ICUs) At 2 months (N=982): Age 61 (17 – 99) yrs ICU LOS 9 (2 – 48) days SIR data from 2009-2010

39. 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 2009-2010

40. 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 10th Anniversary Saltsjöbaden 2011

41. www.icuregswe.org (with link to my presentation coming shortly) info@icuregswe.org 010 209 41 00