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
The Swedish Intensive Care Registry:
New (?) insights for the surgeon
Source for research!
 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
Data sources
My ICU
Critical care
outreach
ICU-care
aftercare
Your
ICU
Many
other
ICUs
Swedish
Intensive Care
Registry
Microbiology
lab data
Swedish
population
registry
Data sources
My ICU
Critical care
outreach
Data coupling possible using
 Unique admission identifier
 Unique person identifier
ICU-care
aftercare
Your
ICU
Many
other
ICUs
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
Swedish
Intensive Care
Registry
Microbiology
lab data
Swedish
population
registry
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
Which data?
Consult
Follow up
Critical care outreach
Minimal dataset
ICU-care aftercare
Withdrawal / Withholding
ICU
Reason for admission
CardioThor ICU
SOFA
Adverse events
Pediatric ICU
Admit
Treat
SAPS 3
Nursing workload
APACHE II
Procedures
ICU-Higgins
PIM 2
Renal RT
Ventilator therapy
Discharge
Diagnosis
Key diagnosis
ICU outcome
Data transfer: interaction over time
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
Old admissions
Corrected errors
New admissions
Swedish Intensive Care Registry
Swedish Population Registry
Data transfer: interaction over time
My ICU
Preferably weekly
At least monthly
Swedish Intensive Care Registry
Swedish Population Registry
Data transfer: interaction over time
My ICU
Preferably weekly
At least monthly
Swedish Intensive Care Registry
Vital status update
Weekly
Swedish Population Registry
Criteria for assessing coverage and accuracy
Registry metrics (DocDAT stuk)
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




Criteria for assessing coverage and accuracy
Registry metrics (DocDAT stuk)



Health related
Quality of Life


Vital status

Criteria …. (cont’d)





Black et al, Qual Saf Health Care 2003 12: 348-352
http://www.icuregswe.org
Admission types in the ICU: SIR 2010
Intensive care
General incl. neuro
– 37 071
Other care types
Post-operative
– 12 367
Cardiothoracic
– 3 863
Other
– 10 493
Specialized pediatric
Coronary
– 1 651
– 5 321
 42 585
 28 181
70 766
Case study I
Survival: ICU admissions from General surgery
1.00
0.80
No surgery
Elective surgery
0.60
Emergency surgery
0.40
0.20
0.00
0
1
2
Survival (yrs)
Swedish Intensive Care Registry 2008-2011, N=46 382
3
Survival: Gastrointestinal bleeding
(Principal diagnosis, Primary admission only)
Kaplan-Meier survival estimates
1.00
0.80
No surgery
0.60
Surgery
0.40
0.20
0.00
0
.5
1
Survival (yrs)
1.5
2
2716
396
1816
260
1359
193
974
137
674
86
Number at risk
No surgery
Surgery
Swedish Intensive Care Registry 2008-2011
Survival: Gastrointestinal bleeding
(Principal diagnosis, Primary ICU admission only)
Kaplan-Meier survival estimates
1.00
0.80
No surgery
Surgery
69 (SD 15)
67 (SD 16)
No surgery
Age (yrs)
0.60
Male / Female
0.40
SAPS3 risk
estimate
0.20
Length of
ICU stay
(days)
0.00
0
.5
Number at risk
No surgery
Surgery
2716
396
1816
260
Dead1in ICU
Survival (yrs)
Dead < 30
days1359
193
Swedish Intensive Care Registry 2008-2011
Surgery
64 % / 36 %
60 % / 40 %
Median 0.26
(IQR 0.16 – 0.42)
Median 0.36
(IQR 0.16 – 0.45)
Median 0.9
(IQR 0.5 – 1.6)
Median 1.0
(IQR 0.6 – 1.9)
1.5 5.5 %
2
17 %
974
137
5.7 %
19 %
674
86
Risk adjustment with SAPS3
0.50
0.75
1.00
GI-bleeding (N=1282).
Survival 30 days after admission to ICU
0.00
0.25
Discrimination is good:
aROC = 0.84
0.00
0.25
Area under ROC curve = 0.8433
0.50
1 - Specificity
0.75
1.00
Survival: Gastrointestinal bleeding
(Repeated admissions)
Kaplan-Meier survival estimates
1.00
0.80
0.60
0.40
0.20
0.00
0
.5
1
Survival (yrs)
1.5
2
3113
702
234
2076
441
131
1552
313
88
1111
210
53
760
145
33
Number at risk
1st adm
2nd adm
3rd adm
Swedish Intensive Care Registry 2008-2011
Survival: Gastrointestinal bleeding and gender
(Primary ICU admission)
Kaplan-Meier survival estimates
1.00
0.90
Similar also after
risk adjustment
0.80
0.70
0.60
0.50
0.40
0
.5
1
Survival (yrs)
1.5
2
1122
1991
739
1337
559
993
404
707
281
479
Number at risk
Female
Male
Swedish Intensive Care Registry 2008-2011
Survival: Abdominal aortic aneurysm
Kaplan-Meier survival estimates
1.00
Not ruptured
0.80
0.60
Ruptured
0.40
0.20
0.00
0
1
2
3
394
222
122
64
Survival (yrs)
Number at risk
Not ruptured 1283
Ruptured 961
764
426
Swedish Intensive Care Registry 2008-2011
Survival: Abdominal aortic aneurysm
Kaplan-Meier survival estimates
1.00
0.80
Not
ruptured
Ruptured
0.60
Dead < 30d
SIR2010
5.5 %
34.7 %
0.40
Dead < 30d
Swedvasc 2010
2.4 %
35.1 %
0.20
0.00
0
1
2
3
394
222
122
64
Survival (yrs)
Number at risk
Not ruptured 1283
Ruptured 961
764
426
Swedish Intensive Care Registry 2008-2011
Survival: Abdominal aortic aneurysm
Kaplan-Meier survival estimates
1.00
Regional
County
0.90
Local
0.80
0.70
0.60
0.50
0
1
2
3
222
352
42
61
110
15
Survival (yrs)
Number at risk
Regional 828
County 1168
Local 248
419
651
120
Swedish Intensive Care Registry 2008-2011
Survival: Abdominal aortic aneurysm
Kaplan-Meier survival estimates
1.00
Regional
County
0.90
Local
0.80
Differences remain
favoring County ICUs
after adjustment for
risk (SAPS3) and
rupture
0.70
0.60
0.50
0
1
2
3
222
352
42
61
110
15
Survival (yrs)
Number at risk
Regional 828
County 1168
Local 248
419
651
120
Swedish Intensive Care Registry 2008-2011
Guidelines …..
Case study II
Time to death in the ICU:
Operative vs. Non-operative admissions
1.00
0.80
0.60
0.40
Operative
0.20
Non-operative
0.00
0
10
20
30
40
Time to death (days)
50
Swedish Intensive Care Registry 2008-2011 (N: Op=1632, Non-op=7356)
60
Time to death in the ICU:
Operative vs. Non-operative admissions
1.00
0.80
0.60
50th
percentile
75th
percentile
Operative
2.0 days
6.0 days
Nonoperative
1.4 days
4.0 days
0.40
Operative
0.20
Non-operative
0.00
0
10
20
30
40
Time to death (days)
50
Swedish Intensive Care Registry 2008-2011 (N: Op=1632, Non-op=7356)
60
Case study III
Procedures in the ICU: Tracheotomy
1
Karlskoga
Linköping NIVA
.8
.6
Värnamo
Sundsvall
Hudiksvall
.4
.2
Linköping IVA
Östersund
Halmstad
Umeå IVA
Norrköping
K Huddinge IVA
Linköping TIVA
Eksjö
Skövde
Kristianstad
Södertälje SÖS IVA Eskilstuna
St Göran Borås
Västerås
Gävle
Nyköping
Lindesberg
Falun
Karlstad
Alingsås
Varberg Malmö Inf
Malmö IVA
Torsby
Lidköping
Helsingborg
Örebro IVA
Arvika
Jönköping
Ystad
Danderyd
Örnsköldsvik
Sollefteå Norrtälje
Kungälv
K Solna CIVA
Lund IVA
Lund BIVA
0
0
50
100
150
200
Number of admissions with mechanical ventilation >72 hrs
Tracheotomy: Technique and timing
200
200
Open technique
Percutaneous tracheotomy
Percutaneous technique
150
100
50
150
100
50
0
0
0
7
14
Days with mechanical ventilation
21
0
7
14
Days with mechanical ventilation
21
Tracheotomy: Technique and timing
200
200
Open technique
Percutaneous tracheotomy
Percutaneous technique
150
100
50
150
100
50
0
0
0
7
14
Days with mechanical ventilation
21
0
7
14
Days with mechanical ventilation
Open
N=1630
Percutaneous
N=1201
61 (SD 16) yrs
63 (SD 15) yrs
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)
Age
Male /
Female
21
Tracheotomy: Technique and timing
28
21
y=1.3x + 11 (adjusted for SAPS3 and technique)
14
7
0
0
7
14
Duration of mechanical ventilation before tracheotomy (days)
 ICU length of stay increases by 1.3 days for every day
tracheostomy is ‘delayed’
Guidelines …..
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
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
SF-36: All assessments (27 ICUs)
PF
MH
RP
RE
PF
RP
BP
GH
VT
SF
RE
MH
Physical Functioning
Role - Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role - Emotional
Mental Health
BP
20
40
60
SF
80
100
GH
Reference
2 months, N=982
6 months, N=701
12 months, N=302
VT
SIR data from 2009-2010
At 2 months (N=982):
Age 61 (17 – 99) yrs
ICU LOS 9 (2 – 48) days
Health related quality of life after ICU
SF-36: Admissions after surgery
PF
MH
RP
RE
PF
RP
BP
GH
VT
SF
RE
MH
Physical Functioning
Role - Physical
Bodily Pain
General Health
Vitality
Social Functioning
Role - Emotional
Mental Health
What is the appropriate
reference?
For how long should we
measure?
BP
20
40
60
SF
80
100
GH
Reference
2 months, N=66
6 months, N=66
12 months, N=66
VT
SIR data from 2009-2010
Can we accelerate
recovery?
Designing and exploring
interventions
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
www.icuregswe.org
(with link to my presentation coming shortly)
info@icuregswe.org
010 209 41 00