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Nathan Shapiro

Publications and source records attributed to Nathan Shapiro.

5 recordsLinked to original sources
PubMed2006

The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection.

STUDY OBJECTIVE: The critical care community has used standard criteria for defining the sepsis syndromes and organ dysfunction for more than 15 years; however, these criteria are not well validated in the emergency department (ED) setting. The study objectives in our ED population of patients admitted to the hospital are to determine the prevalence of the sepsis syndromes, quantify inhospital mortality and 1-year survival associated with the sepsis syndromes, and assess the inhospital and 1-year survival associated with organ dysfunctions. METHODS: This was a prospective, observational, cohort study from February 1, 2000, to February 1, 2001 in an urban university hospital ED with 50,000 annual visits. There were 3,102 (96% of eligible) consecutive adult patients (aged 18 years or older) with suspected infection (as indicated by the clinical decision to obtain a blood culture) who were enrolled. Patients were screened for systemic inflammatory response syndrome (SIRS) (2 or more indicators of inflammatory response), sepsis (SIRS plus suspected infection), severe sepsis (sepsis plus organ dysfunction), septic shock (sepsis plus hypotension refractory to an initial fluid challenge), and number of organs with acute dysfunction. Main outcome measure was inhospital and 1-year mortality. RESULTS: Overall inhospital mortality was 4.1% and 1-year mortality was 22%. The inhospital mortality rates were suspected infection without SIRS 2.1%, sepsis 1.3%, severe sepsis 9.2%, and septic shock 28%. Compared to suspected infection without SIRS, adjusted risks of inhospital mortality were severe sepsis (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.6 to 6.3) and septic shock (OR 13.8; 95% CI 6.6 to 29). Severe sepsis (OR 2.2; 95% CI 1.8 to 2.6) and septic shock (OR 3.5; 95% CI 2.3 to 5.3) also predicted 1-year mortality. The presence of SIRS criteria alone had no prognostic value for either endpoint. Each additional organ dysfunction increased the adjusted 1-year mortality hazard by 82% (pulse rate: 1.82, 95% CI 1.7 to 2.0). CONCLUSION: Immediate identification of acute organ dysfunction in ED patients with suspected infection may help select patients at increased short- and long-term mortality risk. SIRS criteria offered no additional prognostic value, whereas each additional organ dysfunction increased the 1-year mortality risk.

Adult↗
PubMed2006

When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature.

BACKGROUND: Receiving care in an intensive care unit can greatly influence patients' survival and quality of life. Such treatments can, however, be extremely resource intensive. Therefore, it is increasingly important to understand the costs and consequences associated with interventions aimed at reducing mortality and morbidity of critically ill patients. Cost-effectiveness analyses (CEAs) have become increasingly common to aid decisions about the allocation of scarce healthcare resources. OBJECTIVES: To identify published original CEAs presenting cost/quality-adjusted life year or cost/life-year ratios for treatments used in intensive care units, to summarize the results in an accessible format, and to identify areas in critical care medicine that merit further economic evaluation. METHODS: We conducted a systematic search of the English-language literature for original CEAs of critical care interventions published from 1993 through 2003. We collected data on the target population, therapy or program, study results, analytic methods employed, and the cost-effectiveness ratios presented. RESULTS: We identified 19 CEAs published through 2003 with 48 cost-effectiveness ratios pertaining to treatment of severe sepsis, acute respiratory failure, and general critical care interventions. These ratios ranged from cost saving to 958,423 US dollars/quality-adjusted life year and from 1,150 to 575,054 US dollars/life year gained. Many studies reported favorable cost-effectiveness profiles (i.e., below 50,000 US dollars/life year or quality-adjusted life year). CONCLUSIONS: Specific interventions such as activated protein C for patients with severe sepsis have been shown to provide good value for money. However, overall there is a paucity of CEA literature on the management of the critically ill, and further high-quality CEA is needed. In particular, research should focus on costly interventions such as 24-hr intensivist availability, early goal-directed therapy, and renal replacement therapy. Recent guidelines for the conduct of CEAs in critical care may increase the number and improve the quality of future CEAs.

Cost-Benefit Analysis↗
PubMed2005

Sick? Or, not sick?

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Emergency Service, Hospital↗
PubMedDate not supplied

Concordance of field and emergency department assessment in the prehospital management of patients with dyspnea.

OBJECTIVE: Dyspnea is a common complaint of patients treated by emergency medical services (EMS). Few studies have examined the ability of paramedics to distinguish between etiologies of dyspnea. The authors evaluated the degree of agreement related to cardiac versus noncardiac sources of dyspnea between field and emergency department (ED) assessment of patients transported at the advanced life support level. METHODS: This was a retrospective, cohort study of consecutive patients aged > or =35 years transported by paramedics with dyspnea. The authors compared the concordance between the EMS and ED diagnoses. They also investigated whether patients whose assessments were discordant had worse outcomes. RESULTS: Paramedics correctly assessed the cause of dyspnea in 172 of 222 (77%) patients (kappa=0.60; 95% confidence interval [CI]=0.51, 0.69). Among single-source (i.e., cardiac or noncardiac) dyspnea patients, prehospital providers correctly assessed 70 of 84 (83%) noncardiac causes and 98 of 114 (86%) cardiac causes (kappa=0.69; 95% CI=0.59, 0.79). When the ED diagnosis included both cardiac and noncardiac etiologies, paramedics treated seven of 24 (29%) patients as noncardiac, 13 of 24 (54%) as cardiac, and four of 24 (17%) as combined-source dyspnea. The authors did not observe any statistically significant differences in in-hospital mortality, intubation frequency, or hospital length of stay in patients whose prehospital dyspnea diagnosis was discordant. CONCLUSION: The authors conclude that in this EMS system, field assessment of dyspnea by paramedics is in agreement with that arrived at in the ED in a high proportion of patients with dyspnea from a single source. However, field assessment of dyspnea from multiple etiologies is less concordant.

Adult↗