الفهرس | Only 14 pages are availabe for public view |
Abstract Intensive care has developed over the past 30 years with little scientific evidence about what is, or is not, clinically effective. Without these data, doctors delivering intensive care often have to decide which patients can benefit most. Scoring systems have been developed in response to an increasing emphasis on the evaluation and monitoring of health services. These systems enable comparative audit and evaluative research of intensive care. Scoring systems have been employed in ICU settings since the 1980s, and are intended to help inform decisions related to treatment and prognosis and used to measure ICU quality, the most accepted and used models are the Acute Physiology and Chronic Health Evaluation (APACHE), the Simplified Acute Physiology Score (SAPS) and the Mortality Prediction Model (MPM). The APACHE system incorporates measures of physiologic derangement and co-morbidities, SAPS includes many of the same physiologic variables as APACHE but adjusts for co-morbidities to a more limited extent, and the MPM system uses fewer physiologic measures than either APACHE or SAPS and includes several process variables. Important characteristics of these instruments are calibration and discrimination. Calibration reflects the agreement between individual probabilities and actual outcomes, whereas discrimination is the model’s ability to separate patients who die from those who survive. The scoring system chosen depends on the proposed use there are five major purposes of severity-of-illness scoring systems. First, scoring systems have been used in randomized controlled trials (RCT) and other clinical investigations The second purpose of severity-of-illness scoring systems is to quantify severity of illness for hospital and health care system administrative decisions such as resource allocation. The third purpose of these scoring systems is to assess ICU performance and compare the quality of care of different ICUs and within the same ICU over time. Severity-of-illness scoring systems could be used to assess the impact on patient outcomes of planned changes in the ICU, such as changes in bed number, staffing ratios, and medical coverage the fourth purpose of these scoring systems is to assess the prognosis of individual patients in order to assist families and caregivers in making decisions about ICU care. Finally, scoring systems are now being used to evaluate suitability of patients for novel therapy. The main criteria for selection of a good scoring system should be: 1- Simple, reliable, easily obtainable. 2- Wide patient applicability (Different diagnoses - All age groups - All levels / types of ICU’s) 3- High sensitivity/specificity. 4- Stimulates improvement in outcomes. 5- Independent of treatment. 6- Physiological parameters. 7- Optimal time is unclear. 8- Number of criteria is unclear. Scoring systems in intensive care can be either specific or generic. Specific scoring systems are used for certain types of patient whereas generic systems can be used to assess all, or nearly all, types of patient. The scoring system may be either anatomical or physiological. Anatomical scoring systems assess the extent of injury whereas physiological systems assess the impact of injury on function. Scores from anatomical scoring systems, once assessed, are fixed whereas physiological scores may change as the physiological response to the injury or disease varies. All existing models aim to predict an outcome based on a given set of variables. Although death before discharge from hospital is the usual measure of outcome, disability, functional health, and quality of life should not be ignored. Quality of life after a critical illness has been measured by various methods. The results differ according to the method used and the types of patient studied. Age and pre-existing severe clinical conditions seem to greatly affect quality of life after intensive care. The prediction of outcome is very important for: 1- Prognosis. 2- Cost-benefit analysis. 3- Withdrawal of treatment. 4- Comparison between different centers. 5- Monitoring/assessment of new therapies. 6- Population sample comparison in studies. |