Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation

Oscar J. L. Mitchell, MD; Maya Dewan, MD; Heather A. Wolfe, MD; Karsten J. Roberts, MSc, RRT; Stacie Neefe, BSN; Geoffrey Lighthall, MD; Nathaniel A. Sands, MPH; Gary Weissman, MD, MSHP; Jennifer Ginestra, MD, MSHP; Michael G. S. Shashaty, MD, MSCE; William D. Schweickert, MD; Benjamin S. Abella, MD, MPhil

doi:10.1097/CCE.0000000000000677

Critical Care Explorations (Apr 2022)

Defining Physiological Decompensation: An Expert Consensus and Retrospective Outcome Validation

Oscar J. L. Mitchell, MD,
Maya Dewan, MD,
Heather A. Wolfe, MD,
Karsten J. Roberts, MSc, RRT,
Stacie Neefe, BSN,
Geoffrey Lighthall, MD,
Nathaniel A. Sands, MPH,
Gary Weissman, MD, MSHP,
Jennifer Ginestra, MD, MSHP,
Michael G. S. Shashaty, MD, MSCE,
William D. Schweickert, MD,
Benjamin S. Abella, MD, MPhil

Affiliations

Oscar J. L. Mitchell, MD: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
Maya Dewan, MD: 4 Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH.
Heather A. Wolfe, MD: 3 Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
Karsten J. Roberts, MSc, RRT: 7 Department of Respiratory Care, Hospital of the University of Pennsylvania, Philadelphia, PA.
Stacie Neefe, BSN: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
Geoffrey Lighthall, MD: 8 Department of Anesthesia, Pain and Perioperative Medicine, Stanford University School of Medicine, Stanford, CA.
Nathaniel A. Sands, MPH: 2 Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA.
Gary Weissman, MD, MSHP: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
Jennifer Ginestra, MD, MSHP: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
Michael G. S. Shashaty, MD, MSCE: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
William D. Schweickert, MD: 1 Division of Pulmonary, Allergy, and Critical care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA.
Benjamin S. Abella, MD, MPhil: 2 Center for Resuscitation Science, University of Pennsylvania, Philadelphia, PA.

DOI: https://doi.org/10.1097/CCE.0000000000000677
Journal volume & issue: Vol. 4, no. 4
p. e0677

Abstract

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OBJECTIVES:. Physiological decompensation of hospitalized patients is common and is associated with substantial morbidity and mortality. Research surrounding patient decompensation has been hampered by the absence of a robust definition of decompensation and lack of standardized clinical criteria with which to identify patients who have decompensated. We aimed to: 1) develop a consensus definition of physiological decompensation and 2) to develop clinical criteria to identify patients who have decompensated. DESIGN:. We utilized a three-phase, modified electronic Delphi (eDelphi) process, followed by a discussion round to generate consensus on the definition of physiological decompensation and on criteria to identify decompensation. We then validated the criteria using a retrospective cohort study of adult patients admitted to the Hospital of the University of Pennsylvania. SETTING:. Quaternary academic medical center. PATIENTS:. Adult patients admitted to the Hospital of the University of Pennsylvania who had triggered a rapid response team (RRT) response between January 1, 2019, and December 31, 2020. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Sixty-nine experts participated in the eDelphi. Participation was high across the three survey rounds (first round: 93%, second round: 94%, and third round: 98%). The expert panel arrived at a consensus definition of physiological decompensation, “An acute worsening of a patient’s clinical status that poses a substantial increase to an individual’s short-term risk of death or serious harm.” Consensus was also reached on criteria for physiological decompensation. Invasive mechanical ventilation, severe hypoxemia, and use of vasopressor or inotrope medication were bundled as criteria for our novel decompensation metric: the adult inpatient decompensation event (AIDE). Patients who met greater than one AIDE criteria within 24 hours of an RRT call had increased adjusted odds of 7-day mortality (adjusted odds ratio [aOR], 4.1 [95% CI, 2.5–6.7]) and intensive care unit transfer (aOR, 20.6 [95% CI, 14.2–30.0]). CONCLUSIONS:. Through the eDelphi process, we have reached a consensus definition of physiological decompensation and proposed clinical criteria with which to identify patients who have decompensated using data easily available from the electronic medical record, the AIDE criteria.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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