Ne smith et al.2009.sirs in the icu


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Ne smith et al.2009.sirs in the icu

  1. 1. use only. For copyright permission information:http://www.ajcconline.orgPublished online© 2009 American Association of Critical-Care NursesAm J Crit Care. 2009;18: 339-346 doi: 10.4037/ajcc2009267Hawkins and Martin WeinrichElizabeth G. NeSmith, Sally P. Weinrich, Jeannette O. Andrews, Regina S. Medeiros, Michael L.Predictors of Length of Stay in the Intensive Care UnitSystemic Inflammatory Response Syndrome Score and Race As information for authors a manuscript alertsCopyright © 2009 by AACN. All rights reserved.Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049.bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.journal of the American Association of Critical-Care Nurses (AACN), publishedAJCC, the American Journal of Critical Care, is the official peer-reviewed researchat Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  2. 2. By Elizabeth G. NeSmith, RN, MSN, PhD, Sally P. Weinrich, RN, PhD, Jeannette O.Andrews, PhD, APRN, BC, Regina S. Medeiros, RN, MHSA, DNP, CCRN, Michael L.Hawkins, MD, and Martin Weinrich, PhDBackground Identifying predictors of length of stay in theintensive care unit can help critical care clinicians prioritizecare in patients with acute, life-threatening injuries.Objective To determine if systemic inflammatory responsesyndrome scores are predictive of length of stay in the inten-sive care unit in patients with acute, life-threatening injuries.Methods Retrospective chart reviews were completed onpatients with acute, life-threatening injuries admitted to theintensive care unit at a level I trauma center in the southeast-ern United States. All 246 eligible charts from the trauma reg-istry database from 1998 to 2007 were included. Systemicinflammatory response syndrome scores measured on admis-sion were correlated with length of stay in the intensive careunit. Data on race, sex, age, smoking status, and injury sever-ity score also were collected. Univariate and multivariateregression modeling was used to analyze data.Results Severe systemic inflammatory response syndromescores on admission to the intensive care unit were predictive oflength of stay in the unit (F=15.83; P<.001), as was white race(F=9.7; P=.002), and injury severity score (F=20.23; P<.001).Conclusions Systemic inflammatory response syndrome scorescan be measured quickly and easily at the bedside. Data supportuse of the score to predict length of stay in the intensive careunit. (American Journal of Critical Care. 2009;18:339-347) AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 339SYSTEMIC INFLAMMATORYRESPONSE SYNDROMESCORE AND RACE ASPREDICTORS OF LENGTHOF STAY IN THE INTENSIVECARE UNITCritical Care EvaluationCE 1.0 HourNotice to CE enrollees:A closed-book, multiple-choice examinationfollowing this article tests your understandingof the following objectives:1. Identify the significant results found in this study.2. Describe practical applications of using the sys-temic inflammatory response syndrome score.3. Discuss further areas of research on this topic.To read this article and take the CE test online,visit and click “CE ArticlesinThis Issue.” No CE test fee for AACN members.©2009 American Association of Critical-Care Nursesdoi: 10.4037/ajcc2009267at Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  3. 3. Length of stay in the intensive care unit (ICU)is recognized by the Joint Commission on HealthcareOrganizations as an important outcome measurefor ICU treatment,4which is one of the most costlyand resource-intensive aspects of caring for patients.5Mean costs are more than $10000 on the first dayof admission and nearly $5000/day afterward.6Careful attention to ICU length ofstay by critical care nurses, combinedwith targeted adjustments in patientcare planning, can help reduce asso-ciated costs and complications.ICU length of stay for patientswith acute, life-threatening injuriescan vary widely.5Factors that influenceICU length of stay include patients’demographic variables such as age5and physiological changes that occurwithin the first 24 hours of admis-sion.7An example of an importantphysiological change that occurs within the first 24hours is the quality of the systemic inflammatoryresponse to injury.In the hours after an acute life-threateninginjury, patients are at risk for development of thesystemic inflammatory response syndrome (SIRS), asevere hyperinflammatory condition observed in29% to 61% of patients after life-threateninginjury.8-14The occurrence and severity of SIRS aredetermined by calculating a SIRS score. This score isincreasingly being used to predict injury outcomes.Studies have shown validity for the SIRS score inpredicting deadly complications seen in the ICU,including infection and sepsis.8,10,12,13The predictivevalidity of the SIRS score for ICU length of stay hasnot been tested, however.A valid and easy-to-use bedside tool (such as theSIRS score) that could be used to predict ICU lengthof stay could help nurses maximize planning effi-ciency for interventions aimed at preventing compli-cations, reducing ICU costs, and improving patients’outcomes. In contrast, existing predictor tools such asthe Acute Physiology and Chronic Health Evaluation(APACHE) and the injury severity score (ISS) are nothelpful to bedside nurses. These tools were designedto be used at the system level by health care adminis-trators and require complicated computer softwareto estimate ICU lengths of stay. The purpose of thisstudy was to investigate the validity of the SIRS scoreas well as demographic and clinical variables for pre-dicting ICU length of stay in patients with acute life-threatening injuries.MethodsDesign and SampleThe institutional review board for the MedicalCollege of Georgia and MCGHealth gave approvalto conduct the study. A retrospective chart reviewwas conducted to measure the usefulness of the SIRSscore in predicting ICU length of stay. The studysample consisted of charts entered into the traumaregistry database (National Trauma Registry of theAmerican College of Surgeons, Version 4.1.14, ForestHill, Maryland) at MCGHealth, a level I traumacenter, between 1998 and 2007. Inclusion criteriawere (1) age between 18 and 44 years, (2) presenceof acute, life-threatening injuries defined as an ISSof 15 or greater, and (3) admission to the ICU forat least 24 hours. Exclusion criteria were (1) bloodtransfusion; (2) spinal cord injury; (3) comorbiddiseases that could affect immune function andinflammatory response, including HIV infection,cancer, and autoimmune disease; (4) regular use ofLife-threatening injury is the leading cause of death among persons aged 15 to 44years and costs Americans nearly $40 billion annually.1,2Thirty-six billion peopleare injured each year, and injury is surpassed only by cardiac disease as the mostsignificant threat to health and productivity in the United States.1Experts predictthat by the year 2020, bodily injury will surpass communicable disease as the lead-ing cause of disability-adjusted life-years around the world.3About the AuthorsElizabeth G. NeSmith is an assistant professor and SallyP. Weinrich is a professor emeritus in the school of nurs-ing at the Medical College of Georgia, Augusta. Jean-nette O. Andrews is an associate professor and a seniorresearch scientist in the college of nursing at MedicalUniversity of South Carolina in Charleston. Regina S.Medeiros is a trauma program manager at MCGHealth.Michael L. Hawkins is chief of trauma/surgical care inthe department of surgery at Medical College of Geor-gia. Martin Weinrich is a professor emeritus in thedepartment of biostatistics at the Medical College ofGeorgia.Corresponding author: Elizabeth G. NeSmith, RN, MSN,PhD, School of Nursing, Medical College of Georgia,Augusta, GA 30912 (e-mail: inflam-matory responsesyndrome occursin up to 61% ofpatients followinglife-threateninginjury.340 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 www.ajcconline.orgat Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  4. 4. using data contained in the nursing admissionassessment database. These data are routinely col-lected and documented by the admitting nursefrom the patient or the patient’s next of kin.Degree of acute, life-threatening injury wasmeasured by using the ISS. The ISS is a statisticalscoring system used by injury researchers that quan-tifies multiple injuries and provides guidelines fordefining life-threatening injury forthe purpose of scientific study.18The score has predictive validity:research has validated the ISS as aclassic predictor of injury morbid-ity and mortality since the scorewas defined in 1974. The ISS is cal-culated by the trauma registry soft-ware. Scores range from 0 to 75. Ascore between 0 and 15 indicatesmild injury, a score of 16 to 29 indicates moderateinjury, and 30 or greater indicates severe injury. ICUlength of stay was measured in whole (not partial)24-hour units by counting the number of 24-hourperiods spent in the ICU, using times documentedin the chart. Time units were based on hour anddate of admission to the ICU and hour and date oftransfer to the medical-surgical step-down unit.ProceduresA report was generated from the trauma registrydatabase for use as a screening tool to identify patientsfor inclusion in the study. The trauma registry data-base contains information on injury and demographiccharacteristics, as well as diagnostic and dispositiondata. The American College of Surgeons Committeeon Trauma19mandates that all trauma centers main-tain a trauma registry database. The ISS was collectedfrom the trauma registry database.AnalysisDescriptive analysis of samplevariables was conducted andincluded mean, median, and quar-tile data. Univariate linear regres-sion modeling was used to examinethe relationship between SIRS scoreand ICU length of stay. The distri-bution of ICU length of stay andISS was normalized by using loga-rithmic transforms. Race, sex, age, smoking status,and ISS were also included in the univariate regres-sion modeling. The multiple regression model wasgenerated by using all variables of interest, includingrace, sex, age, smoking, ISS, and SIRS score. All of themodels included linear and quadratic effects for thenonsteroidal anti-inflammatory drugs; and/or (5)missing data required to calculate the SIRS score.The age range of 18 to 44 years was chosen to beconsistent with the injury-reporting age ranges foradults defined by the Centers for Disease Controland Prevention.2All patients who met inclusion andexclusion criteria, regardless of SIRS score, wereincluded in the study. Charts were screened anddata were collected by the primary author.A total of 552 charts were screened: 101 (18%)were excluded for blood transfusions, 108 (20%) formissing data, 79 (14%) for ICU stays of less than 24hours, 41 (7%) for spinal cord injury, and 6 (1%)for comorbid diseases that could influence the devel-opment of SIRS, such as HIV infection, cancer ther-apy, or use of anti-inflammatory medications. Somepatients were excluded for meeting more than 1 ofthese criteria. Of the 79 patients excluded for an ICUstay of less than 24 hours, 40 were patients who diedless than 24 hours after injury (7% of the 552 chartsscreened). Most of these deaths occurred in the emer-gency department before arrival in the ICU. Excludeddeaths resulted primarily from severe traumatic braininjuries caused from gunshot wounds to the head ormotor vehicle crashes.InstrumentsThe independent variables for this study were(1) SIRS; (2) demographic variables including race,sex, and age; (3) smoking status; and (4) degree ofacute, life-threatening injury, operationalized as ISS.ICU length of stay was the dependent variable.SIRS was measured by using the SIRS score, aninstrument developed by a panel of experts at the1991 American College of Chest Physicians/Societyof Critical Care Medicine consensus conference.15This instrument has appropriate content validity.15,16The SIRS score is determined by assigning 1 pointfor each vital sign measure that meets the followingcriteria: (1) body temperature greater than 38°C orless than 36°C, (2) heart rate greater than 90/min,(3) respiratory rate greater than 20/min or PaCO2 lessthan 32 mm Hg, and (4) white blood cell countgreater than 12000/µL or less than 4000/µL or pres-ence of 10% immature neutrophils.15A SIRS score of0 or 1 indicates absence of SIRS. A SIRS score of 2(mild), 3 (moderate), or 4 (severe) indicates theoccurrence of SIRS.17Intrarater reliability for the datacollector was assessed by calculating the SIRS scorefor the same 50 patients on 2 separate occasions.Intrarater reliability was 97%.Demographic variables of race, sex, and age weremeasured by using information contained in thepatient’s chart. Smoking status was measured AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 341The SIRS scoreassigns 1 point foreach vital signmeasure thatmeets the criteria.In this study,79% of patientsmet criteria forSIRS on admissionto the Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  5. 5. SIRS score. For effect sizes that differed by SIRSscore and race, the terms were estimated separately(nested within). The models were compared byusing partial and multiple partial F tests. Statisticalsignificance was determined on the basis of the Fstatistic and an α less than .05.ResultsMost patients in the final sample of 246 werewhite (n=133, 54%) and male (n=178, 72%). Themean age was 29 years (Table 1). Of the 246 patients,118 (52%) were smokers. Two-hundred forty-onepatients had blunt injuries resulting from motorvehicle crashes, falls, or assaults (98%). Five patients(2%) had penetrating injuries, all of which resultedfrom gunshot wounds. Thirty-five patients (14%)had severe traumatic brain injuries, defined as a scoreof 3 on the Glasgow Coma Scale upon admission tothe ICU. The ISS ranged from 16 to 59, with a medianscore of 22 (moderate injury).The ICU length of stay was from 1 to 74 days,with a mean of 8 days (Table 1). Eleven patients(4%) included in the sample died. All 11 patientsdied of traumatic brain injury or a combination oftraumatic brain injury with sepsis and multiple organfailure. The ICU length of stay for these patients wasfrom 1 to 7 days (mean, 4 days). One patient outlierhad an ICU stay of 73 days. This patient died whileawaiting long-term placement after acute care andwas excluded from the analysis. Of the 35 patientswith a score of 3 on the Glasgow Coma Scale onadmission to the ICU, 17 (7% of the total sample)had ICU stays longer than the mean of 8 days.Seventy-nine percent (n=194) of patients metcriteria for SIRS on admission to the ICU. Of these,31% had mild SIRS (score of 2), 37% had moderateTable 1Characteristics of patients and length of stay in the intensive care unitOverallRaceWhitebMinorityAfrican AmericanHispanicOtherSexMaleFemaleAge, yMean (SD)Range18-2627-3536-44Injury severity scoreMedian (SD)RangeScore 16-29bScore ≥30SmokingNonsmokerSmokerUnknownSystemic inflammatory response syndromeNone (score 0 or 1)Mild (score 2)Moderate (score 3)Severe (score 4)b246 (100)133 (54)113 (46)94 (83)16 (14)3 (3)178 (72)68 (28)29 (8.1)18-44112 (45)65 (26)69 (28)22 (7.1)16-59211 (86)35 (14)109 (48)118 (52)19 (8)53 (22)75 (39)92 (48)26 (13)8.09.8b66. Values are number (%) unless otherwise indicated.b Significance at α level <.05.Days in intensive care unit75th %ile25th %ileMedianMeanTotal groupaCharacteristic342 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 www.ajcconline.orgat Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  6. 6. Severe SIRS (score of 4) was predictive of lengthof stay with nearly the same level of significance asthe ISS (F=15.83; P<.001, vs F=20.23; P<.001). Thisfinding is important because the ISS serves as the ref-erence standard in comparing the validity of the SIRSscore for predicting ICU length of stay. Physicians andadministrators use the ISS to predict ICU length ofstay retrospectively and to evaluate associated costs,resource utilization, and health outcomes.Nurses and physicians in the ICU have no suchtools with which to predict ICU length of stay objec-tively in real time. The ISS was designed for use atthe system level and is difficult to apply at the bed-side because of cumbersome calcu-lation methods and lack of datarequired to calculate the score onadmission. Unlike SIRS, which iseasily determined by using infor-mation collected on admission, theISS is based on the final determina-tion of all anatomic injuries, includ-ing those that were initially hiddenduring the first hours or days afteradmission. To calculate the ISS, one must assign anindividual score for each injured body region,square each score, and then add the 3 highestscores. Compared with calculating the SIRS score,this process is much more complicated. Because ofthis complexity, the ISS is most frequently deter-mined after discharge by the trauma data manageror registrar by using a computer software program.RaceIn the exploratory analysis, white race was alsoa strong predictor of ICU length of stay (F=9.7;P=.002). This finding is a new and important addi-tion to the injury literature, because race is oftenoverlooked as a variable in injury research. A recentSIRS (score of 3), and 11% had severe SIRS (scoreof 4). The mean ICU length of stay for patients withsevere SIRS (score of 4) on admission was 19.2 days.Patients with moderate SIRS (score of 3) stayed amean of 8.2 days, whereas patients with mild SIRS(score of 2) stayed a mean of 6.3 days. Patients withno SIRS (score of 1 or 0) on admission stayed a meanof 4.7 days in the ICU (Table 1).Univariate AnalysesUnivariate regression analyses were performedfor each SIRS score to determine predictive validityfor ICU length of stay. Mild SIRS was classified as ascore of 2, moderate was a score of 3, and severe wasa score of 4. Severe SIRS on admission to the ICU waspredictive of ICU length of stay (F=15.83; P<.001),although mild and moderate SIRS were not.Univariate regression analyses were also per-formed on individual variables of race, sex, age,smoking status, and ISS. White race (F=9.70; P=.002)and ISS (F=20.23; P<.001) were predictors of ICUlength of stay (Table 2), whereas age, sex, and smok-ing status were not predictors.Multivariate AnalysisThree multivariate models were analyzed. Thefirst model included all of the dependent variablesof interest regardless of their significance level in theunivariate analysis, including SIRS score, race, sex,age, smoking status, and ISS. This model was notsignificant. A second model was analyzed that elimi-nated the nonsignificant variables of sex, age, andsmoking from the univariate analysis and includedthe significant variables of SIRS score, race, and ISS.This model explained 21% of the variance (R2 =0.21)for ICU length of stay (F=3.51; P=.06). The finalmodel included only nested values for SIRS and race.This model explained 15% of the variance (R2 =.15)for predicting ICU length of stay (F=7.7; P=.006).DiscussionSevere SIRS (score of 4) on admission to theICU was a very strong predictor of ICU length ofstay (F=15.83; P <.001). The prevalence of SIRSfound in this study (79%) is comparable to thatreported by Bochicchio and colleagues11(61%). Itis higher, however, than that found in other stud-ies10,12,13of patients with acute, life-threatening injuries(29%-35%). Results of similar studies10,12have vali-dated severe SIRS as a predictor of hospital lengthof stay in patients with acute, life-threatening injuries.However, the present study is the only one in whichsevere SIRS (score of 4) was a predictor of ICU lengthof stay in patients with acute, life-threatening injuries.Table 2Predictors of length of stay in intensive care unit:univariate regression analysisWhite raceaSexAgeSmokingInjury Severity Scorea,bSevere systemic inflammatoryresponse syndrome (score of 4)a,c0.040.00030.0030.00010.080.12111112. Significance at α level <.05.b Injury Severity Score calculated as log10.c Calculated by using a quadratic fit.PFdfR2Predictor9.700.060.690.0220.2315.83Nurses can useSIRS scores toquickly predictICU length of stayon AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 343at Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  7. 7. review20showed that race was measured as a depend-ent variable for acute outcomes of life-threateninginjury in only 2% of studies (7 of 352). By compar-ison, race is measured more often as a dependentvariable in chronic disease research, and significantfindings are not uncommon.21Age, Sex, and SmokingAge, sex, and smoking were not predictive ofICU length of stay. The findings related to age andsex contrast with results of other research reports.5,22One explanation for the difference in these resultsmay be that the patients’ age ranges and means inprevious studies were much wider (0-104 years old;mean, 44-46 years old) than the agerange and mean for this study (18-44 years old; mean, 29 years old). Instudies23,24for which the age statisticswere comparable, the results of thepresent study were supported.Previous research has alsoshown that female sex is a predictorfor decreased ICU length of stay inthis population of patients, evenwhen females were injured moreseverely than males.25,26These find-ings may be related to recent resultsby Frink et al,27who reported that injured femalesin the ICU had fewer complications related toinflammatory response. It is difficult to compare theresults of Frink and colleagues directly, however,because the complications measured in their studywere not measured in the present research.The findings related to smoking in this researchare inconclusive when compared with results of otherinjury and critical care studies. Two studies showagreement with the present study, and 2 other stud-ies show disagreement. Consistent with the findingsof the present research, Jurkovich and colleagues28reported that smoking did not increase the odds forprolonged ICU length of stay in patients with acuteinjuries. Similarly, Delgado-Rodriguez et al29reportedthat smoking was not a significant predictor for ICUlength of stay in general surgery patients, althoughsmokers in their study did have longer adjusted ICUlengths of stay (11.3 days vs 6.4 days). In contrast,when Baldwin and colleagues30examined both med-ical and surgical ICU patients, smoking was a signif-icant predictor for ICU length of stay (P=.008), asit was in a study of patients who underwent coronarybypass surgery (P<.05).31All 4 of these studies28-31were prospective analyses in which smoking statuswas obtained from chart documentation based onpatient interviews.Clinical Significance of Nested ModelIn the multivariate analysis, the nested model,which included severe SIRS (score of 4) and whiterace, was a significant predictor of ICU length ofstay (P=.006). Multivariable models of predictorsof ICU length of stay that combine demographiccharacteristics such as race with physiologicalresponses to injury such as severe SIRS have notbeen previously reported in the injury literature.Implications for Practice and ResearchCritical care nurses and physicians need toolsthat are easy to use at the bedside, like the SIRS score,to help prioritize preventive care. Based on thisresearch, nurses can expect that patients with severeSIRS (score of 4) will spend more days in the ICUthan will patients with mild or moderate SIRS (scoreof 2 or 3, respectively). The practical application ofthis information for nurses is that it provides a basisfor preventive care in (1) educating and preparingpatients and their families for the challenges associ-ated with recovery from life-threatening injuries, (2)ordering specialty beds to reduce skin breakdown,and (3) prioritizing and planning for the dischargeneeds of patients and their families.Unlike physicians, who recommend using theSIRS score on admission to help make practice deci-sions for immediate care,13,14nurses could use thescore to guide practice decisions for longer termpreventive care. Further, the SIRS score on admis-sion could be added to acuity level assessments andused by nurse managers for planning nurse staffingon the basis of predicted length of stay.Further research is needed to evaluate prospec-tively the usefulness of the SIRS score as a tool forcritical care nurses in planning preventive care. Thepresent study should be replicated prospectively. Allvariables known to influence ICU length of stayshould be included in conjunction with the physio-logical influence of SIRS. Additional research is neededto explore the findings of this study that race is apredictor of ICU length of stay in patients with acute,life-threatening injuries. Research is also needed toassess the practical use of the SIRS score for priori-tizing nursing care in the ICU for patients with acute,life-threatening injuries.LimitationsThis study was conducted in 1 hospital, whichlimited the sample size. However, the characteristicsof the patients in this study, including race, sex, meanISS, and percentages of mild, moderate, and severeSIRS scores were comparable to characteristics ofpatients in other studies with similar variables andSevere SIRSpredicted lengthof stay with nearlythe same levelof significanceas the injuryseverity score.344 AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 www.ajcconline.orgat Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  8. 8. April 8, 2009.2. Centers for Disease Control and Prevention [CDC]. Web-basedInjury Statistics Query and Reporting System (WISQARS). Accessed April 8, 2009.3. Meyer AA. Death and disability from injury: a global chal-lenge. JTrauma. 1998;44(1):1-12.4. Afessa B. Benchmark for intensive care unit length of stay:one step forward, several more to go. Crit Care Med. 2006;34(10):2674-2675.5. Trottier V, McKenney MG, Beninati M, Manning R, Schul-man CI. Survival after prolonged length of stay in a traumaintensive care unit. JTrauma. 2007;62(1):147-150.6. Dasta JF, McLaughlinTP, Mody SH, Piech CT. Daily cost ofan intensive care unit day: the contribution of mechanicalventilation. Crit Care Med. 2005;33(6):1434-1435.7. Gruenburg DA, Shelton W, Rose SL, Rutter AE, Socaris S,McGee G. Factors influencing length of stay in the intensivecare unit. Am J Crit Care. 2006;15(5):502-509.8. Keel M,Trentz O. Pathophysiology of polytrauma. Injury.2005;36:692-709.9. Melley DD, EvansTW, Quinlan GJ. Redox regulation ofneutrophil apoptosis and the systemic inflammatoryresponse syndrome. Clin Sci. 2005;108:413-424.10. Napolitano LM, FerrerT, McCarter RJ Jr, ScaleaTM. Systemicinflammatory response syndrome score at admission inde-pendently predicts mortality and length of stay in traumapatients. JTrauma. 2000;49(4):647-652.11. Bochicchio GV, Napolitano LM, Joshi M, et al. Persistentsystemic inflammatory response syndrome is predictive ofnosocomial infection in trauma. JTrauma. 2002;53(2):245-251.12. Malone DL, Kuhls D, Napolitano LM, McCarter R, ScaleaT.Back to basics: validation of the admission systemicinflammatory response syndrome score in predicting out-come in trauma. JTrauma. 2001;51(3):458-463.13. Bochicchio GV, Napolitano LM, Joshi M, McCarter RJ Jr,ScaleaTM. Systemic inflammatory response syndromescore at admission independently predicts infection inblunt trauma patients. JTrauma. 2001;50(5):817-820.14. Kuhls DA, Malone DL, McCarter RJ, Napolitano LM. Predic-tors of mortality in adult trauma patients: the physiologictrauma score is equivalent to theTrauma and Injury SeverityScore. J Am Coll Surg. 2002;194(6):695-704.15. Bone R, Balk RC, Cerra FB, et al. Definitions for sepsis andorgan failure and guidelines for the use of innovative ther-apies in sepsis. Chest. 1992;101(6):1644-1655.16. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.Intensive Care Med. 2003;29:530-538.17. Bone R.Toward an epidemiology and natural history of SIRS.JAMA. 1992;268(24):3452-3455.18. Baker SP, O’Neil B, Haddon W Jr, Long WB.The injury sever-ity score: a method for describing patients with multipleinjuries and evaluating emergency care. JTrauma. 1974;14(3):187-196.19. American College of Surgeons Committee onTrauma.Resources for Optimal Care of the Injured Patient: 1999.Chicago, IL: American College of Surgeons; 1998.20. NeSmith EG. Racial disparities in acute outcomes of life-threatening injury. J Nurs Scholarsh. 2006;38(3):241-246.21. Smedley B, Stith A, Nelson A, eds. UnequalTreatment:Confronting Racial and Ethnic Disparities in Health Care.Washington, DC: Institute of Medicine, National AcademiesPress; 2003.22. Shen LY, Helmer SD, Huang J, Niyakorn G, Smith RS. “Shiftwork” improves survival and reduces intensive care unit usein seriously injured patients. Am Surg. 2007;73(2):185-191.23. Curtis K, ZouY, Morris R, Black D.Trauma case management:improving patient outcomes. Injury. 2006;37(7):626-632.24. Taylor MD,Tracy KT, Meyer W, Pasquale M, Napolitano LM.Trauma in the elderly: intensive care unit resource use andoutcome. JTrauma. 2002;53(3):407-414.25. Taylor MD,Tracy JK, Meyer W, Pasquale M, Napolitano LM.Trauma in the elderly: intensive care unit resource use andoutcome. JTrauma. 2002;53(3):407-414.26. Mostafa G, HuynhT, Sing RF, Miles WS, Norton HJ,Thoma-son MH. Gender-related outcomes in trauma. JTrauma.2002;53(3):430-434.27. Frink M, Pape HC, van Griensven M, Krettek C, Chaudry IH,Hildebrand F. Influence of sex and age on mods andcytokines after multiple injuries. Shock. 2007;27(2):151-156.purpose statements.10-13This makes it useful toinform the design of future studies to determinehow other, more hospital-based variables affect thevalidity of the SIRS score for predicting ICU lengthof stay. Generalizability is limited to patients withmild, moderate, or severe SIRS (score of 2, 3, or 4).A comparison of ICU length of stay in patients withno SIRS (score of 0 or 1) was not made because ofthe relatively small number of patients in this sub-sample (n=52). Further, ICU length of stay is affectedby other variables that may not be reflected in thechart, such as communication and family issues,stress and depression, palliative care and ethicalissues, 24-hour presence of a physician, and avail-ability of a unit-specific social worker.7Use of the SIRS score in this research is sup-ported by (1) the outcomes of the 2001 consensusconference,16(2) research that correlates the pres-ence of SIRS with inflammatory biomarkers,32-35and(3) research that validates its use for predicting out-comes in critically ill patients, including those withacute, life-threatening injuries.10-13ConclusionsThis research supports that severe SIRS (score of4) on admission to the ICU is a valid predictor ofICU length of stay for patients with acute life-threat-ening injuries. This information can be used to helpcritical care nurses and physicians maximize resourceutilization within a known time frame and reducethe possibility of poor outcomes.ACKNOWLEDGMENTSThe authors acknowledge and thank the following fortheir assistance in the conduct of this research andpreparation of this manuscript:Traci Hentges, BSN, RN,CCRN, Shawn Roberson, BSN, RN, CCRN, VeronicaTurner, BSN,RN, and Brendell Collins, BSN, RN, for their knowledgeableand practical clinical advisement; Melissa Brown andCindy Bishop for their invaluable assistance with thetrauma registry database and record retrieval; and mem-bers of the MCG Scholarship Club for their excellentcontent reviews.FINANCIAL DISCLOSURESSupport for this research was provided by the Center forNursing Research at Medical College of Georgia.REFERENCES1. Agency for Healthcare Research and Quality [AHRQ]. Heartdisease, cancer, and trauma injury top the list of the 15 mostcostly medical conditions in the United States. AccessedeLettersNow that you’ve read the article, create or contribute to anonline discussion on this topic. and click “Respond toThis Article”in either the full-text or PDF view of the AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 345at Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  9. 9. 28. Jurkovich GJ, Rivara FP, Gurney JG, et al.The effect ofacute alcohol intoxication and chronic alcohol abuse onoutcome from trauma. JAMA. 1993;270(1):51-56.29. Delgado-Rodriguez M, Medina-Cuadros M, Martinez-Gallego G, et al. A prospective study of tobacco smokingas a predictor of complications in general surgery. InfectControl Hosp Epidemiol. 2003;24(1):37-43.30. Baldwin WA, Rosenfeld BA, Breslow MJ, BuchmanTG,Deutschman CS, Moore RD. Substance abuse-relatedadmissions to adult intensive care. Chest. 1993;103(1):21-25.31. Christakis GT, Fremes SE, Naylor CD, Chen E, Rao V, Gold-man BS. Impact of preoperative risk and perioperativemorbidity on ICU stay following coronary by-pass surgery.Cardiovasc Surg. 1996;4(1):29-35.32. Miyaoka K, Iwase M, Suzuki R, et al. Clinical evaluation of cir-culating interleukin-6 and interleukin-10 levels after surgery-induced inflammation. J Surg Res. 2005;125(2):144-150.33. Ogura H,Tanaka H, KohT, et al. Enhanced production ofendothelial microparticles with increased binding to leuko-cytes in patients with severe systemic inflammatoryresponse syndrome. JTrauma. 2004;56(4):823-831.34. Iwasaki A, ShirakusaT, Maekawa SE, Maekawa S. Clinicalevaluation of systemic inflammatory response syndrome(SIRS) in advanced lung cancer (T3 andT4) with surgicalresection. Eur J Cardiothorac Surg. 2005;27(1):14-18.35. Wanner GA, Keel M, Steckholzer U, Beier W, Stocker R,Ertel W. Relationship between procalcitonin plasma levelsand severity of injury, sepsis, organ failure, and mortalityin injured patients. Crit Care Med. 2000;28(4):950-957.To purchase electronic or print reprints, contactTheInnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax,(949) 362-2049; e-mail, AJCC AMERICAN JOURNAL OF CRITICAL CARE, July 2009, Volume 18, No. 4 www.ajcconline.orgat Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from
  10. 10. Name Member #AddressCity State ZIPCountry Phone E-mail addressRN License #1 StateRN License #2 StatePayment by: K Visa K M/C K AMEX K CheckCard # Expiration DateSignatureCE Test TestIDA0918042:SystemicInflammatoryResponseSyndromeScoreandRaceasPredictorsofLengthofStayintheIntensiveCareUnit.Learning objectives: 1. Identify the significant results found in this study. 2. Describe practical applications of using the systemic inflammatory response syndromescore. 3. Discuss further areas of research on this topic.Program evaluationYes NoObjective 1 was met K KObjective 2 was met K KObjective 3 was met K KContent was relevant to mynursing practice K KMy expectations were met K KThis method of CE is effectivefor this content K KThe level of difficulty of this test was:K easy K medium K difficultTo complete this program,it took me hours/minutes.7. The research method used by the authors was which of the following?a. Qualitative, phenomenologicalb. Quantitative, prospectivec. Qualitative, focus groupd. Quantitative, retrospective8. Based on the authors’ recommendations, what further researchneeds to be done?a. No further research is neededb. A meta-analysis of all studies utilizing the SIRS scorec. A replication of their study using a prospective sampled. A replication of their study using severe sepsis patientsWhat is identified as one of the limitations of this study?a. Nonhomogeneous sample groupb. Study conducted at only 1 hospitalc. Small sample sized. There was no control group or randomization10.ThisresearchwasabletoshowthatasevereSIRSscoreisavalidpredic-tor of increased length of stay for what type of patients?a. Acute, life-threatening injuriesb. Postcardiovascular surgeryc. Spinal cord injuriesd. Comatose survivors of cardiac arrest11. A group of trauma ICU nurses, after reading this study, would like todo further research using the SIRS score. What is one area the authorsrecommend for further research in the practical use of this tool?a. Budgeting tool for the trauma ICU nurse managerb. Validation of increased staffing needsc. Physician treatment decisionsd. Prioritizing nursing care12. How would a severe SIRS score affect the patient and family edu-cation plan?a. Delaying the education plan until the patient is transferred from the ICUb. Educating and preparing patients and families of the challenges related torecovering from their injuriesc. Focusing the education on the family as the patient would be unable toparticipated. Giving the family written material on the subject in the language andgrade level they best understandFor faster processing, takethis CE test online (“CEArticles in This Issue”) ormail this entire page to:AACN, 101 Columbia,Aliso Viejo, CA 92656.Fee: AACN members, $0; nonmembers, $10 Passing score: 9 Correct (75%) Category: A, Synergy CERP A Test writer: Rosemary Koehl Lee, MSN, RN-CNS, ACNP-BC, CCNS, CCRN9. KaKbKcKd8. KaKbKcKd7. KaKbKcKd6. KaKbKcKd5. KaKbKcKd4. KaKbKcKd3. KaKbKcKd2. KaKbKcKd1. KaKbKcKd12. KaKbKcKd10. KaKbKcKd11. KaKbKcKdThe American Association of Critical-Care Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.AACN has been approved as a provider of continuing education in nursing by the State Boards of Nursing of Alabama (#ABNP0062), California (#01036), and Louisiana (#ABN12). AACNprogramming meets the standards for most other states requiring mandatory continuing education credit for relicensure.Test ID: A0918042 Contact hours: 1.0 Form expires: July 1, 2011. Test Answers: Mark only one box for your answer to each question. You may photocopy this form.1. A patient in the trauma unit has been admitted with blunt chestand abdominal trauma. He is a 55-year-old white male, with no signif-icant past medical history. He is currently on a ventilator with anassist control rate of 14; his current respiratory rate is 28; blood pres-sure is 100/70 mm Hg; heart rate is 113; and his core temperature viaan esophageal temperature probe is 38.8°C. His arterial blood gasesreveal a pH of 7.48, PaCO2 of 31, PaO2 of 118, HCO3 of 18; the completeblood cell count reveals a hemoglobin and hematocrit of 11 and 33,and white blood cell count of 14 000. Based on this patient’s assess-ment what would his SIRS score be?a. 1 c. 3b. 2 d. 42. In this study, which of the following was the dependent variable?a. Degree of acute life-threatening injuryb. Intensive care unit (ICU) length of stayc. SIRS scored. White race3. According to the results of this study, having severe SIRS on admis-sion to the ICU is correlated significantly with what variable?a. ICU length of stay c. Smoking historyb. Injury Severity Score d. White race4. How may an ICU nurse use the information that a trauma patienthas a SIRS score of 4?a. To plan for preventive careb. To initiate the 6-hour sepsis bundlec. To plan a family conference to discuss end-of-life issuesd. To know the patient’s condition warrants transfer to a progressive care unit5. The SIRS score is noted by the authors to be a validated tool. Whatother characteristic do the authors identify that would make this toolfeasible for use in the ICU by a bedside nurse?a. To predict staffing needsb. It is based on reliable quadratic equationsc. Simple and easy to used. The P value is 0.056. The admission into an ICU of a trauma patient on average costs howmuch?a. $1000 c. $10 000b. $5000 d. $20 000at Medical College of Georgia Greenblatt Library on June 25, 2009ajcc.aacnjournals.orgDownloaded from