Tag (SPOT)id

Entries 13 Total

What if the baseline CXR is clear?

Aug 2, ’11 10:43 AM

Question: With the current screening regime, and the screening out if the CXR result is reported clear, you are quite likely to miss a large part of the viral pneumonias I would think. It may be conceivable that a patient indeed is quite unwell, but nonetheless is deemed to have a viral pathology, so antibiotics are stopped. So while he may need respiratory support, and be a candidate for the study in the spirit of the trial, we would have to filter him/her out. Was this intentional and pre-planned or just unavoidable?

Answer: So a clear CXR is not an exclusion (just something we might stratify differently). The CXR can be used to rule out a case if a different diagnosis is confirmed but to use a cliché (sorry) “absence of evidence isn’t …”. However, this leaves us with the sticky problem of exacerbation of COPD. To distinguish an exacerbation of COPD from pneumonia then it will be necessary for the CXR to have pneumonic changes. Sorry this is not 100% consistent but I think it gets at the spirit of the study.

 

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Is a tracheostomy a clinical event in (SPOT)id?

Aug 2, ’11 10:13 AM

Question: One of our SpotID patients had a percutaneous tracheostomy performed – I assume this is an “event” (on the daily CRF sheet) but cannot find a code for it within the coding system.

Answer: One the one hand I probably wouldn’t code this as an event on the ground that assuming it went well it shouldn’t be a cause of major physiological disturbance but if the patient was sedated and this affected the physiological observations then please use the code 1.1.1.x.x. which is Surgery/Respiratory/Upper Airway/x/x … (the ‘x’s meaning that there is no more specific code beyond this level).  If you have written a diagnosis in the free text then we’ll be fine with that.

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S:F ratio update

Aug 2, ’11 4:46 AM

Those of you with sharp mental arithmetic will have noticed it is impossible to have a SOFA score with zero points when calculating the Day 4 SOFA for the (SPOT)id study.  The SpO2:FiO2 cut-off for a SOFA score of 1 is currently 502 which means that all patients with perfect oxygen saturations on room air (100% over 0.21) have an S:F ratio of 476 and earn 1 SOFA point.  The numbers come from a Critical Care Medicine paper (Pandharipande 2009).

I think that we should continue to use the rest of the thresholds that they suggest, but if the S:F ratio is ≥ 450 patients should be assigned zero (0) SOFA points. This means that using the S:F ratio you will skip directly from zero to two SOFA points.

  • S:F ≥ 450 – SOFA 0
  • S:F < 450
    • Do not estimate SOFA score from this value
    • Use the last recorded P:F if available and measured within 48 hours
    • If not available assign SOFA 0
  • S:F < 370 – SOFA 2
  • S:F < 240 – SOFA 3
  • S:F < 115 – SOFA 4

The old threshold of S:F < 502 to give a SOFA score of 1 comes from the limits of the data set and possibly shows the problems with following a regression line beyond your data set.

 

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Hourly urines

Jul 25, ’11 7:36 AM

On the SpotID CRF the hourly urine output is requested.  For some patients the urine output is not measured hourly – so there may be a recording of, say, 300ml on the observation chart – but this will be for a few hours not one.  Do you want this figure added to the hourly urine box(es) on the CRF?

No.

The number should always be an hourly total. If hourly measurements were not available at the first hour after the start of the time period then please use the 2nd (or 3rd of 4th if necessary). If you are confident that the 300ml accurately summarises the 4 hour observation period then it would be acceptable to divide this by 4 and enter the answer (75). If you are not confident then better just to stick with 24 hour totals.

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Screening workflow

Jul 13, ’11 4:54 PM

Screening for patients starting from a list of chest x-rays can easily be very inefficient. We would suggest a minor modification to the procedure.

  1. Select and follow as per the original discussions a limited but targeted number of wards (this should include ICU/HDU, the main respiratory ward, and probably the medical admissions ward as well as an area with a risk of hospital acquired pneumonia (e.g. a surgical HDU, trauma ward).
  2. Identify Monday-Friday new admissions to those wards
  3. Where a new admission has also had a chest x-ray then start the screening process which includes checks for
  • a working diagnosis of pneumonia / LRTI from the clinical team
  • a new or modified ongoing prescription of antibiotics
  • a minimum level of severity (CURB-65≥2 or SOFA≥1)

Enter eligible patients into the study

Stop follow-up under the following conditions

  • the chest x-ray is reported as not being consistent with pneumonia
  • the clinical team revise the working diagnosis
  • the patient recovers by day 4 (SOFA≤1) although in this situation please visit once more on Day 9 to confirm recovery

 

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Consider the SOFA score instead of CURB-65

Jul 13, ’11 4:50 PM

Young patients with apparently severe pneumonia are frequently not making the CURB-65 criteria. The current protocol also permits patients to be entered if the SOFA score is ≥1 on the calendar of the chest x-ray so please consider this too. Check out the online calculator.

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(SPOT)id CRF update

Jul 13, ’11 4:47 PM

I have attached the updated (SPOT)id Case Report Form. There are no major changes just a couple of small corrections which have been highlighted by the site teams.

  • Total white cell count and lymphocytes can now be reported with a precision of one decimal place
  • Sinus rhythm should be reported as ‘Sinus’ or ‘Other’ instead of just using a check mark to confirm sinus
  • Steroids now have space for the three possible codes rather than relying on you to look up the code
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An online SOFA score calculator ….

Jul 8, ’11 3:12 PM

An online SOFA score calculator.

Thanks to Nuno from Medway for the tip.

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The platelet count was not available to calculate the Day 4 SOFA score. What should I do?

Jul 8, ’11 3:09 PM

When you come to estimate the SOFA score on day 4 to decide if the patient should continue under follow-up then please follow the ‘last value carried forward’ principle. This means that you should use the last available value so if the platelet count was not measured on day 4 then you should use the value from day 3, if the day value is not available then the day 2 value and so on.

If the measurement has never been made then you will have to assume the value is normal and assign it a score of zero points.

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How to use the ICNARC coding method?

Jul 8, ’11 3:04 PM

Clear instructions and an online tool to generate the diagnostic code when patients are admitted with a diagnosis other than pneumonia (or) when you are reporting a major physiogical event during follow-up.

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