Hvor skal man udføre akutmedicinsk forskning? Finn E. Nielsen Forskningslektor, overlæge, dr.med. MPA, MAppStat

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1 Hvor skal man udføre akutmedicinsk forskning? Finn E. Nielsen Forskningslektor, overlæge, dr.med. MPA, MAppStat

2 Perspektiver Sundhedsloven Akademisk

3 Hvad siger sundhedsloven om forskning? Alle hospitaler har forskningsret og forskningspligt (Sundhedsloven nr. 546 af 24. juni 2005 Indenrigs- og Sundhedsministeriet Regionsrådet skal sikre udviklings- og forskningsarbejde Kommunalbestyrelsen skal medvirke til udviklings- og forskningsarbejde

4 Fortolkning af Sundhedsloven? Alle danske akutafdelinger har forskningspligt og forskningsret Målet er at ydelser præciseret i Sundhedsloven skal varetages på et højt fagligt niveau Vores regionspolitikere skal sikre forskningsarbejdet: Økonomi Personelle ressourcer/uddannelse

5 I et lovperspektiv skal der udføres akutmedicinsk forskning på alle danske akutafdelinger Akutafdelingen, Slagelse Sygehus, har sin egen forskningsstrategi: Vision Mission Fokusområder Handleplaner Samarbejdsaftaler Økonomi

6 Hvad med det akademiske perspektiv?

7 Akademisk miljø Sygdomsudredning og sygdomsbehandling planlægges af akademikere Behandling gennemføres i overensstemmelse med bedste videnskabelige evidens Evidens udfordres dagligt i det akademiske miljø Lav grad af evidens vil stimulere til ny forskning på området

8 Et akademisk miljø skaber forskning og omvendt Daglig uddannelse og træning i akademisk tilgang til patientbehandling det er sundheds- og lægevidenskab

9 Forskning skal foregå på alle afdelinger og med forankring og ansvar i afdelingsledelsen Pligt og ret Bidrager til udvikling af udredning og behandling Akademisk miljø

10 Er det muligt at skabe forskningsmiljø udenfor universitetsafdelinger? Ansæt forskere i forskningsstillinger Samarbejd med universitetsafdelinger nationalt/internationalt Allokering af forskningsmidler som en fast andel af budgetterne Overvej at stimulere forskning ved favoriseret økonomisk støtte til klinisk forskning udenfor universitetsafdelinger. Fokus på afgrænsede forskningsområder Eksempler fra Akutafdelingen, Slagelse Rhabdomyolyse Genindlæggelse efter hurtig udskrivelse Sepsis Hjertesvigt

11 Survival among 1024 patients with rhabdomyolysis according to the level of creatine kinase Nielsen FE, Cordtz J, Christiansen CF 2016

12 QuickSOFA is an independent predictor of 30-day mortality among patients admitted to an emergency department with suspected or documented infection Osama Bin Abdullah 1, Johannes Grand 1, Astha Sijapati 1, Petrine Nimskov 1, Finn Erland Nielsen. 2 1 Department of Emergency Medicine, Slagelse Hospital, Slagelse, DENMARK 2 Department of Emergency Medicine & Institute of Regional Health Research Faculty, Slagelse Hospital & University of Southern Denmark, Slagelse, DENMARK Background In 2016 a new sepsis criteria, qsofa 1, has been proposed, which incorporates hypotension (systolic BP 100 mmhg), altered mental status and RR> 21/min. The presence of at least two of these criteria have been associated with poor outcomes among sepsis patients. AIM The aim of this study was to evaluate qsofa as a predictor of 30-day mortality in a model with other predictors of death among patients admitted to a single-center emergency department (ED). Patients & Methods A historical cohort study among 464 patients admitted to the ED during the period 1 November 2013 to 31 October 2014 with at least two SIRS criteria, and either documented or suspected infection. A total of 30 patients were excluded. Data for SIRS criteria and initial treatment were obtained from a standard sepsis admission form. Baseline clinical data and data for survival were obtained from the patient records and The Danish Civil Registration System. Logistic regression analysis was used to adjust for potential confounders and to determine whether the risk factors for death in the crude analyses were independently associated with 30-day mortality. Table 1. A crude logistic regression modeling of factors associated with 30-day mortality among sepsis patients Baseline variables Unadjusted odds ratio (95% CI) Age a Female sex Charlsons Comorbidity Index >2 Diabetes mellitus qsofa criteria 0 1 =>2 Systolic blood pressure (mmhg) => < 90 Lactate value < => 4.0 Recent surgical history Site of infection Lungs Urinary tract Abdomen Culture positive Creatinine value a International normalized ratio (INR) b Platelet count a Bilirubin a White blood cell count b CRP a Time (hour ) of delivery of 1.39 ( ) 1.31 ( ) 2.50 ( ) 6.20 ( ) 1.43 ( ) 1.73 ( ) 6.77 ( ) 2.65 ( ) 4.96 ( ) 2.54 ( ) 4.22 ( ) 1.57 ( ) 1.72 ( ) 0.36 ( ) 1.09 ( ) 2.00 ( ) 1.05 ( ) 1.40 ( ) 1.02 ( ) 1.08 ( ) 1.00 ( ) 1.00 ( ) 1.06 ( ) a antibiotics OR is for a b 10-units increase of the variable. b OR is for a one-unit change of the variable. Baseline variables Adjusted odds ratio (95% qsofa 0 1 => 2 Age a Results Mortality Overall 30-day mortality was 13.1%. Predictors of death An unadjusted model of predictors of 30-day mortality is given in Table 1. In an adjusted logistic regression model, it was found that qsofa was associated with 30-day mortality. Other factors associated to death were high age, increasing values of lactate and the burden of comorbidity (Table 2). Table 2. Adjusted logistic regression modelling of factors associated with 30-day mortality among sepsis patients admitted to the emergency department Lactate value < => 4 Charlsons Comorbidity Index => 3 a OR is for a 10-units increase of the variable. Conclusion This study shows that qsofa can be helpful to identify infected patients with increased risk of 30-day mortality. CI) 1.qSOFA: quick Sequential [sepsis related] Organ Failure Assessment BP: Blood Pressure; RR: Respiratory Rate ( ) 4.78 ( ) 1.29 ( ) 2.21 ( ) 3.97 ( ) 1.96 ( ) 3.83 ( ) 2

13 Konklusion Hvor skal man udføre akutmedicinsk forskning? Alle akutmedicinske afdelinger Hvorfor? Pligt Forudsætning Akademisk miljø og forskningskultur