Apache Score

Rev. 001Eff. Date: June 17, 2005Owner: Critical Outcomes

APACHE IV Calculations31TRGEXT000013

Tab 1, p. 1 of 36Reviewed by: Fern MalilaApproved by: Kim Hlobik

INSTRUCTIONS

To Calculate APS Score:

To determine disease category

Following the methodology precisely, determine the physiological variable furthest from the reference point, whether higher or lower/above or below. Assign APS points to that single, most deviant value.

Resources for the correct collection of data elements:

1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE. The APACHE III prognostic system: risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991; 100:1619-1636.

2. http://train.apache-web.com/apacheIIIwebcourse/courselogin/login.cfm

The accuracy of APACHE predictions is dependent upon the quality of data upon which predictions are made. Deviations from the precise data collection methodology may result in errors in prediction which Cerner Corporation cannot be responsible for.

Using the disease mapping table, select the single primary reason for ICU admission. Patients coming to the ICU from the operating room or post-anesthesia care unit must be assigned surgical diagnoses. ALL OTHER PATIENTS will receive a non-operative diagnosis.

Diseases are categorized by body system, and then into operative and non-operative categories for ease of use of this table.




Additional Notes

Determine the disease category associated with the ICU admitting diagnosis.

To calculate hospital mortality and/or ICU length of stay

First, select the appropriate worksheet for the prediction required and the patient (CABG, Non-CABG) type

Enter the required values or use 1=yes, blank=no.

For each set of variables, the options within each color block are mutually exclusive. Select only one of the options as a "yes" (1), the rest "no" (0) or blank. More than one selection from a single group will result in an error message.

Example: If disease category is SCAROTID=1, all other disease categories=blank.

Error messages will appear in red if more than one mutually exclusive variable is selected.

All cells except those that accept data for the calculations are "locked".




Step 1: Calculate Acute Physiology Score

Pulse (beats/min) <=39 8 Pulse points 0Select heart rate furthest from 75 40-49 5

50-99 0100-109 1110-119 5120-139 7140-154 13

>=155 17

Mean Blood Pressure (MAP) <=39 23 MAP points 0Select MAP furthest from 90 40-59 15

60-69 770-79 680-99 0

100-119 4120-129 7130-139 9

>=140 10

Temperature (degrees Centigrade) <=32.9 20 Temperature points 0Select core temperature furthest from 38. 33-33.4 16Add 1 degree Centigrade to axillary temps 33.5-33.9 13prior to selecting worst value 34-34.9 8

35-35.9 236-39.9 0

>=40 4

Respiratory Rate (breaths/min)* <=5 17 Respiratory rate pointsSelect respiratory rate furthest from 19 6-11 8*for patients who are ventilated 12-13 7 no points are given for respiratory 14-24 0rates of 6-12. 25-34 6

35-39 940-49 11>=50 18

PaO2 (mmHg)* <=49 15 PaO2 points*Use only for non-intubated patients or 50-69 5intubated patients with FiO2 <0.5 (50%). 70-79 2

>=80 0 OR

as follows, entering the appropriate point value in the blue box to the right of each category:




OR

A-aDO2* <100 0 A-aDO2 points*Only use A-aDO2 for intubated patients 100-249 7with FiO2 >=0.5 (50%). Do not use PaO2 250-349 9weights for these patients. 350-499 11

>=500 14

Hematocrit (%) <=40.9 3 Hematocrit pointsSelect hematocrit furthest from 45.5. 41-49 0

>=50 3

WBC (cu/mm) <1.0 19 WBC pointsSelect WBC furthest from 11.5. 1.0-2.9 5

3.0-19.9 020-24.9 1

>=25 5

Creatinine without ARF* (mg/dl) <=0.4 3 Creatinine without ARF pointsSelect creatinine furthest from 1.0. 0.5-1.4 0

1.5-1.94 4OR >=1.95 7 OR

Creatinine with ARF* (mg/dl) 0-1.4 0 Creatinine with ARF points*Acute Renal Failure (ARF) is defined as creatinine >=1.5 mg/dl >=1.5 10as creatinine >=1.5 mg/dland urine output <410 cc/day and no chronic dialysis

Urine Output (cc/day) <=399 15 Urine output pointsEnter total for day 400-599 8

600-899 7900-1499 5

1500-1999 42000-3999 0

>=4000 1

BUN (mg/dl) <=16.9 0 BUN pointsSelect highest BUN (furthest from 0) 17-19 2

20-39 740-79 11>=80 12

Sodium (mEq/L) <=119 3 Sodium points




Select Sodium furthest from 145.5. 120-134 2135-154 0

>=155 4

Albumin (g/dl) <=1.9 11 Albumin pointsSelect albumin furthest from 3.5. 2.0-2.4 6

2.5-4.4 0>=4.5 4

Bilirubin (mg/dl) <=1.9 0 Bilirubin pointsSelect highest bilirubin (furthest from 0) 2.0-2.9 5

3.0-4.9 65.0-7.9 8

>=8.0 16

Glucose (mg/dl)* <=39 8 Glucose pointsSelect glucose furthest from 130 40-59 9*Glucose <=39 mg/dl is lower 60-199 0weight than 40-59 200-349 3

>=350 5Acid-Base points (see below)

GCS points (see below)

TOTAL APS Score 0

Acid-Base Abnormalities* pCO2<25 25-<30 30-<35 35-<40 40-<45 45-<50 50-<55 55-<60 >=60*Assign score based upon pH-pCO2 pH <7.15

12 4relationship 7.15-<7.27.20-<7.25

96 3 27.25-<7.30

7.30-<7.35

0 17.35-<7.40

57.40-<7.457.45-<7.50 0 27.50-<7.557.55-<7.607.60-<7.65 0 3 12

>=7.65

Neurological Abnormalities*

*If a patient is anesthetized, under the influence of anesthesia, or totally paralyzed/sedated during the ENTIRE data collection period, attempt to obtain a GCS from the twelve-hour period prior to ICU admission when GCS was able to be assessed. If no assessable GCS is documented during that time period, zero points shhould be assigned. If unable to determine verbal score (due to intubation status or similar barriers), use clinical judgement and assign Glasgow Verbal Score according to the following scale:




alert, oriented 5confused 3

nonresponsive 1

verbalconfused conversation (4) no response (1)motor

0 3 10 15

3 8 13 15

3 13 24 24

3 13 29 29

verbalconfused conversation (4) no response (1)motor

16

16

24 33

29 48

*If a patient is anesthetized, under the influence of anesthesia, or totally paralyzed/sedated during the ENTIRE data collection period, attempt to obtain a GCS from the twelve-hour period prior to ICU admission when GCS was able to be assessed. If no assessable GCS is documented during that time period, zero points shhould be assigned. If unable to determine verbal score (due to intubation status or similar barriers), use clinical judgement and assign Glasgow Verbal Score according to the following scale:

If patient's eyes open spontaneously (4) or to oriented, converses (5)

inappropriate words, incomp.

sounds (3,2)painful/verbal stimulation (2,3), use scale:

Note: shaded areas represent unlikely clinical combinations. Placing a patient in any of these cells should be done after careful confirmation of clinical findings.

obeys verbal commands (6)

localizes pain (5)

flexion withdrawal/decorticate rigidity (4,3)

decerebrate rigidity/no response (2,1)

If patient's eyes do not open spontaneously oriented, converses (5)

inappropriate words, incomp.

sounds (3,2)or to painful/verbal stimulation (1), use scale:

Note: shaded areas represent extremely unlikely clinical combinations, and should not be used. If these combinations are verified in a clinical setting, no prediction should be generated for the patient.

obeys verbal commands (6)

localizes pain (5)

flexion withdrawal/decorticate rigidity (4,3)

decerebrate rigidity/no response (1)


(Document title: APACHE IV Calculations)APACHE III Calculations

31TRGEXT000013


The APACHE III Score is the sum of points assigned to Acute Physiology (the APS Score, Age, and Chronic Health.

The predictive models use each of these three components individually, as separate and distinctvariables. Therefore the APACHE III Score is not required for mortality prediction. However, somemay find it valuable for other purposes. Enter appropriate point values in the blue box to the right.

Fill in blue shaded areas to obtain APACHE III Score

Age of patient Points Total age points:Select one Under age 16 do not score

<=44 045-59 560-64 1165-69 1370-74 1675-84 17>=85 24

Chronic Health Items present on admission Points Total chronic health points

AIDS 23Select for non-operative or Hepatic Failure 16emergency surgical patients Lymphoma 13only, otherwise 0 Metastatic cancer 11

Leukemia/multiple myeloma 10Immunosuppression 10Cirrhosis 4None/not available 0

Acute Physiology Score (from previous worksheet) Total APS score

APACHE III Score0

If more than one is present, apply the one with highest point value.



Tab 4, P. 8 of 36Reviewer: Fern MalilaApprover: Kim Hlobik

Cardiovascular (CARDIOVASC)Non-Operative

AMI_ANT Infarction, acute myocardial (MI), ANTERIORAMI_INFLAT Infarction, acute myocardial (MI), INFEROLATERALAMI_NONQ Infarction, acute myocardial (MI), NON Q WaveAMI_OTHER Infarction, acute myocardial (MI), none of the aboveCVOTH AnaphylaxisMEDAORT Aneurysm, dissecting aorticPERIART Aneurysm/pseudoaneurysm, otherCHESTPAIN Angina, stable (asymp or stable pattern of symptoms w/meds) USTAANG Angina, unstable (angina interferes w/quality of life or meds are tolerated poorly)CARDARR Cardiac arrest (with or without respiratory arrest; for respiratory arrest see Respiratory System)CARDIOMY CardiomyopathyCVOTH Cardiovascular medical, otherCHESTPAIN Chest pain, atypical (noncardiac chest pain)CHESTPAIN Chest pain, epigastricCHESTPAIN Chest pain, musculoskeletalCHESTPAIN Chest pain, respiratoryCHESTPAIN Chest pain, unknown originCHFD CHF, congestive heart failureCVOTH Complications of previous open heart MULTRAUM Contusion, myocardial (include R/O)CVOTH Efffusion, pericardial CVOTH EndocarditisCVOTH HematomasHEMORRHAE Hemorrhage (for gastrointestinal bleeding GI-see GI system) (for trauma see Trauma)HYPERT Hypertension, uncontrolled (for cerebrovascularHYPOVOLEM Hypovolemia (including dehydration. Do NOT include shock states.)CVOTH MI admitted > 24hrs after onset of ischemiaCVOTH Monitoring, hemodynamic (pre-operative evaluation)CARDIOG Papillary muscle ruptureCVOTH PericarditisRHYTHM Rhythm disturbance (atrial, supraventricular)RHYTHM Rhythm disturbance (conduction defect)RHYTHM Rhythm disturbance (ventricular)

APACHE Disease Mapping




SEPSISCUT Sepsis, cutaneous/soft tissue SEPSISGI Sepsis, GISEPTICUT Sepsis, gynecologicSEPSISOTH Sepsis, otherSEPSISPULM Sepsis, pulmonarySEPTICUT Sepsis, renal/UTI (including bladder) SEPSISUNK Sepsis, unknownCARDIOG Shock, cardiogenic CVOTH Tamponade, pericardial CVOTH Thrombosis, vascular (deep vein)PERIART Thrombus,arterial DRUGTOXIC Toxicity, drug (i.e., beta blockers, calcium channel blockers, etc.)CVOTH Vascular medical, other

Cardiovascular (CARDIOVASC)Post-Operative

SCARDOTH Ablation or mapping of cardiac conduction pathwaySCARDOTH Aneurysm repair, ventricularSELAORT Aneurysm, abdominal aortic SAORTDIS Aneurysm, abdominal aortic; with dissectionSRUPAOR Aneurysm, abdominal aortic; with ruptureSELAORT Aneurysm, thoracic aortic SAORTDIS Aneurysm, thoracic aortic; with dissectionSRUPAORT Aneurysm, thoracic aortic; with ruptureSCARDOTH Aneurysms, repair of other (except ventricular)SVALVE Aortic and Mitral valve replacementSVALVE Aortic valve replacement (isolated)SCARDOTH Atrial Septal Defect (ASD) RepairSVHDCABG CABG redo with valve repair/replacementSCABGVALV CABG with aortic valve replacementSVHDCABG CABG with double valve repair/replacementSCABGVALV CABG with mitral valve repairSCABGVALV CABG with mitral valve replacementSCABGVALV CABG with pulmonic or tricuspid valve repair or replacement. SCARDOTH CABG, Minimally invasive; Mid-CABGSCARDOTH Cardiovascular surgery, other





SCARDOTH

SCARDOTHSCARDOTH Congenital Defect Repair (Other)SCARDOTH Defibrillator, automatic implantable cardiac; insertion of SPERISC Dilatation (with general anesthesia)SPERISC Dilatation (without general anesthesia)SPERISC Embolectomy (with general anesthesia)SPERISC Embolectomy (without general anesthesia)SCARDOTH Endarterectomy (other vessels)SCAROTID Endarterectomy, carotidSCARDOTH Graft for dialysis, insertion of SAGRAFT Graft, aorto-femoral bypass SAGRAFT Graft, aorto-iliac bypassSCARDOTH Graft, femoral-femoral bypass SFEMPGRAF Graft, femoral-popliteal bypassSPERISC Grafts, all other bypass (except renal)SPERISC Grafts, all renal bypass SCARDOTH Grafts, removal of infected vascular SVALVE Mitral valve repairSVALVE Mitral valve replacementSCARDOTH Pericardial effusion/tamponadeSCARDOTH Pericardiectomy (total/subtotal)SVALVE Pulmonary valve surgerySPERISC Thrombectomy (with general anesthesia)SPERISC Thrombectomy (without general anesthesia)SVALVE Tricuspid valve surgerySCARDOTH Tumor removal, intracardiac SCARDOTH Vascular surgery, otherSCARDOTH Vena cava clippingSCARDOTH Vena cava filter insertionSCARDOTH Ventricular Septal Defect (VSD) Repair

Genitourinary (GENITOURIN)Non-Operative

RENOTH Genitourinary medical, other

Complications of prev. peripheral vasc. surgery,surgery for (i.e.ligation of bleeder, exploration and evacuation of hematoma, debridement, pseudoaneurysms, clots, fistula, etc.)

Complications of previous open-heart surgery, surgery for (i.e. bleeding, infection, mediastinal rewiring,leaking aortic graft etc.)





CVOTH Hemorrhage, postpartum (female only)HEPATF Hepato-renal syndromeHYPERT Pre-eclampsia/eclampsia (female only)RENOTH Renal bleedingRENOTH Renal failure, acuteRENOTH Renal infection/abscessRENOTH Renal neoplasm, cancerRENOTH Renal obstruction

Genitourinary (GENITOURIN)Post-Operative

SRENOTH Bladder repair for perforation/ruptureGENOTH Cesarean sectionGENOTH Cyst, ruptured ovarian SRENOTH Cystectomy (other reasons)SRENCA Cystectomy for neoplasmGENOTH Ectopic pregnancy (all)GENOTH Exenteration, pelvic -maleGENOTH Exenteration, pelvic-femaleGENOTH Genitourinary surgery, otherSOBHYST Hysterectomy for cancer with or without lymph node dissectionSOBHYST Hysterectomy for other benign neoplasm/fibroidsGENOTH Lymph node dissection, pelvic or retroperitoneal(female)GENOTH Lymph node dissection, pelvic or retroperitoneal(male)GENOTH Mastectomy (all)SRENOTH Nephrectomy (other reasons)SRENCA Nephrectomy for neoplasmSRENCA Obstruction due to neoplasm ,surgery for; (with or without ileal-conduit)SRENOTH Obstruction due to nephrolithiasis, surgery for (with or without ileal-conduit)SRENOTH Obstruction/other, surgery for (with or without ileal-conduit)GENOTH Oophorectomy with/without salpingectomy with/without lymph node dissectionSRENOTH Orchiectomy with/without pelvic lymph node dissectionGENOTH Pelvic relaxation (cystocele, rectocele, etc.)SRENOTH Prostatectomy, suprapubic; for benign prostatic hypertrophySRENCA Prostatectomy, suprapubic; for cancerSRENOTH TURP, transurethral prostate resection for benign prostatic hypertrophySRENCA TURP, transurethral prostate resection for cancer





Gastrointestinal (GI)Non-Operative

OD Alcohol withdrawalGIBLVAR Bleeding, GI from esophageal varices/portal hpertensionGIBLEED Bleeding, GI-location unknownGIBLEUL Bleeding, lower GIGIBLEED Bleeding, upper GI GINEOP Cancer, colon/rectal GINEOP Cancer, esophageal GINEOP Cancer, other GIGINEOP Cancer, pancreaticGINEOP Cancer, stomachGIINFLA CholangitisGIINFLA Diverticular diseaseHEPATF Encephalopathy, hepaticGIINFLA GI Abscess/cyst GIOTHER GI medical, otherGIOBSTR GI Obstruction GIPERF GI Perforation/rupture GIVASC GI Vascular insufficiencyPERITOHEM Hemorrhage, intra/retroperitoneal HEPATF Hepatic failure, acuteGIINFLA Inflammatory bowel diseasePANCRE PancreatitisGIINFLA PeritonitisGIOTHER Ulcer disease, peptic

Gastrointestinal (GI)Post-Operative

SGIOTH AppendectomySGIBLEE Bleeding-lower GI, surgery for SGIBLEE Bleeding-other GI, surgery forSGIBLEE Bleeding-upper GI, surgery forSGIBLEE Bleeding-variceal, surgery for (excluding vascular shunting-see surgery for portosystemic shunt)SGICA Cancer-colon/rectal, surgery for (including abdominoperineal resections)SGICA Cancer-esophageal, surgery for (abdominal approach)SGICA Cancer-other GI tract, surgery for (i.e. hepatoma, gallbladder etc.)






SGICA Cancer-small intestinal, surgery forSGICA Cancer-stomach, surgery forSGIOTH CAPD catheter insertionSGICHOL Cholecystectomy/cholangitis, surgery for (gallbladder removal)SGIOTH Complications of previous GI surgery; surgery for (anastomotic leak, bleeding, abscess, infection, dehiscence, etc.)SGIINFL Diverticular disease, surgery forSGIOTH Esophageal surgery, otherSGIABCES Fistula/abscess, surgery for (not inflammatory bowel disease)SGIOTH GastrostomySGIABCES GI Abscess/cyst-primary, surgery for (for complications of GI surgery see below)SGIOBS GI Obstruction, surgery for (including lysis of adhesions)SGIPERF GI Perforation/rupture, surgery for SGIOTH GI surgery, otherSGIVASC GI Vascular ischemia, surgery for (resection)SGIOTH Hernia-hiatal, esophageal surgery for SGIOTH HerniorrhaphySGIINFL Inflammatory bowel disease, surgery for SGIOTH Obesity-morbid, surgery for SGIOTH Pancreatitis, surgery forSGIOTH Peritoneal lavageSGIPERF Peritonitis, surgery forSGIOTH Shunt, peritoneal-venous;surgery forSGIOTH Shunt-portosystemic, surgery for SGIOTH SplenectomySGICA Whipple-surgery for pancreatic cancer

Hematology (HEMATO)Non-Operative

HEMAMISC AnemiaHEMAMISC Blood transfusion reactionCOAGTHRO CoagulopathyHEMAMISC Hematologic medical, otherHEMAMISC Leukemia, acute lymphocytic HEMAMISC Leukemia, acute myelocytic HEMAMISC Leukemia, chronic lymphocyticHEMAMISC Leukemia, chronic myelocyticHEMAMISC Leukemia, other





HEMAMISC Lymphoma, HodgkinsHEMAMISC Lymphoma, non-Hodgkins COAGTHRO NeutropeniaCOAGTHRO PancytopeniaHEMAMISC Sickle cell crisisCOAGTHRO Thrombocytopenia

Hematology (HEMATO)Post-Operative

HEMAMISC Hematologic surgery, otherHEMAMISC Lymphoma Hodgkins, surgery for (including staging)HEMAMISC Lymphoma, non-Hodgkins; surgery for (including staging)

Metabolic/Endocrine (METAB/ENDO)Non-Operative

ACIDBASE Acid-base electrolyte disturbanceMETAMISC Addisons diseaseGIOTHER Adrenal neoplasm (including pheochromocytoma)COMAMETU Diabetic hyperglycemic hyperosmolar nonketotic coma (HHNC)DIABETIC Diabetic ketoacidosisMETAMISC Heat exhaustion/strokeMETAMISC HyperthermiaMETAMISC Hyperthyroid storm/crisisMETAMISC HypoglycemiaMETAMISC HypothermiaMETAMISC Hypothyroid/myxedemaMETAMISC Metabolic/endocrine medical, otherMETAMISC Thyroid neoplasm

Metabolic/Endocrine (METAB/ENDO)Post-Operative

HEMAMISC AdrenalectomyHEMAMISC Metabolic/endocrine surgery, otherHEMAMISC ParathyroidectomyHEMAMISC Thyroidectomy and parathyroidectomyHEMAMISC Thyroidectomy

Musculoskeletal/Skin (MUSKELSKIN)Non-Operative

GENOTH Arthritis, rheumatoid








GENOTH Arthritis, septicPERIART Cellulitis and localized soft tissue infectionsGENOTH Connective tissue disease (mixed)GENOTH Lupus, systemicGENOTH Musculoskeletal medical, otherGENOTH Myositis, viral GENOTH RhabdomyolysisGENOTH SclerodermaGENOTH Vasculitis

Musculoskeletal/Skin (MUSKELSKIN)Post-Operative

SAMPUTATE Amputation (non-traumatic)SPERISC Cellulitis and localized soft tissue infections, surgery forGENOTH Cosmetic surgery (all)GENOTH Fracture-pathological, non-union, non-traumatic, for fractures due to trauma see TraumaGENOTH Grafting, skin (all)GENOTH Hip replacement, total (non-traumatic) GENOTH Knee replacement, total (non-traumatic) GENOTH Orthopedic surgery, otherGENOTH Skin surgery, other

Neurologic (NEUROLOGIC)Non-Operative

NEURINF Abscess, neurologicNEURMUS Amyotrophic lateral sclerosisCOMAMETU Coma/change in level of consciousness (for hepatic see GI, for diabetic see Endocrine, if related to cardiac arrest, see CV)STROKE CVA, cerebrovascular accident/strokeOD Drug withdrawalNEURINF EncephalitisCOMAMETU Encephalopathies (excluding hepatic)NEURMUS Guillian-Barre syndromeSAHMED Hematoma, epidural SAHMED Hematoma, subduralICHMED Hemorrhage/hematoma, intracranial NEUROTH Hydrocephalus, obstructive NEURINF MeningitisNEURMUS Myasthenia gravis






NEONEUR Neoplasm, neurologicNEUROTH Neurologic medical, otherNEURMUS Neuromuscular medical, otherCARDARR Nontraumatic coma due to anoxia/ischemiaOD Overdose, alcohols (bethanol, methanol, ethylene glycol)OD Overdose, analgesic (aspirin, acetaminophen)OD Overdose, antidepressants (cyclic, lithium)OD Overdose, other toxin, poison or drugOD Overdose, sedatives, hypnotics, antipsychotics, benzodiazepinesOD Overdose, street drugs (opiates, cocaine, amphetamine)CARDARR Poisoning, carbon monoxide, arsenic, cyanideSEIZ Seizures (primary-no structural brain disease)SAHICH Subarachnoid hemorrhage/arteriovenous malformationSAHICH Subarachnoid hemorrhage/intracranial aneurysm

Neurologic (NEUROLOGIC)Post-Operative

SNEUROTH Abscess/infection-cranial, surgery forSNEUROTH Anastomosis, vascularSNEUROTH Arteriovenous malformation, surgery forSNEUROTH Biopsy, brain SNEUROTH Burr hole placementSNEUROTH Cerebrospinal fluid leak, surgery forSLAMINE Complications of previous spinal cord surgery, surgery for SNEUROTH Cranial nerve, decompression/ligation SNEUROTH Cranioplasty and complications from previous craniotomiesSLAMINE Devices for spine fracture/dislocationSLAMINE Fusion-spinal/Harrington rodsSSDH Hematoma, epidural, surgery for SSDH Hematoma, subdural, surgery forSICH Hemorrhage/hematoma-intracranial, surgery for SLAMINE Laminectomy/spinal cord decompression (excluding malignancies)SCRANNEO Neoplasm-cranial, surgery for (excluding transphenoidal)SLAMINE Neoplasm-spinal cord surgery or other related proceduresSNEUROTH Neurologic surgery, otherSNEUROTH Seizures-intractable, surgery forSNEUROTH Shunts and revisions





SLAMINE Spinal cord sugery, otherSNEUROTH Stereotactic procedure SSAH Subarachnoid hemorrhage/intracranial aneurysm, surgery for SLAMINE SympathectomySCRANNEO Transphenoidal surgerySNEUROTH Ventriculostomy

Respiratory (RESPIRAT)Non-Operative

RESPOTH Apnea, sleep PULEDEM ARDS-adult respiratory distress syndrome, non-cardiogenic pulmonary edemaRESPARR Arrest, respiratory (without cardiac arrest)ALLERGY AsthmaRESPOTH AtelectasisRESPCA Cancer, laryngeal RESPCA Cancer, lungRESPCA Cancer, oralRESPCA Cancer, trachealPLEUREFFUS Effusions, pleural PULEMB Embolus, pulmonaryCOPD Emphysema/bronchitisRESPOTH Hemorrhage/hemoptysis, pulmonaryRESPOTH HemothoraxRESPOTH Hypertension-pulmonary, primary/idiopathicRESPOTH Near drowning accidentAIROBS Obstruction-airway (i.e. acute epiglottitis, post-extubation edema, foreign body, etc.)ASPPNEU Pneumonia, aspirationBACPNEU Pneumonia, bacterialPARAPNEU Pneumonia, fungalBACPNEU Pneumonia, otherPARAPNEU Pneumonia, parasitic (i.e. Pneumocystis pneumonia)BACVPNEU Pneumonia, viralRESPOTH PneumothoraxRESPOTH Respiratory- medical, otherRESLUNGDIS Restrictive lung disease (i.e. sarcoidosis, pulmonary fibrosis)RESPOTH Smoke inhalationRESPOTH Weaning from mechanical ventilation (transfer from other unit or hospital only)





Respiratory (RESPIRAT)Post-Operative

SRESTOTH Apnea-sleep; surgery for (i.e. UPPP -uvulopalatopharyngoplasty)SLUNG Biopsy, open lung SRESOTH BullectomySRESPLAR Cancer oral/sinus, surgery for SRESPLAR Cancer-laryngeal/tracheal, surgery for SRESOTH Facial surgery (if related to trauma, see Trauma)SRESPINF Infection/abscess, other surgery for SRESOTH Respiratory surgery, otherSRESPCA Thoracotomy for benign tumor (i.e. mediastinal chest wall mass, thymectomySRESOTH Thoracotomy for bronchopleural fistulaSGICA Thoracotomy for esophageal cancerSRESPCA Thoracotomy for lung cancerSRESOTH Thoracotomy for lung reductionSRESPCA Thoracotomy for other malignancy in chestSRESOTH Thoracotomy for other reasonsSLUNG Thoracotomy for pleural diseaseSRESPINF Thoracotomy for thoracic/respiratory infectionSRESOTH Tracheostomy

APACHE Disease Transplant (TRANSPLANT)Mapping Non-Operative

RENOTH Kidney transplantHEPATF Liver transplantNON-PREDICTIVE ALL OTHER NON_OPERATIVE TRANSPLANTS

Transplant (TRANSPLANT)Post-Operative

SRENTRAN Kidney transplantSLIVERTR Liver transplantNON-PREDICTIVE ALL OTHER POST-OPERATIVE TRANSPLANTS

Trauma (TRAUMA)Non-Operative

MULTRAUM Abdomen only traumaMULTRAUM Abdomen/extremity traumaMULTRAUM Abdomen/face traumaMULTRAUM Abdomen/multiple trauma







MULTRAUM Abdomen/pelvis traumaMULTRAUM Abdomen/spinal traumaMULTRAUM Chest/abdomen traumaMULTRAUM Chest/extremity traumaMULTRAUM Chest/face traumaTRAUMCHSP Chest/multiple traumaMULTRAUM Chest/pelvis traumaTRAUMCHSP Chest/spinal traumaMULTRAUM Chest/thorax only traumaMULTRAUM Extremity only traumaMULTRAUM Extremity/face traumaMULTRAUM Extremity/multiple traumaMULTRAUM Face only traumaMULTRAUM Face/multiple traumaTRHEADONLY Head (CNS) only traumaHEADTR Head/abdomen traumaHEADTR Head/chest traumaTRHEADEXF Head/extremity traumaTRHEADEXF Head/face traumaTRHEADMULT Head/multiple traumaHEADTR Head/pelvis traumaHEADTR Head/spinal traumaMULTRAUM Pelvis/extremity traumaMULTRAUM Pelvis/face traumaMULTRAUM Pelvis/hip only traumaMULTRAUM Pelvis/multiple traumaMULTRAUM Pelvis/spinal traumaTRAUMSPINE Spinal cord only traumaMULTRAUM Spinal/extremity traumaMULTRAUM Spinal/face traumaMULTRAUM Spinal/multiple traumaMULTRAUM Trauma medical, other

Trauma (TRAUMA)Post-Operative

SMULTR Abdomen only trauma, surgery forSMULTR Abdomen/extremity trauma, surgery for





SMULTR Abdomen/face trauma, surgery forSMULTR Abdomen/multiple trauma, surgery forSMULTR Abdomen/pelvis trauma, surgery forSMULTR Abdomen/spinal trauma, surgery forSMULTR Chest/abdomen trauma, surgery forSMULTR Chest/extremity trauma, surgery forSMULTR Chest/face trauma, surgery for SMULTR Chest/multiple trauma, surgery forSMULTR Chest/pelvis trauma, surgery for SMULTR Chest/spinal trauma, surgery forSMULTR Chest/thorax only trauma, surgery forSTRAUMEXT Extremity only trauma, surgery forSMULTR Extremity/face trauma, surgery for SMULTR Extremity/multiple trauma, surgery for SMULTR Face only trauma, surgery forSMULTR Face/multiple trauma, surgery forSTRHDONLY Head (CNS) only trauma, surgery forSHEADTR Head/abdomen trauma, surgery forSHEADTR Head/chest trauma, surgery forSHEADTR Head/extremity trauma, surgery forSHEADTR Head/face trauma, surgery forSHEADTR Head/multiple trauma, surgery forSHEADTR Head/pelvis trauma, surgery forSHEADTR Head/spinal trauma, surgery forSMULTR Pelvis/extremity trauma, surgery forSMULTR Pelvis/face trauma, surgery forSMULTR Pelvis/hip only trauma,surgery forSMULTR Pelvis/multiple trauma, surgery forSMULTR Pelvis/spinal trauma, surgery forSMULTR Spinal cord only trauma, surgery forSMULTR Spinal/extremity trauma, surgery forSMULTR Spinal/face trauma, surgery forSMULTR Spinal/multiple trauma, surgery for SMULTR Trauma surgery, other

Rev. 001Eff. Date: June 17, 2005Owener: Critical Outcomes



APACHE IV HOSPITAL MORTALITY NON-CABG PATIENT Value Coefficient Knot Points Cross ProductIntercept 1 -5.950471952 -5.950471951626Age Age 0 0.0241774552 0

AGE1 0 -4.38862E-06 27 0AGE2 0 5.014223E-05 51 0AGE3 0 -0.000127787 64 0AGE4 0 0.000109606 74 0AGE5 0 -2.75723E-05 86 0

Chronic Health (0/1)* None 0

For non-op and emergency AIDS 0.9581005157 0

surgery pts., select item used Hepatic Failure 1.0373799253 0

to calculate APACHE III score. Lymphoma 0.743471748 0

If multiple chronic health items are presenMetastatic Cancer 1.0864237522 0

use the one with the highest point value (Leukemia/Multiple Myeloma 0.9693082989 0

APACHE IV spreadsheet), NOT the one witImmunosuppression 0.4355810827 0

the highest coefficient. Cirrhosis 0.8146650877 0

0Acute Physiology Score APS 0 0.0556349159 0

APS3ALL1 0 8.718522E-06 10 0Enter the Acute Physiology APS3ALL2 0 -4.51101E-05 22 0Score. Splining of this variable APS3ALL3 0 5.038004E-05 32 0will autocalculate APS3ALL APS3ALL4 0 -1.31231E-05 48 0

APS3ALL5 0 -8.65349E-07 89 0PA/FI Ratio -0.000397068 0

Ventilated at any time during ICU Day 1 1=Yes 0.2717600356 0

ICU Admission Information (0/1) Adm to ICU from floor 0.0171491928 0

Select only one 0.0221062655 0Admit to ICU from OR/PACU -0.583828121 0

0

Transfer to ICU from other hospital




Emergency Surgery 0/1 0.2490734585 0

PreICU LOS in dayssquare root of days (aut 0 -0.310487496 0PRELOS21 0 1.4746725115 0.121 0PRELOS22 0 -2.8618857 0.423 0PRELOS23 0 1.4216590103 0.794 0PRELOS24 0 -0.034445822 2.806 0

Admitting Diagnosis* ACIDBASE -0.640575517 0

*See mapping table AIROBS -0.977669154 0

*Select only one ALLERGY -1.540678498 0

AMI_ANT 0.1029497654 0

AMI_INFRLATR -0.152525079 0

AMI_NONQ -0.270872458 0

ASPPNEU -0.37223658 0

BACPNEU -0.043365914 0

BACVPNEU 0.2543749044 0

CARDARR 0.4169191406 0

CARDIOG 0.2397114719 0

CARDIOMY 0.0599624438 0

CHESTPAIN -1.122354572 0CHFD -0.422587793 0

COAGTHRO 0.2581724351 0

COMAMETU -0.927156778 0

COPDD -0.398697453 0

CVOTH -0.369658509 0

DIABETIC -1.775702142 0

DRUGTOXIC -0.690943246 0

GENOTH -0.667576408 0

GIBLEED -0.551832894 0

# Days between ICU and Hosp Admission




GIBLEUL -0.579471867 0

GIBLVAR -0.527719358 0

GIINFLA -0.211771894 0

GINEOP 0.1951302908 0

GIOBSTR -0.369945003 0

GIOTHER -0.252586643 0

GIPERF -0.327171182 0

GIVASC 0.714879336 0

HEADTR -0.372350315 0

HEMAMISC -0.342352862 0

HEMORRHAGE -0.656757432 0

HEPATF -0.119675791 0

HYPERT -0.813921325 0

HYPOVOLEM -0.622592285 0

ICHMED 0.9450561547 0

MEDAORT 0.6491493051 0

METAMISC -0.986438209 0

MULTRAUM -0.678110274 0

NEONEUR 0.0189527274 0

NEURINF -0.535783229 0

NEURMUS -0.550653067 0

NEUROTH -0.176828697 0

OD -1.55261952 0

PANCRE -0.513627563 0

PARAPNEU 1.0561873472 0

PERIART -0.502752032 0

PERITOHEM -0.659544401 0

PLEUREFFUS 0.1899005237 0

PULEDEM -0.2416873 0

PULEMB -0.051527401 0

RENOTH -0.54158014 0

RESLUNGDIS 1.5552965796 0




RESPARR -0.390631425 0

RESPCA 0.966313802 0

RESPOTH -0.202823617 0

RHYTHM -0.603060945 0

SAGRAFT -0.831194514 0

SAHICH 0.6159503846 0

SAHMED 0.2950939014 0

SAMPUTATE 0.604910303 0

SAORTDIS -0.178456475 0

SCABGVALV -1.199434806 0

SCARDOTH -0.59044574 0

SCAROTID -1.332642438 0

SCRANNEO -0.437737676 0

SEIZ -0.942170992 0

SELAORT -0.760703396 0

SEPSISCUT 0.1264403154 0

SEPSISGI -0.13010935 0

SEPSISOTH -0.04233671 0

SEPSISPULM -0.258766455 0

SEPSISUNK -0.093377498 0SEPTICUT -0.732788506 0

SFEMPGRAF -0.786571016 0SGIABCES -0.556661177 0

SGIBLEE -0.329679773 0

SGICA 0.1362826618 0

SGICHOL -0.593293673 0

SGIINFL -0.165585527 0

SGIOBS -0.189005132 0

SGIOTH -0.295894316 0

SGIPERF -0.189960264 0

SGIVASC 0.4983280142 0

SHEADTR 0.3577977348 0




SICH 0.5267174102 0

SLAMINE -0.628609547 0

SLIVERTR -1.370278559 0

SLUNG 0.4057380077 0

SMULTR -0.377807998 0

SNEUROTH 0.0039963394 0

SOBHYST -0.795847883 0

SPERISC -0.504208244 0

SRENCA -1.397212695 0

SRENOTH -0.693574061 0

SRENTRAN -1.308449407 0

SRESOTH -0.249217228 0

SRESPCA 0.086933576 0

SRESPINF -0.005937516 0

SRESPLAR -1.152870135 0

SRUPAOR 0.204404736 0

SSAH 0.318905704 0

SSDH 0.7156826217 0

STRAUMEXT -0.180386981 0

STRHDONLY 1.0888193243 0

STROKE 0.5194530354 0

SVALVE -1.371763972 0

SVHDCABG -0.155141644 0

TRAUMCHSP -0.717432122 0TRAUMSPINE 0.0337694835 0

TRHEADEXF -0.364128015 0

TRHEADMULT -0.067960926 0

TRHEADONLY 0.5958694161 0

USTAANG -1.212730735 0

0 0

IF diagnosis is ACUTEMI Thrombolytic Therapy -0.579874039 0




Unable to obtain GCS (Unable = 1) 0.7857643165 0

GCS Eyes + Motor + Verbal

Adjusted GCS (autocalc) 0 0.0391175318 0

Sum of cross products -5.9504719516Natural antilog of sum =x 0.00260461098

Prediction = x/(1+x) 0.26%

Note: Predictions after the initial day contain an additional variable that updates the patient's APACHE III score for changes in physiological status,

and the relative contributions of age and comorbidities are also different on subsequent days. These equations are intended to be used to generate

predictions.

due to meds, sedation, or anesthesia. See methodology for rules.

hospital mortality prediction on Day 1 of the patient's ICU stay ONLY. Using these coefficients for other days is inappropriate and will yield erroneous



Tab 6, p.27 of 36Reviewed by: Fern MalilaApproved by: Kim Hlobik

HOSPITAL MORTALITY-CABG Only CABG Patient Only Value Coefficient Knot PointCross ProductIntercept 1 -7.246664 -7.246664

Age (0/1) Select one <45 0 0 0

45-54 0 -0.737078 0

55-59 -0.765009 0

60-64 -0.529345 0

65-69 -0.222009 0

70-74 0.107859 0

75-84 0.169567 0

>=85 0.765707 0

0Chronic Health Do not use chronic

health items forCABG mortalityprediction.

Acute Physiology Score APS 0 0.044207 0 Internal calculations, do not changeEnter the Acute Physiology EQ18_APS3ALL1 0 0.17313 15 0 0 0 0Score. Splining of this variable EQ18_APS3ALL2 0 -0.041316 30 0 0 0 0will autocalculate APS3ALL EQ18_APS3ALL3 0 -1.145473 40 0 0 0 0

EQ18_APS3ALL4 0 1.713847 50 0 0 0 0Internal calculations, kd 17.784467 60 do not change diff 30 90

Emergency Surgery 0/1 0 0.76644 0

CABG-Specific Variables Female (yes=1) 0 0.861304 0

Enter all that apply Redo CABG (yes=1) 1.206335 0

Number of grafts 0 0.082575 0



Tab 6, p.28 of 36Reviewed by: Fern MalilaApproved by: Kim Hlobik

Sum of cross products -7.246664Natural antilog of sum =x 0.00071255

Prediction = x/(1+x) 0.07%

Note: Predictions after the initial day contain an additional variable that updates the patient's APACHE III score for changes in physiological status,and the relative contributions of age and comorbidities are also different on subsequent days. This equation is intended to be used to generate

predictions.hospital mortality prediction on Day 1 of the patient's ICU stay ONLY. Using these coefficients for other days is inappropriate and will yield erroneous




APACHE IV ICU LENGTH OF STAY NON CABG Patient Only Value Coefficient Knot Points Cross ProductIntercept 1 1.6738879246 1.6738879245555Age (0/1) Select one Age 0.0176033952 0

AGE1 0 -7.68259E-06 27 0AGE2 0 3.956673E-05 51 0AGE3 0 -0.000166793 64 0AGE4 0 0.0002281564 74 0AGE5 0 -9.32478E-05 86 0

Chronic Health (0/1)* None 0 0

For non-op and emergency AIDS -0.10285942 0

surgery pts., select item used Hepatic Failure -0.16012995 0

to calculate APACHE III score. Lymphoma -0.28079854 0If multiple chronic health items are present,Metastatic Cancer -0.491932974 0use the one with the highest point value (seLeukemia/Multiple Myeloma -0.803754341 0APACHE IV spreadsheet), NOT the one with Immunosuppression -0.07438064 0the highest coefficient. Cirrhosis 0.3626586131 0

0

Acute Physiology Score APS 0.0444269895 0APS3ALL1 0 -5.83049E-05 10 0

Enter the Acute Physiology APS3ALL2 0 0.0002970084 22 0Score. Splining of this variable APS3ALL3 0 -0.000404434 32 0will autocalculate APS3ALL APS3ALL4 0 0.0001892508 48 0

APS3ALL5 0 -2.35199E-05 89 0

PaO2/FIO2 Ratio -0.004581842 0

Ventilated at any time during ICU Day 1 1=Yes 1.8353095408 0

ICU Admission Information (0/1) Adm to ICU from floor 0.0065293818 0

Select only one 0.8555050425 0

Admit to ICU from OR/PACU -0.599591763 0

Transfer to ICU from other hospital




0Readmit 0/1 0.5403684594 0

Emergency Surgery 0/1 1.0406906318 0

PreICU LOS in days 0square root of days (autocalc) 0 0.4598231293 0PRELOS21 0 0.3977919374 0.121 0PRELOS22 0 -0.945210953 0.423 0PRELOS23 0 0.5886512665 0.794 0PRELOS24 0 -0.041232251 2.806 0

Admitting Diagnosis* ACIDBASE -0.382017407 0

*See mapping table AIROBS 0.3471484637 0

*Select only one ALLERGY -0.542185912 0AMI_ANT 0.0857685121 0AMI_INFRLATR -0.036016015 0AMI_NONQ -0.057916835 0ASPPNEU 0.8602584271 0BACPNEU 1.3067446009 0BACVPNEU 1.1560647567 0CARDARR -0.751470488 0CARDIOG 0.3299898856 0CARDIOMY 0.5570053879 0CHESTPAIN -0.520128136 0CHFD -0.219091549 0COAGTHRO 0.3998174157 0COMAMETU -0.081962609 0COPDD -0.446092483 0CVOTH -0.132883369 0DIABETIC -0.58421484 0DRUGTOXIC -0.882634505 0

# Days between ICU and Hosp Admission




GENOTH -0.420843422 0GIBLEED 0.0213604052 0GIBLEUL 0.1856965939 0GIBLVAR -0.083385343 0GIINFLA 0.532982522 0GINEOP 1.3368312875 0GIOBSTR 2.0686144603 0GIOTHER 0.5565887447 0GIPERF 2.2086995672 0GIVASC 1.9440608345 0HEADTR 2.1289081715 0HEMAMISC -0.126173954 0HEMORRHAGE -0.381155309 0HEPATF 0.1949458349 0HYPERT -0.067961418 0HYPOVOLEM -0.389881468 0ICHMED 0.8632948203 0MEDAORT 1.3106215068 0METAMISC -0.363969853 0MULTRAUM 1.5211879362 0NEONEUR 0.9748471868 0NEURINF 1.1655653196 0NEURMUS 3.9256604297 0NEUROTH 0.3575043808 0OD -0.89006849 0PANCRE 2.7626886748 0PARAPNEU 1.6197005464 0PERIART 0.8443265288 0PERITOHEM 0.1652656354 0PLEUREFFUS 0.8100930286 0PULEDEM 1.4427509398 0PULEMB 0.1068340489 0




RENOTH -0.152233731 0RESLUNGDIS 1.024903996 0RESPARR -0.053291846 0RESPCA -0.140474342 0RESPOTH 0.2404909089 0RHYTHM -0.302546395 0SAGRAFT 0.5239223901 0SAHICH 3.0086087597 0SAHMED 1.1953150967 0SAMPUTATE -0.325703861 0SAORTDIS 1.1100214568 0SCABGVALV -1.358289429 0SCARDOTH -1.28358348 0SCAROTID -0.14649332 0SCRANNEO 0.319065119 0SEIZ -0.330810671 0SELAORT 0.7739464631 0SEPSISCUT 1.5642195701 0SEPSISGI 1.2453136733 0SEPSISOTH 0.6490771069 0SEPSISPULM 1.9266479992 0SEPSISUNK 0.4025902569 0SEPTICUT 0.4531372416 0SFEMPGRAF -0.204188913 0SGIABCES 0.7199377967 0SGIBLEE -0.045403893 0SGICA 0.3248658754 0SGICHOL -0.588512311 0SGIINFL 0.6869364416 0SGIOBS 0.1873047354 0SGIOTH 0.2170447191 0SGIPERF 1.0553746251 0




SGIVASC 0.6206952495 0SHEADTR 3.20631279 0SICH 2.9498695693 0SLAMINE -0.251392367 0SLIVERTR -0.848656603 0SLUNG 0.1859748668 0SMULTR 1.4854303079 0SNEUROTH 0.5513312249 0SOBHYST -0.162493249 0SPERISC 0.1022934618 0SRENCA -0.423760975 0SRENOTH -0.58901834 0SRENTRAN -0.556650506 0SRESOTH -0.359443815 0SRESPCA 0.1999254548 0SRESPINF 0.044451048 0SRESPLAR -0.053892181 0SRUPAOR 2.7766388797 0SSAH 2.599592539 0SSDH 1.3423449617 0STRAUMEXT -0.481004907 0STRHDONLY 2.1021826433 0STROKE 0.3132337931 0SVALVE -2.076438218 0SVHDCABG -0.332456954 0TRAUMCHSP 2.574268317 0TRAUMSPINE 2.1681426709 0TRHEADEXF 0.8600333425 0TRHEADMULT 3.6375602953 0TRHEADONLY 0.834081141 0USTAANG -0.368981979 0

0




IF diagnosis is ACUTEMI Thrombolytic Therapy 0.062385214 0

Unable to obtain GCS (Unable = 1) 1.7893266131 0

GCS Eyes + Motor + VerbalAdjusted GCS (autocalc) 0 -0.015182904 0

Sum of cross products 1.6738879245555

Prediction (days) 1.67

Note: Length of Stay predictions are intended to be used to generate ICU length of stay predictions on Day 1 of the patient's stay ONLY.

due to meds, sedation, or anesthesia. See methodology for rules.

Using these coefficients for other days is inappropriate and will yield erroneous predictions.




ICU Length of Stay-CABG ONLY CABG Patient Only Value Coefficien Knot PointCross ProductIntercept 1 2.004583 2.004583

Age (0/1) Select one AGE 0.012994 0EQ18_AGE1 0 -8.19E-06 46 0EQ18_AGE2 0 5.92E-05 59 0EQ18_AGE3 0 -0.000181 67 0EQ18_AGE4 0 0.000189 73 0EQ18_AGE5 0 -5.94E-05 81 0

Chronic Health Do not use chronic health health items forCABG mortality prediction.

Diabetes (medication dependent) (yes=1) 0 0.159896 0

Acute Physiology Score APS -0.02843 0Enter the Acute Physiology EQ18_APS3ALL1 0 0.000126 15 0Score. Splining of this variable EQ18_APS3ALL2 0 -0.000295 25 0will autocalculate APS3ALL EQ18_APS3ALL3 0 0.000167 32 0

EQ18_APS3ALL4 0 -1.04E-06 40 0EQ18_APS3ALL5 0 2.85E-06 61 0

Emergency Surgery 0/1 0 0.284642 0

Creatinine CREA -0.004945 0EQ18_CREA1 0 -3.581329 0.6 0EQ18_CREA2 0 21.94124 0.8 0EQ18_CREA3 0 -608.0213 1.09 0EQ18_CREA4 0 591.272 1.1 0EQ18_CREA5 0 -1.610631 1.9 0




Ejection Fraction PLVEJECT 0 -0.005927 0EQ18_PLVEJECT1 0 -7.65E-06 20 0EQ18_PLVEJECT2 0 0.000136 45 0EQ18_PLVEJECT3 0 -0.000334 54.21552 0EQ18_PLVEJECT4 0 0.000211 60 0EQ18_PLVEJECT5 0 5.06E-06 99 0

CABG-Specific Variables Female (yes=1) 0.278597 0

Enter all that apply Redo CABG (yes=1) 0.336221 0

IMA used (yes=1) -0.197821 0

MIDUR (yes=1) 0.214881 0

Number of grafts = 2 0.052944 0

Number of grafts = 3 0.111277 0

Number of grafts = 4 -0.053388 0



Number of grafts >=7 0 -0.482726 0

0

Sum of cross products 2.004583

Prediction = 2.00

Note: Predictions after the initial day contain an additional variable that updates the patient's APACHE III score for changes in physiological status,and the relative contributions of age and comorbidities are also different on subsequent days. This equation is intended to be used to generatehospital mortality prediction on Day 1 of the patient's ICU stay ONLY. Using these coefficients for other days is inappropriate

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