Managing ICU surge during the COVID-19 crisis: rapid guidelines

Surviving The Surge: Nonurgent Elective Procedures, Intensive Care, And Mississippi's COVID-19 Waves

During the COVID-19 pandemic in Mississippi in 2020 and 2021, nonurgent elective procedures requiring hospitalization were halted three times to preserve the state's hospital resources. To evaluate the change in hospital intensive care unit (ICU) capacity after the implementation of this policy, we analyzed Mississippi's hospital discharge data. We compared daily mean ICU admissions and census for nonurgent elective procedures between three intervention periods and baseline periods corresponding to Mississippi State Department of Health executive orders. We further evaluated the observed and predicted trends, using interrupted time series analyses. Overall, the executive orders reduced the mean number of ICU admissions for elective procedures from 13.4 patients to 9.8 patients daily (a 26.9 percent decline). This policy also decreased the mean ICU census for nonurgent elective procedures from 68.0 patients to 56.6 patients daily (a 16.8 percent decline). The state managed to free, on average, eleven ICU beds daily. Postponing nonurgent elective procedures in Mississippi was a successful strategy that resulted in a decline in ICU bed use for nonurgent elective surgeries during times of unprecedented stress on the health care system.

Delayed mechanical ventilation with prolonged high-flow nasal cannula exposure time as a risk factor for mortality in acute respiratory distress syndrome due to SARS-CoV-2

In a high proportion of patients, infection by COVID-19 progresses to acute respiratory distress syndrome (ARDS), requiring invasive mechanical ventilation (IMV) and admission to an intensive care unit (ICU). Other devices, such as a high-flow nasal cannula (HFNC), have been alternatives to IMV in settings with limited resources. This study evaluates whether HFNC exposure time prior to IMV is associated with mortality. This observational, analytical study was conducted on a historical cohort of adults with ARDS due to SARS-CoV-2 who were exposed to HFNC and subsequently underwent IMV. Univariate and multivariate logistic regression was used to analyze the impact of HFNC exposure time on mortality, controlling for multiple potential confounders. Of 325 patients with ARDS, 41 received treatment with HFNC for more than 48 h before IMV initiation. These patients had a higher mortality rate (43.9% vs. 27.1%, p: 0.027) than those using HFNC < 48 h. Univariate analysis evidenced an association between mortality and HFNC ≥ 48 h (OR 2.16. 95% CI 1.087-4.287. p: 0.028). Such an association persisted in the multivariable analysis (OR 2.21. 95% CI 1.013-4.808. p: 0.046) after controlling for age, sex, comorbidities, basal severity of infection, and complications. This study also identified a significant increase in mortality after 36 h in HFNC (46.3%, p: 0.003). In patients with ARDS due to COVID-19, HFNC exposure ≥ 48 h prior to IMV is a factor associated with mortality after controlling multiple confounders. Physiological mechanisms for such an association are need to be defined.

Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic

PURPOSE

The mobilization of most available hospital resources to manage coronavirus disease 2019 (COVID-19) may have affected the safety of care for non-COVID-19 surgical patients due to restricted access to intensive or intermediate care units (ICU/IMCUs). We estimated excess surgical mortality potentially attributable to ICU/IMCUs overwhelmed by COVID-19, and any hospital learning effects between two successive pandemic waves.

METHODS

This nationwide observational study included all patients without COVID-19 who underwent surgery in France from 01/01/2019 to 31/12/2020. We determined pandemic exposure of each operated patient based on the daily proportion of COVID-19 patients among all patients treated within the ICU/IMCU beds of the same hospital during his/her stay. Multilevel models, with an embedded triple-difference analysis, estimated standardized in-hospital mortality and compared mortality between years, pandemic exposure groups, and semesters, distinguishing deaths inside or outside the ICU/IMCUs.

RESULTS

Of 1,870,515 non-COVID-19 patients admitted for surgery in 655 hospitals, 2% died. Compared to 2019, standardized mortality increased by 1% (95% CI 0.6-1.4%) and 0.4% (0-1%) during the first and second semesters of 2020, among patients operated in hospitals highly exposed to pandemic. Compared to the low-or-no exposure group, this corresponded to a higher risk of death during the first semester (adjusted ratio of odds-ratios 1.56, 95% CI 1.34-1.81) both inside (1.27, 1.02-1.58) and outside the ICU/IMCU (1.98, 1.57-2.5), with a significant learning effect during the second semester compared to the first (0.76, 0.58-0.99).

CONCLUSION

Significant excess mortality essentially occurred outside of the ICU/IMCU, suggesting that access of surgical patients to critical care was limited.

A Brief Assessment of Patient Safety Culture in Anesthesia and Intensive Care Departments

Due to the nature of their activity, anesthesia and critical care have generally well-developed patient safety cultures, which are linked to a greater level of incident awareness and reporting during clinical activity. In order to determine the status quo and identify and adopt, where appropriate, techniques and instruments for further improving patient safety, it is necessary to evaluate the culture and barriers in these departments. The main objective of our study was to assess patient safety culture in Romanian anesthesia and intensive care departments (AICDs), to pinpoint the areas that may need improvement, and to examine the correlation between the prevalence of adverse event reporting, as well as the level of self-reported patient safety culture. To determine how anesthesia and intensive care department staff perceived patient safety, the Hospital Survey on Patient Safety Culture (HSOPSC) was used in a translated Romanian version. In total, 1200 employees from 36 anesthesiology and intensive care departments across 32 hospitals in Romania received the questionnaire, representing 42.66% of all anesthesia and intensive care departments in the country. In 7 of the 12 examined dimensions, significant differences between tertiary and secondary hospitals were observed. Among all dimensions, the highest positive score was for "organizational learning and continuous development". In general, our study revealed a positive view on patient safety in anesthesia and intensive care departments. Further studies are required to determine a threshold of the level of culture development.

Burnout and Turnover Intention in Critical Care Professionals During the COVID-19 Pandemic in Japan: A Cross-sectional Survey

Rationale: The prevalence of burnout among critical care professionals during the coronavirus disease (COVID-19) pandemic varies in different countries. Objectives: To investigate the prevalence of burnout and turnover intention in Japanese critical care professionals in March 2021. Methods: This cross-sectional study used a web-based survey of Japanese critical care professionals working in 15 intensive care units in 15 prefectures. Burnout was measured using the Mini Z 2.0 Survey. Intention to leave (turnover intention) was assessed by survey. Resilience was measured using the Brief Resilience Scale (Japanese version). Demographics and personal and workplace characteristics were also collected. Results: Of 1,205 critical care professionals approached, 936 (77.6%) completed the survey. Among these, 24.3%, 20.6%, and 14.2% reported symptoms of burnout, depression, and anxiety, respectively. A total of 157 respondents (16.8%) reported turnover intention. On multivariate analysis, higher resilience scores (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.84-0.95; and OR, 0.94; 95% CI, 0.91-0.96) and perceived support from the hospital (OR, 0.64; 95% CI, 0.44-0.93; and OR, 0.54; 95% CI, 0.40-0.73) were associated with a lower odds of burnout and turnover intention, respectively. Conclusions: Approximately 24% and 17% of the Japanese critical care professionals surveyed had symptoms of burnout and turnover intention from critical care, respectively, during the COVID-19 pandemic. Such professionals require organizational support to cultivate both individual and organizational resilience to reduce burnout and turnover intention.

Techniques for Oxygenation and Ventilation in Coronavirus Disease 2019

This paper discusses mechanisms of hypoxemia and interventions to oxygenate critically ill patients with COVID-19 which range from nasal cannula to noninvasive and mechanical ventilation. Noninvasive ventilation includes continuous positive airway pressure ventilation (CPAP) and high-flow nasal cannula (HFNC) with or without proning. The evidence for each of these modalities is discussed and thereafter, when to transition to mechanical ventilation (MV). Various techniques of MV, again with and without proning, and rescue strategies which would include extra corporeal membrane oxygenation (ECMO) when it is available and permissive hypoxemia where it is not, are discussed.

'Do-not-intubate' orders in patients assisted by noninvasive respiratory support for acute hypoxaemic failure caused by coronavirus disease 2019; a systematic review and meta-analysis

BACKGROUND

Noninvasive respiratory support (NIRS) has been revealed feasible solutions to cope with the massive request for ventilatory support in patients subjected to 'do-not-intubate' order (DNI).

OBJECTIVES

The aims of the present systematic review and meta-analysis was to estimate pooled incidence of DNI orders and the associated in-hospital mortality in patients undergoing NIRS for hypoxaemic acute respiratory failure (ARF) related to coronavirus disease 2019 (COVID-19).

DESIGN

Systematic review of observational studies and randomized-controlled trials with meta-analyses.

DATA SOURCES

PUBMED, EMBASE, and Cochrane Controlled Clinical trials register were searched for observational studies and randomised-controlled trials from inception to the end of April 2022.

ELIGIBILITY CRITERIA

Inclusion criteria were: observational studies enrolling ≥50 hospitalised patients with hypoxaemic COVID-19-related ARF requiring NIRS and DNI order application. Two authors independently extracted data from enrolled investigations. Data are presented as proportions with 95% confidence interval.

RESULTS

Thirty-one observational studies were included for a total of 6645 COVID-19 patients undergoing NIRS, of whom 1590 received DNI orders. Among patients assisted by NIRS, a DNI order was expressed in a summary estimate of 25.4% [20.0-31.1] of the cases with a high between-study heterogeneity. The summary estimated of in-hospital mortality was 83.6% [75.3-90.7] for DNI patients and 20.0% [14.2-26.5] for full treatment patients, both with a high between-study heterogeneity.

CONCLUSIONS

In COVID-19 patients assisted through NIRS for hypoxaemic ARF, a DNI order was frequently issued and associated with a high in-hospital mortality.

TRIAL REGISTRATION

Prospero registration number: CRD42021271313.

Family support in intensive care units during COVID-19 visit ban: A multinational Delphi Study during first COVID-19 wave

OBJECTIVES

This study assessed opinions and experiences of healthcare professionals, former patients and family members during the first wave of the COVID-19 pandemic and focuses on challenges in family-centred care for intensive care unit patients and affected families.

RESEARCH METHODOLOGY/DESIGN

A two-round modified Delphi process assessed the opinions and experiences of experts such as healthcare professionals, former patients and their families (n = 151).

SETTING

This study was conducted across four countries in Europe.

RESULTS

In total, 121 participants (response rate 80.13%) answered the first Delphi round; the second was answered by 131 participants (response rate 86.75%). Participants perceived family support in the intensive care unit as highly important during the COVID-19 pandemic. Enabling contact amongst patients, families and clinicians is regarded as essential to build hope and confidence in the treatment and the recovery process. The extraordinary situation led to the implementation of new communication structures such as video calls and websites.

CONCLUSION

A consensus was reached between healthcare professionals that virtual contact is essential for patients with COVID-19 and their families during visit restrictions. This should be done to establish confidence in the treatment.

Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units

BACKGROUND

COVID-19 patients requiring mechanical ventilation are particularly at risk of developing ventilator-associated pneumonia (VAP). Risk factors and the prognostic impact of developing VAP during critical COVID-19 have not been fully documented.

METHODS

Patients invasively ventilated for at least 48 h from the prospective multicentre COVID-ICU database were included in the analyses. Cause-specific Cox regression models were used to determine factors associated with the occurrence of VAP. Cox-regression multivariable models were used to determine VAP prognosis. Risk factors and the prognostic impact of early vs. late VAP, and Pseudomonas-related vs. non-Pseudomonas-related VAP were also determined.

MAIN FINDINGS

3388 patients were analysed (63 [55-70] years, 75.8% males). VAP occurred in 1523/3388 (45.5%) patients after 7 [5-9] days of ventilation. Identified bacteria were mainly Enterobacteriaceae followed by Staphylococcus aureus and Pseudomonas aeruginosa. VAP risk factors were male gender (Hazard Ratio (HR) 1.26, 95% Confidence Interval [1.09-1.46]), concomitant bacterial pneumonia at ICU admission (HR 1.36 [1.10-1.67]), PaO₂/FiO₂ ratio at intubation (HR 0.99 [0.98-0.99] per 10 mmHg increase), neuromuscular-blocking agents (HR 0.89 [0.76-0.998]), and corticosteroids (HR 1.27 [1.09-1.47]). VAP was associated with 90-mortality (HR 1.34 [1.16-1.55]), predominantly due to late VAP (HR 1.51 [1.26-1.81]). The impact of Pseudomonas-related and non-Pseudomonas-related VAP on mortality was similar.

CONCLUSION

VAP affected almost half of mechanically ventilated COVID-19 patients. Several risk factors have been identified, among which modifiable risk factors deserve further investigation. VAP had a specific negative impact on 90-day mortality, particularly when it occurred between the end of the first week and the third week of ventilation.

Trends in clinical characteristics and outcomes of all critically ill COVID-19 adult patients hospitalized in France between March 2020 and June 2021: a national database study

INTRODUCTION

Studies regarding coronavirus disease 2019 (COVID-19) were mainly performed in the initial wave, but some small-scale data points to prognostic differences for patients in successive waves. We therefore aimed to study the impact of time on prognosis of ICU-admitted COVID-19 patients.

METHOD

We performed a national retrospective cohort study, including all adult patients hospitalized in French ICUs from March 1, 2020 to June 30, 2021, and identified three surge periods. Primary and secondary outcomes were in-hospital mortality and need for invasive mechanical ventilation, respectively.

RESULTS

105,979 critically ill ICU-admitted COVID-19 patients were allocated to the relevant three surge periods. In-hospital mortality for surges 1, 2, and 3 was, respectively, 24%, 27%, and 24%. Invasive mechanical ventilation was the highest level of respiratory support for 42%, 32%, and 31% (p < 0.001) over the whole period, with a decline in the use of vasopressors over time. Adjusted for age, sex, comorbidities, and modified Simplified Acute Physiology Score II at ICU admission, time period was associated with less invasive mechanical ventilation and a high risk of in-hospital death. Vaccination against COVID-19 was associated with a lower likelihood of invasive mechanical ventilation (adjusted sub-hazard ratio [aSHR] = 0.64 [0.53-0.76]) and intra-hospital death (aSHR = 0.80, [0.68-0.95]).

CONCLUSION

In this large database of ICU patients admitted for COVID-19, we observed a decline in invasive mechanical ventilation, vasopressors, and RRT use over time but a high risk of in-hospital death. Vaccination was identified as protective against the risk of invasive mechanical ventilation and in-hospital death.

Predictive markers related to local and systemic inflammation in severe COVID-19-associated ARDS: a prospective single-center analysis

BACKGROUND

As the COVID-19 pandemic strains healthcare systems worldwide, finding predictive markers of severe courses remains urgent. Most research so far was limited to selective questions hindering general assumptions for short- and long-term outcome.

METHODS

In this prospective single-center biomarker study, 47 blood- and 21 bronchoalveolar lavage (BAL) samples were collected from 47 COVID-19 intensive care unit (ICU) patients upon admission. Expression of inflammatory markers toll-like receptor 3 (TLR3), heme oxygenase-1 (HO-1), interleukin (IL)-6, IL-8, leukocyte counts, procalcitonin (PCT) and carboxyhemoglobin (CO-Hb) was compared to clinical course. Clinical assessment comprised acute local organ damage, acute systemic damage, mortality and outcome after 6 months.

RESULTS

PCT correlated with acute systemic damage and was the best predictor for quality of life (QoL) after 6 months (r = - 0.4647, p = 0.0338). Systemic TLR3 negatively correlated with impaired lung function (ECMO/ECLS: r = - 0.3810, p = 0.0107) and neurological short- (RASS mean: r = 0.4474, p = 0.0023) and long-term outcome (mRS after 6 m: r = - 0.3184, p = 0.0352). Systemic IL-8 correlated with impaired lung function (ECMO/ECLS: r = 0.3784, p = 0.0161) and neurological involvement (RASS mean: r = - 0.5132, p = 0.0007). IL-6 in BAL correlated better to the clinical course than systemic IL-6. Using three multivariate regression models, we describe prediction models for local and systemic damage as well as QoL. CO-Hb mean and max were associated with higher mortality.

CONCLUSIONS

Our predictive models using the combination of Charlson Comorbidity Index, sex, procalcitonin, systemic TLR3 expression and IL-6 and IL-8 in BAL were able to describe a broad range of clinically relevant outcomes in patients with severe COVID-19-associated ARDS. Using these models might proof useful in risk stratification and predicting disease course in the future. Trial registration The trial was registered with the German Clinical Trials Register (Trial-ID DRKS00021522, registered 22/04/2020).

Peter SD, Sato TT. Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis

INTRODUCTION

With the expected surge of adult patients with COVID-19, the Children's Hospital Association recommended a tiered approach to divert children to pediatric centers. Our objective was understanding changes in interfacility transfer to Pediatric Trauma Centers (PTCs) during the first 6 mo of the pandemic.

METHODS

Children aged < 18 y injured between January 1, 2016 and September 30, 2020, who met National Trauma Databank inclusion criteria from 9 PTCs were included. An interrupted time-series analysis was used to estimate an expected number of transferred patients compared to observed volume. The "COVID" cohort was compared to a historical cohort (historical average [HA]), using an average across 2016-2019. Site-based differences in transfer volume, demographics, injury characteristics, and hospital-based outcomes were compared between cohorts.

RESULTS

Twenty seven thousand thirty one/47,382 injured patients (57.05%) were transferred to a participating PTC during the study period. Of the COVID cohort, 65.4% (4620/7067) were transferred, compared to 55.7% (3281/5888) of the HA (P < 0.001). There was a decrease in 15-y-old to 17-y-old patients (10.43% COVID versus 12.64% HA, P = 0.003). More patients in the COVID cohort had injury severity scores ≤ 15 (93.25% COVID versus 87.63% HA, P < 0.001). More patients were discharged home after transfer (31.80% COVID versus 21.83% HA, P < 0.001).

CONCLUSIONS

Transferred trauma patients to Level I PTC increased during the COVID-19 pandemic. The proportion of transferred patients discharged from emergency departments increased. Pediatric trauma transfers may be a surrogate for referring emergency department capacity and resources and a measure of pediatric trauma triage capability.

Machine Learning Successfully Detects Patients with COVID-19 Prior to PCR Results and Predicts Their Survival Based on Standard Laboratory Parameters in an Observational Study

INTRODUCTION

In the current COVID-19 pandemic, clinicians require a manageable set of decisive parameters that can be used to (i) rapidly identify SARS-CoV-2 positive patients, (ii) identify patients with a high risk of a fatal outcome on hospital admission, and (iii) recognize longitudinal warning signs of a possible fatal outcome.

METHODS

This comparative study was performed in 515 patients in the Maria Skłodowska-Curie Specialty Voivodeship Hospital in Zgierz, Poland. The study groups comprised 314 patients with COVID-like symptoms who tested negative and 201 patients who tested positive for SARS-CoV-2 infection; of the latter, 72 patients with COVID-19 died and 129 were released from hospital. Data on which we trained several machine learning (ML) models included clinical findings on admission and during hospitalization, symptoms, epidemiological risk, and reported comorbidities and medications.

RESULTS

We identified a set of eight on-admission parameters: white blood cells, antibody-synthesizing lymphocytes, ratios of basophils/lymphocytes, platelets/neutrophils, and monocytes/lymphocytes, procalcitonin, creatinine, and C-reactive protein. The medical decision tree built using these parameters differentiated between SARS-CoV-2 positive and negative patients with up to 90-100% accuracy. Patients with COVID-19 who on hospital admission were older, had higher procalcitonin, C-reactive protein, and troponin I levels together with lower hemoglobin and platelets/neutrophils ratio were found to be at highest risk of death from COVID-19. Furthermore, we identified longitudinal patterns in C-reactive protein, white blood cells, and D dimer that predicted the disease outcome.

CONCLUSIONS

Our study provides sets of easily obtainable parameters that allow one to assess the status of a patient with SARS-CoV-2 infection, and the risk of a fatal disease outcome on hospital admission and during the course of the disease.

Validation of a pre-established triage protocol for critically ill patients in a COVID-19 outbreak under resource scarcity: A retrospective multicenter cohort study

INTRODUCTION

In case of COVID-19 related scarcity of critical care resources, an early French triage algorithm categorized critically ill patients by probability of survival based on medical history and severity, with four priority levels for initiation or continuation of critical care: P1 -high priority, P2 -intermediate priority, P3 -not needed, P4 -not appropriate. This retrospective multi-center study aimed to assess its classification performance and its ability to help saving lives under capacity saturation.

METHODS

ICU patients admitted for severe COVID-19 without triage in spring 2020 were retrospectively included from three hospitals. Demographic data, medical history and severity items were collected. Priority levels were retrospectively allocated at ICU admission and on ICU day 7-10. Mortality rate, cumulative incidence of death and of alive ICU discharge, length of ICU stay and of mechanical ventilation were compared between priority levels. Calculated mortality and survival were compared between full simulated triage and no triage.

RESULTS

225 patients were included, aged 63.1±11.9 years. Median SAPS2 was 40 (IQR 29-49). At the end of follow-up, 61 (27%) had died, 26 were still in ICU, and 138 had been discharged. Following retrospective initial priority allocation, mortality rate was 53% among P4 patients (95CI 34-72%) versus 23% among all P1 to P3 patients (95CI 17-30%, chi-squared p = 5.2e-4). The cumulative incidence of death consistently increased in the order P3, P1, P2 and P4 both at admission (Gray's test p = 3.1e-5) and at reassessment (p = 8e-5), and conversely for that of alive ICU discharge. Reassessment strengthened consistency. Simulation under saturation showed that this two-step triage protocol could have saved 28 to 40 more lives than no triage.

CONCLUSION

Although it cannot eliminate potentially avoidable deaths, this triage protocol proved able to adequately prioritize critical care for patients with highest probability of survival, hence to save more lives if applied.

Reconfiguring the social organization of work in the intensive care unit: Changed relationships and new roles during COVID-19

The COVID-19 pandemic caused hospitals to make changes to workflow that exacerbated emotional exhaustion and burnout among health care workers. This article examines one of those changes, restricted visitation, showing how it changed the social organization of work by upending established interactional patterns and relationships between health care workers, patients, and patients' families. Based on 40 interviews with intensive care unit (ICU) workers in units that were full of COVID-19 patients and had fully restricted visitation, study findings show that staff took on emotional support roles with patients that had typically been done by families at the bedside. They also faced increased anger, distrust, and misunderstandings from families who were not allowed to see their dying loved one. With each other, staff bonded together with dark humor and candid talk about the scale of deaths, constructing a shared understanding and solidarity amidst the tragedy of the pandemic.

The impact of the COVID-19 pandemic on a surgical PICU in China that did not admit COVID-19 patients

Background

The unprecedented COVID-19 pandemic has been spreading for a long time. However, it is unclear whether the pandemic influenced admission in a surgical pediatric intensive care unit (PICU) that never received COVID-19 patients during the early outbreak in China.

Methods

A retrospective study was conducted in a surgical PICU in a tertiary hospital in Chengdu, China. We sought to describe the trend in admission numbers from January 2018 to April 2021. We explored the impact of the COVID-19 outbreak on PICU admission characteristics by including all patients younger than 18 years admitted to the PICU between January 23 and April 8 in 2020 and those admitted in the same time periods in prepandemic years (2018 and 2019) and in 2021.

Results

The percentage of patients admitted to the PICU from the Chengdu region increased from 34.2 percent in 2019 to 40.4 percent in 2020, whereas that from other provinces decreased from 11.7 percent in 2019 to 5.8 percent in 2020 (P = 0.012). The median length of stay (LOS) in the PICU was significantly longer in the 2020 cohort (4.0 days) than in the 2019 cohort (2.0 days) (P < 0.001); the median hospital LOS was also significantly longer in the former (12.0 days) than in the latter (8.0 days) (P < 0.001). Hospital outcomes (P = 0.005) and primary diagnosis distributions (P = 0.025) between the 2020 and 2019 cohorts were both statistically significant.

Conclusions

In a surgical PICU that never received COVID-19 patients, the onset of the 2020 major outbreak was accompanied by changes in the composition of the regional sources of patients, longer PICU and hospital stays, increased proportions of unauthorized discharges, and changes in the distribution of primary diseases for admission. These findings have yet to be strengthened by additional studies involving similar healthcare backgrounds.

Impact of the COVID-19 pandemic on critical care utilization in Japan: a nationwide inpatient database study

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has disrupted critical care services worldwide. Examining how critical care systems responded to the COVID-19 pandemic on a national level will be useful in setting future critical care plans. The present study aimed to describe the utilization of critical care services before and during the COVID-19 pandemic using a nationwide Japanese inpatient administrative database.

METHODS

All patients admitted to an intensive care unit (ICU) or a high-dependency care unit (HDU) from February 9, 2019, to February 8, 2021, in the Japanese Diagnosis Procedure Combination inpatient database were included. February 9, 2020, was used as the breakpoint separating the periods before and during COVID-19 pandemic. Hospital and patient characteristics were compared before and during the COVID-19 pandemic. Change in ICU and HDU bed occupancy before and during the COVID-19 pandemic was evaluated using interrupted time-series analysis.

RESULTS

The number of ICU patients before and during the COVID-19 pandemic was 297,679 and 277,799, respectively, and the number of HDU patients was 408,005 and 384,647, respectively. In the participating hospitals (383 ICU-equipped hospitals and 460 HDU-equipped hospitals), the number of hospitals which increased the ICU and HDU beds capacity were 14 (3.7%) and 33 (7.2%), respectively. Patient characteristics and outcomes in ICU and HDU were similar before and during the COVID-19 pandemic except main etiology for admission of COVID-19. The mean ICU bed occupancy before and during the COVID-19 pandemic was 51.5% and 47.5%, respectively. The interrupted time-series analysis showed a downward level change in ICU bed occupancy during the COVID-19 pandemic (- 4.29%, 95% confidence intervals - 5.69 to - 2.88%), and HDU bed occupancy showed similar trends. Of 383 hospitals with ICUs, 232 (60.6%) treated COVID-19 patients in their ICUs. Their annual hospital case volume of COVID-19 ICU patients varied greatly, with a median of 10 (interquartile range 3-25, min 1, max 444).

CONCLUSIONS

The ICU and HDU bed capacity did not increase while their bed occupancy decreased during the COVID-19 pandemic in Japan. There was no change in clinicians' decision-making to forego ICU/HDU care for selected patients, and there was no progress in the centralization of critically ill COVID-19 patients.

Experience of relatives in the first three months after a non-COVID-19 Intensive Care Unit discharge: a qualitative study

Background

The novel coronavirus brought Intensive Care Units (ICUs) back to their past when they were closed to family members. The difficulties of family caregivers encountered after the ICU discharge might have been increased during the coronavirus disease 2019 (COVID-19) pandemic. However, no traces of their experience have been documented to date. The objective of this study is to explore the everyday life experience of relatives in the first three months after a non-COVID-19 ICU discharge.

Methods

A descriptive qualitative study was conducted in 2020–2021. Two Italian general non-COVID-19 ICUs were approached. Follow-up telephone interviews were conducted three months after the ICU discharge. The study has been conducted according to the COnsolidated criteria for REporting Qualitative research principles.

Results

A total of 14 family members were interviewed. Participants were mostly females (n = 11; 78.6%), with an average age of 53.9 years. After three months of care of their beloved at home, relatives’ experience is summarised in three themes: “Being shaken following the ICU discharge”, as experiencing negative and positive feelings; “Returning to our life that is no longer the same”, as realising that nothing can be as before; and “Feeling powerless due to the COVID-19 pandemic”, given the missed care from community services and the restrictions imposed.

Conclusions

Relatives seem to have experienced a bilateral restriction of opportunities – at the hospital without any engagement in care activities and their limited possibility to visit the ICU, and at home in terms of formal and informal care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01720-z.

Surging ICU during COVID-19 pandemic: an overview

PURPOSE OF REVIEW

The coronavirus disease 2019 (COVID-19) pandemic has posed great challenges to intensive care units (ICUs) across the globe. The objective of this review is to provide an overview on how ICU surging was managed during COVID-19 pandemic, with a special focus on papers published in the last 18 months.

RECENT FINDINGS

From the onset of the COVID-19 pandemic, it was apparent that the biggest challenge was the inequity of access to an adequately equipped and staffed ICU bed. The first wave was overwhelming; large surge of patients required critical care, resources were limited and non-COVID-19 care processes were severely compromised. Various approaches were used to address ICU staffing shortage and to expand the physical ICU space capacity. Because of restrictions to family visitations in most ICUs, the pandemic posed a threat to communication and family-centered ICU care. The pandemic, especially during the first wave, was accompanied by a high level of apprehension in the community, many uncertainties about clinical course and therapy and an influx of speculations and misinformation.

SUMMARY

Although healthcare systems learned how to face some of the challenges with subsequent waves, the pandemic had persistent effects on healthcare systems.

Fundamental drivers of nurses' experiences of ICU surging during the coronavirus disease 2019 (COVID-19) pandemic

PURPOSE OF REVIEW

Nurses working in intensive care units have been heavily impacted by the coronavirus disease 2019 (COVID-19) pandemic. This review summarizes the current state of the evidence regarding intensive care nurses experience of the pandemic.

RECENT FINDINGS

The pandemic has had an impact on: nursing workload, the organization of nurse staffing, experiences of staff redeployed into ICU, nurses' perceptions of the safety and quality of patient care, and staff health. In the few comparative studies, mental health was worse for nurses than other healthcare workers in intensive care. Despite some of this evidence being published early in the pandemic, no studies were found to evaluate interventions to improve nurses' experiences.

SUMMARY IMPLICATIONS FOR PRACTICE OR RESEARCH

Many of the adverse impacts of the pandemic are interdependent; for example, reducing nurses' workload is likely to have benefits for mental health indicators.Adverse mental health outcomes are likely to have an impact on future recruitment and retention for intensive care nursing.More studies are needed to understand the longer term impact of the pandemic on intensive care nurses.

Out-of-hospital cardiac arrest and in-hospital mortality among COVID-19 patients: A population-based retrospective cohort study

BACKGROUND/PURPOSE

Predictors for out-of-hospital cardiac arrest (OHCA) in COVID-19 patients remain unclear. We identified the predictors for OHCA and in-hospital mortality among such patients in community isolation centers.

METHODS

From May 15 to June 20, 2021, this cohort study recruited 2555 laboratory-confirmed COVID-19 patients admitted to isolation centers in Taiwan. All patients were followed up until death, discharge from the isolation center or hospital, or July 16, 2021. OHCA was defined as cardiac arrest confirmed by the absence of circulation signs and occurring outside the hospital. Multinomial logistic regressions were used to determine factors associated with OHCA and in-hospital mortality.

RESULTS

Of the 37 deceased patients, 7 (18.9%) had OHCA and 30 (81.1%) showed in-hospital mortality. The mean (SD) time to OHCA was 6.6 (3.3) days from the symptom onset. After adjusting for demographics and comorbidities, independent predictors for OHCA included age ≥65 years (adjusted odds ratio [AOR]: 13.24, 95% confidence interval [CI]: 1.85-94.82), fever on admission to the isolation center (AOR: 12.53, 95% CI: 1.68-93.34), and hypoxemia (an oxygen saturation level below 95% on room air) (AOR: 26.54, 95% CI: 3.18-221.73). Predictors for in-hospital mortality included age ≥65 years (AOR: 10.28, 95% CI: 2.95-35.90), fever on admission to the isolation centers (AOR: 7.27, 95% CI: 1.90-27.83), and hypoxemia (AOR: 29.87, 95% CI: 10.17-87.76).

CONCLUSIONS

Time to OHCA occurrence is rapid in COVID-19 patients. Close monitoring of patients' vital signs and disease severity during isolation is important, particularly for those with older age, fever, and hypoxemia.

Coronavirus disease 2019 aftermath: psychological trauma in ICU healthcare workers

PURPOSE OF REVIEW

We aim to describe the extent of psychological trauma and moral distress in healthcare workers (HCW) working in the intensive care unit (ICU) during the coronavirus disease 2019 (COVID-19) pandemic. Specifically, we review reports on prevalence of mental health symptoms, highlight vulnerable populations and summarize modifiable risk factors associated with mental health symptoms in ICU HCW.

RECENT FINDINGS

The pandemic has resulted in a multitude of closely intertwined professional and personal challenges for ICU HCW. High rates of posttraumatic stress disorder (14-47%), burnout (45-85%), anxiety (31-60%), and depression (16-65%) have been reported, and these mental health symptoms are often interrelated. Most studies suggest that nurses and female HCW are at highest risk for developing mental health symptoms. The main personal concerns associated with reporting mental health symptoms among ICU HCW were worries about transmitting COVID-19 to their families, worries about their own health, witnessing colleagues contract the disease, and experiencing stigma from their communities. Major modifiable work-related risk factors were experiencing poor communication from supervisors, perceived lack of support from administrative leadership, and concerns about insufficient access to personal protective equipment, inability to rest, witnessing hasty end-of-life decisions, and restriction of family visitation policies.

SUMMARY

The COVID-19 pandemic has severely impacted ICU HCW worldwide. The psychological trauma, manifesting as posttraumatic stress disorder, burnout, anxiety, and depression, is substantial and concerning. Urgent action by lawmakers and healthcare administrators is required to protect ICU HCW and sustain a healthy workforce.

Evidence-based updates to the 2021 Surviving Sepsis Campaign guidelines Part 2: Guideline review and clinical application

ABSTRACT

NPs should be prepared to screen for sepsis, initiate treatment, and optimize care for sepsis survivors. The 2021 Surviving Sepsis Campaign guidelines offer best practices for identification and management of sepsis and septic shock. This article, second in a 2-part series, presents evidence updates and discusses implications for NPs.

Pandemic Critical Care Research during the COVID-19 (2020-2022): A Bibliometric Analysis Using VOSviewer

This paper has reviewed the global research on the pandemic critical care research during the COVID-19 from 2020 to 2022. To this end, a bibliometric and cluster analysis by full counting has been carried out using VOSviewer software and bibliographic data extracted from the Scopus database. The research found and studied 2778 documents. The types of research documents were limited to an article (81.46%), a letter (9.43%), an editorial (3.92%), a note (3.92%), a conference paper (0.90), and a short survey (0.04%). The results show an incessant increase in the number of research documents published and citations received during the COVID-19 pandemic. The U.S., U.K., Italy, and France have been shown to be the most productive countries, and there is a predominance of European institutions supporting and fostering research on pandemic critical care. Cecconi, M. (Italy) and Shankar-Hari, M. (U.K.) produced the highest number of research documents. Mapping of citation, co-citation, co-authorship, and keyword cooccurrence highlighted the hotspot, knowledge structure, and important themes. Citation dynamics for the top-cited research documents revealed static discourse. By reviewing the evolutionary trends of pandemic critical care research investigated factors, such as the influential works, main research topics, and the research frontiers, this paper reveals the scientific literature production's main research objectives and directions that could be addressed and explored in future studies. This paper reveals the scientific literature production's main research objectives and directions that could be addressed and explored in future studies after reviewing the evolutionary trends of pandemic critical care research during the COVID-19 and the investigated factors, such as influential works, main research topics, and research frontiers.

Evaluating methodological approaches to assess the severity of infection with SARS-CoV-2 variants: scoping review and applications on Belgian COVID-19 data

BACKGROUND

Differences in the genetic material of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants may result in altered virulence characteristics. Assessing the disease severity caused by newly emerging variants is essential to estimate their impact on public health. However, causally inferring the intrinsic severity of infection with variants using observational data is a challenging process on which guidance is still limited. We describe potential limitations and biases that researchers are confronted with and evaluate different methodological approaches to study the severity of infection with SARS-CoV-2 variants.

METHODS

We reviewed the literature to identify limitations and potential biases in methods used to study the severity of infection with a particular variant. The impact of different methodological choices is illustrated by using real-world data of Belgian hospitalized COVID-19 patients.

RESULTS

We observed different ways of defining coronavirus disease 2019 (COVID-19) disease severity (e.g., admission to the hospital or intensive care unit versus the occurrence of severe complications or death) and exposure to a variant (e.g., linkage of the sequencing or genotyping result with the patient data through a unique identifier versus categorization of patients based on time periods). Different potential selection biases (e.g., overcontrol bias, endogenous selection bias, sample truncation bias) and factors fluctuating over time (e.g., medical expertise and therapeutic strategies, vaccination coverage and natural immunity, pressure on the healthcare system, affected population groups) according to the successive waves of COVID-19, dominated by different variants, were identified. Using data of Belgian hospitalized COVID-19 patients, we were able to document (i) the robustness of the analyses when using different variant exposure ascertainment methods, (ii) indications of the presence of selection bias and (iii) how important confounding variables are fluctuating over time.

CONCLUSIONS

When estimating the unbiased marginal effect of SARS-CoV-2 variants on the severity of infection, different strategies can be used and different assumptions can be made, potentially leading to different conclusions. We propose four best practices to identify and reduce potential bias introduced by the study design, the data analysis approach, and the features of the underlying surveillance strategies and data infrastructure.

Post-intensive care syndrome: A review for the primary care NP

ABSTRACT

Post-intensive care syndrome is a costly and complicated collection of physical, cognitive, and mental health problems experienced by survivors of critical illness. The primary care NP is uniquely positioned to assess, monitor, manage, and treat patients with this syndrome following hospital discharge.

Hospital characteristics associated with COVID-19 mortality: data from the multicenter cohort Brazilian Registry

The COVID-19 pandemic caused unprecedented pressure over health care systems worldwide. Hospital-level data that may influence the prognosis in COVID-19 patients still needs to be better investigated. Therefore, this study analyzed regional socioeconomic, hospital, and intensive care units (ICU) characteristics associated with in-hospital mortality in COVID-19 patients admitted to Brazilian institutions. This multicenter retrospective cohort study is part of the Brazilian COVID-19 Registry. We enrolled patients ≥ 18 years old with laboratory-confirmed COVID-19 admitted to the participating hospitals from March to September 2020. Patients' data were obtained through hospital records. Hospitals' data were collected through forms filled in loco and through open national databases. Generalized linear mixed models with logit link function were used for pooling mortality and to assess the association between hospital characteristics and mortality estimates. We built two models, one tested general hospital characteristics while the other tested ICU characteristics. All analyses were adjusted for the proportion of high-risk patients at admission. Thirty-one hospitals were included. The mean number of beds was 320.4 ± 186.6. These hospitals had eligible 6556 COVID-19 admissions during the study period. Estimated in-hospital mortality ranged from 9.0 to 48.0%. The first model included all 31 hospitals and showed that a private source of funding (β = - 0.37; 95% CI - 0.71 to - 0.04; p = 0.029) and location in areas with a high gross domestic product (GDP) per capita (β = - 0.40; 95% CI - 0.72 to - 0.08; p = 0.014) were independently associated with a lower mortality. The second model included 23 hospitals and showed that hospitals with an ICU work shift composed of more than 50% of intensivists (β = - 0.59; 95% CI - 0.98 to - 0.20; p = 0.003) had lower mortality while hospitals with a higher proportion of less experienced medical professionals had higher mortality (β = 0.40; 95% CI 0.11-0.68; p = 0.006). The impact of those association increased according to the proportion of high-risk patients at admission. In-hospital mortality varied significantly among Brazilian hospitals. Private-funded hospitals and those located in municipalities with a high GDP had a lower mortality. When analyzing ICU-specific characteristics, hospitals with more experienced ICU teams had a reduced mortality.

Effect of SARS-CoV-2 infection and pandemic period on healthcare-associated infections acquired in intensive care units

OBJECTIVES

To compare the occurrence of healthcare-associated infections acquired in intensive care units (HAI-ICUs) in France among patients with COVID-19 and those without it in 2020 and the latter with that in patients before the COVID-19 pandemic.

METHODS

Multicentre HAI-ICU surveillance network (REA-REZO) data were used to identify 3 groups: 2019 patients (2019Control), a COVID-19 group (2020Cov), and a non-COVID-19 group (2020NonCov). The primary outcome was the occurrence of HAI-ICU (ventilator-associated pneumonia [VAP], bloodstream infections [BSIs], catheter-related bacteraemia). Standardized infection ratios of VAP were calculated for each quarter in 2020 and compared with those in 2019.

RESULTS

A total of 30 105 patients were included in 2020: 23 798 in the 2020NonCov group, 4465 in 2020Cov group, and 39 635 patients in the 2019Control group. The frequency of VAP was strikingly greater in the 2020Cov group: 35.6 (33.4-37.8) episodes/1000 days of mechanical ventilation versus 18.4 (17.6-19.2) in the 2020NonCov group. VAP standardized infection ratio was high in 2020 patients, particularly during the 2 quarters corresponding to the 2 waves. BSI/1000 days were more frequent in the 2020Cov group (6.4% [6.4-6.4%] vs. 3.9% [3.8-3.9%] in the 2020NonCov group). VAP and BSI were also more frequent in the 2020NonCov group than in the 2019Control group. The microbial epidemiology was only slightly different.

DISCUSSION

The data presented here indicate that HAI-ICUs were more frequent during the COVID-19 period, whether the patients were admitted for COVID-19 or, to a lesser extent, for another cause. This implies that managing patients with severe disease in a pandemic context carries risks for all patients.

Is There a Relationship between Hyperventilation Syndrome and History of Acute SARS-CoV-2 Infection? A Cross-Sectional Study

Following COVID-19 infection, many patients suffer from long-lasting symptoms that may greatly impair their quality of life. Persisting dyspnea and other functional respiratory complaints can evoke hyperventilation syndrome (HVS) as a putative contributor to long-COVID presentation in COVID-19 survivors. We aimed to assess the possible relationship between HVS and previous acute COVID-19 infection. We designed a cross-sectional, single-center study, including all patients consecutively referred to our Lung Function and Exercise Testing Department between January and June 2021. Participants completed a systematic Nijmegen Questionnaire, a modified Medical Research Council dyspnea scale assessment, a post-COVID screening questionnaire, and performed a standardized lung function test. The population was divided according to HVS diagnosis, defined as a Nijmegen score of > 23/64. The occurrence of previous COVID-19 infection was compared according to the Nijmegen score after adjustment for potential confounders by multivariate logistic regression. In total, 2846 patients were included: 1472 men (51.7%) with a mean age of 56 (±16.6) years. A total of 455 patients (16%) declared a previous SARS-CoV-2 infection, and 590 patients presented a positive score (>23/64) in the Nijmegen Questionnaire (20.7%). Compared with COVID-19-free patients, there was an increased occurrence of HVS+ in cases of COVID-19 infection that did not require hospitalization (aOR = 1.93 [1.17−3.18]). The results of this large-scale, cross-sectional study suggest an association between HVS diagnosis and a history of COVID-19 disease in patients who were not hospitalized.

No Excess Mortality in Geriatric Patients With Femoral Neck Fractures Due to Shorter Intensive Care Caused by COVID-19

Background

Since March 2020, increasing numbers of hospitalized patients with coronavirus disease-2019 (COVID-19) infections have been registered. The first and the second waves necessitated the extensive restructuring of hospital infrastructure with prioritization of intensive care capacity. Elective surgeries in all surgical disciplines were postponed to preserve intensive care capacity for COVID-19 patients. However, emergency care for trauma patients had to be maintained. Especially, geriatric patients with hip fractures often require intensive care.

This study sought to investigate the possible excess mortality of geriatric patients with femoral neck fractures due to shorter intensive care unit stays because of COVID-19.

Material and methods

All patients over the age of 70 between March 2019 and February 2020 who underwent surgical treatment for femoral neck fractures were included. This cohort (group 1) was compared with all patients over 70 who received surgical treatment for hip fractures during the period of the pandemic between March 2020 and February 2021 with attention to potential excess mortality due to low intensive care capacity (group 2). Demographic data, American Society of Anesthesiologists (ASA) score, surgical modality, ICU stay, complications, and mortality were analyzed and compared.

Results

A total of 356 patients with 178 in each cohort with a mean age of 82.7 in group 1 and 84.8 in group 2 (p<0.05) were included. No significant difference was seen in sex and ASA scores. During the pandemic, patients with hip fractures had a significantly shorter stay in ICU (0.4 ± 0.9 vs 1.2 ± 2.8 days; p<0.05), shorter time to surgery (29.9 ± 8.2 vs 16.8 ± 5.3 h; p<0.05) and operations were significantly more often performed out-of-hour (4 pm-12 am 47.8% vs 56.7%; 12 am-8 am 7.9% vs 13.5%, p<0.05). Interestingly, mortality was lower during the pandemic, but the difference did not reach significance (6.7% vs 12.4%, p=0.102).

Conclusion

During the pandemic, ICU capacity was reserved for COVID patients. Due to a change in the law of the Joint Federal Committee with effect from January 1, 2021, all patients with proximal femur fractures had to be operated on within the first 24 hours, which is why a significantly shorter time to surgery was observed during the pandemic period. As a consequence, a lower mortality rate was observed, although no significance could be reached.

Critical Care Pandemic Preparation: Considerations and Lessons Learned from COVID-19

Pandemics, increases in disease incidence that affect multiple regions of the world, present huge challenges to health care systems and in particular to policymakers, public health authorities, clinicians, and all health care workers (HCWs). The recent COVID-19 pandemic has resulted in millions of severely ill patients, many of whom who have required hospital and intensive care unit (ICU) admission. The discipline of critical care is a vital and integral component of pandemic preparedness. Safe and effective critical care has the potential to improve outcomes, motivate individuals to seek timely medical attention, and attenuate the devastating sequelae of a severe pandemic. To achieve this, suitable critical care planning and preparation are essential.

Dual Role of Extracellular Vesicles in Sepsis-Associated Kidney and Lung Injury

Extracellular vesicles form a complex intercellular communication network, shuttling a variety of proteins, lipids, and nucleic acids, including regulatory RNAs, such as microRNAs. Transfer of these molecules to target cells allows for the modulation of sets of genes and mediates multiple paracrine and endocrine actions. EVs exert broad pro-inflammatory, pro-oxidant, and pro-apoptotic effects in sepsis, mediating microvascular dysfunction and multiple organ damage. This deleterious role is well documented in sepsis-associated acute kidney injury and acute respiratory distress syndrome. On the other hand, protective effects of stem cell-derived extracellular vesicles have been reported in experimental models of sepsis. Stem cell-derived extracellular vesicles recapitulate beneficial cytoprotective, regenerative, and immunomodulatory properties of parental cells and have shown therapeutic effects in experimental models of sepsis with kidney and lung involvement. Extracellular vesicles are also likely to play a role in deranged kidney-lung crosstalk, a hallmark of sepsis, and may be key to a better understanding of shared mechanisms underlying multiple organ dysfunction. In this review, we analyze the state-of-the-art knowledge on the dual role of EVs in sepsis-associated kidney/lung injury and repair. PubMed library was searched from inception to July 2022, using a combination of medical subject headings (MeSH) and keywords related to EVs, sepsis, acute kidney injury (AKI), acute lung injury (ALI), and acute respiratory distress syndrome (ARDS). Key findings are summarized into two sections on detrimental and beneficial mechanisms of actions of EVs in kidney and lung injury, respectively. The role of EVs in kidney-lung crosstalk is then outlined. Efforts to expand knowledge on EVs may pave the way to employ them as prognostic biomarkers or therapeutic targets to prevent or reduce organ damage in sepsis.

Medium-term impacts of the waves of the COVID-19 epidemic on treatments for non-COVID-19 patients in intensive care units: A retrospective cohort study in Japan

Background

Maintaining critical care for non-Coronavirus-disease-2019 (non-COVID-19) patients is a key pillar of tackling the impact of the COVID-19 pandemic. This study aimed to reveal the medium-term impacts of the COVID-19 epidemic on case volumes and quality of intensive care for critically ill non-COVID-19 patients.

Methods

Administrative data were used to investigate the trends in case volumes of admissions to intensive care units (ICUs) compared with the previous years. Standardized mortality ratios (SMRs) of non-COVID-19 ICU patients were calculated in each wave of the COVID-19 epidemic in Japan.

Results

The ratios of new ICU admissions of non-COVID-19 patients to those in the corresponding months before the epidemic: 21% in May 2020, 8% in August 2020, 9% in February 2021, and 14% in May 2021, approximately concurrent with the peaks in COVID-19 infections. The decrease was greatest for new ICU admissions of non-COVID patients receiving invasive mechanical ventilation (IMV) on the first day of ICU admission: 26%, 15%, 19%, and 19% in the first, second, third, and fourth waves, respectively. No statistically significant change in SMR was observed in any wave of the epidemic; SMRs were 0.990 (95% uncertainty interval (UI), 0.962–1.019), 0.979 (95% UI, 0.953–1.006), 0.996 (95% UI, 0.980–1.013), and 0.989 (95% UI, 0.964–1.014), in the first, second, third, and fourth waves of the epidemic, respectively.

Conclusions

Compared to the previous years, the number of non-COVID-19 ICU patients continuously decreased over the medium term during the COVID-19 epidemic. The decrease in case volumes was larger in non-COVID-19 ICU patients initially receiving IMV than those undergoing other initial treatments. The standardized in-hospital mortality of non-COVID-19 ICU patients did not change in any waves of the epidemic.

Clinical Characteristics and Mortality-Associated Factors in COVID-19 Critical Patients in a Portuguese ICU

INTRODUCTION

Severe COVID-19 is associated with serious complications and poor outcomes. Older age and underlying comorbidities are known risk factors for severe COVID-19, but a better understanding of baseline characteristics and outcomes of patients with severe COVID-19 is urgently needed.

METHODS

This study was a retrospective case series of 227 consecutive patients with laboratory-confirmed COVID-19 admitted to the intensive care unit (ICU) at our institution between March 2020 and December 2021. Demographic and clinical data were collected.

RESULTS

The median age of patients was 65 years, and 180 (79.3%) were male. Cardiovascular comorbidities were frequent and included hypertension (n=148; 65.2%), dyslipidemia (n=116; 51.1%), obesity (n=114; 50.2%), and diabetes mellitus (n=80; 35.2%). About 20% of the patients had the chronic respiratory disease, with sleep apnea being the most common. Immunosuppression was identified in 13% of the patients, with autoimmunity, post-transplantation, and neoplasms being the most represented causes. Most patients were admitted to the ICU at six to 15 days after symptom onset, corresponding to stages IIb (pulmonary involvement/hypoxia) and III (hyperinflammatory). All patients received systemic steroids, with an average treatment duration of 22 days. Several ventilatory support strategies were used; 80 patients were supported entirely noninvasively with high flow nasal oxygenation and noninvasive ventilation, while 164 patients were invasively ventilated. Most intubations (65%) occurred in the first 24 hours after admission, and the mean duration of mechanical ventilation was 14 days. The reintubation rate was 10%, occurring on average two to three days after planned extubation. Thirty-two tracheostomies were performed. Bacterial co-infection was treated in 75% of patients, and Aspergillus co-infection complicating COVID-19 pneumonia was diagnosed in eight patients. Median ICU and hospital stays were 15 and 25 days, respectively, and the 28-day mortality rate was 38%. Patients over 75 years experienced a higher mortality rate (56%). Increased age and multimorbidity, particularly comprising cardiovascular disease and associated risk factors, were significantly more common in patients who died within 28 days after ICU admission.

CONCLUSIONS

A large proportion of critically ill COVID-19 patients required prolonged mechanical ventilation. ICU/hospital stay and mortality were particularly elevated in older patients and patients with cardiovascular risk factors. Considerable discrepancy existed between the proportion of patients with microbiological documentation of bacterial infections and those receiving antimicrobials. Improved methods for adequate microbiological diagnosis are needed and stewardship programs should be reinforced.

Investigation of possible preventable causes of COVID-19 deaths in the Kampala Metropolitan Area, Uganda, 2020-2021

BACKGROUND

Identifying preventable causes of COVID-19 deaths is key to reducing mortality. We investigated possible preventable causes of COVID-19 deaths over a six-month period in Uganda.

METHODS

A case-patient was a person testing reverse transcription polymerase chain reaction-positive for SARS-CoV-2 who died in Kampala Metropolitan Area hospitals from August 2020 to February 2021. We reviewed records and interviewed health workers and case-patient caretakers.

RESULTS

We investigated 126 (65%) of 195 reported COVID-19 deaths during the investigation period; 89 (71%) were male, and the median age was 61 years. A total of 98 (78%) had underlying medical conditions. Most (118, 94%) had advanced disease at admission to the hospital where they died. A total of 44 (35%) did not receive a COVID-19 test at their first presentation to a health facility despite having consistent symptoms. A total of 95 (75%) needed intensive care unit admission, of whom 45 (47%) received it; 74 (59%) needed mechanical ventilation, of whom 47 (64%) received it.

CONCLUSION

Among hospitalized patients with COVID-19 who died in this investigation, early opportunities for diagnosis were frequently missed, and there was inadequate intensive care unit capacity. Emphasis is needed on COVID-19 as a differential diagnosis, early testing, and care-seeking at specialized facilities before the illness reaches a critical stage. Increased capacity for intensive care is needed.

In-hospital mortality prediction using frailty scale and severity score in elderly patients with severe COVID-19

Background

Elderly patients with coronavirus disease 2019 (COVID-19) have a high disease severity and mortality. However, the use of the frailty scale and severity score to predict in-hospital mortality in the elderly is not well established. Therefore, in this study, we investigated the use of these scores in COVID-19 cases in the elderly.

Methods

This multicenter retrospective study included severe COVID-19 patients admitted to seven hospitals in Korea from February 2020 to February 2021. We evaluated patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II score; confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older (CURB-65) score; modified early warning score (MEWS); Sequential Organ Failure Assessment (SOFA) score; clinical frailty scale (CFS) score; and Charlson comorbidity index (CCI). We evaluated the predictive value using receiver operating characteristic (ROC) curve analysis.

Results

The study included 318 elderly patients with severe COVID-19 of whom 237 (74.5%) were survivors and 81 (25.5%) were non-survivors. The non-survivor group was older and had more comorbidities than the survivor group. The CFS, CCI, APACHE II, SOFA, CURB-65, and MEWS scores were higher in the non-survivor group than in the survivor group. When analyzed using the ROC curve, SOFA score showed the best performance in predicting the prognosis of elderly patients (area under the curve=0.766, P<0.001). CFS and SOFA scores were associated with in-hospital mortality in the multivariate analysis.

Conclusions

The SOFA score is an efficient tool for assessing in-hospital mortality in elderly patients with severe COVID-19.

Video calls did not reduce PTSD symptoms in relatives during restricted ICU visits in the COVID-19 pandemic

To help reduce the spread of the SARS-CoV-2 virus during the COVID-19 pandemic, ICU visits were banned or restricted. Therefore, family-centered care as usually practiced was not feasible Video calls were recommended to meet relatives’ needs. The aim of this study was to investigate the effect of video calls on symptoms of post-traumatic stress disorder (PTSD) in relatives of ICU patients. This single-center study was performed during the first wave (15.03.2020‒30.04.2020; visits banned) and the second wave (01.10.20‒08.02.21: visits restricted) of the COVID-19 pandemic. The Impact of Event Scale-Revised (IES-R) was used to assess PTSD symptoms and an adapted version of the Family Satisfaction in the Intensive Care Unit 24-Item-Revised questionnaire (aFS-ICU 24R) to assess family satisfaction 3 months after ICU stay. The primary outcome was the difference in IES-R score at 3 months between the video call group (VCG) and the standard care group (SCG, no video calls). In addition, inductive content analysis of relatives’ comments regarding their satisfaction with decision-making and ICU care was performed. Fifty-two relatives (VCG: n = 26, SCG: n = 26) were included in this study. No significant difference in IES-R scores was observed between the VCG and the SCG (49.52 ± 13.41 vs. 47.46 ± 10.43, p = 0.54). During the ICU stay (mean 12 days, range 5.25‒18.75 days), the members of the VCG made a median of 3 (IQR 1‒10.75) video calls. No difference between the groups was found for conventional telephone calls during the same period (VCG: 9 calls, IQR 3.75‒18.1; SCG: 5 calls, IQR 3‒9; p = 0.12). The aFS-ICU 24R scores were high for both groups: 38 (IQR 37‒40) in the VCG and 40 (IQR 37‒40: p = 0.24) in the SCG. Video calls appeared largely ineffective in reducing PTSD symptoms or improving satisfaction among relatives affected by banning/restriction of ICU visits during the COVID-19 pandemic. Further investigations are needed to acquire more data on the factors involved in PTSD symptoms experienced by relatives of ICU patients during the COVID-19 pandemic.

Impact of one year of pandemic on Spanish Intensive Care Units

OBJECTIVE

To measure the impact of the pandemic in Spanish ICUs.

METHODS

On-line survey, conducted in April 2021, among SEMICYUC members. Participants were asked about number of patients admitted, increase in the number of beds and staff, structures created in the hospital and self-assessment of the work performed.

RESULTS

We received 246 answers from 157 hospitals. 67.7% of the ICUs were expanded during the pandemic, overall increase in beds of 58.6%. The ICU medical staff increased by 6.1% and there has been a nursing shortage in 93.7% of units. Patients exceeded 200% the pre-pandemic ICU capacity. In 88% of the hospitals the collaboration of other specialists was necessary. The predominant collaboration model consisted of the intensive care medicine specialist being responsible for triage and coordinating patient management. Despite that 53.2% centres offered training for critical care, a deterioration in the quality of care was perceived. 84.2% hospitals drew up a Contingency Plan and in 77.8% of the hospitals a multidisciplinary committee was set up to agree on decision-making. Self-evaluation of the work performed was outstanding and 91.9% felt proud of what they had achieved, however, up to 15% considered leaving their job.

CONCLUSIONS

The Spanish ICUs assumed an unprecedented increase in the number of patients. They achieved it without hardly increasing their staff and, while intensive care medicine training was carried out for other specialists who collaborated. The degree of job satisfaction was consistent with pre-pandemic levels.

Associations between the COVID-19 Pandemic and Hospital Infrastructure Adaptation and Planning-A Scoping Review

The SARS-CoV-2 pandemic has put unprecedented pressure on the hospital sector around the world. It has shown the importance of preparing and planning in the future for an outbreak that overwhelms every aspect of a hospital on a rapidly expanding scale. We conducted a scoping review to identify, map, and systemize existing knowledge about the relationships between COVID-19 and hospital infrastructure adaptation and capacity planning worldwide. We searched the Web of Science, Scopus, and PubMed and hand-searched gray papers published in English between December 2019 and December 2021. A total of 106 papers were included: 102 empirical studies and four technical reports. Empirical studies entailed five reviews, 40 studies focusing on hospital infrastructure adaptation and planning during the pandemics, and 57 studies on modeling the hospital capacity needed, measured mostly by the number of beds. The majority of studies were conducted in high-income countries and published within the first year of the pandemic. The strategies adopted by hospitals can be classified into short-term (repurposing medical and non-medical buildings, remote adjustments, and establishment of de novo structures) and long-term (architectural and engineering modifications, hospital networks, and digital approaches). More research is needed, focusing on specific strategies and the quality assessment of the evidence.

SARS-CoV-2 and COVID-19 Research Trend during the First Two Years of the Pandemic in the United Arab Emirates: A PRISMA-Compliant Bibliometric Analysis

Scientific research is an integral part of fighting the COVID-19 pandemic. This bibliometric analysis describes the COVID-19 research productivity of the United Arab Emirates (UAE)-affiliated researchers during the first two years of the pandemic, 2020 to 2022. The Web of Science Core Collection (WoSCC) database was utilized to retrieve publications related to COVID-19 published by UAE-affiliated researcher(s). A total of 1008 publications met the inclusion criteria and were included in this bibliometric analysis. The most studied broad topics were general internal medicine (11.9%), public environmental occupational health (7.8%), pharmacology/pharmacy (6.3%), multidisciplinary sciences (5%), and infectious diseases (3.4%). About 67% were primary research articles, 16% were reviews, and the remaining were editorials letters (11.5%), meeting abstracts/proceedings papers (5%), and document corrections (0.4%). The University of Sharjah was the leading UAE-affiliated organization achieving 26.3% of the publications and funding 1.8% of the total 1008 published research. This study features the research trends in COVID-19 research affiliated with the UAE and shows the future directions. There was an observable nationally and international collaboration of the UAE-affiliated authors, particularly with researchers from the USA and England. This study highlights the need for in-depth systematic reviews addressing the specific COVID-19 research-related questions and studied populations.

Comparison of clinical characteristics and hospital mortality in critically ill patients without COVID-19 before and during the COVID-19 pandemic: a multicenter, retrospective, propensity score-matched study

Background

The high transmission and fatality rates of coronavirus disease 2019 (COVID-19) strain intensive care resources and affect the treatment and prognosis of critically ill patients without COVID-19. Therefore, this study evaluated the differences in characteristics, clinical course, and prognosis of critically ill medical patients without COVID-19 before and during the COVID-19 pandemic.

Methods

This retrospective cohort study included patients from three university-affiliated tertiary hospitals. Demographic data and data on the severity, clinical course, and prognosis of medical patients without COVID-19 admitted to the intensive care unit (ICU) via the emergency room (ER) before (from January 1 to May 31, 2019) and during (from January 1 to May 31, 2021) the COVID-19 pandemic were obtained from electronic medical records. Propensity score matching was performed to compare hospital mortality between patients before and during the pandemic.

Results

This study enrolled 1161 patients (619 before and 542 during the pandemic). During the COVID-19 pandemic, the Simplified Acute Physiology Score (SAPS) 3 and Sequential Organ Failure Assessment (SOFA) scores, assessed upon ER and ICU admission, were significantly higher than those before the pandemic (p < 0.05). The lengths of stay in the ER, ICU, and hospital were also longer (p < 0.05). Finally, the hospital mortality rates were higher during the pandemic than before (215 [39.7%] vs. 176 [28.4%], p < 0.001). However, in the propensity score-matched patients, hospital mortality did not differ between the groups (p = 0.138). The COVID-19 pandemic did not increase the risk of hospital mortality (odds ratio [OR] 1.405, 95% confidence interval [CI], 0.937–2.107, p = 0.100). SAPS 3, SOFA score, and do-not-resuscitate orders increased the risk of in-hospital mortality in the multivariate logistic regression model.

Conclusions

In propensity score-matched patients with similarly severe conditions, hospital mortality before and during the COVID-19 pandemic did not differ significantly. However, hospital mortality was higher during the COVID-19 pandemic in unmatched patients in more severe conditions. These findings imply collateral damage to non-COVID-19 patients due to shortages in medical resources during the COVID-19 pandemic. Thus, strategic management of medical resources is required to avoid these consequences.

Effect of Awake Prone Positioning on Endotracheal Intubation in Patients With COVID-19 and Acute Respiratory Failure: A Randomized Clinical Trial

IMPORTANCE

The efficacy and safety of prone positioning is unclear in nonintubated patients with acute hypoxemia and COVID-19.

OBJECTIVE

To evaluate the efficacy and adverse events of prone positioning in nonintubated adult patients with acute hypoxemia and COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic, unblinded randomized clinical trial conducted at 21 hospitals in Canada, Kuwait, Saudi Arabia, and the US. Eligible adult patients with COVID-19 were not intubated and required oxygen (≥40%) or noninvasive ventilation. A total of 400 patients were enrolled between May 19, 2020, and May 18, 2021, and final follow-up was completed in July 2021.

INTERVENTION

Patients were randomized to awake prone positioning (n = 205) or usual care without prone positioning (control; n = 195).

MAIN OUTCOMES AND MEASURES

The primary outcome was endotracheal intubation within 30 days of randomization. The secondary outcomes included mortality at 60 days, days free from invasive mechanical ventilation or noninvasive ventilation at 30 days, days free from the intensive care unit or hospital at 60 days, adverse events, and serious adverse events.

RESULTS

Among the 400 patients who were randomized (mean age, 57.6 years [SD, 12.83 years]; 117 [29.3%] were women), all (100%) completed the trial. In the first 4 days after randomization, the median duration of prone positioning was 4.8 h/d (IQR, 1.8 to 8.0 h/d) in the awake prone positioning group vs 0 h/d (IQR, 0 to 0 h/d) in the control group. By day 30, 70 of 205 patients (34.1%) in the prone positioning group were intubated vs 79 of 195 patients (40.5%) in the control group (hazard ratio, 0.81 [95% CI, 0.59 to 1.12], P = .20; absolute difference, -6.37% [95% CI, -15.83% to 3.10%]). Prone positioning did not significantly reduce mortality at 60 days (hazard ratio, 0.93 [95% CI, 0.62 to 1.40], P = .54; absolute difference, -1.15% [95% CI, -9.40% to 7.10%]) and had no significant effect on days free from invasive mechanical ventilation or noninvasive ventilation at 30 days or on days free from the intensive care unit or hospital at 60 days. There were no serious adverse events in either group. In the awake prone positioning group, 21 patients (10%) experienced adverse events and the most frequently reported were musculoskeletal pain or discomfort from prone positioning (13 of 205 patients [6.34%]) and desaturation (2 of 205 patients [0.98%]). There were no reported adverse events in the control group.

CONCLUSIONS AND RELEVANCE

In patients with acute hypoxemic respiratory failure from COVID-19, prone positioning, compared with usual care without prone positioning, did not significantly reduce endotracheal intubation at 30 days. However, the effect size for the primary study outcome was imprecise and does not exclude a clinically important benefit.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04350723.

Family-centred care of patients admitted to the intensive care unit in times of COVID-19: A systematic review

OBJECTIVES

To describe clinical practice interventions aimed at providing Family-Centred Care in intensive care units during the COVID-19 pandemic.

RESEARCH METHODOLOGY

A systematic review was carried out following the PRISMA recommendations in various databases: PubMed, Cinahl, Web of Science, Scopus, and Google Scholar were consulted, as well as within the grey literature found on the web pages of official organizations related to Intensive Care Medicine and Nursing.

SETTING

Adult intensive care unit.

RESULTS

The search yielded 209 documents of which 24 were included in this review: eight qualitative studies, seven protocols and recommendations from official bodies, one mixed-method studies, five descriptive studies, one cross-sectional study, one pilot program and one literature review. A thematic analysis revealed four major themes: the use of communication systems, multidisciplinary interventions; the promotion of family engagement and family support. The results show different strategies that can be implemented in clinical practice to solve the difficulties encountered in Family-Centred Care in critical care units during the COVID-19 pandemic.

CONCLUSIONS

There is a great variety in the nature of the interventions developed, with the use of telecommunication systems in daily practice being the most repeated aspect. Future research should aim to assess whether the interventions implemented increase the quality of patient and family care by meeting their needs.

Modeling robust COVID-19 intensive care unit occupancy thresholds for imposing mitigation to prevent exceeding capacities

In non-pharmaceutical management of COVID-19, occupancy of intensive care units (ICU) is often used as an indicator to inform when to intensify mitigation and thus reduce SARS-CoV-2 transmission, strain on ICUs, and deaths. However, ICU occupancy thresholds at which action should be taken are often selected arbitrarily. We propose a quantitative approach using mathematical modeling to identify ICU occupancy thresholds at which mitigation should be triggered to avoid exceeding the ICU capacity available for COVID-19 patients and demonstrate this approach for the United States city of Chicago. We used a stochastic compartmental model to simulate SARS-CoV-2 transmission and disease progression, including critical cases that would require intensive care. We calibrated the model using daily COVID-19 ICU and hospital census data between March and August 2020. We projected various possible ICU occupancy trajectories from September 2020 to May 2021 with two possible levels of transmission increase and uncertainty in core model parameters. The effect of combined mitigation measures was modeled as a decrease in the transmission rate that took effect when projected ICU occupancy reached a specified threshold. We found that mitigation did not immediately eliminate the risk of exceeding ICU capacity. Delaying action by 7 days increased the probability of exceeding ICU capacity by 10-60% and this increase could not be counteracted by stronger mitigation. Even under modest transmission increase, a threshold occupancy no higher than 60% was required when mitigation reduced the reproductive number Rt to just below 1. At higher transmission increase, a threshold of at most 40% was required with mitigation that reduced Rt below 0.75 within the first two weeks after mitigation. Our analysis demonstrates a quantitative approach for the selection of ICU occupancy thresholds that considers parameter uncertainty and compares relevant mitigation and transmission scenarios. An appropriate threshold will depend on the location, number of ICU beds available for COVID-19, available mitigation options, feasible mitigation strengths, and tolerated durations of intensified mitigation.

European countries' responses in ensuring sufficient physical infrastructure and workforce capacity during the first COVID-19 wave

The COVID-19 pandemic has placed unprecedented pressure on health systems' capacities. These capacities include physical infrastructure, such as bed capacities and medical equipment, and healthcare professionals. Based on information extracted from the COVID-19 Health System Reform Monitor, this paper analyses the strategies that 45 countries in Europe have taken to secure sufficient health care infrastructure and workforce capacities to tackle the crisis, focusing on the hospital sector. While pre-crisis capacities differed across countries, some strategies to boost surge capacity were very similar. All countries designated COVID-19 units and expanded hospital and ICU capacities. Additional staff were mobilised and the existing health workforce was redeployed to respond to the surge in demand for care. While procurement of personal protective equipment at the international and national levels proved difficult at the beginning due to global shortages, countries found innovative solutions to increase internal production and enacted temporary measures to mitigate shortages. The pandemic has shown that coordination mechanisms informed by real-time monitoring of available health care resources are a prerequisite for adaptive surge capacity in public health crises, and that closer cooperation between countries is essential to build resilient responses to COVID-19.