1
|
Baudemont G, Tardivon C, Monneret G, Cour M, Rimmelé T, Garnier L, Yonis H, Richard JC, Coudereau R, Gossez M, Wallet F, Delignette MC, Dailler F, Buisson M, Lukaszewicz AC, Argaud L, Laouenan C, Bertrand J, Venet F. Joint modeling of monocyte HLA-DR expression trajectories predicts 28-day mortality in severe SARS-CoV-2 patients. CPT Pharmacometrics Syst Pharmacol 2024. [PMID: 38837680 DOI: 10.1002/psp4.13145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/11/2024] [Accepted: 04/04/2024] [Indexed: 06/07/2024] Open
Abstract
The recent SarsCov2 pandemic has disrupted healthcare system notably impacting intensive care units (ICU). In severe cases, the immune system is dysregulated, associating signs of hyperinflammation and immunosuppression. In the present work, we investigated, using a joint modeling approach, whether the trajectories of cellular immunological parameters were associated with survival of COVID-19 ICU patients. This study is based on the REA-IMMUNO-COVID cohort including 538 COVID-19 patients admitted to ICU between March 2020 and May 2022. Measurements of monocyte HLA-DR expression (mHLA-DR), counts of neutrophils, of total lymphocytes, and of CD4+ and CD8+ subsets were performed five times during the first month after ICU admission. Univariate joint models combining survival at day 28 (D28), hospital discharge and longitudinal analysis of those biomarkers' kinetics with mixed-effects models were performed prior to the building of a multivariate joint model. We showed that a higher mHLA-DR value was associated with a lower risk of death. Predicted mHLA-DR nadir cutoff value that maximized the Youden index was 5414 Ab/C and led to an AUC = 0.70 confidence interval (95%CI) = [0.65; 0.75] regarding association with D28 mortality while dynamic predictions using mHLA-DR kinetics until D7, D12 and D20 showed AUCs of 0.82 [0.77; 0.87], 0.81 [0.75; 0.87] and 0.84 [0.75; 0.93]. Therefore, the final joint model provided adequate discrimination performances at D28 after collection of biomarker samples until D7, which improved as more samples were collected. After severe COVID-19, decreased mHLA-DR expression is associated with a greater risk of death at D28 independently of usual clinical confounders.
Collapse
Affiliation(s)
- Gaelle Baudemont
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | - Coralie Tardivon
- Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP.Nord, Hôpital Bichat, Paris, France
- Centre d'Investigations Cliniques-Epidémiologie Clinique 1425, INSERM, Hôpital Bichat, Paris, France
| | - Guillaume Monneret
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hôpital, Lyon, France
- Joint Research Unit HCL-bioMérieux, EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux), Lyon, France
| | - Martin Cour
- Medical intensive Care Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Thomas Rimmelé
- Joint Research Unit HCL-bioMérieux, EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux), Lyon, France
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Lorna Garnier
- Immunology Laboratory, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre Bénite, France
| | - Hodane Yonis
- Medical intensive Care Department, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Jean-Christophe Richard
- Medical intensive Care Department, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Remy Coudereau
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hôpital, Lyon, France
- Joint Research Unit HCL-bioMérieux, EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux), Lyon, France
| | - Morgane Gossez
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hôpital, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| | - Florent Wallet
- Intensive Care Department, Hospices Civils de Lyon, Lyon-Sud University Hospital, Pierre-Bénite, France
| | - Marie-Charlotte Delignette
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Croix-Rousse University Hospital, Lyon, France
| | - Frederic Dailler
- Neurological Anesthesiology and Intensive Care Department, Hospices Civils de Lyon, Pierre Wertheimer Hospital, Lyon, France
| | - Marielle Buisson
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Anne-Claire Lukaszewicz
- Joint Research Unit HCL-bioMérieux, EA 7426 "Pathophysiology of Injury-Induced Immunosuppression" (Université Claude Bernard Lyon 1 - Hospices Civils de Lyon - bioMérieux), Lyon, France
- Anesthesia and Critical Care Medicine Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Laurent Argaud
- Medical intensive Care Department, Hospices Civils de Lyon, Edouard Herriot Hospital, Lyon, France
| | - Cédric Laouenan
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
- Département d'Epidémiologie Biostatistique et Recherche Clinique, AP-HP.Nord, Hôpital Bichat, Paris, France
| | - Julie Bertrand
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, IAME, Paris, France
| | - Fabienne Venet
- Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hôpital, Lyon, France
- Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude Bernard-Lyon 1, Lyon, France
| |
Collapse
|
2
|
Azoulay E, De Waele JJ, Cecconi M. Empowering excellence in intensive care: a vision for the European Society of Intensive Care Medicine. Intensive Care Med 2024:10.1007/s00134-024-07484-7. [PMID: 38829530 DOI: 10.1007/s00134-024-07484-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024]
Affiliation(s)
- Elie Azoulay
- Critical Care Department, APHP, Hôpital Saint-Louis, Paris Cité University, 1 Avenue Claude Vellefaux, 75010, Paris, France.
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| |
Collapse
|
3
|
Subramanian S, Pamplin JC. Telemedicine for emergency patient rescue. Curr Opin Crit Care 2024; 30:217-223. [PMID: 38690953 DOI: 10.1097/mcc.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
PURPOSE OF REVIEW This article summarizes recent developments in the application of telemedicine, specifically tele-critical care (TCC), toward enhancing patient care during various types of emergencies and patient rescue scenarios when there are limited resources in terms of staff expertise (i.e., knowledge, skills, and abilities), staffing numbers, space, and supplies due to patient location (e.g., a non-ICU bed, the emergency department, a rural hospital) or patient volume as in pandemic surges. RECENT FINDINGS The COVID-19 pandemic demonstrated the need for rapidly scalable and agile healthcare delivery systems. During the pandemic, clinicians and hospital systems adopted telemedicine for various applications. Taking advantage of technological improvements in cellular networks and personal mobile devices, and despite the limited outcomes literature to support its use, telemedicine was rapidly adopted to address the fundamental challenge of exposure in outpatient settings, emergency departments, patient follow-up, and home-based monitoring. A critical recognition was that the modality of care (e.g., remote vs. in-person) was less important than access to care, regardless of the patient outcomes. This fundamental shift, facilitated by policies that followed emergency declarations, provided an opportunity to maintain and, in many cases, expand and improve clinical practices and hospital systems by bringing expertise to the patient rather than the patient to the expertise. In addition to using telemedicine to maintain patient access to healthcare, TCC was harnessed to provide local clinicians, forced to manage critically ill patients beyond their normal scope of practice or experience, access to remote expertise (physician, nursing, respiratory therapist, pharmacist). These practices supported decades of literature from the telemedicine community describing the effectiveness of telemedicine in improving patient care and the many challenges defining its value. SUMMARY In this review, we summarize numerous examples of innovative care delivery systems that have utilized telemedicine, focusing on 'mobile' TCC technology solutions to effectively deliver the best care to the patient regardless of patient location. We emphasize how a 'paradigm of better' can enhance the entirety of the healthcare system.
Collapse
Affiliation(s)
| | - Jeremy C Pamplin
- Medicine and Emergency and Operational Medicine, Uniformed Services University, Bethesda
- Telemedicine and Advanced Technology Research Center, Medical Research and Development Command, Ft. Detrick, Maryland, USA
| |
Collapse
|
4
|
Cornelius AP, Rodrigues-Rosa A. A faculty-led resident strike team as a force expander during disaster. Am J Disaster Med 2024; 19:5-13. [PMID: 38597642 DOI: 10.5055/ajdm.0467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
The emergence of the coronavirus disease 2019 (COVID-19) pandemic produced an unprecedented strain on the United States medical system. Prior to the pandemic, there was an estimated 20,000 physician shortage. This has been further stressed by physicians falling ill and the increased acuity of the COVID-19 patients. Federal medical team availability was stretched to its capabilities with the large numbers of deployments. With such severe staffing shortages, creative ways of force expansion were undertaken. New Orleans, Louisiana, was one of the hardest hit areas early in the pandemic. As the case counts built, a call was put out for help. The Louisiana State University (LSU) system responded with a faculty-led resident strike team out of the LSU Health Shreveport Academic Medical Center. Residents and faculty alike volunteered, forming a multispecialty, attending-led medical strike team of approximately 10 physicians. Administrative aspects such as institution-specific credentialing, malpractice coverage, resident distribution, attending physician oversight, among other aspects were addressed, managed, and agreed upon between the LSU Health Shreveport and the New Orleans hospital institutions and leadership prior to deployment in April 2020. In New Orleans, the residents managed patients within the departments of emergency medicine, medical floor, and intensive care unit (ICU). The residents assigned to the medical floor became a new hospitalist service team. The diversity of specialties allowed the team to address patient care in a multidisciplinary manner, leading to comprehensive patient care plans and unhindered team dynamic and workflow. During the first week alone, the team admitted and cared for over 100 patients combined from the medical floor and ICU. In a disaster situation compounded by staff shortages, a resident strike team is a beneficial solution for force expansion. This article qualitatively reviews the first published incidence of a faculty-led multispecialty resident strike team being used as a force expander in a disaster.
Collapse
Affiliation(s)
- Angela P Cornelius
- John Peter Smith Hospital, Fort Worth Emergency Medicine Residency; Associate Professor, Clinical Emergency Medicine TCU/UNT, Fort Worth, Texas; Associate Professor, Louisiana State University-Shreveport Academic Medical Center, Shreveport, Louisiana. ORCID: https://orcid.org/0000-0002-0405-1433
| | | |
Collapse
|
5
|
Causby B, Jakimowicz S, Levett-Jones T. Upskill training and preparedness of non-critical-care registered nurses deployed to intensive care units during the COVID-19 pandemic: A scoping review. Aust Crit Care 2024:S1036-7314(24)00032-8. [PMID: 38582624 DOI: 10.1016/j.aucc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/16/2024] [Accepted: 02/06/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND The increase in intensive care unit (ICU) capacity compelled by the COVID-19 pandemic required the rapid deployment of non-critical-care registered nurses to the ICU setting. The upskill training needed to prepare these registered nurses for deployment was rapidly assembled due to the limited timeframe associated with the escalating pandemic. Scoping the literature to identify the content, structure, and effectiveness of the upskill education provided is necessary to identify lessons learnt during the COVID-19 pandemic response so that they may guide workforce preparation for future surge planning. AIM The aim of this scoping review was to map the literature to identify the available information regarding upskill training and preparedness of non-critical-care registered nurses deployed to the ICU during the COVID-19 pandemic. METHODS This scoping review was conducted in accordance with JBI methodology. A protocol outlined the review questions and used the participants, concept, and context framework to define the inclusion and exclusion criteria. A search of healthcare databases MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), Cochrane, and Scopus was supplemented with a grey literature search via Google. RESULTS Screening and review found 32 manuscripts that met the inclusion criterion for examination. Analysis revealed variation in duration of programs, theoretical versus practical content, face-to-face or online mode of delivery, and duration of preparation time at the bedside in the ICU setting. Data on contributors to preparedness for deployment were sparse but included training, support, peer education, buddy time, and clarity around responsibilities and communication. DISCUSSION Evaluation of upskill education was mostly limited to post-training surveys. Few studies explored the preparedness of deployed registered nurses as an outcome of their upskill training or described measures of effectiveness of ICU deployment. CONCLUSION There is limited evidence describing preparedness of non-critical-care registered nurses on deployment to the ICU. Further research is needed to identify what elements of upskill education led to preparedness and effective deployment to the ICU setting.
Collapse
Affiliation(s)
- Belinda Causby
- Faculty of Health, University of Technology Sydney, NSW, Australia; Intensive Care Unit, St Vincent's Hospital, Sydney, NSW, Australia.
| | - Samantha Jakimowicz
- Faculty of Health, University of Technology Sydney, NSW, Australia; Faculty of Science and Health, Charles Sturt University, NSW, Australia.
| | | |
Collapse
|
6
|
Bastos LSL, Hamacher S, Kurtz P, Ranzani OT, Zampieri FG, Soares M, Bozza FA, Salluh JIF. The Association Between Prepandemic ICU Performance and Mortality Variation in COVID-19: A Multicenter Cohort Study of 35,619 Critically Ill Patients. Chest 2024; 165:870-880. [PMID: 37838338 DOI: 10.1016/j.chest.2023.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/20/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, ICUs remained under stress and observed elevated mortality rates and high variations of outcomes. A knowledge gap exists regarding whether an ICU performing best during nonpandemic times would still perform better when under high pressure compared with the least performing ICUs. RESEARCH QUESTION Does prepandemic ICU performance explain the risk-adjusted mortality variability for critically ill patients with COVID-19? STUDY DESIGN AND METHODS This study examined a cohort of adults with real-time polymerase chain reaction-confirmed COVID-19 admitted to 156 ICUs in 35 hospitals from February 16, 2020, through December 31, 2021, in Brazil. We evaluated crude and adjusted in-hospital mortality variability of patients with COVID-19 in the ICU during the pandemic. Association of baseline (prepandemic) ICU performance and in-hospital mortality was examined using a variable life-adjusted display (VLAD) during the pandemic and a multivariable mixed regression model adjusted by clinical characteristics, interaction of performance with the year of admission, and mechanical ventilation at admission. RESULTS Thirty-five thousand six hundred nineteen patients with confirmed COVID-19 were evaluated. The median age was 52 years, median Simplified Acute Physiology Score 3 was 42, and 18% underwent invasive mechanical ventilation. In-hospital mortality was 13% and 54% for those receiving invasive mechanical ventilation. Adjusted in-hospital mortality ranged from 3.6% to 63.2%. VLAD in the most efficient ICUs was higher than the overall median in 18% of weeks, whereas VLAD was 62% and 84% in the underachieving and least efficient groups, respectively. The least efficient baseline ICU performance group was associated independently with increased mortality (OR, 2.30; 95% CI, 1.45-3.62) after adjusting for patient characteristics, disease severity, and pandemic surge. INTERPRETATION ICUs caring for patients with COVID-19 presented substantial variation in risk-adjusted mortality. ICUs with better baseline (prepandemic) performance showed reduced mortality and less variability. Our findings suggest that achieving ICU efficiency by targeting improvement in organizational aspects of ICUs may impact outcomes, and therefore should be a part of the preparedness for future pandemics.
Collapse
Affiliation(s)
- Leonardo S L Bastos
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Silvio Hamacher
- Department of Industrial Engineering, Pontifical Catholic University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Kurtz
- Hospital Copa Star, Rio de Janeiro, Brazil; Paulo Niemeyer State Brain Institute, Rio de Janeiro, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Barcelona Institute for Global Health, ISGlobal, Universitat Pompeu Fabra, CIBER Epidemiología y Salud Pública, Barcelona, Spain
| | - Fernando G Zampieri
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Marcio Soares
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; National Institute of Infectious Disease Evandro Chagas, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Jorge I F Salluh
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil; Postgraduate Program of Internal Medicine, Federal University of Rio de Janeiro, (UFRJ), Rio de Janeiro, Brazil
| |
Collapse
|
7
|
Hammarskjöld F, Berg S, Bavelaar H, Henningson AJ, Taxbro K. Pulmonary superinfection diagnosed with bronchoalveolar lavage at intubation in COVID patients: A Swedish single-centre study. Acta Anaesthesiol Scand 2024; 68:512-519. [PMID: 38282310 DOI: 10.1111/aas.14378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/05/2023] [Accepted: 01/11/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patients with severe coronavirus disease 2019 (COVID) pneumonia and acute respiratory distress syndrome (C-ARDS) on invasive mechanical ventilation (IMV) have been found to be prone to having other microbial findings than severe acute respiratory syndrome coronavirus 2 (SARS-2)-CoV-19 in the bronchoalveolar lavage (BAL) fluid at intubation causing a superinfection. These BAL results could guide empirical antibiotic treatment in complex clinical situations. However, there are limited data on the relationship between microbial findings in the initial BAL at intubation and later ventilator-associated pneumonia (VAP) diagnoses. OBJECTIVE To analyse the incidence of, and microorganisms responsible for, superinfections in C-ARDS patients at the time of first intubation through microbial findings in BAL fluid. To correlate these findings to markers of inflammation in plasma and later VAP development. DESIGN Retrospective single-centre study. SETTING One COVID-19 intensive care unit (ICU) at a County Hospital in Sweden during the first year of the pandemic. PATIENTS All patients with C-ARDS who were intubated in the ICU. RESULTS We analysed BAL fluid specimens from 112 patients at intubation, of whom 31 (28%) had superinfections. Blood levels of the C-reactive protein, procalcitonin, neutrophil granulocytes, and lymphocytes were indistinguishable between patients with and without a pulmonary superinfection. Ninety-eight (88%) of the patients were treated with IMV for more than 48 h and of these patients, 37% were diagnosed with VAP. The microorganisms identified in BAL at the time of intubation are normally found at the oral, pharyngeal, and airway sites. Only one patient had an indistinguishable bacterial strain responsible for both superinfection at intubation and in VAP. CONCLUSIONS One fourth of the patients with C-ARDS had a pulmonary superinfection in the lungs that was caused by another microorganism identified at intubation. Routine serum inflammatory markers could not be used to identify this complication. Microorganisms located in BAL at intubation were rarely associated with later VAP development.
Collapse
Affiliation(s)
- Fredrik Hammarskjöld
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Sören Berg
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Herjan Bavelaar
- Division of clinical Microbiology, Department of Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
| | - Anna J Henningson
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Division of clinical Microbiology, Department of Laboratory Medicine, Region Jönköping County, Jönköping, Sweden
| | - Knut Taxbro
- Department of Anaesthesia and Intensive Care Medicine, Ryhov County Hospital, Jönköping, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
8
|
Heer RS, Selby FL, Mandal AKJ, Baktash V, Szawarski P, Mattoo S, Mohiaddin H, Makuloluwa KK, Chreif H, Amin FR, Missouris CG. Fragmentation of the QRS Complex Is Associated with Right Ventricular Dilatation and Mortality in Critically Unwell Coronavirus Disease 2019 Patients. Anatol J Cardiol 2024; 28:286-293. [PMID: 38530215 PMCID: PMC11168715 DOI: 10.14744/anatoljcardiol.2024.3494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND QRS fragmentation (fQRS) is a depolarization disorder that can be detected on routine electrocardiography (ECG). Current evidence suggests that fQRS is a prognosticator of adverse cardiovascular events. This study aimed to assess the relationship between fQRS and all-cause mortality in critically unwell coronavirus disease 2019 (COVID-19) patients and to investigate the significance of associated abnormalities on echocardiography. METHODS A retrospective cohort study of COVID-19 patients in a critical care setting was performed. Electrocardiography was performed on presentation to hospital, admission to the critical care unit, and at subsequent points according to clinical need. Transthoracic echocardiography was performed at clinical discretion to assess for structural and functional cardiac abnormalities. Primary outcome was in-hospital mortality and secondary outcome was the need for mechanical invasive ventilation. RESULTS Totally, 212 consecutive patients were included of which 120 (57%) exhibited fQRS and inferior leads were involved in 88% of the patients. Overall, fQRS was a significant predictor of mortality [65% vs. 44% P =.003; multivariate odds ratio = 2.96, 95% confidence interval (CI): 1.42-6.40, P =.005] and inferior fQRS itself was a significant predictor of mortality (P =.03). There was no significant association between fQRS and the need for invasive mechanical ventilation. A total of 112 patients underwent echocardiography. There was a greater incidence of right ventricular (RV) dilatation in the fQRS group (16% vs. 2% respectively, P =.02) and pulmonary hypertension (33% vs. 14% respectively, P =.03) based on echocardiographic criteria. CONCLUSION Our study demonstrates that fQRS is significantly associated with RV dilation, pulmonary hypertension, and mortality in critically unwell COVID-19 patients.
Collapse
Affiliation(s)
| | - Faye L. Selby
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
| | | | - Vadir Baktash
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
| | | | - Sirtaaj Mattoo
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
| | | | | | - Hussein Chreif
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
| | - Fouad R. Amin
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
| | - Constantinos G. Missouris
- Wexham Park Hospital, Frimley Health NHS Trust, Slough, UK
- University of Nicosia Medical School, Nicosia, Cyprus
| |
Collapse
|
9
|
Phua J, Kulkarni AP, Mizota T, Hashemian SMR, Lee WY, Permpikul C, Chittawatanarat K, Nitikaroon P, Arabi YM, Fang WF, Konkayev A, Hashmi M, Palo JE, Faruq MO, Shrestha BR, KC B, Mat Nor MBB, Sann KK, Ling L, Haniffa R, Al Bahrani M, Mendsaikhan N, Chan YH. Critical care bed capacity in Asian countries and regions before and during the COVID-19 pandemic: an observational study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2024; 44:100982. [PMID: 38143717 PMCID: PMC10733690 DOI: 10.1016/j.lanwpc.2023.100982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 12/26/2023]
Abstract
Background The coronavirus disease 2019 (COVID-19) pandemic highlighted the importance of critical care. The aim of the current study was to compare the number of adult critical care beds in relation to population size in Asian countries and regions before (2017) and during (2022) the pandemic. Methods This observational study collected data closest to 2022 on critical care beds (intensive care units and intermediate care units) in 12 middle-income and 7 high-income economies (using the 2022-2023 World Bank classification), through a mix of methods including government sources, national critical care societies, personal contacts, and data extrapolation. Data were compared with a prior study from 2017 of the same countries and regions. Findings The cumulative number of critical care beds per 100,000 population increased from 3.0 in 2017 to 9.4 in 2022 (p = 0.003). The median figure for middle-income economies increased from 2.6 (interquartile range [IQR] 1.7-7.8) to 6.6 (IQR 2.2-13.3), and that for high-income economies increased from 11.4 (IQR 7.3-22.8) to 13.9 (IQR 10.7-21.7). Only 3 countries did not see a rise in bed capacity. Where data were available in 2022, 10.9% of critical care beds were in single rooms (median 5.0% in middle-income and 20.3% in high-income economies), and 5.3% had negative pressure (median 0.7% in middle-income and 18.5% in high-income economies). Interpretation Critical care bed capacity in the studied Asian countries and regions increased close to three-fold from 2017 to 2022. Much of this increase was attributed to middle-income economies, but substantial heterogeneity exists. Funding None.
Collapse
Affiliation(s)
- Jason Phua
- Fast and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore
- Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System, Singapore
| | - Atul Prabhakar Kulkarni
- Division of Critical Care Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Toshiyuki Mizota
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
| | - Seyed Mohammad Reza Hashemian
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Won-Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Chairat Permpikul
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kaweesak Chittawatanarat
- Faculty of Medicine, Department of Surgery, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
| | - Phongsak Nitikaroon
- Health Administration Division, Ministry of Public Health, Nonthaburi, Thailand
| | - Yaseen M. Arabi
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Wen-Feng Fang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Aidos Konkayev
- Anaesthesiology and Intensive Care Department, Astana Medical University, Nur-Sultan, Kazakhstan
- National Science Center of Traumatology and Orthopedia Named Batpenov, Nur-Sultan, Kazakhstan
| | - Madiha Hashmi
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
| | - Jose Emmanuel Palo
- Acute and Critical Care Institute, The Medical City, Pasig City, Philippines
| | - Mohammad Omar Faruq
- General Intensive Care Unit and Emergency Department, United Hospital Ltd, Dhaka, Bangladesh
| | - Babu Raja Shrestha
- Department of Anesthesia and Intensive Care, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Bijay KC
- Department of Anesthesia and Intensive Care, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
| | | | - Kyi Kyi Sann
- Department of Anaesthesiology and Intensive Care Unit, Yangon General Hospital, University of Medicine 1, Yangon, Myanmar
| | - Lowell Ling
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland
| | - Maher Al Bahrani
- Department of Anesthesia and Critical Care, Royal Hospital, Muscat, Oman
| | - Naranpurev Mendsaikhan
- Mongolia-Japan Hospital, Mongolian National University Medical Sciences, Ulaanbaatar, Mongolia
| | - Yiong Huak Chan
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University Health System, Singapore
| | - Asian Critical Care Clinical Trials (ACCCT) Group
- Fast and Chronic Programmes, Alexandra Hospital, National University Health System, Singapore
- Division of Respiratory and Critical Care Medicine, National University Hospital, National University Health System, Singapore
- Division of Critical Care Medicine, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
- Department of Anesthesia, Kyoto University Hospital, Kyoto, Japan
- Chronic Respiratory Diseases Research Center, National Research Institute of Tuberculosis and Lung Diseases, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
- Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Faculty of Medicine, Department of Surgery, Maharaj Nakorn Chiang Mai Hospital, Chiang Mai University, Chiang Mai, Thailand
- Health Administration Division, Ministry of Public Health, Nonthaburi, Thailand
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Chang Gung University of Science and Technology, Chiayi, Taiwan
- Anaesthesiology and Intensive Care Department, Astana Medical University, Nur-Sultan, Kazakhstan
- National Science Center of Traumatology and Orthopedia Named Batpenov, Nur-Sultan, Kazakhstan
- Department of Critical Care Medicine, Ziauddin University, Karachi, Pakistan
- Acute and Critical Care Institute, The Medical City, Pasig City, Philippines
- General Intensive Care Unit and Emergency Department, United Hospital Ltd, Dhaka, Bangladesh
- Department of Anesthesia and Intensive Care, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
- International Islamic University Malaysia Medical Centre, Kuantan, Malaysia
- Department of Anaesthesiology and Intensive Care Unit, Yangon General Hospital, University of Medicine 1, Yangon, Myanmar
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong SAR, China
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, Scotland
- Department of Anesthesia and Critical Care, Royal Hospital, Muscat, Oman
- Mongolia-Japan Hospital, Mongolian National University Medical Sciences, Ulaanbaatar, Mongolia
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University Health System, Singapore
| |
Collapse
|
10
|
Pei Y, Li T, Chen C, Huang Y, Yang Y, Zhou T, Shi M. Clinical features that predict the mortality risk in older patients with Omicron pneumonia: the MLWAP score. Intern Emerg Med 2024; 19:465-475. [PMID: 38104038 PMCID: PMC10954909 DOI: 10.1007/s11739-023-03506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023]
Abstract
In December 2022, the Chinese suffered widespread Omicron of SARS-CoV-2 with variable symptom severity and outcome. We wanted to develop a scoring model to predict the mortality risk of older Omicron pneumonia patients by analyzing admission data. We enrolled 227 Omicron pneumonia patients aged 60 years and older, admitted to our hospital from December 15, 2022, to January 16, 2023, and divided them randomly into a 70% training set and a 30% test set. The former were used to identify predictors and develop a model, the latter to verify the model, using the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow goodness-of-fit test, a calibration curve to test its performance and comparing it to the existing scores. The MLWAP score was calculated based on a multivariate logistic regression model to predict mortality with a weighted score that included immunosuppression, lactate ≥ 2.4, white blood cell count ≥ 6.70 × 109/L, age ≥ 77 years, and PaO2/FiO2 ≤ 211. The AUC for the model in the training and test sets was 0.852 (95% CI, 0.792-0.912) and 0.875 (95% CI, 0.789-0.961), respectively. The calibration curves showed a good fit. We grouped the risk scores into low (score 0-7 points), medium (8-10 points), and high (11-13 points). This model had a sensitivity of 0.849, specificity of 0.714, and better predictive ability than the CURB-65 and PSI scores (AUROC = 0.859 vs. 0.788 vs. 0.801, respectively). The MLWAP-mortality score may help clinicians to stratify hospitalized older Omicron pneumonia patients into relevant risk categories, rationally allocate medical resources, and reduce the mortality.
Collapse
Affiliation(s)
- Yongjian Pei
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Ting Li
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Chen Chen
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Yongkang Huang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Yun Yang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Tong Zhou
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China
| | - Minhua Shi
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Soochow University, 1055 SanXiang Road, Gusu District, Suzhou, 215004, Jiangsu, China.
| |
Collapse
|
11
|
Tamayo Medel G, Ramasco Rueda F, Ferrando Ortolá C, González de Castro R, Ferrandis Comes R, Pastorini C, Méndez Hernández R, García Fernández J. Description of Intensive Care and Intermediate Care resources managed by Anaesthesiology Departments in Spain and their adaptation capacity during the COVID-19 pandemic. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:76-89. [PMID: 38280420 DOI: 10.1016/j.redare.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/18/2023] [Indexed: 01/29/2024]
Abstract
INTRODUCTION It is essential to understand the strategic importance of intensive care resources in the sustainable organisation of healthcare systems. Our objective has been to identify the intensive and intermediate care beds managed by Anaesthesiology and Resuscitation Services (A-ICU and A-IMCU) in Spain, their human and technical resources, and the changes made to these resources during the COVID-19 pandemic. MATERIAL AND METHODS Prospective observational study performed between December 2020 and July 2021 to register the number and characteristics of A-ICU and A-IMCU beds in hospitals listed in the catalogue published by the Spanish Ministry of Health. RESULTS Data were obtained from 313 hospitals (98% of all hospitals with more than 500 beds, 70% of all hospitals with more than 100 beds). One hundred and forty seven of these hospitals had an A-ICU with a total of 1702 beds. This capacity increased to 2107 (124%) during the COVID-19 pandemic. Three hundred and eight hospitals had an A-IMCU with a total of 3470 beds, 52.9% (2089) of which provided long-term care. The hospitals had 1900 ventilators, at a ratio of 1.07 respirators per A-ICU; 1559 anaesthesiologists dedicated more than 40% of their working time to intensive care. The nurse-to-bed ratio in A-ICUs was 2.8. DISCUSSION A large proportion of fully-equipped ICU and IMCU beds in Spanish hospitals are managed by the anaesthesiology service. A-ICU and A-IMCUs have shown an extraordinary capacity to adapt their resources to meet the increased demand for intensive care during the COVID-19 pandemic.
Collapse
Affiliation(s)
- G Tamayo Medel
- Hospital Universitario Cruces, ISS BioCruces, Bizkaia, Spain.
| | | | - C Ferrando Ortolá
- Hospital Clínic, Institut d'Investigació August Pi i Sunyer, Barcelona, Spain; CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | | | - R Ferrandis Comes
- Hospital Universitari i Politècnic La Fe, Valencia, Spain; Facultad de Medicina, Universidad de Valencia, Valencia, Spain
| | | | | | | |
Collapse
|
12
|
Jackson JL, Kuriyama A, Muramatsu K. A Model of Burnout Among Healthcare Professionals. J Gen Intern Med 2024; 39:373-376. [PMID: 37946016 PMCID: PMC10897092 DOI: 10.1007/s11606-023-08514-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/24/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Burnout is common and can lead to worse outcomes for both healthcare workers and patients. Our study purpose was to assess the structural relationship among factors that protect against or worsen burnout. DATA SOURCES AND STUDY SETTING We surveyed healthcare professionals in 15 different Japanese intensive care units during the 3rd wave of the COVID-19 pandemic (March 2021). Surveys assessed burnout (Mini Z 2.0), resilience (Brief Resilience Scale), depressive (PHQ-9) and anxiety (GAD-7) symptoms, job and work environment characteristics, and personal experience with COVID. We explored survey domains with principal component factor analysis and modeled our results using structural equation modeling. PRINCIPAL FINDINGS Among 936 ICU professionals, 24.3% met criteria for burnout. Our model suggested that resilience (β = - 0.26, 95% CI - 0.32 to - 0.20), teamwork (β = - 0.23, 95% CI - 0.30 to - 0.16), and feeling safe (β = - 0.11, 95% CI - 0.18 to - 0.04) reduced burnout. Depression (β = - 0.32, 95% CI - 0.41 to - 0.23) and anxiety (β = - 0.20, 95% CI - 0.29 to - 0.10) both decreased resilience as did COVID fear (β = 0.08, 95% CI - 0.14 to - 0.02). In addition to directly reducing resilience, anxiety also indirectly reduced resilience by increasing COVID fear (0.23, 95% CI 0.17 to 0.23), which decreased resilience (β - 0.08, 95% CI - 0.14 to - 0.02). CONCLUSIONS Burnout is common among Japanese ICU professionals. Resilience, teamwork, and safety are all correlated with reduced burnout. Those who had depression or anxiety or COVID fear had higher degrees of burnout, an effect that appears to be mediated by reduced resilience. These are potential targets for interventions to reduce burnout.
Collapse
Affiliation(s)
| | - Akira Kuriyama
- Emergency and Critical Care Medicine, Kurashiki Central Hospital, Okayama, Japan.
| | - Kumiko Muramatsu
- Department of Clinical Psychology, Graduate School of Niigata Seiryo University, Niigata, Japan
| |
Collapse
|
13
|
Aarab Y, Debourdeau T, Garnier F, Capdevila M, Monet C, De Jong A, Capdevila X, Charbit J, Dagod G, Pensier J, Jaber S. Management and outcomes of COVID-19 patients admitted in a newly created ICU and an expert ICU, a retrospective observational study. Anaesth Crit Care Pain Med 2024; 43:101321. [PMID: 37944861 DOI: 10.1016/j.accpm.2023.101321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND The COVID-19 pandemic abruptly increased the inflow of patients requiring intensive care units (ICU). French health institutions responded by a twofold capacity increase with temporary upgraded beds, supplemental beds in pre-existing ICUs, or newly created units (New-ICU). We aimed to compare outcomes according to admission in expert pre-existing ICUs or in New-ICU. METHODS This multicenter retrospective observational study was conducted in two 20-bed expert ICUs of a University Hospital (Expert-ICU) and in one 16-bed New-ICU in a private clinic managed respectively by 3 and 2 physicians during daytime and by one physician during the night shift. All consecutive adult patients with COVID-19-related acute hypoxemic respiratory failure admitted after centralized regional management by a dedicated crisis cell were included. The primary outcome was 180-day mortality. Propensity score matching and restricted cubic spline for predicted mortality over time were performed. RESULTS During the study period, 165 and 176 patients were enrolled in Expert-ICU and New-ICU respectively, 162 (98%) and 157 (89%) patients were analyzed. The unadjusted 180-day mortality was 30.8% in Expert-ICU and 28.7% in New-ICU, (log-rank test, p = 0.7). After propensity score matching, 123 pairs (76 and 78%) of patients were matched, with no significant difference in mortality (32% vs. 32%, OR 1.00 [0.89; 1.12], p = 1). Adjusted predicted mortality decreased over time (p < 0.01) in both Expert-ICU and New-ICU. CONCLUSIONS In COVID-19 patients with acute hypoxemic respiratory failure, hospitalization in a new ICU was not associated with mortality at day 180.
Collapse
Affiliation(s)
- Yassir Aarab
- Intensive Care Unit, Clinique Saint-Jean Sud de France, Montpellier, France; Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France.
| | - Theodore Debourdeau
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Fanny Garnier
- Intensive Care Unit, Clinique Saint-Jean Sud de France, Montpellier, France
| | - Mathieu Capdevila
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Clément Monet
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Audrey De Jong
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Xavier Capdevila
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Jonathan Charbit
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Geoffrey Dagod
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, Lapeyronie Hospital, Montpellier, France
| | - Joris Pensier
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| | - Samir Jaber
- Department of Anaesthesiology and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, Montpellier, France
| |
Collapse
|
14
|
Schmidt G, Martens A, Koch C, Markmann M, Schneck E, Matt U, Hecker M, Tello K, Wolff M, Sander M, Vadász I. Nucleated red blood cells are a late biomarker in predicting intensive care unit mortality in patients with COVID-19 acute respiratory distress syndrome: an observational cohort study. Front Immunol 2024; 15:1313977. [PMID: 38304431 PMCID: PMC10830722 DOI: 10.3389/fimmu.2024.1313977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/04/2024] [Indexed: 02/03/2024] Open
Abstract
Background Nucleated red blood cells (nRBC) are precursor cells of the erythropoiesis that are absent from the peripheral blood under physiological conditions. Their presence is associated with adverse outcomes in critically ill patients. This study aimed to evaluate the predictive value of nRBC on mortality in intensive care unit (ICU) patients with COVID-19 acute respiratory distress syndrome (ARDS). Material and methods This retrospective, observational cohort study analyzed data on 206 ICU patients diagnosed with COVID-19 ARDS between March 2020 and March 2022. The primary endpoint was ICU mortality, and secondary endpoints included ICU and hospital stay lengths, ventilation hours, and the time courses of disease severity scores and clinical and laboratory parameters. Results Among the included patients, 68.9% tested positive for nRBC at least once during their ICU stay. A maximum nRBC of 105 µl-1 had the highest accuracy in predicting ICU mortality (area under the curve of the receiver operating characteristic [AUCROC] 0.780, p < 0.001, sensitivity 69.0%, specificity 75.5%). Mortality was significantly higher among patients with nRBC >105 µl-1 than ≤105 µl-1 (86.5% vs. 51.3%, p = 0.008). Compared to patients negative for nRBC in their peripheral blood, those positive for nRBC required longer mechanical ventilation (127 [44 - 289] h vs. 517 [255 - 950] h, p < 0.001), ICU stays (12 [8 - 19] vs. 27 [13 - 51] d, p < 0.001), and hospital stays (19 [12 - 29] d vs. 31 [16 - 58] d, p < 0.001). Peak Sepsis-related Organ Failure Assessment (SOFA), Simplified Acute Physiology Score, PaO2/FiO2, interleukin-6, and procalcitonin values were reached before the peak nRBC level. However, the predictive performance of the SOFA (AUCROC 0.842, p < 0.001) was considerably improved when a maximum SOFA score >8 and nRBC >105 µl-1 were combined. Discussion nRBC predict ICU mortality and indicate disease severity among patients with COVID-19 ARDS, and they should be considered a clinical alarm signal for a worse outcome. nRBC are a late predictor of ICU mortality compared to other established clinical scoring systems and laboratory parameters but improve the prediction accuracy when combined with the SOFA score.
Collapse
Affiliation(s)
- Götz Schmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Arnd Martens
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Christian Koch
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Ulrich Matt
- Department of Internal Medicine V, Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Matthias Hecker
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Khodr Tello
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| | - Matthias Wolff
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Justus Liebig University Giessen, Giessen, Germany
| | - István Vadász
- Department of Internal Medicine II, Universities of Giessen and Marburg Lung Center (UGMLC), Excellence Cluster Cardiopulmonary Institute (CPI), Member of the German Center for Lung Research (DZL), Justus-Liebig University, Giessen, Germany
| |
Collapse
|
15
|
Barker AK, Valley TS, Kenes MT, Sjoding MW. Early Deep Sedation Practices Worsened During the Pandemic Among Adult Patients Without COVID-19: A Retrospective Cohort Study. Chest 2024:S0012-3692(24)00027-8. [PMID: 38218219 DOI: 10.1016/j.chest.2024.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND There is substantial evidence that patients with COVID-19 were treated with sustained deep sedation during the pandemic. However, it is unknown whether such guideline-discordant care had spillover effects to patients without COVID-19. RESEARCH QUESTION Did patterns of early deep sedation change during the pandemic for patients on mechanical ventilation without COVID-19? STUDY DESIGN AND METHODS We used electronic health record data from 4,237 patients who were intubated without COVID-19. We compared sedation practices in the first 48 h after intubation across prepandemic (February 1, 2018, to January 31, 2020), pandemic (April 1, 2020, to March 31, 2021), and late pandemic (April 1, 2021, to March 31, 2022) periods. RESULTS In the prepandemic period, patients spent an average of 13.0 h deeply sedated in the first 48 h after intubation. This increased 1.9 h (95% CI, 1.0-2.8) during the pandemic period and 2.9 h (95% CI, 2.0-3.8) in the late pandemic period. The proportion of patients that spent over one-half of the first 48 h deeply sedated was 18.9% in the prepandemic period, 22.3% during the pandemic period, and 25.9% during the late pandemic period. Ventilator-free days decreased during the pandemic, with a subdistribution hazard ratio of being alive without mechanical ventilation at 28 days of 0.87 (95% CI, 0.79-0.95) compared with the prepandemic period. Tracheostomy placement increased during the pandemic period compared with the prepandemic period (OR, 1.41; 95% CI, 1.08-1.82). In the medical ICU, early deep sedation increased 2.5 h (95% CI, 0.6-4.4) during the pandemic period and 4.9 h (95% CI, 3.0-6.9) during the late pandemic period, compared with the prepandemic period. INTERPRETATION Among patients on mechanical ventilation without COVID-19, sedation use increased during the pandemic. In the subsequent year, these practices did not return to prepandemic standards.
Collapse
Affiliation(s)
- Anna K Barker
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI.
| | - Thomas S Valley
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| | | | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI
| |
Collapse
|
16
|
Schut MC, Dongelmans DA, de Lange DW, Brinkman S, de Keizer NF, Abu-Hanna A. Development and evaluation of regression tree models for predicting in-hospital mortality of a national registry of COVID-19 patients over six pandemic surges. BMC Med Inform Decis Mak 2024; 24:7. [PMID: 38166918 PMCID: PMC10762959 DOI: 10.1186/s12911-023-02401-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/11/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Objective prognostic information is essential for good clinical decision making. In case of unknown diseases, scarcity of evidence and limited tacit knowledge prevent obtaining this information. Prediction models can be useful, but need to be not only evaluated on how well they predict, but also how stable these models are under fast changing circumstances with respect to development of the disease and the corresponding clinical response. This study aims to provide interpretable and actionable insights, particularly for clinicians. We developed and evaluated two regression tree predictive models for in-hospital mortality of COVID-19 patient at admission and 24 hours (24 h) after admission, using a national registry. We performed a retrospective analysis of observational routinely collected data. METHODS Two regression tree models were developed for admission and 24 h after admission. The complexity of the trees was managed via cross validation to prevent overfitting. The predictive ability of the model was assessed via bootstrapping using the Area under the Receiver-Operating-Characteristic curve, Brier score and calibration curves. The tree models were assessed on the stability of their probabilities and predictive ability, on the selected variables, and compared to a full-fledged logistic regression model that uses variable selection and variable transformations using splines. Participants included COVID-19 patients from all ICUs participating in the Dutch National Intensive Care Evaluation (NICE) registry, who were admitted at the ICU between February 27, 2020, and November 23, 2021. From the NICE registry, we included concerned demographic data, minimum and maximum values of physiological data in the first 24 h of ICU admission and diagnoses (reason for admission as well as comorbidities) for model development. The main outcome measure was in-hospital mortality. We additionally analysed the Length-of-Stay (LoS) per patient subgroup per survival status. RESULTS A total of 13,369 confirmed COVID-19 patients from 70 ICUs were included (with mortality rate of 28%). The optimism-corrected AUROC of the admission tree (with seven paths) was 0.72 (95% CI: 0.71-0.74) and of the 24 h tree (with 11 paths) was 0.74 (0.74-0.77). Both regression trees yielded good calibration and variable selection for both trees was stable. Patient subgroups comprising the tree paths had comparable survival probabilities as the full-fledged logistic regression model, survival probabilities were stable over six COVID-19 surges, and subgroups were shown to have added predictive value over the individual patient variables. CONCLUSIONS We developed and evaluated regression trees, which operate at par with a carefully crafted logistic regression model. The trees consist of homogenous subgroups of patients that are described by simple interpretable constraints on patient characteristics thereby facilitating shared decision-making.
Collapse
Affiliation(s)
- M C Schut
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
- Department of Laboratory Medicine, Amsterdam UMC location Vrije Universiteit, De Boelelaan 1117, 1081, HV, Amsterdam, The Netherlands.
| | - D A Dongelmans
- Department of Intensive Care Medicine, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - D W de Lange
- Department of Intensive Care Medicine and Dutch Poisons Information Center (DPIC), University Medical Center Utrecht, University Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, The Netherlands
| | - S Brinkman
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - N F de Keizer
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| | - A Abu-Hanna
- Department of Medical Informatics, Amsterdam Public Health research institute, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands
| |
Collapse
|
17
|
Blusztein D, Sarwary S, Parikh DS, Garcia S, Price MJ, Nayak K, Aragon J, Mahadevan VS. Safety of Same-Day Hospital Discharge Post Patent Foramen Ovale Closure: Findings from a Multicenter Study. Am J Cardiol 2023; 208:118-123. [PMID: 37832208 DOI: 10.1016/j.amjcard.2023.09.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/05/2023] [Accepted: 09/09/2023] [Indexed: 10/15/2023]
Abstract
Transcatheter patent foramen ovale (PFO) closure is indicated for patients with cryptogenic stroke. Although procedural safety is well established, there are limited data on the safety of same-day (SD) discharge. We aimed to review the outcomes of PFO closure with SD. Patients who underwent transcatheter PFO closure between January 2011 and May 2022 at 4 large US hospitals were retrospectively analyzed, comparing outcomes of SD versus delayed discharge (DD). The primary end point was a composite of access-site complication, stroke, device embolization, atrial arrhythmia, and bleeding. Secondary analysis comparing imaging modality and outcomes was performed. 554 patients (49.2% female) were analyzed (382 discharged SD). Average age was 54.3 ± 15. Baseline characteristics in both groups were broadly similar. Previous stroke (78.0% SD vs 76.2% DD, p = 0.32) was the commonest indication for PFO closure. In the SD group, there was less general anesthesia use (5.5% vs 16.9%, p <0.001). Intraprocedural intracardiac echocardiography was used more frequently in SD cases (95.0% vs 81.4%, p <0.001). In the DD group, median stay was 1 night, and 34.9% stayed beyond 1 night. At 30 days, there was no difference in the primary composite end point (14.9% vs 11.6%, p = 0.15). There was no inter-group difference in individual adverse events (all p >0.05). When comparing imaging modality and outcomes, there was no difference in composite end points between transesophageal and intracardiac echocardiography (6.5% vs 14.7%, p = 0.063). In conclusion, SD discharge after transcatheter PFO closure appears safe. This efficient approach may be advantageous in optimizing workflow and minimizing hospital occupancy.
Collapse
Affiliation(s)
- David Blusztein
- Department of Cardiology, University of California, San Francisco, California.
| | - Shabir Sarwary
- Department of Cardiology, University of California, San Francisco, California
| | - Devang S Parikh
- Department of Cardiology, University of California, San Francisco, California
| | - Santiago Garcia
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Matthew J Price
- Department of Cardiology, Scripps Clinic, San Diego, California
| | - Keshav Nayak
- Department of Cardiology, Scripps Clinic, San Diego, California
| | - Joseph Aragon
- Department of Cardiology, Santa Barbara Cottage Hospital, Santa Barba, California
| | - Vaikom S Mahadevan
- Department of Cardiology, University of California, San Francisco, California
| |
Collapse
|
18
|
Srichawla BS, Quast J, Pacut P, Sivakumar S, Garcia-Dominguez MA, Belgrad J, Panda A, Carbone S, Sanders DT, Min E, Hayes NT, Bose A, Lee V, Ghasemi M. COVID-19 in the intensive care unit: Unmasking the critical factors impacting patient survival. J Investig Med 2023; 71:907-916. [PMID: 37485922 DOI: 10.1177/10815589231191813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
In the midst of the coronavirus disease 2019 (COVID-19) pandemic, intensive care units (ICUs) around the world have been pushed to their limits as they grapple with the effects of the severe acute respiratory syndrome coronavirus 2 virus. Identifying prognostic factors that influence mortality in COVID-19 patients admitted to the ICU could offer valuable insights for clinicians seeking to prevent disease progression. A retrospective analysis was conducted on COVID-19 patients admitted to the ICU between January and September 2020. The analysis considered patient demographics, comorbidities, neurological and non-neurological symptoms, as well as laboratory markers. The multivariate logistic regression analysis aims to uncover associations between these factors and patient outcomes. Of the 387 patients included in this study, nearly half (48.5%) of the ICU patients succumbed to COVID-19. Factors that contributed to increased mortality included being 60 years of age or older, impaired consciousness, lung disease, elevated international normalized ratio (INR), and elevated blood urea nitrogen (BUN) levels. Surprisingly, symptoms such as dizziness/lightheadedness, myalgia, and headache were associated with a higher likelihood of survival. In addition, elevated D-dimer and aspartate aminotransferase (AST) levels, as well as lymphopenia, were more commonly observed in deceased patients. The study concluded that those who died in the ICU tended to be older, white, and burdened with more comorbidities and impaired consciousness. With the intriguing link between specific symptoms and survival, further research is essential to uncover the underlying pathophysiological mechanisms that influence ICU patient outcomes in the context of COVID-19.
Collapse
Affiliation(s)
| | - Jared Quast
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Peter Pacut
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | | | | | - Jillian Belgrad
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Ashwin Panda
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Sara Carbone
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Delia T Sanders
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Eli Min
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nicole T Hayes
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Abigail Bose
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Vanessa Lee
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Mehdi Ghasemi
- University of Massachusetts Chan Medical School, Worcester, MA, USA
| |
Collapse
|
19
|
Thomson WR, Puthucheary ZA, Wan YI. Critical care and pandemic preparedness and response. Br J Anaesth 2023; 131:847-860. [PMID: 37689541 PMCID: PMC10636520 DOI: 10.1016/j.bja.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/21/2023] [Accepted: 07/23/2023] [Indexed: 09/11/2023] Open
Abstract
Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.
Collapse
Affiliation(s)
- William R Thomson
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
| | - Zudin A Puthucheary
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Yize I Wan
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
20
|
Bianco C, Guidet B, Flaatten H, Dechartres A, Vallet H. Mortality in older patients admitted to an ICU for COVID-19: A systematic review. Acta Anaesthesiol Scand 2023; 67:1140-1147. [PMID: 37323022 DOI: 10.1111/aas.14299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/06/2023] [Accepted: 06/02/2023] [Indexed: 06/17/2023]
Abstract
PURPOSE The objective was to conduct a systematic review of mortality and factors independently associated with mortality of older patients admitted to an intensive care unit (ICU) for COVID-19. MATERIALS AND METHODS Data sources were MEDLINE, EMBASE, the Cochrane Library, and references of included studies. Two reviewers independently selected studies evaluating mortality of older patients (≥ 70 years) admitted to an ICU for COVID-19. They extracted general characteristics, mortality rate, and factors independently associated with mortality. The methodological quality of each study was evaluated by using the Critical Appraisal Skills Programme checklist. RESULTS We selected 36 studies (11,989 patients). Many of the studies were conducted in Europe (42%) and many were retrospective (61%) and multicenter (61%). ICU mortality ranged from 8% to 90%, 1-month mortality from 33% to 90% and 3-month mortality, reported in five studies, from 46% to 60%. Frailty, assessed by the Clinical Frailty Score (CFS), was significantly associated with 1-month and 3-month mortality respectively in two studies (hazard ratio [HR]: 3.2 [2.56-4.13] and HR: 2.83 [95% CI: 1.96-4.08]). CONCLUSION In this systematic review of older patients admitted to an ICU with COVID-19, we documented high heterogeneity of mortality rates.
Collapse
Affiliation(s)
- Céline Bianco
- Department of Geriatrics, Saint Antoine Hospital, APHP, Paris, France
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Service de Réanimation Médicale, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Agnès Dechartres
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, Département de Santé Publique, Paris, France
| | - Hélène Vallet
- Sorbonne Université, INSERM, UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Department of Geriatrics, Saint Antoine Hospital, APHP, Paris, France
| |
Collapse
|
21
|
Heidinger BA, Downar A, Frolic A, Downar J, Isenberg SR. Physician and administrator experience of preparing to implement Ontario's intensive care unit Triage Emergency Standard of Care during the COVID-19 pandemic: a qualitative study. CMAJ Open 2023; 11:E838-E846. [PMID: 37726116 PMCID: PMC10516683 DOI: 10.9778/cmajo.20220168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics. METHODS We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis. RESULTS We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard). INTERPRETATION The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.
Collapse
Affiliation(s)
- Brandon A Heidinger
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Ariane Downar
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Andrea Frolic
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - James Downar
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
| |
Collapse
|
22
|
Odetola FO, Carlton EF, Dews A, Anspach RR, Evans MC, Howell JD, Keenan H, Kolovos NS, Levin AB, Mendelson J, Ushay HM, Yager PH. A Tale of 8 Cities: Pediatric Critical Care Redeployment to Adult Care During Wave 1 of COVID-19. Hosp Pediatr 2023; 13:822-832. [PMID: 37646091 DOI: 10.1542/hpeds.2023-007187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
BACKGROUND Pediatric hospital resources including critical care faculty (intensivists) redeployed to provide care to adults in adult ICUs or repurposed PICUs during wave 1 of the coronavirus disease 2019 (COVID-19) pandemic. OBJECTIVES To determine the magnitude of pediatric hospital resource redeployment and the experience of pediatric intensivists who redeployed to provide critical care to adults with COVID-19. METHODS A mixed methods study was conducted at 9 hospitals in 8 United States cities where pediatric resources were redeployed to provide care to critically ill adults with COVID-19. A survey of redeployed pediatric hospital resources and semistructured interviews of 40 redeployed pediatric intensivists were simultaneously conducted. Quantitative data were summarized as median (interquartile range) values. RESULTS At study hospitals, there was expansion in adult ICU beds from a baseline median of 100 (86-107) to 205 (108-250). The median proportion (%) of redeployed faculty (88; 66-100), nurses (46; 10-100), respiratory therapists (48; 18-100), invasive ventilators (72; 0-100), and PICU beds (71; 0-100) was substantial. Though driven by a desire to help, faculty were challenged by unfamiliar ICU settings and culture, lack of knowledge of COVID-19 and fear of contracting it, limited supplies, exhaustion, and restricted family visitation. They recommended deliberate preparedness with interprofessional collaboration and cross-training, and establishment of a robust supply chain infrastructure for future public health emergencies and will redeploy again if asked. CONCLUSIONS Pediatric resource redeployment was substantial and pediatric intensivists faced formidable challenges yet would readily redeploy again.
Collapse
Affiliation(s)
- Folafoluwa O Odetola
- Department of Pediatrics, Division of Pediatric Critical Care Medicine
- Child Health Evaluation and Research Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Erin F Carlton
- Department of Pediatrics, Division of Pediatric Critical Care Medicine
- Child Health Evaluation and Research Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Alyssa Dews
- Child Health Evaluation and Research Center, University of Michigan Health System, Ann Arbor, Michigan
| | - Renee R Anspach
- Department of Sociology, University of Michigan, Ann Arbor, Michigan
| | - Melissa C Evans
- Division of Critical Care Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Joy D Howell
- Division of Critical Care Medicine, Department of Pediatrics, Weill Cornell Medical College, New York, New York
| | - Heather Keenan
- Division of Critical Care Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nikoleta S Kolovos
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Amanda B Levin
- Division of Pediatric Critical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jenny Mendelson
- Division of Critical Care, Department of Pediatrics, College of Medicine, Tucson, Arizona
| | - H Michael Ushay
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Phoebe H Yager
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
23
|
Hill K, McCabe C, Brenner M. Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review. BMJ Open 2023; 13:e068174. [PMID: 37640456 PMCID: PMC10462976 DOI: 10.1136/bmjopen-2022-068174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 08/14/2023] [Indexed: 08/31/2023] Open
Abstract
OBJECTIVES The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research. DESIGN Scoping review. METHODS This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate. RESULTS 47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges. CONCLUSION COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.
Collapse
Affiliation(s)
- Katie Hill
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| | - Catherine McCabe
- School of Nursing & Midwifery, Trinity College Dublin, Dublin, Ireland
| | - Maria Brenner
- School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
| |
Collapse
|
24
|
Alhoufie ST, Mumena WA, Alsharif N, Makhdoom HM, Almutawif YA, Alfarouk KO, Alharbi MZ, Aljabri K, Aljifri A. Epidemiological Characteristics and Outcomes Predictors for Intensive Care Unit COVID-19 Patients in Al-Madinah, Saudi Arabia. Retrospective Cohort Study. Infect Drug Resist 2023; 16:5573-5586. [PMID: 37645558 PMCID: PMC10461755 DOI: 10.2147/idr.s419724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023] Open
Abstract
Introduction The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, COVID-19) increased the demand for intensive care unit (ICU) services. Mortality and morbidity rates among ICU COVID-19 patients are affected by several factors, such as severity, comorbidities, and coinfections. In this study, we describe the demographic characteristics of COVID-19 patients admitted to an ICU in Saudi Arabia, and we determined the predictors for mortality and prolonged ICU length of stay. Additionally, we determined the prevalence of bacterial coinfection and its effect on the outcomes for ICU COVID-19 patients. Methods We retrospectively studied the medical records of 142 COVID-19 patients admitted to the ICU at a tertiary hospital in Madinah, Saudi Arabia. Data on demographics, medical history, mortality, length of stay, and presence of coinfection were collected for each patient. Results Neutrophil-to-Lymphocyte ratio (NLR) and intubation were reliable predictors of mortality and ICU length of stay among these ICU COVID-19 patients. Moreover, bacterial coinfections were detected in 23.2% of the patients and significantly (p < 0.001) prolonged their ICU length of stay, explaining the 10% increase in the length of stay for these patients. Furthermore, mortality reached 70% among the coinfected patients, and 60.8% of the isolated coinfecting pathogens were multidrug-resistant (MDR) strains of Klebsiella pneumoniae, Acinetobacter baumannii, and Staphylococcus aureus. Conclusion Increased NLR and intubation are predictors of mortality and prolonged length of stay in COVID-19 patients admitted to the ICU. Coinfection with MDR bacterial strains potentially results in complications and is a high-risk factor for prolonged ICU length of stay.
Collapse
Affiliation(s)
- Sari T Alhoufie
- Medical Laboratories Technology Department, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Walaa A Mumena
- Department of Clinical Nutrition, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Naif Alsharif
- King Salman Medical City, Al-Madinah General Hospital, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Hatim M Makhdoom
- Medical Laboratories Technology Department, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Yahya A Almutawif
- Medical Laboratories Technology Department, College of Applied Medical Sciences, Taibah University, Al-Madinah Al-Munwarah, Saudi Arabia
| | | | - Mohammed Z Alharbi
- King Salman Medical City, Al-Madinah General Hospital, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Khaled Aljabri
- King Salman Medical City, Al-Madinah General Hospital, Al-Madinah Al-Munwarah, Saudi Arabia
| | - Alanoud Aljifri
- Al-Madinah Health Cluster, Ministry of Health, Al-Madinah Al-Munwarah, Saudi Arabia
| |
Collapse
|
25
|
Alhamed S, Aljohani S. Oral manifestations in hospital-admitted COVID-19 patients: a case control study. FRONTIERS IN ORAL HEALTH 2023; 4:1180017. [PMID: 37636481 PMCID: PMC10448403 DOI: 10.3389/froh.2023.1180017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/25/2023] [Indexed: 08/29/2023] Open
Abstract
The oral cavity can present early manifestations of several systemic diseases. Since the emergence of the COVID-19 pandemic, there have been many published studies reporting the direct effect of the virus on orofacial structures. In the present study, oral signs and symptoms of 22 hospital-admitted COVID-19 patients were examined and compared to a matching control group. Loss of taste and smell was the most prevalent symptom (65%), followed by oral dryness (45%) and halitosis (30%). The most common oral lesions were candidal infections (68%). Other less common manifestations were oral ulcerations (36%) followed by the appearance of white patches (27.3%). There was a statistically significant association between candidal infection and age in the study group, where the p-value was 0.008. In the present study, 80% of those who had candida infections were aged 60 years or above. There was no significant association with comorbidities such as diabetes mellitus and hypertension.
Collapse
|
26
|
Winnand P, Fait Y, Ooms M, Bock A, Heitzer M, Laurentius T, Bollheimer LC, Hölzle F, Priebe JA, Modabber A. Assessment of psychological and physical stressors among nurses in different functional areas before and during the COVID-19 pandemic: a cross-sectional study. BMC Nurs 2023; 22:257. [PMID: 37545003 PMCID: PMC10405408 DOI: 10.1186/s12912-023-01424-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 07/30/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND The COVID-19 (coronavirus disease) pandemic placed a great burden on all health-care resources, especially nurses. The prevalence and underlying risk factors of affective symptoms related to the COVID-19 pandemic have been studied primarily among nurses in intensive care units (ICU) and emergency departments. The aim of this study was to identify at-risk nursing areas by examining the psychological and physical stress values of nurses in different functional areas. METHODS A questionnaire with standardized items was developed to assess psychological and physical stress values. At least 50 nurses with a minimum work experience of 3 years were recruited from the ward, outpatient clinic (OC), intermediate care (IMC) unit, and operating room (OR) of the University Hospital RWTH Aachen. The participants answered the questionnaire by referring to their perceptions before and during the COVID-19 pandemic. Absolute differences and relative trends in psychological and physical stress values were compared within and across functional areas. RESULTS The ward and OR nurses experienced significant increases in workload (p < 0.001 and p = 0.004, respectively) and time stressors (p < 0.001 and p = 0.043, respectively) during the COVID-19 pandemic. Regardless of functional area, the nurses showed strong tendencies toward increases in subclinical affective symptoms. After adjustments for age, sex, working in a shift system, the treatment of patients with COVID-19, and the impact of the COVID-19 pandemic on personal life, the values for working with pleasure decreased significantly among the ward (p = 0.001) and OR nurses (p = 0.009) compared with the OC nurses. In addition, the ward (p < 0.001) and OR nurses (p = 0.024) were significantly more likely to express intent to leave their profession than OC nurses. CONCLUSIONS The IMC nurses showed good adaptation to the exacerbated situation caused by the COVID-19 pandemic. The ward nurses, followed by the OR nurses, were the most vulnerable to mental and physical exhaustion, which threatened the nurses' resilience and retention in the wake of the COVID-19 pandemic. Therefore, intervention programs must specifically address the professional and emotional needs of ward and OR nurses to prepare the health-care system for future crises.
Collapse
Affiliation(s)
- Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany.
| | - Yvonne Fait
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
- Department of Geriatrics, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Anna Bock
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Thea Laurentius
- Department of Geriatrics, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Leo Cornelius Bollheimer
- Department of Geriatrics, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| | - Janosch A Priebe
- Department of Neurology, Center for Interdisciplinary Pain Management-Rise-uP, Klinikum rechts der Isar, MRI, Technical University of Munich, Ismaninger Str. 22, D-81675, Munich, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, D-52074, Aachen, Germany
| |
Collapse
|
27
|
Varghese MP, Selwyn T, Nair S, Samuel S, Chacko B, Pichamuthu K. Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study. Indian J Crit Care Med 2023; 27:537-544. [PMID: 37636852 PMCID: PMC10452773 DOI: 10.5005/jp-journals-10071-24504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023] Open
Abstract
Background During the pandemic, traditional family meetings were replaced by remote telecommunications. We assessed the families' satisfaction with these communications using a survey-based questionnaire. Methods The study involved 20-minute telephonic surveys conducted with the family member who was updated during the hospitalization of the patient. A thematic-based questionnaire with responses on a scale of 5 ranging from very dissatisfied to very satisfied was used. The responses were dichotomized into bad and good reports for analysis. Results A total of 196 patients were eligible. Only 154 patients' family representatives consented to the study. The frequency and content of the telephonic updates were satisfactory. The bad report was assigned to 5% of families only. Among features assessing empathy of communication providers, the satisfaction rate was much higher with 3% of families alone providing a bad report. The response was significantly biased against the final outcome of the patient with poor review often provided by relatives of patients who had succumbed to the illness. The dissatisfaction rate was much higher, above 12% for the trust of communication and ICU visitation. However, the final outcome of the patient did not affect the trust in the information conveyed by the physician. Interpretation This study highlights several drawbacks in the communication strategy during the second surge of coronavirus disease-2019 (COVID-19). The final outcome of the patient was the key decisive factor for the response to most of the questionnaire. Sustained faith in communication by the physician despite the final outcome of the patient, re-emphasizes the need for emotional connection and training for breaking bad news. How to cite this article Varghese MP, Selwyn T, Nair S, Samuel S, Chacko B, Pichamuthu K. Assessment of Family Satisfaction with Remote Communication for Critically Ill COVID-19 Patients: An Observational Cohort Study. Indian J Crit Care Med 2023;27(8):537-544.
Collapse
Affiliation(s)
- Mammen Philip Varghese
- Department of Neuro Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Tryphena Selwyn
- Department of Neuro Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shalini Nair
- Department of Neuro Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shobha Samuel
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Binila Chacko
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Kishore Pichamuthu
- Department of Medical Intensive Care Unit, Christian Medical College, Vellore, Tamil Nadu, India
| |
Collapse
|
28
|
Delmore B, Deppisch M, Cox J, Newton D, Gillespie C, Todd J, Sonenblum SE. Necessary Products for the Prevention and Treatment of Pressure Injuries: Lessons Learned That Translate Beyond the COVID-19 Pandemic. Adv Skin Wound Care 2023; 36:361-369. [PMID: 37338948 DOI: 10.1097/01.asw.0000935996.96447.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To identify the challenges encountered in obtaining the required support surfaces and products to meet pressure injury (PrI) prevention and treatment needs during COVID-19. METHODS The authors used SurveyMonkey to gather data on healthcare perceptions and the challenges experienced regarding specific product categories deemed necessary for PrI prevention and treatment in US acute care settings during the pandemic. They created three anonymous surveys for the target populations of supply chain personnel and healthcare workers. The surveys addressed healthcare workers' perceptions, product requests, and the ability to fulfill product requests and meet facility protocols without substitution in the categories of support surfaces and skin and wound care supplies. RESULTS Respondents answered one of the three surveys for a total sample of 174 respondents. Despite specific instructions, nurses responded to the surveys designed for supply chain personnel. Their responses and comments were interesting and capture their perspectives and insights. Three themes emerged from the responses and general comments: (1) expectations differed between supply chain staff and nurses for what was required for PrI prevention and treatment; (2) inappropriate substitution with or without proper staff education occurred; and (3) preparedness. CONCLUSIONS It is important to identify experiences and challenges in the acquisition and availability of appropriate equipment and products for PrI prevention and treatment. To foster ideal PrI prevention and treatment outcomes, a proactive approach is required to face daily issues or the next crisis.
Collapse
Affiliation(s)
- Barbara Delmore
- Barbara Delmore, PhD, RN, CWCN, MAPWCA, IIWCC, FAAN, is Senior Nurse Scientist, Center for Innovations in the Advancement of Care, Department of Nursing, NYU Langone Health, and Clinical Assistant Professor, Hansjörg Wyss, Department of Plastic Surgery, NYU Grossman School of Medicine, New York, New York, USA. Michelle Deppisch, PT, CWS, FACCWS, LLC, is Wound Care Consultant, Hertford, North Carolina. Jill Cox, PhD, RN, APN-c, CWOCN, FAAN, is Clinical Professor, Rutgers University School of Nursing, Newark, New Jersey, and WOC Advanced Practice Nurse, Englewood Health, Englewood, New Jersey. David Newton, MEng, CEng, MIET, MIEEE, is Product Development Manager, Arjo Inc, San Antonio, Texas. Carroll Gillespie, MS, RN, CWOCN, is Clinical Solutions Manager, Wound Care and Bariatrics, Arjo Inc, Addison, Illinois. Jackie Todd, MBA, BSN, RN, CWCN, is Clinical Consultant, Epic Clinical Consulting, Charleston, South Carolina. Sharon Eve Sonenblum, PhD, is Principal Research Scientist, George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | | | | | | | | | | | | |
Collapse
|
29
|
Kulkarni S, Flescher A, Ahmad M, Bayliss G, Bearl D, Biondi L, Davis E, George R, Gordon E, Lyons T, Wightman A, Ladin K. Ethical analysis examining the prioritisation of living donor transplantation in times of healthcare rationing. JOURNAL OF MEDICAL ETHICS 2023; 49:389-392. [PMID: 34983855 PMCID: PMC10314075 DOI: 10.1136/medethics-2021-107574] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/17/2021] [Indexed: 05/20/2023]
Abstract
The transplant community has faced unprecedented challenges balancing risks of performing living donor transplants during the COVID-19 pandemic with harms of temporarily suspending these procedures. Decisions regarding postponement of living donation stem from its designation as an elective procedure, this despite that the Centers for Medicare and Medicaid Services categorise transplant procedures as tier 3b (high medical urgency-do not postpone). In times of severe resource constraints, health systems may be operating under crisis or contingency standards of care. In this manuscript, the United Network for Organ Sharing Ethics Workgroup explores prioritisation of living donation where health systems operate under contingency standards of care and provide a framework with recommendations to the transplant community on how to approach living donation in these circumstances.To guide the transplant community in future decisions, this analysis suggests that: (1) living donor transplants represent an important option for individuals with end-stage liver and kidney disease and should not be suspended uniformly under contingency standards, (2) exposure risk to SARS-CoV-2 should be balanced with other risks, such as exposure risks at dialysis centres. Because many of these risks are not quantifiable, donors and recipients should be included in discussions on what constitutes acceptable risk, (3) transplant hospitals should strive to maintain a critical transplant workforce and avoid diverting expertise, which could negatively impact patient preparedness for transplant, (4) transplant hospitals should consider implementing protocols to ensure early detection of SARS-CoV-2 infections and discuss these measures with donors and recipients in a process of shared decision-making.
Collapse
Affiliation(s)
- Sanjay Kulkarni
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Flescher
- Department of English, Stony Brook University, Stony Brook, New York, USA
| | - Mahwish Ahmad
- Center for Bioethics, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - George Bayliss
- Department of Medicine, Brown Univeristy School of Medicine, Providence, Rhode Island, USA
| | - David Bearl
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Lynsey Biondi
- Department of Surgery, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | | | - Roshan George
- Department of Pediatrics, Emory Univeristy School of Medicine, Atlanta, Georgia, USA
| | - Elisa Gordon
- Department of Surgery, Northwestern University School of Medicine, Chicago, Illinois, USA
| | - Tania Lyons
- UNOS Ethics Committee, Richmond, Virginia, USA
| | - Aaron Wightman
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Keren Ladin
- Department of Community Health, Tufts University, Medford, Massachusetts, USA
| |
Collapse
|
30
|
Zimmerman SL, Rutherford AR, van der Waall A, Norena M, Dodek P. A queuing model for ventilator capacity management during the COVID-19 pandemic. Health Care Manag Sci 2023:10.1007/s10729-023-09632-9. [PMID: 37212974 DOI: 10.1007/s10729-023-09632-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/13/2023] [Indexed: 05/23/2023]
Abstract
We applied a queuing model to inform ventilator capacity planning during the first wave of the COVID-19 epidemic in the province of British Columbia (BC), Canada. The core of our framework is a multi-class Erlang loss model that represents ventilator use by both COVID-19 and non-COVID-19 patients. Input for the model includes COVID-19 case projections, and our analysis incorporates projections with different levels of transmission due to public health measures and social distancing. We incorporated data from the BC Intensive Care Unit Database to calibrate and validate the model. Using discrete event simulation, we projected ventilator access, including when capacity would be reached and how many patients would be unable to access a ventilator. Simulation results were compared with three numerical approximation methods, namely pointwise stationary approximation, modified offered load, and fixed point approximation. Using this comparison, we developed a hybrid optimization approach to efficiently identify required ventilator capacity to meet access targets. Model projections demonstrate that public health measures and social distancing potentially averted up to 50 deaths per day in BC, by ensuring that ventilator capacity was not reached during the first wave of COVID-19. Without these measures, an additional 173 ventilators would have been required to ensure that at least 95% of patients can access a ventilator immediately. Our model enables policy makers to estimate critical care utilization based on epidemic projections with different transmission levels, thereby providing a tool to quantify the interplay between public health measures, necessary critical care resources, and patient access indicators.
Collapse
Affiliation(s)
- Samantha L Zimmerman
- Department of Mathematics, Simon Fraser University, 8888 University Dr., Burnaby, V5A 1S6, BC, Canada.
| | - Alexander R Rutherford
- Department of Mathematics, Simon Fraser University, 8888 University Dr., Burnaby, V5A 1S6, BC, Canada
| | - Alexa van der Waall
- Department of Mathematics, Simon Fraser University, 8888 University Dr., Burnaby, V5A 1S6, BC, Canada
| | - Monica Norena
- Center for Health Evaluation and Outcome Sciences, 588 - 1081 Burrard Street St. Paul's Hospital, Vancouver, V6Z 1Y6, BC, Canada
| | - Peter Dodek
- Center for Health Evaluation and Outcome Sciences, 588 - 1081 Burrard Street St. Paul's Hospital, Vancouver, V6Z 1Y6, BC, Canada
- Division of Critical Care, Department of Medicine, Faculty of Medicine, The University of British Columbia, 855 W 12th Ave, Vancouver, V5Z 1M9, BC, Canada
| |
Collapse
|
31
|
Naouri D, Pham T, Dres M, Vuagnat A, Beduneau G, Mercat A, Combes A, Kimmoun A, Schmidt M, Demoule A, Jamme M. Differences in clinical characteristics and outcomes between COVID-19 and influenza in critically ill adult patients: a national database study. J Infect 2023:S0163-4453(23)00289-X. [PMID: 37201858 DOI: 10.1016/j.jinf.2023.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/11/2023] [Accepted: 05/11/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE Prior to the coronavirus disease 2019 (COVID-19) pandemic, influenza was the most frequent cause of viral respiratory pneumonia requiring intensive care unit (ICU) admission. Few studies have compared the characteristics and outcomes of critically ill patients with COVID-19 and influenza. METHODS This was a French nationwide study comparing COVID-19 (March 1, 2020-June 30, 2021) and influenza patients (January 1, 2014-December 31, 2019) admitted to an ICU during pre-vaccination era. Primary outcome was in-hospital death. Secondary outcome was need for mechanical ventilation. RESULTS 105,979 COVID-19 patients were compared to 18,763 influenza patients. Critically ill patients with COVID-19 were more likely to be men with more comorbidities. Patients with influenza required more invasive mechanical ventilation (47 vs. 34%, p<0·001), vasopressors (40% vs. 27, p<0·001) and renal-replacement therapy (22 vs. 7%, p<0·001). Hospital mortality was 25 and 21% (p<0·001) in patients with COVID-19 and influenza, respectively. In the subgroup of patients receiving invasive mechanical ventilation, ICU length of stay was significantly longer in patients with COVID-19 (18 [10-32] vs. 15 [8-26] days, p<0·001). Adjusting for age, gender, comorbidities, and modified SAPS II score, in-hospital death was higher in COVID-19 patients (adjusted sub-distribution hazard ratio [aSHR]=1.69; 95%CI=1.63-1.75) compared with influenza patients. COVID-19 was also associated with less invasive mechanical ventilation (aSHR=0.87; 95%CI=0.85-0.89) and a higher likelihood of death without invasive mechanical ventilation (aSHR=2.40; 95%CI=2.24-2.57). CONCLUSION Despite younger age and lower SAPS II score, critically ill COVID-19 patients had a longer hospital stay and higher mortality than patients with influenza.
Collapse
Affiliation(s)
- Diane Naouri
- Department for Research, Studies, Assessment and Statistics (DREES), French Ministry of Health, Paris, France.
| | - Tai Pham
- Service de Médecine intensive - Réanimation, Hôpital du Kremlin Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Martin Dres
- Service de Pneumologie et Réanimation médicale, Hôpital Pitié Salpétrière, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Albert Vuagnat
- Department for Research, Studies, Assessment and Statistics (DREES), French Ministry of Health, Paris, France
| | - Gaëtan Beduneau
- UNIROUEN, EA 3830, Medical intensive care unit, Rouen University Hospital, Normandie University, 76000 Rouen, France
| | - Alain Mercat
- Service de Réanimation médicale et médecine hyperbare, CHU Angers, Angers, France
| | - Alain Combes
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine intensive - Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Antoine Kimmoun
- Service de Médecine intensive - Réanimation, CHRU Nancy, Nancy, France
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine intensive - Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie et Réanimation médicale, Hôpital Pitié Salpétrière, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Matthieu Jamme
- Service de Réanimation polyvalente, Hôpital Privé de l'Ouest Parisien, Ramsay - Générale de Santé, Trappes, France; CESP, INSERM U1018, Equipe Epidémiologie clinique, Villejuif, France
| |
Collapse
|
32
|
Mekontso Dessap A, Richard JCM, Baker T, Godard A, Carteaux G. Technical Innovation in Critical Care in a World of Constraints: Lessons from the COVID-19 Pandemic. Am J Respir Crit Care Med 2023; 207:1126-1133. [PMID: 36716353 PMCID: PMC10161748 DOI: 10.1164/rccm.202211-2174cp] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/30/2023] [Indexed: 02/01/2023] Open
Abstract
The COVID-19 crisis was characterized by a massive need for respiratory support, which has unfortunately not been met globally. This situation mimicked those which gave rise to critical care in the past. Since the polio epidemic in the 50's, the technological evolution of respiratory support has enabled health professionals to save the lives of critically-ill patients worldwide every year. However, much of the current innovation work has turned around developing sophisticated, complex, and high-cost standards and approaches whose resilience is still questionable upon facing constrained environments or contexts, as seen in resuscitation work outside intensive care units, during pandemics, or in low-income countries. Ventilatory support is an essential life-saving tool for patients with respiratory distress. It requires an oxygen source combined to a ventilatory assistance device, an adequate monitoring system, and properly trained caregivers to operate it. Each of these elements can be subject to critical constraints, which we can no longer ignore. The innovation process should incorporate them as a prima materia, whilst focusing on the core need of the field using the concept of frugal innovation. Having a universal access to oxygen and respiratory support, irrespective of the context and constraints, necessitates: i) developing cost-effective, energy-efficient, and maintenance-free oxygen generation devices; ii) improving the design of non-invasive respiratory devices (for example, with oxygen saving properties); iii) conceiving fully frugal ventilators and universal monitoring systems; iv) broadening ventilation expertise by developing end-user training programs in ventilator assistance. The frugal innovation approach may give rise to a more resilient and inclusive critical care system. This paradigm shift is essential for the current and future challenges.
Collapse
Affiliation(s)
- Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
| | - Jean-Christophe Marie Richard
- Vent’Lab, Medical ICU, Angers University Hospital, University of Angers, Angers, France
- Med2Lab, Air Liquide Medical Systems, Antony, France
| | - Tim Baker
- Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Global Public Health, Karolinska Institute, Stockholm, Sweden
- Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom; and
| | - Aurélie Godard
- Médecins Sans Frontières – Centre Opérationel Paris, Paris, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France
- Faculté de Santé de Créteil, IMRB, GRC CARMAS, Université Paris-Est Créteil, Créteil, France
- INSERM U955, Créteil, France
| |
Collapse
|
33
|
Kissel KA, Filipek C, Folz E, Jenkins J. The Impact of a 3-Tiered Model of Nursing Redeployment During the COVID-19 Pandemic: A Cross-Sectional Study. Intensive Crit Care Nurs 2023; 77:103431. [PMID: 37060812 PMCID: PMC10027952 DOI: 10.1016/j.iccn.2023.103431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 03/14/2023] [Accepted: 03/17/2023] [Indexed: 03/24/2023]
Abstract
Objective The COVID-19 pandemic resulted in extreme system pressures, requiring redeployment of nurses to intensive care units (ICUs). We aimed to assess the impacts of a 3-tiered pandemic surge model on nurses working in ICUs during the COVID-19 pandemic. Methodology In this cross-sectional study, 931 nurses (464 ICU and 467 redeployed nurses) who worked within 4 adult ICUs in Western Canada during pandemic surge(s) were invited via email to participate in a survey. The survey explored the impact of redeployment, rapid ICU orientations, just-in-time training, and the 3-tiered model of nursing during pandemic surge. Burnout was measured utilizing the Copenhagen Burnout Inventory questionnaire. Results A total of 191 survey responses were retained (59 ICU nurses and 132 redeployed). Survey results are reported by tier, with outcomes varying based on team leadership, ICU, and redeployment nursing roles. Burnout in personal and workplace domains was present amongst all nursing tiers, while only team leadership roles experienced burnout in the patient domain. Overall, team leadership roles and permanent ICU nurses experienced the highest rates of burnout. Redeployed nurses reported numerous aids to success including support from colleagues, prior experience, and educational supports. Skill-based orientation, ongoing education, optimized scheduling, role clarity, and mitigators of psychological impacts were identified by respondents as potential facilitators of redeployment and surge models. Conclusion Nurses working within this tiered model experienced high degrees of burnout, with highest prevalence amongst team leads and ICU nurses. Optimization of support for and interventions aimed at improving well-being are important considerations going forward.
Collapse
Affiliation(s)
- Katherine A Kissel
- Department of Critical Care Medicine, Alberta Health Services, Alberta, Canada. https://twitter.com/@kissel_katie
| | - Christine Filipek
- Department of Critical Care Medicine, Alberta Health Services, Alberta, Canada.
| | - Emma Folz
- Department of Critical Care Medicine, Alberta Health Services, Alberta, Canada. https://twitter.com/@emma_folz
| | - Jessica Jenkins
- Department of Critical Care Medicine, Alberta Health Services, Alberta, Canada; Clinical Associate, Faculty of Nursing, University of Calgary, Alberta, Canada. https://twitter.com/@jessjenkinsNP
| |
Collapse
|
34
|
Dobbs T, Staneva M, Byers P. Surviving The Surge: Nonurgent Elective Procedures, Intensive Care, And Mississippi's COVID-19 Waves. Health Aff (Millwood) 2023; 42:416-423. [PMID: 36877908 DOI: 10.1377/hlthaff.2022.00961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- Thomas Dobbs
- Thomas Dobbs , University of Mississippi Medical Center, Jackson, Mississippi
| | - Manuela Staneva
- Manuela Staneva, Mississippi State Department of Health, Jackson, Mississippi
| | - Paul Byers
- Paul Byers, Mississippi State Department of Health
| |
Collapse
|
35
|
López-Ramírez VY, Sanabria-Rodríguez OO, Bottia-Córdoba S, Muñoz-Velandia OM. 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. Intern Emerg Med 2023; 18:429-437. [PMID: 36792855 PMCID: PMC9931170 DOI: 10.1007/s11739-022-03186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/19/2022] [Indexed: 02/17/2023]
Abstract
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.
Collapse
|
36
|
Excess mortality among non-COVID-19 surgical patients attributable to the exposure of French intensive and intermediate care units to the pandemic. Intensive Care Med 2023; 49:313-323. [PMID: 36840798 PMCID: PMC9959950 DOI: 10.1007/s00134-023-07000-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/03/2023] [Indexed: 02/26/2023]
Abstract
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.
Collapse
|
37
|
Weathering the Storm. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2023. [DOI: 10.1097/jat.0000000000000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
|
38
|
A Brief Assessment of Patient Safety Culture in Anesthesia and Intensive Care Departments. Healthcare (Basel) 2023; 11:healthcare11030429. [PMID: 36767004 PMCID: PMC9914654 DOI: 10.3390/healthcare11030429] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/23/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
|
39
|
Burnout and Turnover Intention in Critical Care Professionals During the COVID-19 Pandemic in Japan: A Cross-sectional Survey. Ann Am Thorac Soc 2023; 20:262-268. [PMID: 36122173 PMCID: PMC9989855 DOI: 10.1513/annalsats.202201-029oc] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
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.
Collapse
|
40
|
Richards GA, Smith O. Techniques for Oxygenation and Ventilation in Coronavirus Disease 2019. Semin Respir Crit Care Med 2023; 44:91-99. [PMID: 36646088 DOI: 10.1055/s-0042-1758836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
Collapse
Affiliation(s)
- Guy A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg South Africa
| | - Oliver Smith
- Department of Critical Care and Anaesthesia, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
41
|
Family support in intensive care units during COVID-19 visit ban: A multinational Delphi Study during first COVID-19 wave. Intensive Crit Care Nurs 2023; 74:103308. [PMID: 35985909 PMCID: PMC9343738 DOI: 10.1016/j.iccn.2022.103308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 07/20/2022] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
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.
Collapse
|
42
|
Garnier M, Constantin JM, Heming N, Camous L, Ferré A, Razazi K, Lapidus N. Epidemiology, risk factors and prognosis of ventilator-associated pneumonia during severe COVID-19: Multicenter observational study across 149 European Intensive Care Units. Anaesth Crit Care Pain Med 2023; 42:101184. [PMID: 36509387 PMCID: PMC9731925 DOI: 10.1016/j.accpm.2022.101184] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Abstract
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.
Collapse
Affiliation(s)
- Marc Garnier
- Sorbonne University, GRC29, Assistance Publique-Hôpitaux de Paris (APHP), DMU DREAM, Anesthesiology and Critical Care Medicine Department, Tenon Hospital, Paris, France,Corresponding author at: Anesthesiology and Critical Care Department, Tenon University Hospital, 4 Rue de la Chine, 75020 Paris, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC29, Assistance Publique-Hôpitaux de Paris (APHP), DMU DREAM, Anesthesiology and Critical Care Medicine Department, Pitié-Salpêtrière Hospital, Paris, France
| | - Nicholas Heming
- Department of Intensive Care, Hôpital Raymond Poincaré, APHP University Versailles Saint Quentin — University Paris Saclay, France,Laboratory of Infection & Inflammation — U1173, School of Medicine Simone Veil, University Versailles Saint Quentin — University Paris Saclay, INSERM, Garches, France,FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis) & RHU RECORDS (Rapid rEcognition of CORticosteroiD resistant or sensitive Sepsis), Garches, France
| | - Laurent Camous
- Antilles-Guyane University, Medical and Surgical Intensive Care Unit, Guadeloupe Teaching Hospital, Les Abymes, France
| | - Alexis Ferré
- Intensive Care Unit, Versailles Hospital, Le Chesnay, France
| | - Keyvan Razazi
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France,Université Paris Est Créteil, Faculté de Médecine de Créteil, IMRB, GRC CARMAS, Créteil 94010, France
| | - Nathanaël Lapidus
- Sorbonne University, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, AP-HP, Saint-Antoine Hospital, Public Health Department, F75012 Paris, France
| | | |
Collapse
|
43
|
Naouri D, Vuagnat A, Beduneau G, Dres M, Pham T, Mercat A, Combes A, Demoule A, Kimmoun A, Schmidt M, Jamme M. 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. Ann Intensive Care 2023; 13:2. [PMID: 36631602 PMCID: PMC9834443 DOI: 10.1186/s13613-022-01097-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/17/2022] [Indexed: 01/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Diane Naouri
- Department for Research, Studies, Assessment and Statistics (DREES), French Ministry of Health, 10 Place Des 5 Martyrs du Lycée Buffon, 75014, Paris, France.
| | - Albert Vuagnat
- Department for Research, Studies, Assessment and Statistics (DREES), French Ministry of Health, 10 Place Des 5 Martyrs du Lycée Buffon, 75014, Paris, France
| | - Gaëtan Beduneau
- UNIROUEN, EA 3830, Medical Intensive Care Unit, Rouen University Hospital, Normandie University, 76000, Rouen, France
| | - Martin Dres
- Service de Pneumologie et Réanimation Médicale, Hôpital Pitié Salpétrière, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Tai Pham
- Service de Médecine Intensive-Réanimation, Hôpital du Kremlin Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Alain Mercat
- Service de Réanimation Médicale et Médecine Hyperbare, CHU Angers, Angers, France
| | - Alain Combes
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandre Demoule
- Service de Pneumologie et Réanimation Médicale, Hôpital Pitié Salpétrière, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Antoine Kimmoun
- Service de Médecine Intensive-Réanimation, CHRU Nancy, Nancy, France
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Assistance Publique-Hôpitaux de Paris (APHP) Hôpital Pitié-Salpêtrière, Paris, France
| | - Matthieu Jamme
- Service de Réanimation Polyvalente, Hôpital Privé de l'Ouest Parisien, Ramsay-Générale de Santé, Trappes, France.,CESP, INSERM U1018, Equipe Epidémiologie Clinique, Villejuif, France
| |
Collapse
|
44
|
Lieberum JN, Kaiser S, Kalbhenn J, Bürkle H, Schallner N. Predictive markers related to local and systemic inflammation in severe COVID-19-associated ARDS: a prospective single-center analysis. BMC Infect Dis 2023; 23:19. [PMID: 36631778 PMCID: PMC9832419 DOI: 10.1186/s12879-023-07980-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/02/2023] [Indexed: 01/12/2023] Open
Abstract
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).
Collapse
Affiliation(s)
- Jan Nikolaus Lieberum
- grid.7708.80000 0000 9428 7911Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Freiburg, Germany ,grid.5963.9Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sandra Kaiser
- grid.7708.80000 0000 9428 7911Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Freiburg, Germany ,grid.5963.9Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Kalbhenn
- grid.7708.80000 0000 9428 7911Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Freiburg, Germany ,grid.5963.9Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut Bürkle
- grid.7708.80000 0000 9428 7911Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Freiburg, Germany ,grid.5963.9Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nils Schallner
- grid.7708.80000 0000 9428 7911Department of Anesthesiology and Critical Care Medicine, Medical Center, University of Freiburg, Freiburg, Germany ,grid.5963.9Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
45
|
Ohbe H, Goto T, Okada A, Yasunaga H. Association between COVID-19 pandemic and mental disorders in spouses of intensive care unit patients. Intensive Care Med 2023; 49:112-114. [PMID: 36446853 PMCID: PMC9708118 DOI: 10.1007/s00134-022-06941-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan.
| | - Tadahiro Goto
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan.,TXP Medical Co. Ltd., 7-3-1-252 Hongo, Bunkyo-Ku, Tokyo, 1138454, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033, Japan
| |
Collapse
|
46
|
Flynn-O’Brien KT, Collings AT, Farazi M, Fallat ME, Minneci PC, Speck KE, Van Arendonk K, Deans KJ, Falcone RA, Foley DS, Fraser JD, Gadepalli S, Keller MS, Kotagal M, Landman MP, Leys CM, Markel TA, Rubalcava N, St. Peter SD, Sato TT. Pediatric Injury Transfer Patterns During the COVID-19 Pandemic: An Interrupted time Series Analysis. J Surg Res 2023; 281:130-142. [PMID: 36155270 PMCID: PMC9424522 DOI: 10.1016/j.jss.2022.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/07/2022] [Accepted: 08/21/2022] [Indexed: 01/31/2023]
Abstract
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.
Collapse
Affiliation(s)
- Katherine T. Flynn-O’Brien
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin,Corresponding author. Children's Wisconsin Corporate Center, 999 N. 92nd Street, Ste 320, Milwaukee WI 53266. Tel.: +1 414 266 6557
| | | | - Manzur Farazi
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
| | - Mary E. Fallat
- Norton Children's Hospital, Louisville, Kentucky,Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Peter C. Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - K. Elizabeth Speck
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
| | - Katherine J. Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio,Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard A. Falcone
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S. Foley
- Norton Children's Hospital, Louisville, Kentucky,Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, Kentucky
| | - Jason D. Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Samir Gadepalli
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | - Martin S. Keller
- Division of Pediatric Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Charles M. Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Troy A. Markel
- Department of Surgery, Indiana University, Indianapolis, Indiana
| | - Nathan Rubalcava
- Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, Michigan
| | | | - Thomas T. Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin,Children's Wisconsin, Milwaukee, Wisconsin
| | | |
Collapse
|
47
|
Styrzynski F, Zhakparov D, Schmid M, Roqueiro D, Lukasik Z, Solek J, Nowicki J, Dobrogowski M, Makowska J, Sokolowska M, Baerenfaller K. 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. Infect Dis Ther 2023; 12:111-129. [PMID: 36333475 PMCID: PMC9638383 DOI: 10.1007/s40121-022-00707-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 09/27/2022] [Indexed: 11/06/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Filip Styrzynski
- Department of Rheumatology with Subdepartment of Internal Medicine, Medical University of Lodz, 90-419 Lodz, Poland
| | - Damir Zhakparov
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Herman-Burchard-Strasse 9, 7265 Davos, Switzerland ,Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Marco Schmid
- University of Applied Sciences of the Grisons, 7000 Chur, Switzerland
| | - Damian Roqueiro
- Swiss Institute of Bioinformatics, Lausanne, Switzerland ,Department of Biosystems Science and Engineering, ETH Zurich, 4058 Basel, Switzerland
| | - Zuzanna Lukasik
- Department of Rheumatology with Subdepartment of Internal Medicine, Medical University of Lodz, 90-419 Lodz, Poland ,Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Herman-Burchard-Strasse 9, 7265 Davos, Switzerland
| | - Julia Solek
- Department of Pathology, Chair of Oncology, Medical University of Lodz, 90-419 Lodz, Poland ,Department of Biostatistics and Translational Medicine, Medical University of Lodz, 90-419 Lodz, Poland
| | - Jakub Nowicki
- Department of Paediatrics, Newborn Pathology and Bone Metabolic Diseases, Medical University of Lodz, 90-419 Lodz, Poland
| | - Milosz Dobrogowski
- Maria Sklodowska-Curie Specialty Voivodeship Hospital, 95-100 Zgierz, Poland
| | - Joanna Makowska
- Department of Rheumatology with Subdepartment of Internal Medicine, Medical University of Lodz, 90-419 Lodz, Poland
| | - Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Herman-Burchard-Strasse 9, 7265 Davos, Switzerland ,Christine Kühne – Center for Allergy Research and Education (CK-CARE), 7265 Davos, Switzerland
| | - Katja Baerenfaller
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Herman-Burchard-Strasse 9, 7265 Davos, Switzerland ,Swiss Institute of Bioinformatics, Lausanne, Switzerland
| |
Collapse
|
48
|
Donat N, Mellati N, Frumento T, Cirodde A, Gette S, Guitard PG, Hoffmann C, Veber B, Leclerc T. Validation of a pre-established triage protocol for critically ill patients in a COVID-19 outbreak under resource scarcity: A retrospective multicenter cohort study. PLoS One 2023; 18:e0285690. [PMID: 37167306 PMCID: PMC10174588 DOI: 10.1371/journal.pone.0285690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 04/28/2023] [Indexed: 05/13/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Nicolas Donat
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | - Nouchan Mellati
- ICU, Mercy Regional Hospital, Metz, France
- Legouest Military Teaching Hospital, Metz, France
| | | | - Audrey Cirodde
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | | | | | - Clément Hoffmann
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
| | - Benoît Veber
- ICU, Rouen University Hospital, Rouen, France
- Faculty of Medicine, Rouen University, Rouen, France
| | - Thomas Leclerc
- Burn Treatment Center and COVID-19 ICU, Percy Military Teaching Hospital, Clamart, France
- Val-de-Grâce Military Medical Academy, Paris, France
| |
Collapse
|
49
|
Rodriquez J. Reconfiguring the social organization of work in the intensive care unit: Changed relationships and new roles during COVID-19. Soc Sci Med 2023; 317:115600. [PMID: 36538836 PMCID: PMC9721201 DOI: 10.1016/j.socscimed.2022.115600] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/28/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Jason Rodriquez
- Department of Sociology, University of Massachusetts Boston, 100 Morrissey Blvd, Boston, MA, 02115, USA.
| |
Collapse
|
50
|
Ramirez CC, Farmer Y, Bouthillier ME. Public voices on tie-breaking criteria and underlying values in COVID-19 triage protocols to access critical care: a scoping review. DISCOVER HEALTH SYSTEMS 2023; 2:16. [PMID: 37206881 PMCID: PMC10169297 DOI: 10.1007/s44250-023-00027-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/14/2023] [Indexed: 05/21/2023]
Abstract
Background To reduce the arbitrariness in the allocation of rare resources in intensive care units (ICU) in the context of the pandemic, tiebreakers were considered in some COVID-19 triage algorithms. They were also contemplated to facilitate the tragic decisions of healthcare workers when faced with two patients with similar prognosis and only one ICU bed available. Little is known about the public's perspective on tiebreakers. Objectives To consolidate the available scientific literature on public consultations, particularly on tiebreakers and their underlying values. Also, to obtain an overview of the key arguments presented by the participating public and to identify potential gaps related to this topic. Methods The steps described by Arksey and O'Malley was the preferred method to our approach. Seven electronic databases were searched from January 2020 to April 2022, using keywords for each database: PubMed, Medline, EMBASE, Web of Science, PsycINFO, EBM reviews, CINAHL complete. We also searched in Google and Google Scholar, and in the references of the articles found. Our analysis was mainly qualitative. A thematic analysis was performed to consider the public's perspectives on tiebreakers and their underlying values, according to these studies. Results Of 477 publications found, 20 were selected. They carried out public consultations through various methods: surveys (80%), interviews (20%), deliberative processes (15%) and others (5%) in various countries: Australia, Brazil, Canada, China, France, Germany, India, Iran, Italy, Japan, Korea, Netherlands, Portugal, Spain, Switzerland, Thailand, United Kingdom, and United States. Five themes emerged from our analysis. The public favored the life cycle (50%) and absolute age (45%) as a tiebreaker. Other values considered important were reciprocity, solidarity, equality, instrumental value, patient merit, efficiency, and stewardship. Among the new findings were a preference for patient nationality and those affected by COVID-19. Conclusions There is a preference for favoring younger patients over older patients when there is a tie between similar patients, with a slight tendency to favor intergenerational equity. Variability was found in the public's perspectives on tiebreakers and their values. This variability was related to socio-cultural and religious factors. More studies are needed to understand the public's perspective on tiebreakers. Supplementary Information The online version contains supplementary material available at 10.1007/s44250-023-00027-9.
Collapse
Affiliation(s)
- Claudia Calderon Ramirez
- Biomedical Sciences Program, Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
| | - Yanick Farmer
- Department of Social and Public Communication, Faculty of Communication, Université du Québec à Montréal, C.P 8888, Succursale Centre-Ville, Montréal, Québec H3C 3P8 Canada
| | - Marie-Eve Bouthillier
- Department of Family and Emergency Medicine and Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, 2900 Bd Édouard-Montpetit, Montréal, Québec H3T 1J4 Canada
| |
Collapse
|