Prognosis After Emergency Department Intubation to Inform Shared Decision-Making

Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?

OBJECTIVE

To describe the effects of different induction agents on the incidence of post-induction hypotension (PIH) and its associated interventions during rapid sequence intubation (RSI) in the ED.

METHODS

A single centre retrospective study of patients intubated between 2018 and 2021 was conducted in a regional Australian ED. The impact of induction agent choice, in addition to demographic and clinical factors on the incidence of PIH were determined using descriptive statistics and a multivariate analysis presented as adjusted odds ratios (aORs) and their 95% confidence intervals (CIs).

RESULTS

Ketamine and propofol, used either individually or in conjunction with fentanyl, were significantly associated with PIH (ketamine aOR 4.5, 95% CI 1.35-14.96; propofol aOR 4.88, 95% CI 1.46-16.29). Age >60 years was associated with a greater requirement for vasopressors (aOR 4.46, 95% CI 2.49-7.97) and a higher risk of mortality after RSI (aOR 4.2, 95% CI 1.87-9.40). Patients with a shock index >1.0 were significantly more likely to require vasopressors (aOR 5.13, 95% CI 2.35-11.2) and have a cardiac arrest within 15 min of RSI (aOR 3.56, 95% CI 1.07-11.8).

CONCLUSIONS

Exposure to both propofol and ketamine is significantly associated with PIH after RSI, alongside age and shock index. PIH is likely multifactorial in nature, and this data supports the sympatholytic effect of induction agents as the underlying cause of PIH rather than the choice of agent itself. Further prospective work including a randomised controlled trial between induction agents is justified to further clarify this important clinical question.

Institution of a difficult airway response team for emergency department patients with anticipated or encountered difficult airways: Descriptive analysis of a 5-year experience at an academic teaching hospital

Objectives

This study aimed to describe characteristics and outcomes associated with difficult airway response team (DART) encounters in the emergency department (ED).

Methods

We performed a descriptive analysis of a prospective, single-center database of DART encounters in the ED from April 1, 2016 to March 31, 2021 cross-referenced with retrospective chart review. Adult ED patients ≥18 years old for whom a DART was activated were eligible. We prospectively collected activation characteristics, intubation indications, operator characteristics, and intubation methods used for DART encounters. Retrospective chart review was conducted to obtain patient demographics and outcome variables. Descriptive analyses were computed for all outcomes.

Results

We analyzed 89 DART encounters. No intubation attempts were made prior to DART activation in 52 cases (58.4%). The most common indications for intubation were angioedema (n = 17, 19.1%) or other airway obstruction (n = 15, 16.9%). A definitive airway was established by anesthesiology (n = 46, 51.7%), emergency medicine (n = 25, 28.1%), trauma surgery (n = 9, 10.1%), and ENT (n = 5, 5.6%). The most common method of intubation used to establish a definitive airway was video laryngoscopy with a bougie or D-blade (n = 29, 32.6%) followed by flexible fiberoptic intubation (n = 19, 21.3%). A surgical airway was required in eight encounters (cricothyrotomy [n = 4, 4.5%]; tracheostomy [n = 4, 4.5%]). Cases were managed in the ED (n = 73, 82%), operating room (OR) (n = 10, 11.2%), and intensive care unit (ICU) (n = 1, 1.1%). All patients requiring intubation had an endotracheal or surgical airway established.

Conclusion

Our findings provide important insights regarding ED DART utilization and have implications when considering institution of a DART in the ED.

Frequency of Intubation for Medicare Beneficiaries With Acute Stroke and Association With Patient Outcomes

BACKGROUND AND OBJECTIVES

Intubation for acute stroke is common in the United States, with few established guidelines.

METHODS

This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions.

RESULTS

There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients (p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality.

DISCUSSION

Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.

"Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital

BACKGROUND

There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care.

OBJECTIVE

This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting.

METHODS

A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes.

RESULTS

6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level.

CONCLUSION

Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.

Glasgow Coma Scale Intubation Thresholds and Outcomes of Patients With Traumatic Brain Injury: The Need for Tailored Practice Management Guidelines

INTRODUCTION

This study aims to re-evaluate the GCS threshold for intubation in patients presenting to the ED with a traumatic brain injury to optimize outcomes and provide evidence for future practice management guidelines.

METHODS

We retrospectively reviewed the ACS-TQIP-Participant Use File (PUF) 2015-2019 for adult trauma patients 18 years and older who experienced a blunt traumatic head injury and received computerized tomography. Multivariable regressions were performed to assess associations between outcomes and GCS intubation thresholds of 5, 8, and 10.

RESULTS

In patients with a GCS ≤5, there were no differences in mortality (GCS ≤5: 26.3% vs GCS >5: 28.3%, adjusted P = .08), complication rates (GCS ≤5: 9.1% vs GCS >5: 10.3%, adjusted P = .91), or ICU length of stay (GCS ≤5: 5.4 vs GCS >5: 4.7, adjusted P = .36) between intubated and non-intubated patients. Intubated patients at GCS thresholds ≤8 (26.2% vs 19.1%, adjusted P < .0001) and ≤10 (25.6% vs 15.8%, adjusted P < .0001) had significantly higher mortality rates than non-intubated patients. Intubation at all GCS thresholds >5 resulted in higher rates of complications, H-LOS, and ICU-LOS when compared to non-intubated patients with the same GCS score.

CONCLUSION

A GCS ≤5 was the threshold at which intubation in TBI patients conferred an additional benefit in disposition without worsened outcomes of mortality, H-LOS, or ICU-LOS. Trauma societies and hospital institutions should consider revisiting existing guidelines and protocols concerning the appropriate GCS threshold for safer intubation and better outcomes among these patient population.

Arterial to end-tidal carbon dioxide gap and its characterization in mechanically ventilated adults in the emergency department

PURPOSE

To evaluate early measurement of the arterial to end-tidal carbon dioxide (PaCO2-PetCO2) gap, a surrogate for physiologic dead space, and its association with clinical outcomes in intubated adults in the emergency department (ED).

MATERIALS AND METHODS

Observational cohort study of invasively mechanically ventilated adults in an academic medical center (years 2009 to 2016). The association of the PaCO2-PetCO2 gap was evaluated with respect to clinical outcomes; the primary outcome was in-hospital mortality.

RESULTS

519 patients were included. 325 (63%) patients had an elevated (>5 mmHg) PaCO2-PetCO2. Patients with an elevated PaCO2-PetCO2 were significantly older, had higher APACHE II scores, more frequently had chronic obstructive pulmonary disease (COPD), had lower arterial oxygen to fraction of inspired oxygen (P:F) ratios, and were more likely to be intubated for exacerbation of COPD or sepsis. There was no difference in mortality for patients with an elevated PaCO2-PetCO2 (25% vs 26%) in unadjusted analysis (p = 0.829) or adjusted analysis (aOR = 0.81 [95% CI: 0.53-1.26]), as compared to a non-elevated PaCO2-PetCO2.

CONCLUSIONS

An elevated PaCO2-PetCO2 gap is common in the post-intubation period in the ED, but not significantly associated with clinical outcomes.

Diversity, Equity, and Inclusion: Considerations in the Geriatric Emergency Department Patient

This article introduces core topics in health equity scholarship and provides examples of how diversity, equity, and inclusion impact the aging population and emergency care of older adults. It offers strategies for promoting diversity, equity, and inclusion to both strengthen the patient-clinician therapeutic relationship and to address operations and systems that impact care of the geriatric emergency department patient.

One-Year Functional Outcomes After Invasive Mechanical Ventilation for Older Adults With Preexisting Long-Term Care-Needs

OBJECTIVES

To examine 1-year functional outcomes after invasive mechanical ventilation for adults greater than or equal to 65 years with preexisting long-term care-needs.

DESIGN

We used medical and long-term care administrative databases. The database included data on functional and cognitive impairments that were assessed with the national standardized care-needs certification system and were categorized into seven care-needs levels based on the total daily estimated care minutes. Primary outcome was mortality and care-needs at 1 year after invasive mechanical ventilation. Outcome was stratified by preexisting care-needs at the time of invasive mechanical ventilation: no care-needs, support level 1-2 and care-needs level 1 (estimated care time 25-49 min), care-needs level 2-3 (50-89 min), and care-needs level 4-5 (≥90 min).

SETTING

A population-based cohort study in Tochigi Prefecture, one of 47 prefectures in Japan.

PATIENTS

Among people greater than or equal to 65 years old registered between June 2014 and February 2018, patients who received invasive mechanical ventilation were identified.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Among 593,990 eligible people, 4,198 (0.7%) received invasive mechanical ventilation. The mean age was 81.2 years, and 55.5% were male. The 1-year mortality rates after invasive mechanical ventilation in patients with no care-needs, support level 1-2 and care-needs level 1, care-needs level 2-3, and care-needs level 4-5 at the time of invasive mechanical ventilation were 43.4%, 54.9%, 67.8%, and 74.1%, respectively. Similarly, those with worsened care-needs were 22.8%, 24.2%, 11.4%, and 1.9%, respectively.

CONCLUSIONS

Among patients in preexisting care-needs levels 2-5 who received invasive mechanical ventilation, 76.0-79.2% died or had worsened care-needs within 1 year. These findings may aid shared decision-making among patients, their families, and heath care professionals on the appropriateness of starting invasive mechanical ventilation for people with poor functional and cognitive status at baseline.

Validation of a Simple Score for Mortality Prediction in a Cohort of Unselected Emergency Patients

BACKGROUND

Prognostication is an important component of medical decision-making. A patients' general prognosis can be difficult to measure. The Simple Prognostic Score (SPS) was designed to include patients' age, mobility, aggregated vital signs, and the treating physician's decision to admit to aid prognostication. Study Aim. Our study aim is to validate the SPS, compare it with the Emergency Severity Index (ESI) regarding its prognostic performance, and test the interrater reliability of the subjective variable of the decision to admit.

METHODS

Over a period of 9 weeks all patients presenting to the ED were included, routinely interviewed, final disposition registered, and followed up for one year. The C-statistics of discrimination was used to compare SPS and ESI predictions of 7-day, 30-day, and 1-year mortality. Youden J Statistics and Odds ratio, using logistical regression, were calculated for the Simple Prognostic Score. In a subset, a chart review was performed by senior physicians for a secondary assessment of the decision to admit. Interrater reliability was calculated using percentages and Cohens Kappa.

RESULTS

Out of 5648 patients, 3272 (57.9%) had a low SPS (i.e., ≤ 1); none of these patients died within 7 days, 2 (0.1%) died within 30 days after presentation and 19 (0.6%) died within a year. The area under the curve for 1-year mortality of the Simple Prognostic Score was 0.848. Secondary analysis of the interrater agreement for the decision to admit was 92%.

CONCLUSION

In a prospective study of unselected ED patients, the Simple Prognostic Score was validated as a reliable predictor of short- and long-term mortality.

Prognosis of patients with tracheal intubation in the emergency department

Background

Intubation of critically ill patients is one of the increasing emergency procedures. We designed this study to determine age and sex-related mortality rates after emergency intubation.

Methods

This retrospective study collected and analyzed non-trauma intubated patients in a referral hospital from the years 2017-2019 and before the appearance of COVID-19. Patients who were intubated outside of emergency by EMS technicians were excluded. We recorded data of intubated patients, like sex, age, length of being intubated and final diagnosis. P values of less than 0.05 were significant.

Results

Data of 520 non-trauma intubated patients were collected and analyzed. More than 64% of the patients were over 65 years old and had a higher mortality rate (86.7%; P < 0.001) than younger patients. The overall in-hospital mortality rate was 80%. More than three quarters of the decedents died within a week of intubation (P < 0.001). There was no significant relationship between sex and mortality rate (P = 0.535).

Conclusion

Our data showed that with increased age there was a decrease in the chance of being extubated.

In-hospital mortality associated factors in elderly patients with invasive mechanical ventilation in the emergency department

AIMS

To identify factors associated with in-hospital mortality, to estimate the intubation rate and to describe in-hospital mortality in patients over 65 years old with invasive mechanical ventilation (IMV) in the emergency department (ED).

METHODS

Retrospective cohort study of patients over 65 years old, who were intubated in an ED of a high complexity hospital between 2016 and 2018. Demographic data, comorbidities, and severity scores on admission were described. Bivariate and multivariate analyses were performed with logistic regression according to mortality and possible confounders.

RESULTS

A total of 285 patients with a mean age of 80 years required IMV in the emergency department, for a median of 3 days, and with a mean APACHE II score of 20 points of severity. The IMV rate was .48% (95% CI .43-.54), and 55.44% (158) died. Mortality-associated factors after age and sex adjustment were stroke (OR 2.13; 95% CI 1.21-3.76), chronic kidney failure, (OR 4.,38; 95% CI 1.91-10.04), Charlson index (OR 1.19; 95% CI 1.02-1.38), APACHE II score (OR 1.07; 95% CI 1.02-1.12), and SOFA score (OR 1.14; 95% CI 1.03-1.27).

DISCUSSION

Our IMV rate was lower than that stated by Johnson et al. in the United States in 2018 (.59%). In-hospital mortality in our study exceeded that predicted by the APACHE II score (40%) and SOFA (33%). However it was consistent with that reported by Lieberman et al. in Israel and Esteban et al. in the United States.

CONCLUSIONS

Although the IMV rate was low in the ED, more than half the patients died during hospitalization. Pre-existing cerebrovascular and renal diseases and high results in the comorbidities index and severity scores on admission were independent factors associated with in-hospital mortality.

Characteristics and outcomes of mechanically ventilated elderly patients in the absence of an end-of-life care policy: a retrospective study from Bahrain

BACKGROUND

Globally, the percentage of elderly patients has been increasing, leading to a higher demand for healthcare resources and intensive care. Bahrain has a majority Muslim population and Islam governs most policies, including end-of-life care. All patients at our institute receive full resuscitative measures regardless of the prognosis, leading to a high number of mechanically ventilated patients.

OBJECTIVES

Assess characteristics, outcomes, theoretical costs, and use of antibiotics in critically ill elderly patients requiring mechanical ventilation.

DESIGN

Retrospective.

SETTING

Intensive care unit and general ward of a tertiary medical care center.

PATIENTS AND METHODS

We studied all elderly patients (≥60 years old) admitted under general medicine in the period of January to June 2018 who needed intensive care and were intubated.

MAIN OUTCOME MEASURES

The duration of mechanical ventilation, theoretical costs, antibiotic usage.

SAMPLE SIZE

140 patients.

RESULTS

Of 140 patients, 136 died (97%) and half of the deaths (n=69, 50.7%) occurred within the first 24 hours of intubation. Sixty-nine (79.3%) of the patients on short-term ventilation (≤96 hours) died within 24 hours of intubation, while the four survivors were on long-term ventilation (>96 hours) (P<.001). All the nonsurviving patients (n=136) were on antimicrobial therapy, mostly for hospital-acquired infections. The median (interquartile range) APACHE II score was relatively high at 28.0 (8.0) with significantly higher scores in the early mortality group compared to the late mortality group (30 [10] vs 26 [7], P=.013) and higher scores in the short-term vs long-term ventilation group (29 [10] vs 26 [7], P=.029). The median theoretical cost per patient in the early and late mortality groups was USD 10 731 and USD 30 660, respectively (P<.001).

CONCLUSIONS

Given that less than 3% of patients had a favorable outcome, 50% of the cases died within 24 hours after intubation, hospital costs and antimicrobial use were high, the current policy of "full resuscitative measures for all" should be revised. We suggest implementing an end-of-life care policy, since the goal of resuscitation is to reverse premature death, not prolong the dying process.

LIMITATIONS

Small sample size and absence of long-term follow-up. Theoretical costs were used as no direct calculated costs were available in our hospital.

CONFLICT OF INTEREST

None.

Association of Frailty with Adverse Outcomes in Patients with Suspected COVID-19 Infection

Older age and frailty are predictors of adverse outcomes in patients with COVID-19. In emergency medicine, patients do not present with the diagnosis, but with suspicion of COVID-19. The aim of this study was to assess the association of frailty and age with death or admission to intensive care in patients with suspected COVID-19. This single-centre prospective cohort study was performed in the Emergency Department of a tertiary care hospital. Patients, 65 years and older, with suspected COVID-19 presenting to the Emergency Department during the first wave of the pandemic were consecutively enrolled. All patients underwent nasopharyngeal SARS-CoV-2 PCR swab tests. Patients with a Clinical Frailty Scale (CFS) > 4, were considered to be frail. Associations between age, gender, frailty, and COVID-19 status with the composite adverse outcome of 30-day-intensive-care-admission and/or 30-day-mortality were tested. In the 372 patients analysed, the median age was 77 years, 154 (41.4%) were women, 44 (11.8%) were COVID-19-positive, and 125 (33.6%) were frail. The worst outcome was seen in frail COVID-19-patients with six (66.7%) adverse outcomes. Frailty (CFS > 4) and COVID-19-positivity were associated with an adverse outcome after adjustment for age and gender (frailty: OR 5.01, CI 2.56–10.17, p < 0.001; COVID-19: OR 3.47, CI 1.48–7.89, p = 0.003). Frailty was strongly associated with adverse outcomes and outperformed age as a predictor in emergency patients with suspected COVID-19.

Factors Associated With Poor Long-Term Outcomes After Emergency Department Intubation

Introduction

While immediate complications of ED patients undergoing endotracheal intubation (ETI) have been explored, the relationship between ED ETI and patient status at hospital discharge is unknown.

Methods

We performed a retrospective review of all intubations performed in our ED for one calendar year in adult patients (>18 years of age). We abstracted patient and ETI factors (indication, complications, etc.) to determine their impact on patient outcomes. We defined a poor outcome as either (1) death or discharge to a nursing home if admitted to the hospital from home or (2) death if admitted to the hospital from a nursing home. We examined the univariate odds ratios for poor outcomes. 

Results

We identified 122 intubations; 64 (52.5%) had a poor outcome and 58 (47.5%) did not have a poor outcome. Age in years (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07) and ETI performed for an indication of "cardiac arrest" (OR 4.49, 95% CI 1.55-13.01) were the only variables associated with a poor outcome. Other patients and intubation variables were not associated with a poor outcome including; gender, difficult airway characteristics, intubator skill level, first attempt success, airway complications, and post-intubation hypoxia or hypotension.

Conclusion

In our sample from a single ED, over 50% of patients who undergo ED ETI either died in the hospital or failed to return home. While age and an ETI indication of "cardiac arrest" were associated with poor outcomes, future work is required to validate our findings in a larger cohort.

The geriatric emergency literature 2020: COVID and beyond

Older adults are a rapidly growing patient population with unique characteristics and health considerations. Over the past few years, emergency physicians have started to recognize the complexities and importance of Geriatric Emergency Medicine. Several noteworthy elements of their healthcare were brought to the forefront of emergency medicine because this especially vulnerable patient population was disproportionately affected by the pandemic. Clinical topics such as delirium, telehealth, end-of-life care, and elder abuse came into focus; select relevant articles are reviewed. We also highlight equally notable literature which address clinically challenging topics, such as hip fractures and syncope. Finally, articles about improving the experience of and decreasing recidivism in geriatric emergency department patients are reviewed. In short, this review article summarizes geriatric emergency medicine literature that can help you improve your practice while caring for older adults.

Rural and Remote Intubations in an Australian Air Medical Retrieval Service: A Retrospective Cohort Study

OBJECTIVE

Critically unwell patients in rural and remote areas of Queensland, Australia, often require airway management with rapid sequence intubation before retrieval to a tertiary center. Retrieval Services Queensland coordinate retrievals and support rural hospitals, including via telehealth. This study compared the demographics of patients intubated by a retrieval team including a LifeFlight Retrieval Medicine doctor with those intubated by the local hospital team.

METHODS

This was a retrospective cohort study of patients intubated in hospitals in Queensland, Australia, requiring subsequent air medical retrieval between January and December 2019. The data collected included the time of day, mission priority, geographic location, diagnosis, and failure/assistance with intubation. Descriptive statistics were complemented by regression analyses.

RESULTS

In 2019, 684 patients were intubated in hospitals in Queensland, Australia, requiring air medical retrieval by a team including a LifeFlight Retrieval Medicine doctor. One hundred thirty-one (19.2%) were intubated by the retrieval team, and 553 (80.8%) were intubated by the hospital team. In the most rural and remote areas, 64 (43.2%) of the patients were intubated by the retrieval team compared with 84 (56.8%) by the hospital team.

CONCLUSION

A retrieval team is more likely to intubate patients in remote hospitals in Queensland, Australia. Remote hospitals should be given preference for dispatch of the retrieval team for assistance with critical patients.

Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors

BACKGROUND

Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit.

OBJECTIVE

To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors.

METHODS

The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates.

RESULTS

The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = -0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = -0.373, P = .008) were negatively associated with DCCST scores.

CONCLUSIONS

The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.

Cultures of Practice: Specialty-Specific Differences in End-of-Life Conversations

Importance: Goals of care discussions at the end of life give opportunity to affirm the autonomy and humanity of dying patients. Best practices exist for communication around goals of care, but there is no research on differences in approach taken by different specialties engaging these conversations. Objective: To describe the communication practices of internal medicine (IM), emergency medicine (EM), and critical care (CC) physicians in a high-fidelity simulation of a terminally ill patient with stable and defined end-of-life preferences. Design, Setting, and Participants: Mixed-methods secondary analysis of transcripts obtained from a multicenter study simulating high stakes, time-limited end-of-life decision making in a cohort of 88 volunteer physicians (27 IM, 22 EM, and 39 CC) who were called to evaluate a standardized patient in extremis. The patient had clear comfort-oriented goals of care that the physician needed to elicit and use to inform treatment decisions. Discussions were coded at the level of the sentence for semantic content. Exposures: Data were analyzed by physician specialty. Main Outcome Measure: Occurrence of content codes indicative of prudent (right outcome by the right means) goals of care conversations. Data were analyzed both for number of occurrences of the code in a simulated conversation and for presence or absence of the code within a conversation. Results: There was no difference between physician types in intubation rates or intensive care unit admissions. Codes for "comfort as a goal of care," "noncurative goals of care," and "oblique references to death" emerged as significantly different between physician types. Conclusions and Relevance: This experiment shows demonstrable differences in practice patterns between physician specialties when addressing end-of-life decision making. Some of the variation likely arose from differences in setting, but these data suggest that training in goals of care conversations may benefit if it is adapted to the distinct needs and culture of each specialty.

Sleep Quality Associated With Motor Function Among Older Adult Survivors of Critical Illness

BACKGROUND

Poor sleep is associated with worse motor function in older adults. Sleep may affect motor function specifically among older adults recovering from critical illness after transfer out of an intensive care unit (ICU).

OBJECTIVES

Describe motor function (grip strength) of older ICU survivors and explore relationships between sleep and ICU-acquired weakness in the early post-ICU transition period.

METHODS

We enrolled 30 older adults who were functionally independent prior to hospitalization, mechanically ventilated while in ICU, and within 24-48 hours post-ICU discharge. Handgrip dynamometry assessed post-ICU motor function (fully corrected T score on the National Institutes of Health Motor Battery Grip Strength Test). Actigraphy estimated post-ICU sleep duration (total sleep time [TST]) and fragmentation (wake after sleep onset) over two consecutive nights from 22:00 p.m. to 06:00 a.m.. We identified differences in grip strength by history of obstructive sleep apnea (OSA) using independent-samples t tests. We examined associations between sleep duration and grip strength using exploratory multivariate regression analyses, after adjustment for clinically relevant covariates.

RESULTS

Grip strength among this cohort of older ICU survivors was almost 2 SDs below the norm for healthy older adults, indicating considerable ICU-acquired weakness. Grip strength was lower among subjects with history of OSA than those without OSA. Greater TST was associated with worse grip strength, after adjusting for history of OSA and Pittsburgh Sleep Quality Index global score. Moreover, among the subset of male subjects (n = 19), greater TST was significantly and negatively associated with grip strength, after adjusting for Acute Physiology, Age, and Chronic Health Evaluation III score, and Pittsburgh Sleep Quality Index global score.

DISCUSSION

Sleep promotion may be a potentially modifiable risk factor to mitigate ICU-acquired weakness in older ICU survivors. We propose that improving sleep throughout recovery from critical illness may indirectly promote better outcomes, as poor grip strength is linked to longer length of hospital stay, higher acuity of discharge disposition, and worsened functional decline in older adults.

Executive Function, Dexterity, and Discharge Disposition in Older Intensive Care Unit Survivors

BACKGROUND

Dexterity is a component of motor function. Executive function, a subdomain of cognition, may affect dexterity in older adults recovering from critical illness after discharge from an intensive care unit (ICU).

OBJECTIVES

To explore associations between executive function (attention and cognitive flexibility) and dexterity (fine motor coordination) in the early post-ICU period and examine dexterity by acuity of discharge disposition.

METHODS

The study involved 30 older adults who were functionally independent before hospitalization, underwent mechanical ventilation in the ICU, and had been discharged from the ICU 24 to 48 hours previously. Dexterity was evaluated with the National Institutes of Health Toolbox (NIHTB) Motor Battery 9-Hole Pegboard Dexterity Test (PDT); attention, with the NIHTB Cognition Battery Flanker Inhibitory Control and Attention Test (FICAT); and cognitive flexibility, with the NIHTB Cognition Battery Dimensional Change Card Sort Test (DCCST). Exploratory regression was used to examine associations between executive function and dexterity (fully corrected T scores). Independent-samples t tests were used to compare dexterity between participants discharged home and those discharged to a facility.

RESULTS

FICAT (β = 0.375, P = .03) and DCCST (β = 0.698, P = .001) scores were independently and positively associated with PDT scores. Further, PDT scores were worse among participants discharged to a facility than among those discharged home (mean [SD], 26.71 [6.14] vs 36.33 [10.30]; t24 = 3.003; P = .006).

CONCLUSIONS

Poor executive function is associated with worse dexterity; thus, dexterity may be a correlate of both post-ICU cognitive impairment and functional decline. Performance on dexterity tests could identify frail older ICU survivors at risk for worse discharge outcomes.

Long-Term Prognosis of Older Adults Who Survive Emergency Mechanical Ventilation

CONTEXT

Emergent mechanical ventilation represents an important inflection point in seriously ill older adults' illness trajectories. Data are lacking on the long-term prognosis after surviving mechanical ventilation to inform shared decision making in serious illness conversations.

OBJECTIVES

Describe the long-term prognosis of older adults who survive emergency mechanical ventilation to inform shared decision making.

METHODS

This is a retrospective cohort study from a single-center intensive care unit in an academic, urban, and tertiary care medical center. We included adults aged 75 years and older consecutively admitted with mechanical ventilation between 2008 and 2012 in the Multiparameter Intelligent Monitoring of Intensive Care III database. We excluded patients who were electively admitted. Our primary outcome was the long-term prognosis after leaving the hospital stratified by discharge location. Our secondary outcome was the frequency of documented serious illness conversations within 48 hours of hospitalization recommended by the National Quality Forum.

RESULTS

We identified 415 patients (454 hospital admissions) consecutively admitted to the intensive care unit. The median age was 82.6 years, 54.0% were female, 78.2% were white, non-Hispanic, and in-hospital mortality rate was 36.6%. Among the survivors, the median survival after hospital discharge was 163.5 days (interquartile range 37.5-476.8). Only 49.1% of patients had documented serious illness conversations within 48 hours of hospitalization. About 63.4% of patients (59 of 93) who were discharged to long-term acute care hospitals died by six months.

CONCLUSION

This study demonstrated the long-term prognosis of older adults who underwent emergent mechanical ventilation. These data could be used to inform shared decision making in serious illness conversations.

Outcomes of Intensive Care Patients Older Than 90 Years: An 11-Year National Observational Study

BACKGROUND/OBJECTIVES

Many intensive care unit (ICU) physicians are reluctant to admit patients aged 90 years and older, although evidence to support these decisions is scarce. Although the body of evidence on outcomes of patients aged 80 years and older is growing, it does not include patients aged 90 years and older. The aim of this study was to compare the short- and long-term mortality of ICU patients aged 90 years and older in the Netherlands with ICU patients aged 80 to 90 years, that is, octogenarians.

DESIGN

Multicenter national cohort study over an 11-year period (2008-2018), using data of the National Intensive Care Evaluation (NICE) registry and the Dutch insurance claims registry.

SETTING

All 82 ICUs in the Netherlands.

PARTICIPANTS

All patients aged 80 years and older at the time of ICU admission.

MEASUREMENTS

A total of 104,754 patients aged 80 years and older, of whom 9,495 (9%) were 90 years and older, were admitted to Dutch ICUs during the study period.

RESULTS

ICU mortality of the patients aged 90 years and older was lower (13.8% vs 16.1%; P < .001) and hospital mortality was similar (26.1% vs 25.7%; P = .41) compared with octogenarians. After 3 months, mortality was higher for the patients aged 90 years and older (43.1% vs 33.7%; P < .001) and after 1-year mortality was 55.0% vs 42.7%; P < .001.

CONCLUSION

In the Netherlands, mortality rates of patients aged 90 years and older admitted to the ICU are not as disappointing as often assumed. They have a lower ICU mortality and a similar hospital mortality compared with octogenarians. Nevertheless, their longer term mortality is higher compared with octogenarians. However, almost 3 of 4 patients leave the hospital alive, and almost half of the patients aged 90 years and older are still alive 1 year after their ICU admission. J Am Geriatr Soc 68:1842-1846, 2020.

Validation of the Clinical Frailty Scale for Prediction of Thirty-Day Mortality in the Emergency Department

STUDY OBJECTIVE

We validate the Clinical Frailty Scale by examining its independent predictive validity for 30-day mortality, ICU admission, and hospitalization and by determining its reliability. We also determine frailty prevalence in our emergency department (ED) as measured with the Clinical Frailty Scale.

METHODS

This was a prospective observational study including consecutive ED patients aged 65 years or older, from a single tertiary care center during a 9-week period. To examine predictive validity, association with mortality was investigated through a Cox proportional hazards regression; hospitalization and ICU transfer were investigated through multivariable logistic regression. We assessed reliability by calculating Cohen's weighted κ for agreement of experts who independently assigned Clinical Frailty Scale levels, compared with trained study assistants. Frailty was defined as a Clinical Frailty Scale score of 5 and higher.

RESULTS

A total of 2,393 patients were analyzed in this study, of whom 128 died. Higher frailty levels were associated with higher hazards for death independent of age, sex, and condition (medical versus surgical). The area under the curve for 30-day mortality prediction was 0.81 (95% confidence interval [CI] 0.77 to 0.85), for hospitalization 0.72 (95% CI 0.70 to 0.74), and for ICU admission 0.69 (95% CI 0.66 to 0.73). Interrater reliability between the reference standard and the study team was good (weighted Cohen's κ was 0.74; 95% CI 0.64 to 0.85). Frailty prevalence was 36.8% (n=880).

CONCLUSION

The Clinical Frailty Scale appears to be a valid and reliable instrument to identify frailty in the ED. It might provide ED clinicians with useful information for decisionmaking in regard to triage, disposition, and treatment.

A Comparison of Scoring Systems for Predicting Short- and Long-term Survival After Trauma in Older Adults

OBJECTIVES

Early identification of geriatric patients at high risk for mortality is important to guide clinical care, medical decision making, palliative discussions, quality assurance, and research. We sought to identify injured older adults at highest risk for 30-day mortality using an empirically derived scoring system from available data and to compare it with current prognostic scoring systems.

METHODS

This was a retrospective cohort study of injured adults ≥ 65 years transported by 44 emergency medical services (EMS) agencies to 49 emergency departments in Oregon and Washington from January 1, 2011, through December 31, 2011, with follow-up through December 31, 2012. We matched data from EMS to Medicare, inpatient, trauma registries, and vital statistics. Using a primary outcome of 30-day mortality, we empirically derived a new risk score using binary recursive partitioning and compared it to the Charlson Comorbidity Index (CCI), modified frailty index, geriatric trauma outcome score (GTOS), GTOS II, and Injury Severity Score (ISS).

RESULTS

There were 4,849 patients, of whom 234 (4.8%) died within 30 days and 1,040 (21.5%) died within 1 year. The derived score, the geriatric trauma risk indicator (GTRI; emergent airway or CCI ≥ 2), had 87.2% sensitivity (95% confidence interval [CI] = 83.0% to 91.5%) and 30.6% specificity (95% CI = 29.3% to 31.9%) for 30-day mortality (area under the receiving operating characteristic curve [AUROC] = 0.589, 95% CI = 0.566 to 0.611). AUROC values for other scoring systems ranged from 0.592 to 0.678. When the sensitivity for each existing score was held at 90%, specificity values ranged from 7.5% (ISS) to 30.6% (GTRI).

CONCLUSIONS

Older, injured adults transported by EMS to a large variety of trauma and nontrauma hospitals were more likely to die within 30 days if they required emergent airway management or had a higher comorbidity burden. When compared to other risk measures and holding sensitivity constant near 90%, the GTRI had higher specificity, despite a lower AUROC. Using GTOS II or the GTRI may better identify high-risk older adults than traditional scores, such as ISS, but identification of an ideal prognostic tool remains elusive.

Outcomes of non-invasive ventilation in 'very old' patients with acute respiratory failure: a retrospective study

BACKGROUND

Non-invasive ventilation (NIV) is increasingly used to support very old (aged ≥85 years) patients with acute respiratory failure (ARF). This retrospective observational study evaluated the impact of NIV on the prognosis of very old patients who have been admitted to the intermediate care unit (IMC) of the Emergency Department of the University Hospital Policlinico-Vittorio Emanuele of Catania for ARF.

METHODS

All patients admitted to the IMC between January and December 2015 who received NIV as the treatment for respiratory failure were included in this study. Outcomes of patients aged ≥85 years were compared with lower ages. The expected intrahospital mortality was calculated through the Simplified Acute Physiology Score (SAPS) II and compared with the observed mortality.

RESULTS

The mean age was 87.9±2.9 years; the M:F ratio was approximately 1:3. The average SAPS II was 50.1±13.7. The NIV failure rate was 21.7%. The mortality in the very old group was not statistically different from the younger group (20% vs 25.6%; d=5.6%; 95% CI -8% to 19%; p=0.404). The observed mortality was significantly lower than the expected mortality in both the group ≥85 (20.0% vs 43.4%, difference=23.4%; 95% CI 5.6% to 41.1%, p=0.006) and the younger group (25.6% vs 38.5%, difference=12.9%; 95% CI -0.03% to 25.8%, p=0.046). In both age groups, patients treated with NIV for chronic obstructive pulmonary disease had lower mortalities than those treated for other illnesses, although this was statistically significant only in the younger group.

CONCLUSION

In very old patients, when used with correct indications, NIV was associated with mortality similar to younger patients. Patients receiving NIV had lower than expected mortality in all age groups.

Characteristics and outcome of Emergency Department intubation in geriatric patients

INTRODUCTION

The number of elderly patients admitted to the Emergency Department (ED) continues to grow due to the natural aging of the population. Consequently, tracheal intubation will be increasingly used in the oldest old. The objective of this retrospective study is to evaluate the characteristics and outcome of patients of 75 years and older undergoing an endotracheal intubation in the ED.

METHODS

In a single center, retrospective study we reviewed digital medical files of patients of 75 years and older in the period from 1/01/2008 to 31/12/2010, who were admitted to the ED of the Universitair Ziekenhuis Brussel in Brussels, Belgium and underwent endotracheal intubation. Survival served as primary outcome and survival without sequelae as secondary endpoint.

RESULTS

In the study period, 88 patients of 75 years and older were intubated in the ED. Sixty three (72%) patients died after intubation and 25 (28%) survived until discharge. All 23 patients (26%), who were intubated during cardiopulmonary resuscitation died. A survival rate of 48% was observed in patients, who were intubated for respiratory failure (28%), intracerebral hemorrhage or ischemic stroke (17%), cardiac failure (8%) or other reasons. Non-survivors were significant older, of male sex, had higher APACHE scores and more frequently used cholesterol lowering drugs.

CONCLUSION

Senior adults, aged 75 years or older and undergoing endotracheal intubation at the ED, have a high mortality rate. Younger age and female sex at admission were positively correlated with survival. Of those who left the hospital, one-third were able to return home without major sequelae.